Health insurance pays for patients to buy medicine themselves when the hospital lacks medicine.

In which cases will health insurance pay when the hospital lacks medicine?

This Circular regulates the direct payment of costs of medicines and medical equipment within the scope of benefits of health insurance participants when going for medical examination and treatment according to the provisions in Point c, Clause 2 and Clause 3, Article 31 of the Law on Health Insurance at medical examination and treatment facilities that have signed contracts for health insurance examination and treatment from the health insurance fund, including: Cases of medicines and medical equipment within the scope of payment; Payment conditions; Payment levels; Payment records and procedures.

In case of drugs and medical equipment within the scope of payment, including: Drugs on the List of rare drugs issued with Circular No. 26/2019/TT-BYT dated August 30, 2019 of the Minister of Health regulating the List of rare drugs.

Type C or D medical equipment, 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 medical equipment management.

Regarding payment conditions, the Circular of the Ministry of Health clearly states: at the time of prescribing drugs and indicating the use of medical equipment, the following conditions must be ensured:

Firstly, there are no drugs or medical equipment because they are in the process of selecting contractors according to the approved contractor selection plan in one of the following forms: Open bidding or restricted bidding or competitive bidding or direct procurement or contractor selection in special cases but have not yet selected a contractor or online bidding or online procurement and have implemented a shortened bidding appointment according to the provisions of Point c, Clause 1, Clause 2, Article 23 of the Law on Bidding and Clause 1, Article 94 of Decree No. 24/2024/ND-CP dated February 27, 2024 of the Government detailing a number of articles and measures to implement the Law on Bidding on contractor selection but have not yet selected a contractor.

At the same time, at the medical examination and treatment facility, regarding drugs: There are no commercial drugs containing the active ingredient that the patient is prescribed or the same active ingredient but with different concentrations or contents or dosage forms or routes of administration and cannot be substituted for prescriptions for the patient; Regarding medical equipment: There is no medical equipment that the patient is prescribed to use and there is no medical equipment to replace it.

Second, do not transfer the patient to another medical examination and treatment facility in one of the following cases: The patient's health condition or illness is determined to not meet the conditions 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 the law on prevention and control of infectious diseases; The medical examination and treatment facility where the patient is being examined and treated is a specialized medical examination and treatment facility.

Third , it is not possible to transfer drugs and medical equipment between medical examination and treatment facilities according to the provisions of law for the benefit of health insurance participants.

Fourth, the prescribed and indicated drugs and medical equipment must be in accordance with the professional scope of the medical examination and treatment facility and the cost of medical examination and treatment covered by health insurance must be paid for at one of the medical examination and treatment facilities nationwide.

Fifth, prescribed and indicated drugs and medical equipment must be within the scope of benefits of health insurance participants.

Payment level for health insurance patients buying medicine and medical equipment themselves

Regarding direct cost payment, according to the guidance of Circular 22, the Social Insurance agency makes direct payments 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 (including reusable 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 regulation, it must not exceed the payment level prescribed for that medical equipment.

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 for cases where drugs and medical equipment have won bids at the medical examination and treatment facility where the patient was examined and treated.

In case the drugs and medical equipment have 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 a valid contractor in the following order of priority: Results of centralized procurement at the national level or results of price negotiation; Results of centralized procurement at the local level in the area;

And the lowest contractor selection result at the time of payment of public medical examination and treatment facilities at specialized or basic levels or medical examination and treatment facilities of the same technical expertise level in the area;

The results of selecting the lowest bidder at the time of payment of public medical examination and treatment facilities at specialized or basic levels or medical examination and treatment facilities of the same technical expertise level in Hanoi and Ho Chi Minh City.

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: Deduction shall be made from the cost of medical examination and treatment services covered by health insurance of the medical examination and treatment facility at the payment level prescribed in Clauses 1 and 2 of this Article;

In case the cost of medicine and medical equipment is not included in the price structure of medical examination and treatment services: No deduction will 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 calculated in the estimate of the medical examination and treatment facility.

The Circular of the Ministry of Health clearly states: The patient or the patient's legal representative is responsible for the legality and completeness of the direct payment request file.

In the Circular, the Ministry of Health clearly states: The Department of Health of provinces and centrally run cities is responsible for organizing the dissemination, deployment, inspection and supervision of the implementation of this Circular within the scope of its management authority; strengthening the urging, inspection and supervision of the procurement to ensure the availability of medicines and medical equipment for health insurance examination and treatment at health insurance examination and treatment facilities under its management authority; implementing handling measures according to the provisions of law on health insurance examination and treatment for health insurance examination and treatment facilities that do not ensure sufficient conditions according to the medical examination and treatment license and signed health insurance examination and treatment contracts related to the supply of medicines and medical equipment.

Source: https://nhandan.vn/dieu-kien-thanh-toan-cho-nguoi-benh-co-the-bhyt-tu-mua-thuoc-khi-benh-vien-thieu-thuoc-post837776.html