Removing the "bottleneck" in paying for medical examination and treatment costs under health insurance

On the afternoon of October 24, providing information on some new points of Decree No. 75/2023/ND-CP amending and supplementing a number of articles of Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government detailing and guiding measures to implement a number of articles of the Law on Health Insurance, Master Tran Thi Trang, Acting Director of the Department of Health Insurance, Ministry of Health said that Decree 75 has abolished the regulation on the total payment of medical examination and treatment costs under health insurance, implementing payment of medical examination and treatment costs under health insurance according to the payment method according to service prices applied from January 1, 2019. This is an important content, contributing to removing the "bottleneck" in the regulation on payment of medical examination and treatment costs under health insurance.

Add more target groups to the budget supported group

According to the Acting Director of the Department of Health Insurance, Decree 75 has breakthrough regulations, removing "bottlenecks" in the payment mechanism for medical examination and treatment costs under health insurance to facilitate medical examination and treatment under health insurance, ensuring the rights of health insurance participants; supplementing and supporting health insurance premium levels, amending health insurance benefits and enhancing the role and responsibility of ministries, branches, and medical examination and treatment facilities in managing and effectively using the health insurance fund.

Decree 75 added the subjects who are people in safe zone communes and revolutionary safe zones during the resistance war against France and the US, not subject to the provisions of Clauses 1, 2 and 3, Article 12 of the Law on Health Insurance, to the group of subjects whose health insurance is paid by the state budget.

Add ethnic minority people living in communes in regions II, III, and extremely disadvantaged villages in ethnic minority and mountainous areas in the period 2016-2020 that are no longer on the list of communes in regions II, III, and extremely disadvantaged villages in ethnic minority and mountainous areas in the period 2021-2025 according to the Prime Minister's decision to the group of people receiving 70% state budget support for the contribution level for 36 months from November 1, 2023.

These are ethnic minority groups that have just escaped poverty according to Decision No. 861/QD-TTg dated June 4, 2021 of the Prime Minister, but in reality, they are still facing many difficulties, as reflected and recommended by National Assembly Deputies, People's Committees of some provinces and voters.

The regulation that the state budget continues to support for a period of time after escaping poverty so that people can accumulate and have enough economic conditions to participate in health insurance demonstrates the Government's policy of ensuring social security and sustainable poverty reduction.

In addition, Decree 75 has increased the benefit level from 80% to 100% of medical examination and treatment costs under health insurance for a number of groups of people with revolutionary contributions as prescribed in Clause 5, Article 3 of Decree No. 146/2018/ND-CP such as youth volunteers; police officers and soldiers who have been granted benefits according to the provisions of the Prime Minister's Decisions; and frontline workers.

This Decree also adds benefits for ethnic minority groups who have escaped poverty according to Decision 861/QD-TTg dated June 4, 2021 of the Prime Minister and the groups that have been amended and supplemented in Decree 131/2021/ND-CP of the Government detailing and guiding measures to implement the Ordinance on Preferential Treatment for People with Revolutionary Contributions.

Abolish regulations on total payment for medical examination and treatment costs under health insurance

In particular, Decree 75 has abolished the regulation on the total payment for medical examination and treatment costs under health insurance, and implemented payment for medical examination and treatment costs under health insurance according to the payment method according to service prices, which has been applied since January 1, 2019.

At the same time, regulations on the allocation of health insurance medical examination and treatment cost estimates to Vietnam Social Security and Social Security of provinces and centrally-run cities; notification of the estimated amount of health insurance medical examination and treatment costs to medical examination and treatment facilities as a basis for planning the use of health insurance medical examination and treatment costs in the year, but not applying it as a basis for advance payment, payment, and settlement of health insurance medical examination and treatment costs of medical examination and treatment facilities in case of exceeding the estimated amount of expenditure.

"I think this is an important content in the regulations on payment of medical examination and treatment costs under health insurance. In recent years, there has been a situation where medical examination and treatment costs within the scope of conditions, payment rates, and benefits of patients with health insurance cards provided by medical examination and treatment facilities and not collected from patients have been reviewed and not paid, even though they have been assessed by the social insurance agency as legitimate costs. The reason for exceeding the total amount directly affects the operation of medical examination and treatment facilities and leads to impacts on the rights of patients," the acting Director of the Department of Health Insurance stated.

According to the new regulations, the costs of medical examination and treatment covered by health insurance within the scope of benefits and the level of benefits of health insurance participants that have been assessed by the social insurance agency will be covered by the health insurance fund. The payment mechanism is based on the actual technical services, medicines, medical supplies, etc. used for patients and the price according to current regulations.

These regulations will remove difficulties and obstacles in payment of medical examination and treatment costs under health insurance between medical examination and treatment facilities and social insurance agencies, creating conditions for medical examination and treatment facilities to improve operational efficiency and ensure the rights of health insurance patients.

Strengthening the responsibility of ministries, branches and medical examination and treatment facilities

Decree 75 has added regulations to strengthen the responsibility in implementing health insurance policies of the Ministry of Health, medical examination and treatment facilities, and social insurance agencies.

Accordingly, the Decree stipulates the strengthening of the responsibility of the Ministry of Health in directing medical examination and treatment facilities to comply with legal provisions on medical examination and treatment and health insurance, in the procurement and bidding of drugs, chemicals, and medical supplies.

At the same time, the Decree also stipulates the responsibility of the Ministry of Health in regularly updating and amending the list, conditions, scope, and payment rates for drugs, supplies, technical services, and goods covered by the health insurance fund, in regulating and guiding the interconnection of data on test results, functional imaging diagnostics, and medical examination and treatment information to use the health insurance fund economically and effectively.

In addition to strengthening the responsibility of medical examination and treatment facilities in complying with the provisions of the law on health insurance, the law on medical examination and treatment, and the law on procurement and bidding, to ensure the supply of drugs, chemicals, medical supplies, and medical technical services with quality, efficiency, and economy; the Decree also stipulates that medical examination and treatment facilities must review and promptly issue procedures, professional instructions, and measures to prevent abuse and profiteering of health insurance funds according to their authority; regularly organize inspections, review, and verify the increased costs of medical examination and treatment under health insurance at the facility according to the recommendations and warnings of the social insurance agency and make appropriate adjustments.

The Decree clearly states the responsibility of Vietnam Social Security in assessing, proactively reviewing, detecting and promptly sending warning information to medical examination and treatment facilities about health insurance medical examination and treatment costs that are higher than the average cost of medical examination and treatment facilities of the same class, same level, and same specialty.

"It can be said that these regulations aim to promote the implementation of solutions to control health insurance medical examination and treatment costs, manage and use health insurance funds economically and effectively, and prevent abuse, waste, and profiteering of health insurance funds," shared Master Tran Thi Trang.

The Decree takes effect from December 3, 2023. The regulation abolishing the total payment level will be applied from January 1, 2019, while some regulations on adding subjects and increasing the benefit level will be applied from the date of promulgation of the Decree on October 19, 2023 to ensure the timely rights of health insurance participants.