Expanding payment when outpatient examination is outside the line
One of the most notable changes from July 1 is that health insurance participants are expanded in benefits when they go for outpatient examinations in the wrong initially registered place.
Previously, the health insurance fund only paid 100% of the benefit level for some diseases and groups of diseases in the list prescribed by the Ministry of Health. For diseases outside this list, outpatients outside the line are almost not paid by the health insurance fund.
From July 1, 2026, the policy is adjusted in a direction that is more beneficial for patients. Accordingly, diseases on the list of the Ministry of Health are still paid 100% of the benefit level within the scope of health insurance benefits. For the remaining diseases and groups of diseases, the health insurance fund will pay 50% of the benefit level, instead of not paying as before.
Ms. Tran Thi Trang - Director of the Department of Health Insurance (Ministry of Health) - informed that this policy applies to people who self-examine for outpatient visits at basic level medical examination and treatment facilities that have been identified as provincial level, central level or equivalent to provincial level, central level before January 1, 2025. Basic level medical examination and treatment facilities with a total professional competency assessment score of 50 to below 70 points according to regulations on professional and technical ranking, except for facilities before January 1, 2025 that are identified as district level. In-depth level medical examination and treatment facilities that have been identified as provincial level or equivalent to provincial level before January 1, 2025.
Also according to Ms. Tran Thi Trang, the payment level is calculated according to the health insurance benefit rate of each person. For example, people with a health insurance benefit level of 100%, if they have outpatient examinations outside the line with a total cost of 1 million VND at a qualified hospital, they will be paid 500,000 VND by the health insurance fund and only have to pay themselves the remaining 500,000 VND. Meanwhile, people with a health insurance benefit level of 80% with the same cost level will be paid 400,000 VND by the health insurance fund, and the part that patients pay themselves is 600,000 VND.
According to Ms. Nguyen Lan Huong - Deputy Head of the Health Insurance Policy Implementation Board (Vietnam Social Security), the new regulation helps health insurance participants receive additional cost support when going for outpatient check-ups. However, the 50% benefit level does not apply to all cases but also depends on the type of medical examination and treatment facility, the disease diagnosed, as well as the health insurance benefit level of each person.
Representatives of Vietnam Social Security also noted that "50% benefit level" does not mean that the health insurance fund pays half of the total amount recorded on the medical examination invoice. The payment is calculated based on the health insurance benefit level of each subject and only applies to expenses within the scope of payment by the health insurance fund.
Examination at the right tuyến cost under 379,500 VND is paid at maximum
Another new point effective from July 1st is that health insurance participants with total medical examination and treatment costs in one examination equal to or below 15% of the base salary (equivalent to 379,500 VND) will be paid by the health insurance fund according to the benefit level if they are examined at the right level.
The policy applies to all medical examination and treatment facilities at the initial, basic and specialized technical levels. For example, people belonging to the group entitled to 100% health insurance, with a total examination cost of 370,000 VND at a qualified facility will be fully reimbursed by the health insurance fund.
For people in the group receiving 80%, the fund will pay 296,000 VND, and patients will co-pay 74,000 VND.
In case only 40% of the benefit level is enjoyed when receiving inpatient treatment at a specialized level medical examination and treatment facility as prescribed, the health insurance fund will pay 148,000 VND for people belonging to the 100% benefit group. If belonging to the 80% benefit group, the amount paid by the fund is 118,400 VND.
People can look up the level of technical expertise and hospital capacity on the Portal of the Department of Medical Examination and Treatment Management (Ministry of Health), Department of Health or directly at a medical facility - this is mandatory public information.
The Ministry of Health is building a Health Insurance Benefit Information Portal, integrating search utilities, supporting people, businesses and medical facilities to implement policies more conveniently.
