The VSS has made numerous proposals for the revised health insurance law to ensure the rights and interests of health insurance participants and address the shortcomings and obstacles of current regulations.

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Making amendments and supplements to the definition and scope of health insurance review is an urgent need that arises from practical requirements.

According to Clause 2, Article 29 of Law No 46/2014/QH13 dated June 13, 2014 on amending and supplementing a number of articles of the Law on Health Insurance (current Law on Health Insurance), health insurance review performed by the VSS includes verifying the procedures for health insurance examination and treatment; checking and evaluating the prescription of treatment, use of drugs, chemicals, medical supplies, equipment, and medical technical services for patients; checking and determining the costs of health insurance examination and treatment.

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Many years of implementation revealed that the regulation is no longer practical and causes numerous issues for both the agencies and healthcare facilities.

In reality, medical facilities are specialised agencies with a team of well-trained doctors, the most in-depth medical expertise and qualifications, and are also the ones who directly examine, treat, and understand the patient's conditions.

Assigning social security offices with the responsibility of verifying the prescriptions for the use of drugs, medical supplies, technical services provided by doctors and medical staff is not aligned with the expertise of health insurance assessors.

In many cases, to evaluate treatment prescriptions, it is necessary to have a medical professional council.

The human resources for health insurance review are trained from different majors such as medicine, pharmacy, economics, finance. There is now a shortage of this force.

Those issues led to disagreements between the social security offices and medical facilities on assessment results, delaying the settlement of health insurance claims and affecting the operation of healthcare facilities.

To ensure the benefits of health insurance and its effectiveness, feasibility, and compliance with current regulations, the VSS has proposed revising the definition and scope of health insurance assessment in the draft revised Law on Health Insurance.

The proposal suggests that health insurance assessments focus on verifying, reviewing and comparing health insurance claims submitted by healthcare facilities and insured individuals against the relevant legal provisions to determine which expenses are covered by the health insurance fund. It also calls for timely recommendations and warnings to healthcare facilities regarding unreasonable costs to allow adjustments.

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This proposal aligns with the government's responsibilities assigned to social security offices, providing detailed guidance on implementing certain provisions of the Law on Health Insurance.

The proposed revisions to health insurance assessment definitions and content are necessary and urgent.

They aim to address the limitations and challenges of the current law and clarify responsibilities among all parties involved, ensuring feasibility in implementation.

The changes will benefit not only social security offices and healthcare facilities but also State health management agencies and the rights of insured patients.

First, for insured patients, the proposed revisions will not reduce their benefits or affect their health insurance-covered treatments, as the verification process will occur after treatment is completed. Patients will continue to receive appropriate medical evaluations and treatments.

Second, for social security offices, the duties of health insurance assessors will remain the same, involving the verification and review of claims against legal regulations. This ensures that healthcare costs within the scope of the health insurance fund are properly covered, protecting the rights of insured patients.

In recent years, the number of health insurance claims has increased significantly, but the number of health insurance assessors has remained the same due to VSS's strict adherence to downsizing policies set by the government.

In the coming time, the social security offices will continue to strengthen the implementation of health insurance assessment to effectively manage and use the health insurance fund, in accordance with the provisions of law.

This will serve as a basis for assessment agreement between the social security offices and the health insurance-covered medical examination and treatment facilities. It will address the slow payment and settlement of health insurance medical examination and treatment costs and protect the rights of health insurance participants.

Third, for healthcare facilities, the revised definition of health insurance assessments will address inconsistencies between medical expertise at healthcare facilities and social insurance agencies - reducing issues related to policy and legal compliance.

Fourth, State health management agencies will not have to undertake additional tasks, as the oversight of treatment prescriptions, drugs, and service quality will remain under their jurisdiction, as outlined in the Law on Medical Examination and Treatment. The revised law will clearly define responsibilities among all parties.

In addition to proposing changes to health insurance assessment definitions, the VSS has also suggested various measures to protect the rights of insured individuals.

These have been largely incorporated into the draft amendments to the Law on Health Insurance.

Proposed changes include allowing individuals with serious or life-threatening illnesses to receive treatment at out-of-network facilities without needing a referral, expanding health insurance coverage for eye conditions such as strabismus and refractive errors for individuals under 18 years old (currently limited to those under six years old).

The draft amendments to the Law on Health Insurance are currently undergoing consultation with ministries, sectors and experts, with plans to be submitted to the National Assembly in October 2024./.