Examination and treatment as required paid by health insurance
Ms. Nguyen Thi Hang (in Bat Trang, Hanoi) intends to see a digestive examination service at Bach Mai Hospital. At first, she thought she would have to pay all the costs herself because she did not go to the correct clinic and chose the service as requested. However, she heard that health insurance (HI) will pay part of the cost of the examination and some basic tests.
At the service examination area of Bach Mai Hospital, Mr. Tran Van Hong (72 years old, in Ninh Binh) said that he always buys health insurance but rarely uses it. Every time I go to the hospital, I check the service. It was thought that if the examination was required, health insurance would not pay, but anyone would still be supported to some extent.
The lack of information causes many people to miss their legitimate rights, leading to unnecessary financial burdens when going to the doctor.
Health insurance pays within the scope of benefits
Ms. Vu Nu Anh - Deputy Director of the Department of Health Insurance (Ministry of Health) - said that Decree 02/2025 of the Government has added a regulation allowing people with health insurance cards to continue to receive the health insurance fund for the costs covered by the health insurance law, according to the provisions of Article 22 of the Law on Health Insurance.
However, patients must pay the difference between the service price as required and the payment level paid by the health insurance fund. The cost difference between the price of medical examination and treatment services as required and the payment level of the Health Insurance Fund paid by patients to medical examination and treatment facilities - Ms. Vu Nu Anh emphasized.
Also according to the new regulation, medical examination and treatment facilities must clearly publicize the cost levels outside the scope of health insurance benefits, including the difference in service prices and specific payment rates. At the same time, these facilities are responsible for notifying in advance so that patients know and proactively choose.
BSCKII. Tran Thai Son - Deputy Head of the General Planning Department, Bach Mai Hospital - said that this is a very superior policy of health insurance, helping people with better conditions to still enjoy health insurance benefits. When patients use the examination service as requested, health insurance will pay as follows:
Health insurance payment: The Health Insurance Fund will pay for expenses within the scope of benefits (medicines, technical services, bed fees, etc.) according to the price prescribed by the Health Insurance.
The part that patients pay themselves: Patients will pay the difference between the service price as required and the price prescribed by health insurance.
BSCKII. Tran Thai Son gave an example: The cost of medical examination according to health insurance at Bach Mai Hospital is 50,600 VND/visit.
The cost of medical examination as required (for example, Master's exam, BSCK1) is 300,000 VND/visit.
At that time, the patient will pay the difference of: 300,000 - 50,600 = 249,400 VND.
For the remaining amount of VND 50,600, the Health Insurance Fund will continue to pay according to the benefit level on the patient's card (for example 80%, 95% or 100%). Patients only have to co-pay the remainder (if any).
Regarding drugs, there is no concept of "required drugs". If the drug is on the list of health insurance funds, patients will enjoy full benefits according to regulations, regardless of whether it is a health insurance examination or a medical examination as required.
The health insurance card currently clearly states 3 levels of benefits: 80%, 95% and 100%. In case of self-examination at a central hospital (deep-level), if only an outpatient examination is not paid. Only when receiving inpatient or emergency treatment are they entitled to health insurance, with a payment of 40% of the cost according to the benefit level. For example, people with an 80% benefit level will only be paid 32%.
If examined at a provincial hospital (basic level), patients will only receive health insurance when receiving inpatient treatment, with a payment rate of 100% according to the benefit level.
For newly established medical examination and treatment facilities with basic ratings but below 50 points or temporarily ranked, those who go to outpatient treatment will still be covered by health insurance with 100% of the benefits stated on the card.
