According to the Law on Health Insurance, the Minister of Health is authorized to regulate special cases in which the health insurance organization is obligated to directly reimburse health insurance examination and treatment costs for health insurance card holders. Based on this, on October 18, 2024, the Minister of Health issued Circular No. 22/2024/TT-BYT on the direct payment of costs for medication and medical equipment for health insurance card holders seeking medical examination and treatment ("Circular No. 22"). Accordingly, from January 1, 2025, medication or medical supplies prescribed by a doctor but not available at the hospital, which health insurance participants have to purchase themselves, will be directly reimbursed by health insurance.
The following are the latest updates on the notable points of Circular No. 22, as provided by ATA Legal Services:
1. Types of medication and medical equipment are directly reimbursed.
Circular No. 22 clearly stipulates the types of medication and medical equipment that are covered for direct payment of medication and medical equipment costs for health insurance participants, including:
(i) For medications: included in the list of rare medications issued together with Circular No. 26/2019/TT-BYT by the Minister of Health.
(ii) For medical equipment: Category C or D medical equipment, except for in vitro diagnostic equipment, personal specialized medical equipment, and medical equipment listed by the Minister of Health, can be purchased and sold like regular goods according to regulations.
2. Requirements for direct reimbursement of medication and medical equipment costs for health insurance beneficiaries.
According to Circular No. 22, in order to be directly reimbursed for the costs of purchasing medication and medical equipment for health insurance during medical examinations and treatments, the following 5 conditions must be met at the time of prescribing medication or indicating the use of medical equipment:
Firstly, there are no medications or medical equipment that are currently under the procurement process according to the approved procurement plan but have not yet selected a supplier, and a simplified bidding process has been implemented as per regulations. Moreover, at the medical facility:
+ For medication: There are no commercial medications with the same active ingredient as prescribed for the patient, or with the same active ingredient but different concentrations, dosages, formulations, or routes of administration that cannot be substituted for prescribing to the patient;
+ For medical equipment: There is no medical equipment that the patient is prescribed and there are no alternative medical equipment;
Secondly, patients cannot be transferred to another healthcare facility if their health condition is deemed unsuitable for transfer; if the healthcare facility where the patient is being examined and treated is under quarantine as per regulations; or if the healthcare facility where the patient is being examined and treated is a specialized healthcare facility;
Thirdly, medication and medical equipment cannot be transferred between healthcare facilities as per regulations;
Fourthly, prescribed medication and medical equipment must be within the scope of the healthcare facility's expertise and have been paid for by health insurance at one of the healthcare facilities nationwide;
Finally, prescribed medication and medical equipment must be within the scope of benefits covered by the health insurance participant.
3. The basis for calculating the direct payment to the patient
Under Circular No. 22, the Social Insurance Agency will directly reimburse the patient based on the quantity and unit price as stated on the invoice for purchased medications and medical equipment at pharmacies or medical equipment suppliers. In cases where there are regulations on payment levels or successful bidding, this unit price shall not exceed the approved unit price in previously executed contracts.
In addition, the Social Insurance Agency will deduct the health insurance payment costs of the medical facility where the patient is treated in cases where the costs of medications and medical equipment are included in the medical service price. Conversely, there will be no deduction for cases where the medications and medical equipment are not included in the medical service price structure.
Circular No. 22 takes effect from January 01, 2025. In cases where patients are admitted to a health facility for examination and treatment before January 1, 2025, but the treatment is completed after January 1, 2025, the provisions of Circular 22 shall be applied.
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