Rights of Participants in Health Insurance

The benefits for participants of health insurance (BHYT) are stipulated in Official Dispatch 4996/BHXH-CSYT of 2018 as follows:

3.1. Persons with BHYT cards who seek medical examination and treatment (KCB) from December 1, 2018, receive outpatient or inpatient treatment before December 1, 2018, but complete outpatient treatment or discharge from the hospital from December 1, 2018, shall be reimbursed by the BHYT fund within the scope of BHYT benefits stipulated in Article 21 of the Law on Health Insurance and reimbursement levels as regulated in Clauses 2, 3, 4, 5, and 6, Article 22 of the Law on Health Insurance and Article 14 of Decree No. 146/2018/ND-CP.

3.2. In cases where persons with BHYT cards arbitrarily choose a KCB facility (visit a KCB establishment not initially registered on their BHYT card, except for cases specified in Clause 4, Article 22 of the Law on Health Insurance), and are subsequently referred by the attending KCB facility, the BHYT fund pays for KCB costs at the reimbursement level stipulated in Clause 3, Article 22 of the Law on Health Insurance, except for the following cases: emergencies; inpatient treatment where disease detection is outside the specialty of the KCB facility; disease progression beyond the professional capability of the KCB facility.

Provincial Social Security requests KCB facilities to note the reasons for eligible referrals as "Detection of diseases outside the specialty scope” or “Disease progression beyond the professional capability of the KCB facility” (recorded after the section: Eligibility for referral in the Referral Letter) for the aforementioned referred cases. Additionally, KCB facilities receiving referred patients should verify on the Health Insurance Review Information Portal to determine if patients were eligible for correct BHYT at the referring KCB facility as a basis for resolving BHYT benefits issues accordingly.

3.3. In cases of revisiting using an appointment card as regulated in Clause 5, Article 15 of Decree No. 146/2018/ND-CP, previously referred appropriately as per regulations in Article 10, Article 11 of Circular No. 40/2015/TT-BYT dated November 16, 2015, by the Ministry of Health: the reimbursement level is stipulated in Clause 1, Article 22 of the Law on Health Insurance. Apart from the above cases, reimbursement levels are as stipulated in Clause 3, Article 22 of the Law on Health Insurance.

3.4. For on-demand KCB: The BHYT fund does not cover KCB costs requested by the patient.

3.5. For KCB cases in border neighboring provinces: The Social Security agency only reimburses KCB BHYT costs in cases where the participant initially registers at a health post in a commune bordering a neighboring province, attending KCB at a health post in a commune bordering a neighboring province. The BHYT fund covers 100% of KCB costs within the benefit scope and BHYT reimbursement level.

Provincial Social Security cooperates with the Department of Health and Provincial Social Security, the Health Department of neighboring provinces to compile a list of commune health posts organizing BHYT KCB, reporting to Vietnam Social Security (specifically noting: Commune Health Post A of Province B bordering Commune Health Post C of Province D...).

3.6. For individuals with BHYT cards undergoing inpatient treatment at a KCB facility but whose BHYT cards have expired, the BHYT fund covers KCB costs within the benefit scope and reimbursement level until discharge, but not exceeding 15 days from the expiration of the BHYT card.

Provincial Social Security requests KCB facilities promptly notify the patient and the Social Security agency where the KCB contract is executed in case of inpatient treatment with expired BHYT cards so the patient can continue BHYT participation, and for the Social Security agency to issue or renew the BHYT card for the patient during treatment at the KCB facility.

3.7. For individuals with BHYT cards undergoing outpatient treatment (not yet finished the treatment period) or inpatient treatment at a KCB facility but experiencing a change in BHYT reimbursement level, the new BHYT reimbursement level applies from when the new BHYT card is effective.

3.8. In cases of transferring specimens or patients to another KCB facility for technical services: executed under Ministry of Health guidance. Official Dispatch No. 510/BHXH-CSYT dated December 22, 2017, by Vietnam Social Security on BHYT payment for certain medical services transferred to another KCB facility for execution and Official Dispatch No. 1508/BHXH-CSYT dated May 7, 2018, by Vietnam Social Security on HIV/AIDS treatment monitoring tests payment end of validity from December 1, 2018.

3.9. Payment of costs at commune KCB facilities for patients diagnosed, prescribed treatment, and referred back for management, monitoring, and medication by an upper-level KCB facility: executed per the guidance of the Minister of Health (note these cases require patient cost-sharing per Point h, Clause 1, Article 14 of Decree No. 146/2018/ND-CP).

3.10. Payment for transportation costs: The BHYT fund covers transportation costs as regulated in Article 26 of Decree No. 146/2018/ND-CP. No coverage for transportation costs in the following cases: transferred from commune level to district level; from commune level to provincial level; from commune level to the central level; from provincial level to the central level; lateral transfers; transfers from upper to lower levels.

3.11. Direct payment of KCB BHYT costs in certain cases:

The Social Security agency directly pays KCB BHYT costs as regulated in Article 28, Article 29, and Article 30 of Decree No. 146/2018/ND-CP. Specifically:

- Inpatient treatment at provincial and equivalent KCB facilities, central and equivalent levels without a KCB BHYT contract; KCB at district and equivalent KCB facilities without a KCB BHYT contract.

- KCB at the initial KCB facility not performing all procedures as regulated in Clause 1, Article 28 of the Law on Health Insurance.

- BHYT participants with at least 5 consecutive years and cumulative co-payable KCB BHYT costs in the fiscal year higher than 06 months of the statutory pay rate but not yet exempted from co-payment at the KCB facility.

Other cases are implemented after guidance from the Ministry of Health.

The above is the content regulating the benefits of BHYT participants. To understand this issue more clearly, you should consult Official Dispatch 4996/BHXH-CSYT of 2018.

Respectfully!