Scope and levels of health insurance benefits in Vietnam (latest)

Scope and levels of health insurance benefits in Vietnam (latest) (Internet image)

1.  What is the scope of health insurance benefits in Vietnam? 

Pursuant to Article 21 of the Law on Health Insurance 2008 (amended by the Law on Amendments to Law on Health Insurance 2014), the scope of health insurance benefits is regulated as follows:

- The insured has the following costs covered by the health insurance fund:

+ Costs of medical examination and treatment, function rehabilitation, regular pregnancy check-ups and birth giving;

+ Costs of the transfer of the patients from district hospitals to superior hospitals with regard to the insured prescribed in points a, d, e, g, h and i Clause 3 Article 12 of this Law in case of medical emergency or inpatients needing such transfer.

- The Minister of Health shall take charge and cooperate with the relevant Ministries and regulatory authorities in providing the list, proportion and payment conditions for the medicines, chemicals, medical equipments and services within the scope of benefits of the insured.

2. Levels of health insurance benefits in Vietnam

Article 22 of the Law on Health Insurance 2008 (amended by the Law on Amendments to Law on Health Insurance 2014) stipulates the current levels of health insurance benefits as follows:

- The benefit levels of the insured receiving medical examination and treatment in accordance with the regulations in Articles 26, 27 and 28 of the Law on Health Insurance 2008 whose medical examination and treatment expenditures are covered by the health insurance fund shall be:

+ Total medical examination and treatment expenditures with regard to the insured prescribed in points a, d, e, g, h and i Clause 3 Article 12 of the Law on Health Insurance 2008.

The costs of the non-covered medical services of the insured prescribed in point a Clause 3 Article 12 of the Law on Health Insurance 2008 shall be paid by the health insurance budget used for medical examination and treatment of these insured persons; if this budget is insufficient, the State budget shall be in charge.

+ Total medical examination and treatment expenditures with regard to any medical examination and treatment at commune hospitals whose cost is lower than the cost prescribed by the Government.

+ Total medical examination and treatment expenditures with regard to the at least 5-year-insured whose medical examination and treatment expenditures exceed the total amount of the base salaries in 6 months, except for the insured who go to the hospitals different from the registered hospitals;

+ 95% of the medial examination and treatment expenditures with regard to the insured prescribed in point a Clause 2, point k Clause 3 and point a Clause 4 Article 12 of the Law on Health Insurance 2008;

+ 80 % of the medial examination and treatment expenditures with regard to other insured persons;

- In case an insured person belongs to different groups of the insured, (s)he shall be provided with the highest health insurance benefits.

- In case any card holder goes to a hospital different from the registered hospital except for the insured prescribed in Clause 1 Article 22 of the Law on Health Insurance 2008, his or her costs shall be covered by the health insurance fund according to the benefit levels prescribed in Clause 1 Article 22 of the Law on Health Insurance 2008 as follows:

+ 40% of the inpatient treatment expenditures at the central hospitals.

+ 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.

+ 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.

- The insured applying for medical examination and treatment at commune medical facilities, clinics or district hospitals can receive medical examination and treatment at any commune medial facility, clinic or district hospital in the same province according to the benefit levels prescribed in Clause 1 Article 22 of the Law on Health Insurance 2008 from January 01, 2016.

- The insured who are poor household members or ethnics living in regions facing socio-economic difficulties, regions facing extreme socio-economic difficulties; the insured living in island communes or islands districts who go to the hospitals different from the registered hospital shall be paid for their medical examination and treatment expenditures at the commune hospitals, their inpatient treatment costs at the provincial and central hospital by the health insurance fund according to the benefit levels prescribed in Clause 1 Article 22 of the Law on Health Insurance 2008.

- The inpatient treatment expenditures of the insured who go to any provincial hospital in Vietnam different from their registered hospitals shall be paid by the health insurance fund from January 01, 2021.

3. Cases not eligible for health insurance benefits in Vietnam

Cases not eligible for health insurance benefits specified in Article 23 of the Law on Health Insurance 2008 (amended by the Law on Amendments to Law on Health Insurance 2014), include:

- Cases specified in Clause 1 of Article 21 of the Law on Health Insurance 2008 in which costs have been paid by the state budget.

- Convalescence at sanatoria or convalescence establishments.

- Medical check-up.

- Prenatal tests and diagnosis for non-treatment purposes.

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

- Use of aesthetic services.

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

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

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

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

- Medical assessment, forensic examination, forensic mental examination.

- Participation in clinical trials or scientific research.

Nhu Mai

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