Cases of medical examination and treatment covered by health insurance with the maximum amount in Vietnam

Cases of medical examination and treatment covered by health insurance with the maximum amount in Vietnam (Artwork)

Article 6 of Vietnam's Circular 30/2020/TT-BYT and point c, Clause 3, Article 22 of Vietnam's  Law on Health Insurance 2008 (amended and supplemented by Clause 15, Article 1 of the Law on Health Insurance as amended 2014) specify that the health insurance card holders, upon medical examination and treatment in the following cases, will be paid by the health insurance fund up to the maximum amount according to the benefit level of the health insurance card:

(1) Health insurance participants apply for medical examination and treatment in initial medical examination and treatment establishments specified on their health insurance cards.

(2) Health insurance participants who apply for initial medical examination and treatment in medical examination and treatment establishments of communes or general clinics or district hospitals may receive medical examination and treatment covered by health insurance in other medical stations of communes or general clinics or district hospitals in the same provinces. Children who have not obtained health insurance cards since birth declaration procedures have not been adopted may use birth certificates to receive medical examination and treatment in medical examination and treatment establishments specified under this Clause.

(3) Health insurance participants who are in state of emergency are provided with emergency medical aid in any medical examination and treatment establishment in the country.

Doctors or physicians shall assess and identify state of emergency of the patients, specify in patients’ medical records and be responsible for their decisions.

(4) Health insurance beneficiaries who benefit from transfer of administrative levels for receiving medical examination and treatment under health insurance as per the law, including:

- May transfer according to Article 10 and Article 11 of Vietnam's Circular No. 40/2015/TT-BYT dated November 16, 2015 of Minister of Health on registration for initial medical examination and treatment under health insurance and transfer of administrative level for receiving medical examination and treatment under health insurance. Applications for transfer consist of transfer documents using Form No. 6 attached to Vietnam's Decree 146/2018/ND-CP and other documents (if any);

- May transfer according to Clause 3 Article 14 of Decree 146/2018/ND-CP, including: emergency medical aid; cases where beneficiaries are diagnosed with other diseases exceeding the specialty of medical examination and treatment establishments during inpatient treatment process; disease development exceeds capacity of medical examination and treatment establishments during inpatient or outpatient treatment process;

- May transfer according to Clause 2 Article 6 of Circular 04/2016/TT-BYT dated February 26, 2016 of Minister of Health on elaborating to medical examination, treatment and payment for medical examination, treatment covered by health insurance relating to examination and treatment of tuberculosis.

(5) Health insurance participants who obtain documents proving their stay in other administrative divisions when they go on working trips, participate in concentrated education in training programs, semi-boarding programs and apply for initial medical examination, treatment in medical examination and treatment establishments of the same or equivalent administrative level as their initial medical examination and treatment establishments specified on health insurance cards according to Clause 7 Article 15 of Decree No. 146/2018/ND-CP. Medical examination and treatment establishments are responsible for storing photocopy of documents specified under this Point in medical records of beneficiaries.

(6) Holders of notice of re-examination appointment in case they have been transferred according to Clause 5 Article 15 of Decree No. 146/2018/ND-CP.

(7) Individuals who have donated their organs and require immediate treatment after donating organs.

(8) Newborn babies who must receive treatment upon birth.

(9) Health insurance card holders voluntarily go for medical examination and treatment off-line (not in the 08 cases mentioned above) at district hospitals nationwide.

In particular, in the following cases, the insured person when going for medical examination and treatment will be paid 100% of medical examination and treatment costs within the scope of payment of health insurance regardless of the maximum benefit level of the health insurance card:

- Cases of medical examination and treatment at the commune level.

- In case the cost of a medical examination and treatment is lower than 15% of the base salary.

- In case the patient has participated in health insurance for 5 consecutive years or more and the amount of money jointly paid for medical examination and treatment expenses in the year is greater than 6 months' basic salary, except for the case of going for medical examination and treatment at the wrong line.

In addition, according to Clause 6, Article 22 of the Law on Health Insurance 2008, as amended and supplemented by Clause 15, Article 1 of the Law on Health Insurance, amended in 2014, health insurance participants who go to medical examination and treatment on their own at the wrong level at provincial medical examination and treatment establishments nationwide will be covered by the health insurance fund for the part of inpatient treatment expenses at the same level.

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