After administrative units were merged, many people wondered whether medical examination and treatment using health insurance at medical facilities in the same province would be considered in accordance with the line or not.
The case of Ms. Tran Thu Thao (Ninh Binh) is an example. After the merger, she took her child to be examined at Nam Dinh Children's Hospital, but the hospital announced that this was an out-of-zone examination case, so she could not fully enjoy health insurance benefits.
Ms. Thao asked: When the province has merged, is medical examination and treatment between medical facilities in the same area considered to be on the right line or not? Is the hospital's determination of off-line examination in this case in accordance with regulations?
Answering the above question, Ninh Binh Provincial Social Insurance said that health insurance payments are still being implemented according to the provisions of the Health Insurance Law and Decree No. 188/2025/ND-CP.
Accordingly, from January 1, 2025, Nam Dinh Children's Hospital is classified as basic level, but before this time, it was still identified as a provincial-level hospital.
Current regulations clearly state: people with health insurance when going for outpatient examinations at basic-level facilities will be paid 100% of the benefit level by the health insurance fund, except for facilities previously identified as provincial or central levels.
Therefore, when Ms. Thao's child goes for outpatient examination at Nam Dinh Children's Hospital but is not in the initial registered place for medical examination and treatment, it is still considered for examination not in the correct tuyến. Therefore, this case is not within the scope of payment of the health insurance fund.
However, from July 1, 2026, according to new regulations in Decree No. 188/2025/ND-CP, outpatients at Nam Dinh Children's Hospital or other provincial-level hospitals, even if not in the original registered place, will be paid 50% of the benefit level according to regulations by the health insurance fund.
