General principles of coverage of medical costs incurred by patients holding health insurance policies in Vietnam

General principles of coverage of medical costs incurred by patients holding health insurance policies in Vietnam (Internet image) 

The Minister of Health of Vietnam promulgates Circular 20/2022/TT-BYT dated December 31, 2022 introducing nomenclatures and payment rates, conditions of chemical medications, biologicals, radiopharmaceuticals and tracers under health insurance policyholders’ received coverage.

1. General principles of coverage of medical costs incurred by patients holding health insurance policies in Vietnam

General principles of coverage of medical costs incurred by patients holding health insurance policies according to Article 3 of Circular 20/2022/TT-BYT are as follows:

- The health insurance fund shall cover costs of the covered medications incurred by patients according to the actual quantity of medications used, except those specified in clause 5 of Article 5 of Article 3 of Circular 20/2022/TT-BYT;

The actual procurement prices of these medications defined in law on bidding and the range of health insurance coverage and amounts under law on health insurance.

- The health insurance fund shall pay for a medication when the prescription for such medication is conformable to the prescription stated in one of the following documents:

+ The leaflet attached to the dossier of registration of the medication licensed by the Ministry of Health;

+ The leaflet attached to the dossier of registration of the proprietary medicine or reference biological licensed by the Ministry of Health;

+ The guidelines for diagnosis and treatment adopted by the Ministry of Health;

+ The most updated version of the National Pharmacopoeia of Vietnam.

- The health insurance fund shall not pay for a medication if:

+ The decision on suspension or recall of the medication or the batch comprising that medication is adopted.

Any medication or batch receiving the suspension or recall decision as stated above shall not be covered according to the scope of application of that decision specified in the written notification of or the decision on suspension of marketing authorization or recall of that medication or batch issued by the Ministry of Health;

+ The cost of that medication has been included in the price of technical, medical examination and medical bed service or the lump-sum price per a patient case in accordance with regulations in force;

+ The portion of the cost of that medication is paid by the state budget or other sources of fund;

+ That medication is used in clinical tests or scientific researches.

2. Regulations on payment of reimbursement to several medical establishments in Vietnam

According to Article 4 of Circular 20/2022/TT-BYT, regulations on payment of reimbursement to several medical establishments are as follows:

The health insurance fund shall pay costs of medications to a number of medical establishments that comply with Article 3 and 5 of Circular 20/2022/TT-BYT, and certain regulations in a number of situations as follows:

- For any public medical establishment signing a contract to provide medical services covered by health insurance, but not graded yet:

Based on its human resources, medical equipment, facilities and the list of technical services approved by the competent authority, the Department of Health shall preside over, and cooperate with the provincial Social Insurance in, determining in writing the use of medications by that medical establishment according to its corresponding hospital grade.

- For any public medical establishment under a People’s armed force that signs a contract to provide the medical services covered by the health insurance fund, but not graded yet:

Based on its human resources, medical equipment, facilities and the list of technical services approved by the competent authority, the body directly managing that medical establishment shall preside over, and cooperate with the provincial Department of Health and the social insurance agency which enters into the contract to provide the medical services covered by the health insurance fund in, determining in writing the nomenclature of covered medications provided by that medical establishment according to its corresponding hospital grade.

- Where any medical establishment renders the technical service approved by the competent authority, it may use covered medications to carry out that technical service (including the covered medications to be provided by any higher-grade hospital).

That medical establishment shall compile the list of those medications and submit it to the social insurance agency entering into the contract to provide medical services covered by health insurance with it for use as a proof of payment.

- With regard to any provincial specialized medical establishment providing medications, not including technical services, based on its human resources, medical equipment, facilities and patient’s needs, and medical treatment and diagnosis and treatment guidelines of the Ministry of Health, the Department of Health shall preside over, and cooperate with the provincial Social Insurance in, determining in writing:

The list of medications to be provided by a higher-grade medical establishment that it can provide and get paid by the health insurance fund (including those susceptible to conditions regarding grades and specialties of medical establishments in the 8th column of the Nomenclature of medications specified in Appendix I), on condition that the grade of such higher-grade medical establishment is not higher than the grade of the highest-grade provincial general hospital located in the local area in question.

More details can be found in Circular 20/2022/TT-BYT effective from March 1, 2023.

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