From July 1, 2026, health insurance (HI) participants will have their benefits expanded when going for outpatient medical examination and treatment outside the tuyến. Instead of having to self-pay all costs as currently in many cases, patients will be paid 50% of the benefit level according to regulations by the HI fund. The new regulation is mentioned in Article 19 of Decree 188/2025/ND-CP.
This is the first time patients undergoing outpatient examinations outside the line at many upper-level hospitals have enjoyed part of their health insurance benefits instead of having to pay all costs themselves.
From July 1, 2026, health insurance will pay 50% of the benefit level in the following cases:
Outpatient medical examination and treatment at basic-level medical examination and treatment facilities that were identified as provincial or central-level hospitals before January 1, 2025.
Outpatient medical examination and treatment at basic level medical examination and treatment facilities with scores from 50 to under 70 points.
Outpatient medical examination and treatment at specialized level medical examination and treatment facilities that were previously identified as provincial-level hospitals.
Currently, people who self-go for outpatient examinations outside the line are only 100% reimbursed by health insurance for some diseases and special disease groups according to the regulations of the Ministry of Health. For the remaining diseases, the reimbursement level is 0%, meaning patients must pay all costs themselves.
However, from July 1, 2026, diseases on the list entitled to 100% will continue to be paid 100% of the benefit level.
Diseases not on this list will be paid 50% of the benefit level by health insurance instead of not being paid as before.
Suppose a person has a health insurance benefit level of 80% and goes for outpatient examination outside the line at a provincial-level hospital.
Before July 1, 2026: if the disease is not on the priority list, health insurance does not pay, patients must pay 100% of the costs themselves.
From July 1, 2026: Health insurance will pay 50% of the benefit level. With a benefit level of 80%, the health insurance fund will pay 40% of medical examination and treatment costs, and patients will pay the rest themselves.
The addition of a 50% payment level when outpatient examination is considered a step to expand benefits for health insurance participants, helping to reduce the cost burden when patients need medical examination and treatment at higher-level medical facilities without a referral letter.
Thus, from July 1, 2026, outpatients outside the line at many provincial and central hospitals and specialized level medical examination and treatment facilities will be paid 50% of the benefit level by health insurance for diseases not eligible for 100% benefit, instead of having to pay the full amount themselves as at present.
