Thông tư 24/2025/TT-BYT sửa đổi Thông tư 04/2017/TT-BYT tỷ lệ thanh toán vật tư y tế thuộc phạm vi bảo hiểm y tế

CIRCULAR

AMENDMENTS TO CERTAIN ARTICLES OF CIRCULAR NO. 04/2017/TT-BYT DATED APRIL 14, 2017 PROMULGATING THE SCHEDULE, RATES AND CONDITIONS OF REIMBURSEMENT OF COSTS OF MEDICAL SUPPLIES COVERED UNDER HEALTH INSURANCE SCHEME

Pursuant to the Law on Health Insurance 2008, as amended in 2014 and 2024;

Pursuant to Government's Decree No. 146/2018/ND-CP dated October 17, 2018 elaborating and providing guidance on measures to implement certain Articles of the Law on Health Insurance, as amended by Government’s Decree No. 75/2023/ND-CP dated October 19, 2023;

Pursuant to Government’s Decree No. 42/2025/ND-CP dated February 27, 2025 defining the functions, tasks, powers and organizational structure of the Ministry of Health of Vietnam;

At the request of the Director of the Health Insurance Department, Ministry of Health;

The Minister of Health hereby issues the Circular on amendments to certain articles of Circular No. 04/2017/TT-BYT dated April 14, 2017 promulgating the schedule, rates and conditions of reimbursement of costs of medical supplies covered under health insurance scheme.

Article 1. Amendments to certain articles of Circular No. 04/2017/TT-BYT dated April 14, 2017 promulgating the schedule, rates and conditions of reimbursement of costs of medical supplies covered under health insurance scheme

1. Article 1 is amended as follows:

“Article 1. List of medical equipment covered under health insurance scheme

The list of medical equipment covered under health insurance scheme is specified in Appendix 01 issued with this Circular and serves as the basis for the reimbursement of health insurance-covered medical equipment costs from the health insurance fund in accordance with laws on health insurance.”.

2. Clause 3 Article 2 is amended as follows:

“3. In the case where a private health facility does not apply bidding laws to purchase medical equipment, such health facility shall make a list of medical equipment exempt from the costs of medical services, medical examination services, and hospital stay using Form No. 03 issued with this Circular and submit it to social insurance authorities.”.

3. Points b and Clause 2 Article 3 are amended as follows:

a) Point b is amended as follows:

“b) The amount of reimbursement of total cost of medical equipment in each use of medical service shall not exceed 45 months’ statutory pay rate.

This regulation shall not apply to medical equipment for which rates of reimbursement are prescribed in the 5 ^th column of the Appendix 01 attached hereto:

Example 1: The amount of reimbursement of total cost of medical equipment for a single use of medical services when the statutory pay rate is VND 2.340.000 shall be calculated as follows:

- If the patient is a health insurance participant entitled to 100% coverage for the medical care costs: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as 45 x 100% x 2.340.000 = VND 105.300.000;

- If the patient is a health insurance participant entitled to 95% coverage for the medical care costs whose accumulated consecutive period of health insurance participation is under 5 years: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as 45 x 95% x 2.340.000 = VND 100.035.000;

- If the patient is a health insurance participant entitled to 95% coverage for the medical care costs whose accumulated consecutive period of health insurance participation is more than 5 years:

+ In cases where the patient has not yet paid the co-payment for medical care costs within a year till the date of use of medical services: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as 45 x 95% x 2.340.000 = VND 100.035.000;

+ In cases where the patient has paid the co-payment for medical care costs up incurred within a year till the date of use of medical services of which the amount has reached the equivalent of 6 months' statutory pay rate: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as 45 months’ statutory pay rate = VND 105.300.000;

- If the patient is a health insurance participant entitled to 80% coverage for the medical care costs whose accumulated consecutive period of health insurance participation is more than 5 years: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as 45 x 80% x 2.340.000 = VND 84.240.000;

- If the patient is a health insurance participant entitled to 80% coverage for the medical care costs whose accumulated consecutive period of health insurance participation is more than 5 years:

+ In cases where the patient has not yet paid the co-payment for medical care costs within a year till the date of use of medical services: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as (45 x 80% x 2.340.000) + (45 x 20% - 6) x 2.340.000 = VND 91.260.000;

+ In cases where the patient has paid the co-payment for medical care costs up incurred within a year till the date of use of medical services of which the amount has reached the equivalent of 6 months' statutory pay rate: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as 45 months’ statutory pay rate = VND 105.300.000.

Example 2: (In cases where the total cost of medical equipment exceeds 45 month’s statutory pay rate): When the statutory pay rate is VND 2.340.000, the patient is provided with 01 medical device A and 02 medical devices B in a single use of medical services. If the purchase price of item A is VND 72,000,000, with the health insurance-covered cost specified in the 5 ^th column of Appendix 01 attached hereto is VND 70.000.000; the purchase price of item B is VND 20.000.000, without any health insurance-covered cost specified in the 5 ^th column of Appendix 01 attached hereto;

the total cost of medical equipment for the patient (where medical device A is calculated based on the specified health insurance-covered cost specified in the 5 ^th column of Appendix 01 attached hereto, and medical device B is calculated based on the purchase price) for a single use shall be determined as 70.000.000 x 1 + 20.000.000 x 2 = VND 110.000.000. As this cost exceeds 45 month’s statutory pay rate (VND 105,300,000), the health insurance fund shall reimbursement the total cost of medical equipment for patients falling under different coverage levels as the total reimbursement for medical equipment in Example 1 in point b of this Clause.

Example 3: (In cases where the total cost of medical equipment is less than 45 month’s statutory pay rate): The patient is provided with 01 medical device A, 02 medical devices B and 03 medical devices C in a single use of medical services.

If the purchase price of item A is VND 72,000,000, with the health insurance-covered cost specified in the 5th column of Appendix 01 attached hereto is VND 70.000.000; the purchase price of item B is VND 10.000.000, without any health insurance-covered cost specified in the 5th column of Appendix 01 attached hereto; the purchase price of item C is VND 4.000.000, without any health insurance-covered cost specified in the 5th column of Appendix 01 attached hereto;

the total cost of medical equipment for the patient (where medical device A is calculated based on the specified health insurance-covered cost specified in the 5th column of Appendix 01 attached hereto, and medical device B is calculated based on the purchase price) for a single use shall be determined as 70.000.000 x 1 + 10.000.000 x 2 + 4.000.000 x 3 = VND 102.000.000. As this cost is less than 45 months' statutory pay rate (VND 105.300.000), the health insurance fund shall pay the total cost of medical equipment for the patient as follows:

- If the patient is a health insurance participant entitled to 100% coverage for of the medical care cost: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as 102.000.000 x 100% = VND 102.000.000;

- If the patient is a health insurance participant entitled to 95% coverage for the medical care costs whose accumulated consecutive period of health insurance participation is more than 5 years: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as 102.000.000 x 95% = VND 96.900.000;

- If the patient is a health insurance participant entitled to 95% coverage for the medical care costs whose accumulated consecutive period of health insurance participation is at least 5 years:

+ In cases where the patient has not yet paid the co-payment for medical care costs within a year till the date of use of medical services: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as 102.000.000 x 95% = VND 96.900.000;

+ In cases where the patient has paid the co-payment for medical care costs up incurred within a year till the date of use of medical services of which the amount has reached the equivalent of 6 months' statutory pay rate: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as VND 102.000.000;

- If the patient is a health insurance participant entitled to 80% coverage for the medical care costs whose accumulated consecutive period of health insurance participation is more than 5 years: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as 102.000.000 x 80% = VND 81.600.000;

- If the patient is a health insurance participant entitled to 80% coverage for the medical care costs whose accumulated consecutive period of health insurance participation is at least 5 years:

+ In cases where the patient has not yet paid the co-payment for medical care costs within a year till the date of use of medical services: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as (102.000.000 x 80%) + (102.000.000 x 20% - 6 x 2.340.000) = VND 87.960.000;

+ In cases where the patient has paid the co-payment for medical care costs up incurred within a year till the date of use of medical services of which the amount has reached the equivalent of 6 months' statutory pay rate: the amount of reimbursement of total cost of medical equipment for a single use of medical services by the patient shall be determined as VND 102.000.000;

b) Point c is amended as follows:

“c) For medical service of drug-eluting stent placement in the coronary artery that require the use of more than one stent, the total cost of medical equipment includes the first stent and other medical equipment for a single use of medical services (according to reimbursement guidelines in point b Clause 2 of this Article), half (1/2) of the cost for the second stent based on the purchase price of the health facility which does not exceed VND 18.000.000, and one-third (1/3) of the cost for the third and fourth stents based on the purchase price of the health facility which does not exceed VND 12.000.000 for each stent.

Example: Drug-eluting stent A was purchased by a health facility at the price of VND 40.000.000; the amount of reimbursement of cost of a drug-eluting stent specified in the 5 ^th column of Appendix I attached hereto is VND 36.000.000. The patient was admitted to this healthcare facility to be provided with the medical service of placing 05 drug-eluting stents A. The cost of other medical equipment excluding the stents, which has not been included in the cost of medical service, medical care service, hospital stay per day or episode of care (hereinafter referred to as “other medical equipment”) is VND 50.000.000. The amount of reimbursement for these other medical equipment costs are not specified in the 5 ^th column of Appendix I attached hereto.

- If the patient is a health insurance participant entitled to 100% coverage for the medical care costs, the reimbursement for the total cost of medical equipment for a single use of medical services by the patient shall be determined as VND 105.300.000 according to Example 1 in point b Clause 2 Article 3 hereof. The total cost of 01 drug-eluting stent A calculated based on the amount of reimbursement specified in the 5 ^th column of Appendix I attached hereto and other medical equipment is 36.000.000 + 50.000.000 = VND 86.000.000; which is less than VND 105.300.000. The health insurance fund shall reimburse the patient: (i) VND 86.000.000 for the first stent and other medical supplies; (ii) VND 18.000.000 for the second stent; (iii) VND 12.000.000 per stent for the third and fourth stents; (iv) and the fifth stent shall not be reimbursed.

Therefore, the health insurance fund shall pay the total cost of medical equipment for a single use of medical services by the patient as: 86.000.000 + 1 x (1/2 x 36.000.000) ⁺ 2 x (1/3 x 36.000.000) = VND 128.000.000

- If the patient is a health insurance participant entitled to 80% coverage for the medical care costs whose accumulated consecutive period of health insurance participation is more than 5 years, the reimbursement for the total cost of medical equipment for a single use of medical services by the patient shall be determined as VND 84.240.000 according to Example 1 in point b of this Clause. The total cost of 01 drug-eluting stent A calculated based on the amount of reimbursement specified in the 5th column of Appendix I attached hereto and other medical equipment is 36.000.000 + 50.000.000 = VND 86.000.000; which is higher than VND 84.240.000.

Therefore, the health insurance fund shall reimburse the total cost of medical equipment for a single use of medical services by the patient as: 84.240.000 + 1 x (1/2 x 36.000.000) + 2 x (1/3 x 36.000.000) = VND 126.240.000

4. Clause 4 Article 4 is amended as follows:

“4. In respect of medical equipment of which the measurement unit is “set”, the health insurance fund shall make its reimbursement as follows:

a) If all components of the “set” are entirely used: full payment for the whole set shall be made;

b) If one or several components of the “set” are used, the full payment for the whole set shall be made in the event that the rest of components of the "set” is unusable. Health facilities shall take an inventory of unusable components and notify this in writing to health insurance authorities;

c) If one or several components of the “set” are used and the rest of components of the "set” is usable, the reimbursement for each used component at its predetermined price shall be made.”.

5. Some Clauses of Article 6 are amended as follows:

a) Clause 1 is amended as follows:

“1. The Heath Insurance Department - Ministry of Health shall:

a) Organize and supervise the implementation of this Circular nationwide;

b) Lead and cooperate with relevant agencies to address any issues arising during the implementation process; update the to propose amendments to the list of medical equipment in Appendix 01 issued with this Circular.”.

b) Point c is added after point b Clause 2 as follows:

“c) Promptly provide complete data and documents related to the reimbursement of health insurance for medical costs to the Ministry of Finance to develop and update the list of medical equipment.”;

c) Point c is added after point b Clause 3 as follows:

“c) Direct health facilities in the area to establish a list of medical equipment used at the facility in accordance with this Circular and implementing solutions to ensure the timely and adequate supply of medical equipment to ensure quality, meet treatment needs, and ensure the rights of health insurance participants;”

d) Clause 6 is added after Clause 5 as follows:

“6. Based on the actual operational needs, health facilities, centralized procurement units, and price negotiation units shall formulate the contractor selection plan and conduct bidding for procurement of medical equipment as a set or components of a set to align with the usage at the facility, avoiding wastage.”

6. Amendments to the list of medical equipment covered under health insurance scheme specified in Appendix 01 issued with Circular No. 04/2017/TT-BYT as follows:

a) Medical equipment No. 31, 153, 183, 195, 228, 279, 304, and 330 are amended as follows:

b) The following medical equipment is added:

7. The phrase “vật tư y tế” (“medical supplies”) and the phrase “trang thiết bị y tế” (“medical equipment and supplies”) are replaced with the phrase “thiết bị y tế” (“medical equipment”) in all articles, clauses, points, and appendices of Circular No. 04/2017/TT-BYT.

Article 2. Implementation

1. This Circular comes into force from September 01, 2025.

2. Clause 6 Article 3 and the phrase “Không thanh toán riêng” (“No separate reimbursement”) in the column "Notes" of Appendix 01 issued with Circular No. 04/2017/TT-BYT are annulled.

Article 3. Transition clauses

1. Supplies that are not medical devices but listed in Appendix 01 issued with Circular No. 04/2017/TT-BYT shall be subject to the provisions of Circular No. 04/2017/TT-BYT and this Circular until there are regulations on reimbursement for supplies of the Minister of Health, except for regulations on marketing authorization.

2. Patients who are health insurance participants admitted for inpatient or day treatment before the effective date of this Circular and completed their inpatient or day treatment (discharged from the hospital) from the effective date of this Circular shall comply with the provisions of this Circular for the entire treatment period.

Any difficulties or proposals to amend or supplement that arise during implementation must be reported to the Ministry of Health (Health Insurance Department) for consideration and settlement./.