What are the regulations on health insurance benefits?

Pursuant to Article 22 of the 2014 Law on Health Insurance and the provisions of Article 14 of Decree 146/2018/ND-CP, the level of health insurance benefits will depend on the group of subjects participating in health insurance and whether the case of health insurance examination and treatment is in the right line or out of line.

1. Health insurance benefits in line

Health insurance benefits when right medical treatment as follows:

1.1. If you are in the group of subjects entitled to 100% of medical examination and treatment costs and there is no limit on the payment rate, you will not have to pay for services in the list of the Ministry of Health when you go to the initial medical examination and treatment facility or are referred to a higher level as prescribed by a doctor.

This group includes the following subjects: Revolutionary activists before January 1, 1945; Revolutionary activists from January 1, 1945 to the August 1945 uprising; Vietnamese heroic mothers; War invalids, people enjoying policies like war invalids, war invalids of type B, sick soldiers with a labor capacity reduction of 81% or more; War invalids, people enjoying policies like war invalids, war invalids of type B, sick soldiers when treating wounds, recurring diseases; Resistance activists infected with toxic chemicals with a labor capacity reduction rate of 81% or more; Children under 6 years old.

1.2. If you are in the group of subjects entitled to 100% of medical examination and treatment costs and have a payment rate limit applied, you will not have to pay for services in the list of the Ministry of Health when receiving medical examination and treatment at the initial medical examination and treatment facility or being referred to a higher level as prescribed by a doctor.

However, if you go to a different health facility without a doctor's prescription or in a non-emergency situation, you will have to pay 60% of the health care costs.

This group includes the following subjects: People with meritorious services to the Revolution as prescribed in the Ordinance on preferential treatment for people with meritorious services to the Revolution; Veterans who participated in the resistance war after April 30, 1975 and returned to the country as prescribed in Clauses 1, 2, 3 and 4, Article 2 of Decree 150/2006/ND-CP dated December 12, 2006; Veterans who participated in the resistance war after April 30, 1975 as prescribed in Clause 5, Article 2 of Decree 150/2006/ND-CP and in Clause 1, Article 1 of Decree 157/2016/ND-CP dated November 24, 2016; People in poor households according to income criteria, people in multidimensional poor households with health insurance deficiency as prescribed in Decision 59/2015/QD-TTg and other decisions of competent authorities amending, supplementing or replacing the poverty line applicable for each period.

1.3. If you are in the group of beneficiaries who are entitled to 95% to 40% of the cost of medical examination and treatment and are subject to a payment rate limit, you will have to pay a portion of the cost for services listed by the Ministry of Health when you receive medical examination and treatment at the initial medical examination and treatment facility or are transferred to a higher level as prescribed by a doctor. However, if you receive medical examination and treatment outside the prescribed level without a doctor's prescription or in non-emergency cases, you will have to pay 60% of the cost of medical examination and treatment.

This group includes the following subjects: Employees in agencies, organizations, and enterprises; Freelancers; Employers; People receiving pensions, social insurance benefits...

2. Out-of-network health insurance benefits

In case a person with a health insurance card goes to a medical facility that is not in the right line, and is then transferred to another medical facility by the receiving facility, the health insurance fund will pay for the medical examination and treatment costs according to the benefit level prescribed in Clause 3, Article 22 of the Law on Health Insurance. Specifically:

The payment level in case a person with a health insurance card goes to a medical facility not in the right line will be paid by the health insurance fund according to the benefit level of the health insurance card type at the following rate:

- At central hospitals, 40% of inpatient treatment costs;

- At provincial hospitals, 100% of inpatient treatment costs from January 1, 2021 nationwide;

- At district hospitals, 100% of medical examination and treatment costs will be covered from January 1, 2016.

In addition to the two typical cases of medical examination and treatment mentioned above, in some special cases as prescribed by law, health insurance participants who go to a medical examination and treatment outside the designated area will enjoy the same benefits as those in the designated area.

In case a participant belongs to many health insurance groups at the same time, he/she will enjoy health insurance benefits according to the group with the highest benefit level.

3. Will people with health insurance cards be covered by health insurance?

People with health insurance cards when going to medical examination and treatment at medical facilities will be supported with part or all of the cost of medical examination and treatment, helping to reduce the financial burden and help patients have better treatment conditions.

However, not all people with health insurance cards will have their hospital fees covered by health insurance when they go to the hospital (in-line or out-of-line).

Pursuant to Article 23 of the Law on Health Insurance 2008 (amended and supplemented in Clause 16, Article 1 of the Law on Health Insurance amended in 2014), there are 12 cases where people with health insurance cards are not entitled to health insurance even though they go to the right medical facility for examination and treatment, and the patient will have to pay all medical examination and treatment costs themselves.