Mr. Ha The in Phu Tho is a person with particularly severe disabilities, unable to serve himself. Although he has been issued a health insurance card (HI), every time he goes for examination and treatment, he almost still has to buy medicine himself. Even some solutions such as protein and glucose are not issued by the hospital.
Faced with this reality, Mr. The wondered what he had to do to fully enjoy his health insurance benefits. At the same time, having to travel many times just to apply for a referral also causes large costs, especially for people with severe disabilities. He asked: is the current regulation on medical examination and treatment at the right level still appropriate?
Answering this question, Phu Tho Provincial Social Insurance said that according to point c, clause 1, Article 21 of the Health Insurance Law No. 51/2024/QH15, health insurance participants are paid by the health insurance fund for the use of medical technical services, medicines, medical equipment, blood, blood products, medical gas, supplies, tools, and chemicals used in medical examination and treatment, if within the scope of payment of the health insurance fund.
This means that not all types of drugs or medical supplies are covered by health insurance. Only drugs on the payment list of the health insurance fund are eligible for patients according to their level of benefits. Currently, this list is being applied according to Consolidated Document No. 15/VBHN-BYT dated December 16, 2024 of the Ministry of Health, stipulating the list, rates and conditions for payment for pharmaceuticals, biological products, radioactive drugs and markers within the scope of benefits of health insurance participants.
Regarding the issue of transferring health insurance medical examination and treatment, Phu Tho Provincial Social Insurance said that Clause 2, Article 9 of Circular No. 01/2025/TT-BYT has clearly stipulated cases of transferring patients between health insurance medical examination and treatment facilities in the correct order. Including cases of transfer from the initial level to the basic level, from the basic level to the specialized level when exceeding professional capacity, or transferring chronic patients, long-term treatment according to regulations. Notably, for people with chronic diseases or requiring long-term treatment according to the prescribed list, the medical examination and treatment facility transfer slip is valid for 1 year from the date of signing.
In addition, Circular No. 01/2025/TT-BYT also stipulates some cases where health insurance participants do not have to carry out procedures to transfer to medical examination and treatment facilities. Specifically, cases of rare diseases, critical illnesses, diseases requiring surgery or using high technology according to the list issued by the Ministry of Health. People in this category are entitled to medical examination and treatment at the right level without having to carry out referral procedures as usual.
Thus, according to Phu Tho Provincial Social Insurance, people with health insurance cards are only reimbursed by the insurance fund for drugs, supplies, and services on the list of beneficiaries. With referrals, the law currently also has separate regulations for some groups of chronic diseases, long-term treatment or severe diseases, and critical illnesses to reduce procedures for patients.
In Mr. Ha The's case, to ensure his rights, it is necessary to specifically compare the type of medicine, intravenous fluid or medical supplies that the hospital requests to buy themselves to see if they are on the health insurance payment list or not. At the same time, it is also necessary to see if his condition belongs to the group eligible for long-term referral slips or is not subject to referral according to current regulations.
