Arrangements for Reimbursement/ Direct Payment of Medical Expenses

Reimbursement of Medical Expenses

Notwithstanding the comprehensive scope of services provided by the Hospital Authority (HA), there may be occasions where the required drugs/ equipment/ services which form an essential part of the medical treatment as prescribed by the attending HA doctor on medical grounds are either chargeable by HA, or not available in HA. Under such circumstances, a civil service eligible person (CSEP) may procure them from HA, or from outside only when the required drugs/ equipment/ services are not available in HA, and then apply to the Department of Health (DH) for reimbursement of medical expenses or direct payment in respect of specified items.

A summary of the coverage of the reimbursement programme and the relevant application form is provided below:

Reimbursable Note: Must be prescribed on medical grounds		Not reimbursable
Through direct payment from DH to HA	Through subsequent reimbursement
Drugs Drugs on HA’s self-financed items list and available at the pharmacy of the attending HA facility [use Application FORM A] Services/equipment Specified services/equipment provided by HA [use Application FORM B]	Drugs Drugs not available at the pharmacy of the attending HA facility [use Application FORM B] Services/equipment Services/equipment other than those covered under the direct payment arrangement (i.e. direct payment from DH to HA) [use Application FORM B]	Drugs/services/equipment not prescribed on medical grounds (such as lifestyle drugs, including but not limited to those listed) Drugs available at the attending HA facility but procured by the patient outside Services/equipment available at HA but procured by the patient outside HA

For reimbursement of expenses on medical equipment, our policy is that unless the attending HA doctor has certified that a specific or a more sophisticated model of the equipment is required, only the cost of the basic model will be reimbursable.  Specifically, for Continuous Positive Airway Pressure machines, please refer to the detailed note setting out the reimbursement arrangements, including the maximum rate for a basic model.

The reimbursement programme is also applicable in cases where an attending DH doctor prescribes drugs which form an essential part of the medical treatment to the CSEP on medical grounds and the drugs are not available in the pharmacy of the attending DH clinic. For such cases, the civil servant or pensioner concerned may apply to DH for reimbursement of medical expenses incurred on the drugs. The application FORM B is also applicable for this purpose.

Application for Direct Payment of Medical Expenses from DH on Drugs Provided by HA

The application FORM A should be used for applying for direct payment arrangement for drugs available at the pharmacy of the attending HA facility. Subject to the compliance of the criteria, CSEPs need not pay out-of-pocket for any drugs on HA’s self-financed items list (except lifestyle items) prescribed on medical grounds and available at the pharmacy of the attending HA facility. Instead, DH will settle the payment for drugs with HA direct.

The stock of drugs varies from facility to facility under HA. If the prescribed drug(s) shown in the attending HA doctor’s prescription is/are available from the pharmacy of the attending HA facility, CSEPs must obtain the drugs from that pharmacy. In such cases, DH will not arrange reimbursement to any CSEP who buys the prescribed drug from an outside pharmacy.

The CSEP will present the drug prescription obtained from the attending HA doctor to the pharmacy at the attending HA facility to obtain an invoice. For hospital in-patients, invoice(s) will be provided by ward staff. The duly completed FORM A together with the invoice issued by the pharmacy should be submitted by the CSEP to the shroff office of the attending HA facility. Upon checking the patient’s eligibility for civil service medical benefits, the shroff will issue a receipt to the CSEP for presenting to the ward/ pharmacy in order to obtain the prescribed drugs. The CSEP will not be required to make any payment. It should be noted that the CSEP will no longer be provided with an invoice for retention.

For each episode of hospitalisation in the same hospital, a CSEP in-patient is only required to submit one application. For CSEPs using outpatient services, including patients who have been discharged from hospital, a fresh application should be submitted for each round of prescription. The CSEP attending the medical consultation is advised to bring along a FORM A, duly completed and signed by the applicant (i.e. civil servant or pensioner), for use if necessary.

Please refer to the flow chart for the steps for applying for direct payment from DH for drugs provided by the pharmacy at the attending HA facility.  Separately, please note the salient points for application for direct payment using FORM A.

Application for Reimbursement / Direct Payment of Medical Expenses (except drugs provided by the HA)

The application FORM B should be used for applying for–

1. direct payment of medical expenses for specified equipment/services provided by HA;


2. reimbursement of medical expenses for other chargeable equipment/services provided by/through HA; and


3. reimbursement of medical expenses for drugs/equipment/services not available at HA.

1. Direct payment of medical expenses from DH for specified equipment/ services provided by HA
   
   Provided that the equipment / services are prescribed on medical grounds, CSEPs are also not required to pay out-of-pocket for the following equipment / services provided by HA which are covered under the direct payment arrangement:
   1. percutaneous transluminal coronary angioplasty (PTCA) cases;
   2. intraocular lens procedures;
   3. non-PTCA consumables for interventional cardiology; and
   4. positron emission tomography (PET) service.

   Unless otherwise advised by the attending HA facility concerned, the completed FORM B should be submitted to the shroff office of the attending HA facility before the equipment/service is provided.

2. Reimbursement of medical expenses for other chargeable equipment/services provided by/through HA, and
3. Reimbursement of medical expenses for drugs/equipment/services not available at HA
   
   For reimbursement of medical expenses for other chargeable equipment/services provided by/through HA and for drugs/equipment/services not available at HA, applicants should complete and submit the original application FORM B and supporting documents to the Medical Reimbursement Section, Finance and Supplies Division of DH (Unit 1107-1108, 11/F, 248 Queen’s Road East, Wan Chai, Hong Kong) (including original itemised bill/receipt(s), photocopy of the drug prescription issued by the HA attending doctor and any other relevant documents) within three months of procurement of the item(s).
   
   Please refer to the flow chart for the steps for applying for direct payment or reimbursement using FORM B.  Separately, please note the salient points for application for reimbursement/ direct payment of medical expenses using FORM B.
   
   Items that are not reimbursable
   
   CSEPs should note that no reimbursement will be provided in the following situations -
   1. the drugs / equipment / services are not prescribed on medical grounds (e.g. lifestyle drugs);
   2. the drugs procured from outside are available at the pharmacy of the attending HA facility (regardless of whether the drugs are chargeable by HA), even in cases of emergency;
   3. the equipment / services procured from outside are available in HA (regardless of whether the equipment / services are chargeable by HA), even in cases of emergency and irrespective of whether the attending doctor has provided medical certification;
   4. drugs / equipment / services are procured from private facilities on the CSEP’s own accord, even in cases of emergency; and/or
   5. medical consultation, drugs, equipment and/or services pursuant to a consultation with an individual HA doctor or a member of the teaching staff of a university in the CSEP’s capacity as the attending doctor’s private patient, even in cases of emergency.

Application Forms

CSEPs may download the following forms for use:

Form A : Application for Direct Payment of Medical Expenses on Drugs Provided by the Hospital Authority (PDF Format)

Form B : Application for Reimbursement / Direct Payment of Medical Expenses (except drugs provided by the Hospital Authority) (PDF Format)

Civil servants may approach the administrative unit of their bureau/department for copies of the forms.  Pensioners who require forms may contact the Pensioner Services Unit of Civil Service Bureau by phone (at 2810 3850) or by email (csbpen@csb.gov.hk).  Separately, a limited quantity of the application forms is available at the shroff of major HA hospitals.

For enquiries concerning processing of applications and related payment and accounting arrangements, please contact the Medical Reimbursement Section, Finance and Supplies Division of DH (at 3107 3415 or 3107 3417; or by email at sco_mr@dh.gov.hk).

Reimbursement of Co-payment under HA's Pilot Public-Private Partnership Scheme in Cataract Surgeries

HA has launched a pilot public-private partnership scheme in cataract surgeries. Patients with the longest waiting time on HA central waiting list and suitable for local anaesthesia cataract surgeries will be invited to participate in the scheme on a voluntary basis. Under the scheme, patients may choose to have the cataract surgery performed by a private ophthalmologist. CSEPs will also be invited by HA to participate in the scheme as other public patients, in accordance with the selection criteria. If they agree to participate in the pilot scheme, they will be subject to co-payment of not more than $8,000 to the private ophthalmologist, the latter will receive the fixed subsidy of $5,000 from HA. CSEPs may apply to DH for reimbursement of co-payment. Details of the pilot scheme and the list of private ophthalmologists participating in this scheme are available at the HA website at www3.ha.org.hk/ppp/csp.aspx. CSEPs may refer to the detailed note setting out the arrangement for reimbursement of co-payment under the scheme.