CIRCULAR

AMENDING A NUMBER OF ARTICLES OF CIRCULAR NO. 35/2016/TT-BYT DATED SEPTEMBER 28, 2016 BY MINISTER OF HEALTH ON LIST OF MEDICAL SERVICES COVERED BY HEALTH INSURANCE, COINSURANCE PERCENTAGES AND COVERAGE THEREOF

Pursuant to the Law on Health Insurance No. 25/2008/QH12 dated November 14, 2008 amended by the Law No. 46/2014/QH13 dated June 13, 2014;

Pursuant to the Law on Medical Examination and Treatment No. 40/2009/QH12 dated November 23, 2009;

Pursuant to the Government’s Decree No. 75/2017/ND-CP dated June 20, 2017 on functions, duties, powers and organizational structure of the Ministry of Health;  

At the request of the Director General of the Department of Health Insurance;

The Minister of Health hereby promulgates a Circular amending a number of Articles of the Circular No. 35/2016/TT-BYT dated September 28, 2016 by the Minister of Health on list of medical services covered by health insurance, coinsurance percentages and coverage thereof.

Article 1. Amendments to a number of Articles and Clauses of Circular No. 35/2016/TT-BYT dated September 28, 2016 by Minister of Health on list of medical services covered by health insurance, coinsurance percentages and coverage thereof

...

...

...

a) Lists of technical qualifications related to medical services issued together with the Circular No. 43/2013/TT-BYT dated December 11, 2013 by the Minister of Health on providing for technical qualifications in the network of health facilities (hereinafter referred to as “Circular No. 43/2013/TT-BYT”); and the Circular No. 21/2017/TT-BYT dated May 10, 2017 by the Minister of Health amending list of medical procedures enclosed with Circular No. 43/2013/TT-BYT (hereinafter referred to as “Circular No. 21/2017/TT-BYT”);

b) List of surgeries and medical procedures issued together with the Circular No.50/2014/TT-BYT dated December 26, 2014 by the Minister of Health on classification of surgeries, medical procedures and personnel norms applied to operations and medical procedures (hereinafter referred to as “Circular No. 50/2014/TT-BYT”);

c) Medical services approved to be provided in health facilities by the Minister of Health but not yet included in Circular No. 43/2013/TT- BYT, Circular No.50/2014/TT-BYT or Circular No. 21/2017/TT-BYT.

2. Section 4 of List 1 - Medical services with specific coverage, coinsurance percentages and payout limits is amended as follows:

No.

Medical service/Medical service group

Coverage

Coinsurance percentages and payout limits

4

...

...

...

1. One of the following services:

a) Scan of the arterial system: cerebral arteries, aorta, thoracic/abdominal aorta, pulmonary arteries, bronchial arteries, mesenteric arteries, renal arteries, pelvic arteries, coronary arteries;

b) Scan of visceral arteries;

c) Brain/organ perfusion scan;

d) Scan of extremity arteries/veins;

dd) Scan of the heart and large blood vessels for anatomical assessment of the heart and relevant large blood vessels;

e) Staging and assessment of recurrence, metastasis and response to treatment for cancer for decision for surgery, chemotherapy, radiotherapy, targeted therapy, immunotherapy;

g) Simulation for radiotherapy treatment planning: brain tumors (brainstem and/or cerebellum), rectal cancer, prostate cancer, cervical cancer, metastatic spinal tumors;

h) 3D reconstruction of the airways;

...

...

...

The cost of the medical service is covered; in case of scans of at least two areas, an amount no higher than the cost of "full-body computed tomography” is covered.

2. Full-body scan for cancer staging or multiple trauma assessment

Diagnostic criteria for multiple trauma: the presence of two or more injuries rated severe according to trauma scoring systems, at least one of which is a severe respiratory, circulatory or central nervous system trauma that endangers the patient's life.

An amount equal to the cost of "full-body computed tomography” is covered.

3. Other cases.

An amount equal to the cost of "computed tomography with 1-32 slice(s)” is covered.

3. Section 5 of List 1 - Medical services with specific coverage, coinsurance percentages and payout limits is amended as follows:

No.

Medical service

...

...

...

Coinsurance percentages and payout limits

5

Computed tomography with at least 256 slices

1. Scan of coronary arteries in patients with heart rate of more than 70 bpm (after taking a heart rate slowing drug or in patients with contraindication to heart rate slowing drugs) or abnormal heart rhythms; congenital heart defects in children under 06 years of age; heart diseases in patients of at least 70 years of age.

The cost of the medical service is covered.

2. One of the following services:

a) Scan of the arterial system: cerebral arteries, aorta, thoracic/abdominal aorta, pulmonary arteries, bronchial arteries, mesenteric arteries, renal arteries, pelvic arteries, coronary arteries;

b) Scan of visceral arteries;

c) Brain/organ perfusion scan;

...

...

...

dd) Scan of the heart and large blood vessels for anatomical assessment of the heart and relevant large blood vessels;

e) Staging and assessment of recurrence, metastasis and response to treatment for cancer for decision for surgery, chemotherapy, radiotherapy, targeted therapy, immunotherapy;

g) Simulation for radiotherapy treatment planning: brain tumors (brainstem and/or cerebellum), rectal cancer, prostate cancer, cervical cancer, metastatic spinal tumors;

h) 3D reconstruction of the airways;

i) Chest radiography in patients with respiratory failure (able to hold breath for more than 10 seconds).

An amount equal to the cost of "computed tomography with 64-128 slices” is covered.

3. Full-body scan for cancer staging or multiple trauma assessment

Diagnostic criteria for multiple trauma: the presence of two or more injuries rated severe according to trauma scoring systems, at least one of which is a severe respiratory, circulatory or central nervous system trauma that endangers the patient's life.

An amount equal to the cost of "full-body computed tomography with 64-128 slices” is covered.

...

...

...

An amount equal to the cost of "computed tomography with 01-32 slice(s)” is covered.

4. Section 7 of List 1 - Medical services with specific coverage, coinsurance percentages and payout limits is amended as follows:

No.

Medical service

Coverage

Coinsurance percentages and payout limits

7.

PET/CT scan

1. Cancer diagnosis

...

...

...

b) Metastasis of unknown primary site.

The cost of the medical service in the first diagnosis is covered in lump sum

2. After cancer confirmation, other diagnosis methods could not determine the cancer stage, recurrence, metastasis or response to treatment for any of the following cases:

a) Pre-treatment determination: nasopharyngeal cancer, hypopharyngeal cancer, laryngeal cancer; non-small cell lung cancer; esophageal cancer; adenocarcinomas; colorectal cancer; breast cancer; cervical cancer; Lymphoma (Hodgkin or non-Hodgkin lymphoma);

a) Recurrence/metastasis determination: nasopharyngeal cancer, hypopharyngeal cancer, laryngeal cancer; non-small cell lung cancer; esophageal cancer; colorectal cancer; breast cancer; cervical cancer; ovarian cancer (when CA 125 level is higher than 35U/ml); Lymphoma (Hodgkin or non-Hodgkin lymphoma); thyroid cancer (when 131I scan is negative); prostate cancer (when PSA level is higher than 4ng/ml);

c) Assessment of response to treatment: hypopharyngeal cancer, laryngeal cancer; breast cancer; cervical cancer.

An amount equal to the cost of the medical service is covered 01 time every 12 month for 01 patient

3. After cancer confirmation, other diagnosis methods could not determine the cancer stage, recurrence, metastasis or response to treatment for any of the following cases: (1) Lymphoma (Hodgkin or non-Hodgkin lymphoma); (2) non-small cell lung cancer; (3) colorectal cancer; (4) esophageal cancer; (5) nasopharyngeal cancer.

An amount equal to the cost of the medical service is covered no more than 02 times within 12 months for 01 patient for the first 12 months after cancer confirmation.

...

...

...

The cost of the medical service is covered.

5. Use of PET/CT scans only for radiotherapy simulation.

An amount equal to the cost of CT simulation for radiotherapy is covered.

5. Section 66 of List 2 - Medical services with specific coverage is amended as follows:

No.

Medical service/Medical service group

Coverage

66

Coronary artery scan

...

...

...

a) Acute ST-elevation myocardial infarction;

b) Unstable angina;

c) Non-ST-elevation myocardial infarction;

d) Stable angina the symptoms of which are not satisfactorily controlled with optimal medical treatment;

dd) Post-CPR;

e) Recurrent angina after percutaneous coronary intervention or coronary artery bypass surgery;

g) Heart failure of unknown cause;

h) Patients with life-threatening arrhythmia (ventricular tachycardia, atrioventricular block);

i) Patients preparing to have heart/large blood vessel surgery, over 45 years of age for males or over 50 years of age for females; patients preparing to undergo an organ transplant;

...

...

...

6. Section 84 of List 2 - Medical services with specific coverage is amended as follows:

No.

Medical service/Medical service group

Coverage

84

HbA1c blood test for diabetes mellitus treatment regimen determination or treatment assessment

1. The cost of a HbA1c blood test is covered for diabetes mellitus patients who have not taken a HbA1c blood test to determine their treatment regimens within 90 (ninety) days.

2. The costs of the second test and subsequent tests for assessment of diabetes mellitus treatment taken at least once every 90 (ninety) days are covered.

7. Sections 87 and 88 are added to List 2 - Medical services with specific coverage as follows:

...

...

...

Medical service/Medical service group

Coverage

87

Quantitative detection of HBV DNA using Real-time PCR; quantitative detection of HBV DNA using automated systems

Indicated by doctors of health facilities with hepatitis treatment units for the following cases:

a) First test.

b) The costs of the first test and subsequent tests taken once every 90 (ninety) to 180 (one hundred eighty) days of the same testing method are covered.

Do not cover the costs of 02 testing methods for 01 patient within 01 treatment cycle.

88

...

...

...

Indicated by doctors of health facilities with hepatitis treatment units for the following cases:

a) First test;

b) The costs of the first test, the second test taken 4 weeks after the first test and subsequent tests taken once every 90 (ninety) to 180 (one hundred eighty) days of the same testing method are covered.

Do not cover the costs of 02 testing methods for 01 patient within 01 treatment cycle.

Article 2. Effect

1. This Circular comes into force from August 10, 2020.

2. Section 6 of List 1 - Medical services with specific coverage, coinsurance percentages and payout limits (Full-body computed tomography) is annulled.

Article 3. Transitional clauses

Costs of medical services covered by health insurance of the cases receiving such services prior to the effective date of this Circular and of patients admitted to hospital prior to the effective date of this Circular but discharged after the effective date of this Circular shall be covered in accordance with regulations of legislative documents promulgated prior to the effective date of this Circular.

...

...

...

In case the documents cited in this Circular are superseded or amended, the superseding or amended documents shall apply.

Article 5. Implementation

1. Head of Office of the Ministry of Health, Chief Inspector of the Ministry of Health, heads of affiliates of the Ministry of Health, Directors of Departments of Health, heads of healthcare units of other ministries and relevant units shall implement this Circular. 

2. Vietnam Social Security shall reimburse costs of medical services covered by health insurance according to regulations of laws on health insurance and this Circular.

During the implementation of this Circular, any difficulty arising should be reported to the Ministry of Health (Department of Health Insurance) in writing for consideration and resolution./.

P.P. THE MINISTER
THE DEPUTY MINISTER




Nguyen Truong Son

...

...

...

Thông tư 13/2020/TT-BYT sửa đổi Thông tư 35/2016/TT-BYT về Danh mục và tỷ lệ, điều kiện thanh toán đối với dịch vụ kỹ thuật y tế thuộc phạm vi được hưởng của người tham gia bảo hiểm y tế do Bộ trưởng Bộ Y tế ban hành