For people with severe disabilities, transportation is very difficult, requiring multiple trips just to request referrals, resulting in significant travel costs. A reader asks, is the current policy of using the designated referral system still appropriate?
Regarding this matter, the Provincial Social Insurance agency responded as follows:
Regarding the payment of medication costs under health insurance: According to point c, clause 1, Article 21 of Law No. 51/2024/QH15 dated November 27, 2024, amending and supplementing a number of articles of the Law on Health Insurance, health insurance participants are entitled to reimbursement from the health insurance fund for the following costs:
"c) Costs for the use of medical technical services, medicines, medical equipment, blood, blood products, medical gases, supplies, instruments, tools, and chemicals used in medical examination and treatment that are covered by the health insurance fund."
Therefore, according to the regulations, for medications covered by the health insurance fund, health insurance participants are entitled to reimbursement within the scope of their benefits.
Currently, the list of drugs covered by the health insurance fund that is still in effect includes Consolidated Document No. 15/VBHN-BYT dated December 16, 2024, issued by the Ministry of Health , which promulgates the list and rates, and conditions for payment of chemical drugs, biological products, radioactive drugs, and markers within the scope of benefits for health insurance participants.
Procedure for referring patients for medical examination and treatment under health insurance.
Regarding the transfer of patients between health insurance-covered medical examination and treatment facilities: According to Clause 2, Article 9 of Circular No. 01/2025/TT-BYT dated January 1, 2025, issued by the Minister of Health, which details and guides the implementation of some articles of the Law on Health Insurance:
"Cases involving the transfer of patients between healthcare facilities covered by health insurance, following the correct procedures, include:
a) Transferring patients between health insurance-covered medical examination and treatment facilities within the same level of medical examination and treatment, from primary-level medical examination and treatment facilities to basic-level medical examination and treatment facilities, and from basic-level medical examination and treatment facilities to specialized-level medical examination and treatment facilities, based on professional requirements, the patient's condition, or exceeding the capacity of the medical examination and treatment facility, in addition to the cases specified in point d of this clause and Article 5 of this Circular;
b) Transferring patients from primary healthcare facilities to specialized healthcare facilities in cases where the capacity of basic healthcare facilities in the province is exceeded;
c) Transferring patients whose condition has stabilized from specialized medical facilities to basic or initial-level medical facilities, or transferring patients from basic-level medical facilities back to initial-level medical facilities for continued treatment and monitoring;
d) Transferring patients from specialized or basic-level medical examination and treatment facilities back to their initial health insurance medical examination and treatment facilities for treatment, management, and monitoring of chronic diseases as prescribed in Article 10 of this Circular;
d) For transferring patients between medical examination and treatment facilities for those with chronic diseases or long-term treatment according to the list of diseases specified in Appendix III issued with this Circular, the medical examination and treatment facility transfer form is valid for one year from the date indicated on the transfer form and shall be implemented in accordance with the provisions of point b, clause 3, clause 4 and clause 5 of Article 5 of this Circular;
e) In cases where a person with a health insurance card seeks medical examination and treatment on their own, not in accordance with the regulations in Articles 26 and 27 of the Health Insurance Law, and falls under the cases specified in points e, g, and h (except for cases entitled to 100% coverage in points e and h) of Clause 4, Article 22 of the Health Insurance Law, and is subsequently referred by the medical facility to another medical facility as required by professional standards;
g) In emergency cases, after the emergency treatment phase, the patient is transferred to inpatient treatment at the medical facility where the emergency treatment was received, or transferred to another medical facility for continued treatment as required by medical professionals, or transferred back to the initial registered medical facility after stable treatment.
Simultaneously, Clauses 1 and 2 of Article 5 of Circular No. 01/2025/TT-BYT stipulate several cases where transferring to another medical examination and treatment facility is not required, specifically:
"1. Attached to this Circular are the lists of rare diseases, serious illnesses, diseases requiring surgery or advanced techniques that are entitled to 100% coverage as stipulated in point a, clause 4, Article 22 of the Health Insurance Law as follows:
a) A list of certain diseases that can be examined and treated at specialized medical facilities is specified in Appendix I;
b) A list of certain diseases that can be examined and treated at basic-level medical examination and treatment facilities is specified in Appendix II.
2. Individuals covered by health insurance who fall under the cases specified in Clause 1 of this Article are not required to comply with the regulations on transferring to another medical examination and treatment facility.
Therefore, in addition to transferring patients between health insurance-covered medical examination and treatment facilities according to the procedures outlined in Article 9 of Circular No. 01/2025/TT-BYT, in some cases, health insurance participants are not required to transfer to another medical examination and treatment facility as instructed above.
The Social Insurance agency provides additional information for readers to understand the regulations on referral procedures for health insurance-covered medical examinations and treatments, as well as cases where referral to another medical facility is not required.
Source: https://baolaocai.vn/cac-chi-phi-kham-chua-benh-duoc-bhyt-chi-tra-post897194.html
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