Article 60 of Decree 188/2025/ND-CP detailing and guiding the implementation of a number of articles of the Law on Health Insurance, recently issued by the Government, clearly stipulates the level of direct payment of costs to patients in cases where patients purchase drugs and medical equipment themselves.
Specifically, the Social Insurance Agency pays directly to patients according to the following regulations:
For drugs: the basis for calculating the payment level is the quantity and unit price stated on the invoice purchased by the patient at the pharmaceutical business establishment. In case the drug has regulations on payment rates and conditions, the payment rates and conditions shall be implemented;
For medical equipment: the basis for calculating the payment level is the quantity and unit price stated on the invoice purchased by the patient at the medical equipment trading facility. In case the medical equipment has a payment level specified, the payment shall not exceed the payment level specified for that medical equipment.
The Decree clearly states that the unit price of drugs and medical equipment used as the basis for determining the payment level must not exceed the unit price paid at the most recent time when making payment for cases where drugs and medical equipment have won bids at medical examination and treatment facilities where the patient was examined and treated.
In case the medicine or medical equipment has not won the bid at the medical examination and treatment facility where the patient has been examined and treated, the unit price used as the basis for determining the health insurance payment level is the result of the selection of the contractor that is still in effect at the time of payment in the following order of priority:
National centralized procurement results or price negotiation results;
Local centralized purchasing results in the area;
The results of selecting the lowest bidder of State medical examination and treatment facilities of the same technical level in the area. In case there are no results of selecting bidders of State medical examination and treatment facilities of the same technical level in the area, the results of selecting the lowest bidder of other State medical examination and treatment facilities in the area shall be based on;
The lowest contractor selection result at the time of payment of State medical examination and treatment facilities of the same technical level nationwide. In case there is no contractor selection result of State medical examination and treatment facilities of the same technical level nationwide, the lowest contractor selection result of other State medical examination and treatment facilities nationwide shall be based on.
The Decree stipulates that the Social Insurance Agency shall deduct the health insurance costs paid by the medical examination and treatment facility where the patient is treated as follows:
In case the cost of medicine and medical equipment is included in the price of medical examination and treatment services: deduct it from the cost of medical examination and treatment services covered by health insurance of the medical examination and treatment facility at the payment level according to regulations;
In case the cost of medicine and medical equipment is not included in the price structure of medical examination and treatment services: deduction will not be made from the cost of medical examination and treatment services covered by health insurance of the medical examination and treatment facility;
The cost of medicine and medical equipment paid directly by the Social Insurance Agency to the patient is included in the estimated expenditure of the medical examination and treatment facility.
Patients are paid directly when the medicine is on the List of Rare Medicines and the medical equipment is type C or D.
The Decree also clearly stipulates: Medicines and medical equipment that are subject to direct payment to patients when they purchase them themselves are medicines on the List of rare medicines as prescribed by the Minister of Health; Medical equipment of type C or D, except for in vitro diagnostic medical equipment, personal medical equipment, medical equipment on the list of medical equipment issued by the Minister of Health are bought and sold like ordinary goods according to the provisions of Decree No. 98/2021/ND-CP dated November 8, 2021 of the Government on the management of medical equipment, amended and supplemented by Decree No. 07/2023/ND-CP dated March 3, 2023 and Decree No. 04/2025/ND-CP dated January 1, 2025 of the Government.
Conditions for direct payment of costs to patients
According to Decree 188/2025/ND-CP, conditions for direct payment of costs to patients in cases where patients purchase drugs and medical equipment themselves At the time of prescribing, indicating drugs, and indicating the use of medical equipment, all of the following conditions must be met:
- At the time the patient is prescribed or indicated, the medical examination and treatment facility does not have available drugs or medical equipment as prescribed and falls under the following cases:
For drugs: there is no commercial drug containing the active ingredient that the patient is prescribed or the same active ingredient but with different concentrations or content or dosage form or route of administration and cannot be substituted for the prescription for the patient;
For medical equipment: there is no medical equipment that the patient is prescribed to use and there is no medical equipment to replace it.
- It is not possible to transfer a patient to another medical examination and treatment facility in one of the following cases:
The patient's health and medical condition are determined to be ineligible for transfer;
The medical examination and treatment facility where the patient is being examined and treated is under medical isolation according to the provisions of law on prevention and control of infectious diseases;
The medical examination and treatment facility where the patient is being examined and treated is a medical examination and treatment facility of the most specialized level or the highest technical level in the province or centrally-run city.
- It is impossible to transfer drugs and medical equipment between medical examination and treatment facilities.
- Prescribed and indicated drugs and medical equipment must be consistent with the scope of expertise of the medical examination and treatment facility.
- Prescribed and indicated drugs and medical equipment must be within the scope of benefits of the health insurance participant and have had their medical examination and treatment costs covered by health insurance paid for at one of the medical examination and treatment facilities nationwide .
- Medical examination and treatment facilities are responsible for providing patients with confirmation of drug and medical equipment shortages as a basis for payment .
Thus, in order to receive direct payment from the Social Insurance Agency in case the patient purchases the medicine and medical supplies themselves, the above criteria and conditions must be met. The patient needs to have a Direct Payment Request (with some documents) and a Confirmation of drug and medical equipment shortage issued by the medical examination and treatment facility responsible for providing the patient to send to the Social Insurance Agency.
Source: https://nhandan.vn/nguoi-benh-tu-mua-thuoc-thiet-bi-y-te-duoc-bao-hiem-y-te-thanh-toan-nhu-the-nao-post893783.html
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