Medical examination and treatment at the same level
According to Point a, Clause 1, Article 22 of the 2024 Health Insurance Law, from January 1, 2026, there are 11 groups of subjects who are 100% reimbursed by the health insurance fund for medical examination and treatment costs when going for examination at the right tuyến.
Groups include:
Officers, professional soldiers of the army; officers, non-commissioned officers of the police; people working in cryptography who receive salaries like soldiers.
Non-commissioned officers, soldiers of the army; soldiers of the police force; military and police trainees, and key players who receive living expenses are Vietnamese people.
Military, police, and cipher students who enjoy living expenses are foreigners.
Trainees who train as reserve officers for 3 months or more have not participated in social insurance or health insurance.
Standing militia.
People with meritorious services to the revolution; veterans.
Children under 6 years old.
Relatives of martyrs, people who nurtured martyrs.
People from poor households; ethnic minorities from near-poor households or living in difficult and extremely difficult areas; people living in island communes and island districts.
People currently receiving social allowances, nursing allowances or monthly death benefits are eligible for social allowances.
People aged 75 and over are entitled to monthly survivor's allowance; people aged 70 to under 75 from near-poor households are currently receiving survivor's allowance.
In addition, health insurance participants can still be paid 100% of the costs in some cases:
The cost for one examination is 15% lower than the base salary.
Medical examination and treatment at the initial level such as health stations, regional general clinics.
Participate in health insurance for 5 consecutive years or more and the amount of co-payment in the year exceeds 6 times the reference level.
Benefit level for out-of-zone examination
If the patient goes for out-of-line examination without a valid referral letter, the health insurance benefit level will be reduced according to the hospital level.
Specifically:
Intensive-care hospital
Inpatient treatment: Benefit 40% of health insurance benefits.
Primary hospital
Inpatient treatment: Enjoy 100% of benefits (for establishments before January 1, 2025, which is provincial level).
Outpatient examination: Enjoy 50% - 100% of the benefit level, depending on the professional level ranking roadmap.
Primary or basic hospital
Enjoy 100% of the benefits for both outpatient and inpatient (for establishments before January 1, 2025, which is district level).
Go to a higher-level hospital yourself
Patients who come for self-examination at central-level hospitals without referral papers (except for emergency) will be considered out-of-line examinations.
At that time, the health insurance fund only pays 40% of the inpatient treatment costs, and the rest is paid by the patient themselves.
Cases that are still entitled to the correct line
Some cases are still entitled to benefits such as proper examination even if they do not go to the initial registration place, including:
Emergency care at any medical facility.
Treat rare and critical diseases according to regulations.
Ethnic minorities in difficult areas.
People living in island communes, island districts.
In case of transfer according to professional procedures.
Unpaid health insurance costs
Health Insurance Fund does not pay for:
Get regular health check-ups.
Cosmetic treatment.
On-demand services.
Medicines and supplies outside the health insurance list.
The cost has been paid by the state budget.
How to calculate health insurance payment levels
The amount of health insurance payment is calculated according to the formula:
Benefit level = Benefit ratio × Expenses within coverage
In which:
Benefit rate: 100%, 95% or 80%.
Expenses within the scope of: expenses belonging to the health insurance list.
To ensure health insurance benefits, people should:
Medical examination and treatment in the correct initially registered place.
Ask for a referral when needing higher-level treatment.
Bring all the papers when going for examination.
Prioritize inpatient treatment if forced to have out-of-zone examinations.
Understanding the health insurance benefit level from 2026 will help participants proactively choose medical examination and treatment facilities and maximize insurance benefits.
