The process of assessing the conditions for drug payment in Vietnam

The process of assessing the conditions for drug payment in Vietnam (Internet image)

On 12/12/2022, Vietnam Social Security issued Decision 3618/QD-BHXH on the process of medical insurance assessment.

The process of assessing drug payment conditions in Vietnam is carried out as follows:

The process of assessing the conditions for drug payment in Vietnam

* Step 1: Collect documents and update the list of drugs on the health insurance assessment information system

- The unit assigned by the Ministry of Health to do national centralized bidding, negotiate drug prices, update the list of winning drugs at the national level, negotiate prices on the receiving portal, check the information, digitally sign the data (if any), and send it to the Inspection software.

- Provincial social insurance

+ Instruct the medical examination and treatment facility to send documents and update the list specified in Article 7 of this procedure to the receiving portal and send it to the assessment software when requesting to sign a contract for medical examination and treatment covered by insurance, when there is a change in the course of contract performance, or after the contractor selection result or procurement decision of a non-public medical facility is available;

+ Update the list of drugs to be procured according to the results of local centralized bidding on the assessment software.

- Change the information on the applied list of drugs

+ When receiving a document from a competent authority on the change of drug information as prescribed in Clause 6, Article 37 of Circular 15/2019/TT-BYT or when allocating and regulating the number of winning drugs according to the results of centralized bidding:

(i) The Center for Health Insurance Assessment and Multi-Line Payments updates information on changes when receiving requests from national-level centralized bidding and procurement units;

(ii) The provincial social insurance agency updates information on changes when receiving requests from the province's centralized procurement unit or from a medical examination and treatment facility.

+ In case the medical examination and treatment establishment purchases additional drugs, the winning bid: after the medical examination and treatment establishment sends a written notice of additional procurement of drugs in the quantity of together with the contract appendix or additional procurement decision, the provincial social insurance agency shall update the quantity of additional drugs purchased on the assessment software.

* Step 2: Check the list of drugs

- The assessment software compares the list of drugs mentioned in Clause 1, Article 7 of this procedure with the list of drugs covered by health insurance coverage issued by the Ministry of Health, and automatically returns the following drugs to the receiving portal:

+ Names of active ingredients, names of radioactive drugs and markers, routes of administration, or forms of administration are not consistent with information in the promulgated list of chemical drugs, biological products, radiopharmaceuticals, and markers together with Circular 30/2018/TT- BYT, Circular 01/2020/TT-BYT and Circular 20/2020/TT-BYT;

+ The active ingredient and route of administration, or dosage form, of the drug do not correspond to the hospital class of the medical examination and treatment establishment, except for the following cases:

(i) Over-class drugs used to perform technical services approved by competent authorities;

(ii) Over-class drugs used at provincial-level specialized hospitals have been unanimously determined by the Department of Health and Social Insurance of the province to be no higher than those of the provincial general hospital.

+ Active ingredients with prescribed payment conditions that are not suitable for the model of organization and specialty of treatment; drugs with prescribed payment rates that do not correspond to the dosage form;

+ Radioactive drugs and markers used in technical services that have not yet been approved by competent authorities;

+ The composition and route of administration of traditional medicine, herbal medicine, and the name and origin of traditional medicine are not in accordance with the list promulgated together with Circular 05/2015/TT-BYT and Circular 50/2017/TT-BYT.

+ Traditional medicines and drugs from herbal ingredients used at medical examination and treatment establishments that are not hospitals or traditional medicine institutes or classified below the hospital grade are paid as prescribed in the List of traditional medicines, herbal medicines and traditional medicine ingredients within the scope of payment of the health insurance fund issued together with Circular 05/2015/TT-BYT;

+ Drugs with registration numbers or product circulation permits that do not match the information on the list of drugs licensed for circulation by the Ministry of Health that are still valid are announced on the website of the Drug Administration of Vietnam - Ministry of Health as prescribed in Circular 08/2022/TT-BYT;

+ Chemical and pharmaceutical drugs, biological products, radiopharmaceuticals, and self-manufactured or prepared tracers with active ingredients that are not in accordance with regulations; Not suitable for route, type, and hospital class used in Appendix 01 or Appendix 02 issued together with Circular 30/2018/TT-BYT, Clauses 1 and 2, Article 2 of Circular 01/2020/TT-BYT, Articles 1 and 2 of Circular 20/2020/TT-BYT.

Traditional Chinese medicine: drugs from herbal ingredients that are not processed or prepared according to the ingredients in the list promulgated together with Circular 05/2015/TT-BYT, Article 1 of Decision 695/QD-BYT, and Article 5 of Circular 50/2017/TT-BYT;

+ The list of drugs mentioned at Points 1.1 and 1.2, Clause 1, Article 7 of this process does not match all information with the list of drugs for centralized bidding or price negotiation if procurement is according to the results of centralized bidding or price negotiation (except for the allocated quantity);

+ The list of drugs at non-public medical examination and treatment establishments procured according to the winning results does not match the information specified at Point c, Clause 7, Article 50 of Circular 15/2019/TT-BYT.

- Provincial social insurance

+ Compare the drug list data with the paper version in case the data has not been digitally signed; return the list for medical examination and treatment establishments to adjust if incorrect;

+ Compare information on the form of bidding and the list of drugs according to the contractor selection results to ensure the same information is on the list data and accompanying documents, and return them to medical examination and treatment establishments for adjustment if they are incorrect;

+ Identify the medical examination and treatment establishment that has been authorized by a competent authority to conduct radiological diagnosis and treatment if it requests payment of radioactive drugs or tracers;

+ Identify the medical examination and treatment establishment that has approved the production process, quality standards, and drug price if it requests payment for self-prepared or prepared drugs.

* Step 3: Verify the quantity and price of drugs

- The inspection software checks the quantity and unit price of drugs on the list mentioned in Clause 1, Article 7 of this process and automatically returns the following drugs to the portal:

+ The quantity of procurement exceeds the quantity according to the results of contractor selection, adjustment, or additional purchase (if any) as prescribed in Clause 1 or 5, Article 37 of Circular 15/2019/TT-BYT in case the medical examination and treatment establishment organizes its own bidding.

Or the quantity is allocated and regulated according to the results of local-level centralized bidding, national-level centralized bidding, and price negotiation;

+ The unit price is higher than the unit price at the approved contractor selection result or higher than the declared price, the declared price is still valid at the time of approval of the announced contractor selection result.
on the website of the Drug Administration of Vietnam - Ministry of Health;

+ Medicines at non-public medical examination and treatment establishments shall be procured according to the results of centralized bidding or according to the bidding results of provincial-level public establishments in the same area:

(i) Improper trade name, circulation registration number or import license, concentration or content, route of administration, dosage form, packing specifications, manufacturing facility, manufacturing country;

(i) The payment price is higher than the drug unit price, according to the winning bid.

+ After processing and preserving medicinal herbs, the loss rate is higher than the rate specified in Clause 5, Article 6 of Circular 43/2017/TT-BYT.

- Provincial social insurance

+ Review the payment prices of self-prepared and prepared modern drugs on the basis of the explanation of the drug's cost and the provisions of Point d, Clause 7, Article 4 of Circular 30/2018/TT-BYT;

+ Review the payment price of traditional medicine ingredients purchased by medical examination and treatment establishments for processing and preparation with the prices of purchased herbal ingredients according to the winning bid plus the expenses in the price list of the drug as prescribed in Article 1 of Circular 27/2020/TT-BYT;

+ Review the payment price of traditional medicine drugs prepared by themselves or prepared with the price of herbal ingredients and drugs procured according to the bidding results plus the expenses in the price explanation sheet of the drug according to the provisions of Article 1 of Circular 27/2020/TT-BYT;

+ Review the payment price of the packaging for medicines on the basis of the explanation of the price of the package when the medical examination and treatment establishment does not decoct the medicine for the patient.

In case it is discovered that the payment prices of the drugs and packaging mentioned at this point are not reasonable, then request that the medical examination and treatment establishment have a document clarifying the costs in order to determine the cost of the drug and its packaging.

Documents on the assessment of drug payment conditions in Vietnam

Documents on the assessment of drug payment conditions include:

- List of drugs covered by health insurance

+ Chemical drugs, biological products, radioactive drugs, and tracers are made according to the form specified in Appendix 1 issued together with Circular 15/2019/TT-BYT;

+ Traditional medicine, herbal medicine, and traditional medicine made according to the form in Appendix 1 issued with Circular 05/2015/TT-BYT;

+ Format the data of the above lists according to Table 3, Form No. 01/QTGD, and write enough information in the following cases:

(i) Using chemical drugs, biological products specified at a higher hospital class, or radioactive drugs and markers to perform technical services approved by competent authorities: write codes for technical services that use such drugs;

(ii) Non-public medical examination and treatment establishments that purchase according to the winning results of other places: bidder information - write the number of the winning decision (including the number and symbol of the decision),
bidding package, bidding group, year of announcing the winning decision, code of province or code of medical examination and treatment facility where the bidding is held;

(iii) Self-medicated, prepared, and processed drugs: the number of the winning decision; write the number and symbol of the document of the medical examination and treatment establishment; and send it to the social insurance agency.

- The document of the head of the medical examination and treatment establishment approving the production process, quality standards, and drug prices as prescribed at Point d Clause 7 Article 4 of Circular 30/2018/TT-BYT and a description of the cost of self-prepared, prepared, and processed drugs as prescribed in Clause 6, Article 5 of Circular 05/2015/TT-BYT, and as amended in Article 1 of Circular 27/2020/TT-BYT.

- Document of the competent authority permitting the implementation of radiological diagnosis and treatment as prescribed in Clause 2, Article 2 of Circular 30/2018/TT-BYT.

- The document of the competent authority approving the contractor selection plan, approving the contractor selection result, and the electronic file of the contractor selection result made according to the form specified in Appendix 1, Appendix 2 promulgated together with Circular 15/2019/TT-BYT if medical examination and treatment establishments organize their own bidding.

More details can be found in Decision 3618/QD-BHXH, which takes effect on January 1, 2023, and replaces Decision 1456/QD-BHXH 2015.

Thanh Rin

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