Understand correctly to avoid getting stuck
Having a health insurance card, Ms. Nguyen Thu Nga, 50 years old in Hanoi, still spends nearly 5 million VND to see a service at Bach Mai Hospital not because she is not eligible for health insurance, but because... she does not know she has the right to pay.
Ms. Nga often has headaches, after a local blood test, she discovered a high plateau, so she went to Bach Mai Hospital (Hanoi) for an in-depth check-up. Not wanting to spend time completing the referral procedure, she chose to see a service doctor as requested to perform a quick spinal cord test.
"This time, I have to pay 4.9 million VND myself. If I had to be hospitalized for treatment, I would have to ask for a referral letter to reduce costs, Ms. Nga shared.
When asked about the new regulation allowing people with health insurance to go to central hospitals for examination on request and are still covered by the health insurance fund for the part within the scope of benefits, Ms. Nga said that she did not know about this policy.
Patient Tran Cong Thanh (42 years old) discovered kidney failure at a private hospital in Son La. Worried that the results were not accurate, he went to the central hospital in Hanoi for re-tests but was not covered by health insurance because he went to the wrong hospital, had no referral papers and was not eligible for emergency care.
After that, Mr. Thanh returned to the initial medical facility to apply for an official referral letter. Thanks to that, the health insurance paid for the following check-ups in accordance with regulations, the cost each time was only a few hundred thousand VND.
Many benefits of participating in health insurance that patients need to understand
From July 1, 2024, health insurance participants who go for medical examination and treatment at the wrong place of initial registration (left line, higher level) will still be paid 100% of the costs in some cases by the health insurance fund such as Endocrinology at district hospitals (basic level); Medical examination and treatment at facilities that were once district or provincial level before January 1, 2025; Endocrinary medical examination and treatment at provincial hospitals (specialized level); Emergency examination at any facility; Basic or specialized examination at the level if suffering from rare diseases, serious diseases, diseases requiring surgery or high techniques according to the list of the Ministry of Health; Ethnic minorities, poor households in disadvantaged areas, communes, island districts, go for inpatient examination at specialized levels...
The Ministry of Health has prescribed a list of 62 diseases that can go directly to specialized facilities without having to be transferred. Mainly malignant tumors, rare diseases, metabolic disorders, birth defects...
According to the 2024 Health Insurance Law, people with health insurance cards who go to the doctor and receive treatment as required will still be covered by the health insurance fund for the cost within the scope of benefits (if any). The difference between the required service price and the health insurance payment will be paid by the patient.
BSCKII. Tran Thai Son - Deputy Head of the General Planning Department, Bach Mai Hospital - said: To receive health insurance when receiving outpatient examination at Bach Mai Hospital (specialized hospital, Central level), patients need to belong to one of the following cases: Having a referral letter from a lower-level medical facility, valid; Having a health insurance re-examination appointment issued by Bach Mai Hospital, valid; Having one of 62 serious diseases, rare diseases, requiring surgery or high-tech surgery according to Circular 01/2025/TT-BYT. Some diseases require additional conditions such as having a diagnosis determined from another medical facility, accompanied by a hospital discharge certificate or a prescription as evidence.
BSCKII. Tran Thai Son further stated that people using on-demand medical examination services are still entitled to health insurance benefits for expenses within the paid scope such as medicine, surgery, bed fees, etc. However, patients must pay the difference between the required service price and the health insurance price. For example: Health insurance examination price at Bach Mai Hospital: 50,600 VND/visit. Required examination price (BSCKI...): 300,000 VND/visit. Patients only paid the difference of 249,400 VND. The remaining 50,600 VND will be paid by the health insurance fund according to the benefit level (80%, 95% or 100%).
As for drugs, regardless of whether they are examined under health insurance or examined on request - if they are in the health insurance list, patients will still be paid.
Even with a 100% health insurance benefit, patients must pay for it themselves if: Using the service as required (choosing a doctor, testing, surgery, bed room...). Using drugs, supplies, and techniques outside the health insurance list. Transdisciplinary medical examination and treatment are not in accordance with regulations. That is, if you go to the central level without a referral letter, health insurance only pays 40% of the boarding fee; the provincial level is 60%. Many new drugs, expensive specialties, high-end supplies... are not included in the health insurance list or are only partially covered, the rest must be paid 100% by patients.
