From January 01, 2021, off-line medical examination and treatment at provincial hospitals will have a change in the percentage of health insurance benefits. However, many people do not understand the nature of this regulation, so they mistakenly believe that 100% of inpatient treatment costs will be covered by health insurance in every case.
Article table of contents
1. Current off-line health insurance benefits
According to Clause 15 Article 1 of the Law on amendments to the Law on Health Insurance 2014 of Vietnam, 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:
- 40% of the inpatient treatment expenditures at the central hospitals.
- 60% of the inpatient treatment expenditures at the provincial hospitals.
- 100% of the medical examination and treatment expenditures (previously 70%).
Currently, there are 03 levels of health insurance benefits as follows:
- 100% of medical examination and treatment expenses;
- 95% of medical examination and treatment expenses;
- 80% of medical examination and treatment costs.
Thus, depending on each level of health insurance benefit when receiving medical examination and treatment at the right level, that person will be paid the corresponding percentage by the health insurance when going to a provincial hospital for an off-line examination. That is, if the patient goes to an outpatient clinic at the provincial level, he will be paid by health insurance at the rate of 60% of 80%, or 60% of 95%, or 60% of 100% of the cost of medical examination and treatment.
For example: A has a health insurance card and is entitled to 80% of medical examination and treatment expenses in case he goes to the right hospital for medical examination and treatment. But A has received inpatient treatment at a provincial hospital, the amount that health insurance will pay for A will be:
60% x 80% x Total cost of medical examination and treatment = 48% x Total cost of medical examination and treatment
2. Benefit levels of health insurance from January 01, 2021
According to Clause 15 Article 1 of the Law on amendments to the Law on Health Insurance 2014 of Vietnam, the health insurance fund will pay 100% of inpatient treatment costs according to the level of benefits specified in Clause 1 of this Article (ie, the right level of health insurance coverage) for the insured when self-diagnosing and receiving medical treatment at the wrong level at health facilities provincial medical examination and treatment centers nationwide. Specifically, people who go to out-of-network medical examination and treatment in the province will be paid as follows:
- Individuals with health insurance cards with 100% benefits: 100% of inpatient treatment costs will be paid.
Example: Health insurance card of a person from a poor household.
- Individuals with health insurance cards with 95% benefits: 95% of inpatient treatment costs will be paid.
Example: Health insurance card of a person from a near-poor household.
- Individuals who have health insurance cards with the rate of 80%: will be paid 80% of inpatient treatment costs.
For example: Health insurance card of the employee; or of cadres, civil servants or public employees.
Thus, not everyone is entitled to 100% of the cost of inpatient treatment when providing medical examination and treatment at a provincial hospital, but can be paid 95% or 80% depending on the benefit level of the health insurance card.
It can be seen that the increase in the rate of health insurance benefits from 60% to 100% when going for medical examination and treatment at provincial hospitals is great news for those participating in health insurance. In addition to the benefit of increased health insurance benefits, this provision also brings many other benefits to patients:
- There is no need for a referral to receive medical care (otherwise known as "provincial referral");
- To be guaranteed medical examination and treatment benefits when it is not possible to get medical examination and treatment at the right level at the place of initial registration;
- To be selected for medical examination and treatment at provincial hospitals with better quality.
However, this regulation is also a challenge for the health sector. Because the opening of provincial health insurance in 2021 will lead to an "overload" situation when lower-level patients pass to the upper-level, medical costs will also increase, creating great pressure on the health insurance fund. Therefore, hospitals need to improve the quality of medical examination and treatment for people; stipulate the number of hospital beds of medical examination and treatment establishments in accordance with human resources, equipment and facilities; plan to coordinate and actively coordinate with other medical examination and treatment facilities, including district-level facilities to transfer patients when overloaded.
In summary, from January 01, 2021, when providing medical examination and treatment at the provincial level, 100% of inpatient treatment costs will be covered according to 03 levels of health insurance benefits as above.
Phuong Thanh
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