In 2023, what levels of health insurance will be paid for people who go to medical examination and treatment at inappropriate-level healthcare establishments in Vietnam?

In 2023, what levels of health insurance will be paid for people who go to medical examination and treatment at inappropriate-level healthcare establishments in Vietnam?

In Clause 3, Article 22 of the Law on Health Insurance 2008 as amended by Clause 15, Article 1 of the Law on Health Insurance Amendment 2014, there are provisions on the level of health insurance benefits as follows:

Health insurance coverage

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3. In case any card holder goes to a hospital different from the registered hospital except for the insured prescribed in Clause 1 this Article, his or her costs shall be covered by the health insurance fund according to the benefit levels prescribed in Clause 1 this Article as follows:

a) 40% of the inpatient treatment expenditures at the central hospitals.

b) 60% of the inpatient treatment expenditures at the provincial hospitals from the effective date of this Law to December 31, 2020; total inpatient treatment costs from January 01, 2021 at all hospitals in Vietnam.

c) 70% of the medical examination and treatment expenditures at the district hospitals from the effective date of this Law to December 31, 2015; total medical examination and treatment expenditures from January 01, 2016.

Thus, if you go to inappropriate-level healthcare establishment by yourself, your health insurance will be paid as follows:

- At the central hospital, 40% of inpatient treatment costs;

- At provincial hospitals, 100% of inpatient treatment costs;

- At district hospitals, 100% of medical examination and treatment costs.

Note: The benefits paid by the health insurance fund above do not apply to ethnic minorities and people from poor households participating in health insurance who are living in areas with difficult socio-economic, areas with extremely difficult socio-economic conditions;

For participants of health insurance who are living in island communes or island districts, when they go to the wrong medical examination and treatment by themselves, the health insurance fund will pay for medical examination and treatment expenses for district hospitals, for inpatient treatment for patients. with hospitals at provincial and central levels and with benefits.

What are 13 cases not entitled to health insurance in 2023 in Vietnam?

In Article 23 of the Law on Health Insurance 2008 as amended by Clause 16, Article 1 of the Law on Health Insurance Amendment 2014, there are provisions on cases not entitled to health insurance as follows:

1. Cases specified in Clause 1 of Article 21 in which costs have been paid by the state budget.

2. Convalescence at sanatoria or convalescence establishments.

3. Medical check-up.

4. Prenatal tests and diagnosis for non-treatment purposes.

5. Use of obstetric supportive techniques, family planning services or abortion services, except for cases of discontinuation of pregnancy due to fetal or maternal diseases.

6. Use of aesthetic services.

7. Treatment of squint, myopia and eye refraction defect except for the children under age 6.

8. Use of prostheses including artificial limbs, eyes, teeth, glasses, hearing aids or movement aids in medical examination, treatment and function rehabilitation.

9. Medical examination, treatment and functional rehabilitation in case of disasters.

10. Medical examination and treatment for addiction to drugs, alcohol or other habit-forming substances.

11. Medical assessment, forensic examination, forensic mental examination.

12. Participation in clinical trials or scientific research.

In 2023, how much is health insurance premium when going for medical examination and treatment in Vietnam?

In Article 14 of Decree 146/2018/ND-CP as amended by Clause 1, Article 183 of Decree 131/2021/ND-CP, it stipulates that when receiving medical examination and treatment services in accordance with Article 26, 27 and 28 in the Law on Health Insurance; clause 4 and 5 of Article 22 in the Law on Health Insurance, health insurance policyholders shall be entitled to the health insurance fund’s coverage of permissible medical costs at the following rates:

a) 100% of medical costs paid by the policyholders prescribed in clause 3, 4, 8, 9, 11 and 17 of Article 3 herein;

b) 100% of medical examination and treatment costs and no limit on payment rates for drugs, chemicals, medical supplies and technical services as prescribed by the Minister of Health for:

- People who were active in the revolution before January 1, 1945;

- People who were active in the revolution from January 1, 1945 to the day of the August uprising, 1945;

- Vietnamese heroic mothers;

- War invalids, including class B war invalids recognized before December 31, 1993, who enjoy the same policy as war invalids with an injury rate of 81% or more;

- Patients with an injury rate of 81% or more;

- Resistance activists infected with toxic chemicals have an injury rate of 81% or more;

- War invalids, including class B war invalids recognized before December 31, 1993, who enjoy the same policy as wounded and sick soldiers when they are treated for recurrent wounds or illnesses;

- Children under 6 years old.

c) 100% of healthcare service costs at the commune level;

d) 100% of medical service costs if the cost of each medical examination or treatment accounts for less than 15% of the base pay rate;

dd) 100% of medical costs if a patient participates in the health insurance for a consecutive period of at least 5 years and has made the co-payment of medical costs in a year which is greater than total base pay amount received during 6 months, except self-referrals to inappropriate-level healthcare establishments;

e) 95% of medical costs paid by the policyholders prescribed in clause 1 of Article 2, clause 12 of Article 3, and clause 1 and 2 of Article 4 herein;

g) 80% of medical costs paid by others;

h) With respect to patients who are diagnosed, given therapeutic indications and referred to commune-level healthcare establishments for their management, monitoring and dispensing of medicines by higher-level healthcare establishments under regulations of the Minister of Health, their medical costs shall be paid by the health insurance fund within their scope of insurance benefit entitlement and contribution rates as prescribed in point a, b, dd, e ad g of clause 1 of this Article.

Best Regards!