The Government has just issued Decree No. 188/2025/ND-CP, detailing the implementation roadmap and the rate of benefits when examining and treating outpatient patients as well as examining and treating patients according to the requirements of the Law on Health Insurance (BHYT). These changes significantly expand the rights of health insurance participants, especially for the group of outpatients on the outpatient line and patients using services on request.
Expanding payment benefits for outpatient medical examination and treatment
Previously, patients who went to a provincial or central hospital for outpatient examination were almost not covered by health insurance, except for some cases of emergency care or outpatient treatment at the provincial or central level. This causes outpatients to cover all costs themselves.
Since Decree 188 takes effect, benefits have been adjusted according to the roadmap:
From January 1, 2025: For outpatient examination at a basic medical facility with less than 50 points or temporarily classified as a basic level, health insurance participants will be paid 100% of the benefit level.
From July 1, 2026: Outpatient examination at a basic level reaches from 50 to under 70 points, the health insurance fund pays 50% of the benefit level.
From July 1, 2026: Outpatient examination at a basic or specialized level that before January 1, 2025 had been identified as a provincial or central level or equivalent, the health insurance fund also paid 50% of the benefit level.
This regulation helps ensure that patients are still sharing medical expenses, instead of having to pay for the entire cost themselves as before.
Medical examination and treatment as required to receive health insurance
Another important new point is that health insurance has begun to pay part of the cost for medical examination and treatment as required.
Accordingly, people with a health insurance card when choosing a medical examination service as required (for example, professor's examination, service department, etc.) will still be covered by the health insurance fund within the scope of benefits and benefits according to the law. The cost difference compared to standard services is paid by patients to medical facilities.
Medical examination and treatment facilities must publicize and notify in advance the costs outside the scope of health insurance for patients to proactively choose.
Previously, the cost of service examination as required was entirely paid by patients, and health insurance did not participate in the payment. The addition of this policy is considered to eliminate the "spacing" of benefits, helping patients have more flexible options and optimize health insurance card benefits.
Dr. Tran Thai Son - Deputy Head of the General Planning Department, Bach Mai Hospital said that one of the big questions of people today is whether when choosing to see a doctor as required at the hospital, will health insurance benefits be applied or not?
In principle, the health insurance fund will pay for expenses within the scope of benefits (medicines, technical services, bed fees, etc.) according to the prescribed price. The cost difference between the price of the required medical examination service and the price of health insurance will be paid by the patient.
Doctor Son gave a specific example: at Bach Mai Hospital, the examination price according to health insurance regulations is 50,600 VND/visit, while the examination price according to requirements (for example, examination with Master, BSCKI) is 300,000 VND/visit. At that time, the patient must pay the difference of VND 249,400. For the remaining 50,600 VND, the health insurance fund will pay according to the benefit level stated on the card (80%, 95% or 100%), patients will only co-pay the remaining if any.
Notably, regarding drugs for treatment, there is no concept of "required drugs". If the drug is on the list of drugs covered by health insurance, patients will enjoy full benefits as prescribed, regardless of whether it is a regular health insurance examination or a medical examination on request.
"People can be completely assured that when choosing to see a doctor as required, health insurance benefits are still guaranteed within the prescribed scope. The difference is only the difference in cost that patients pay for to be served as desired, Dr. Son affirmed.
In addition to expanding the scope of payment, Decree 188 also stipulates the responsibility of medical facilities in checking the level of benefits of health insurance participants before being discharged from the hospital, ensuring that payments are made fully and promptly.
