LÀM THẾ NÀO ĐỂ NGƯỜI BỆNH CÓ THẺ BHYT ĐƯỢC THANH TOÁN CHI PHÍ THUỐC, THIẾT BỊ Y TẾ KHI BỆNH VIỆN KHÔ

Scenario: I am a patient with a chronic illness who went for a check-up at a provincial hospital on January 15, 2025. After being prescribed medication and medical equipment by the doctor, I was informed that the hospital did not have some of the prescribed medicines and medical devices available. Since I needed them immediately for treatment, I purchased the medication from an external pharmacy and kept the receipt. I would like to know if I can get reimbursed for these costs and what procedures I need to follow. I sincerely hope to receive advice from a lawyer. Thank you. 

Answer: Thank you for trusting and submitting your question to FDVN Law Company ("FDVN"). After reviewing legal regulations, FDVN provides the following information: 

1. Conditions for Direct Reimbursement of Medicine and Medical Equipment Costs Covered by Health Insurance

 According to the new regulations in Article 3 of Circular 22/2024/TT-BYT, to be eligible for direct reimbursement of medicine and medical equipment costs, the following conditions must be met at the time of prescription: 

The hospital does not have the prescribed medicine/medical equipment because it is in the process of contractor selection (via open/restricted bidding, competitive offers, direct procurement, or special cases where no contractor has been selected) and has followed abbreviated bidding procedures under Article 23 of the Bidding Law and Article 94 of Decree 24/2024/ND-CP. For medicine: No commercial drug contains the same active ingredient (or same ingredient but different concentration, dosage form, or administration route) that can be substituted.

For medical equipment: No equivalent replacement is available. 

The patient cannot be transferred to another facility due to: 

- Health conditions not permitting transfer. 

- The hospital being under quarantine per infectious disease laws.

- The hospital being a specialized facility. 

- Medicine/equipment cannot be transferred between facilities per regulations. 

- The prescribed medicine must align with the hospital’s expertise and be covered by health insurance nationwide.

The medicine/equipment must be within the health insurance coverage scope. 

Thus, if you have health insurance and the hospital lacks the prescribed medicine/equipment under the above conditions, you are eligible for direct reimbursement when purchasing externally. 

2. Reimbursement amount 

Per Article 4 of Circular 22/2024/TT-BYT, the Social Insurance Agency will reimburse based on: 

Medicine: Quantity and unit price on the pharmacy receipt. If there’s a capped reimbursement rate, it applies. 

Medical equipment: Quantity and unit price on the receipt, not exceeding the regulated price for that equipment. 

Notes: 

- The unit price must not exceed the latest contracted price at the hospital (if the medicine was previously bid on).

- If no prior bidding exists, reimbursement is based on (in order of priority):

• National centralized procurement/negotiated prices. 
• Local centralized procurement prices. 
• Lowest bid prices at public hospitals of the same level in the area (or in Hanoi/Ho Chi Minh City if applicable).

3. Required Documents and Procedures

*Documents for reimbursement (Article 28 of Decree 146/2018/ND-CP): 

- Copies (with originals for verification) of: Health insurance card, ID. 

- Discharge papers, medical examination slip, or health record for the relevant visit. 

- Receipts and related proof of purchase. 

Procedures (Article 29 of Decree 146/2018/ND-CP): 

- Submit the dossier to the district-level Social Insurance Agency where you reside. 

- The agency must: 

• Acknowledge receipt and guide supplementation if incomplete. 
• Process reimbursement within 40 days of receiving a complete dossier or provide a written explanation if denied.

The above is FDVN’s legal advice based on current regulations. We hope this information is helpful.

According to Tuấn Thi - FDVN Law Firm