Diseases outside the list are paid 50% of the health insurance benefit level
Before July 1, 2026, health insurance participants when self-going for outpatient examination and treatment at some basic and specialized medical facilities are only paid 100% of the benefit level by the health insurance fund for diseases and disease groups on the list prescribed by the Ministry of Health. For the remaining diseases, patients must self-pay all outpatient examination costs because they have not been paid by the health insurance fund.
From July 1, 2026, the benefits of health insurance participants are expanded in a more beneficial direction. Specifically:
For diseases and groups of diseases included in the list issued with Circular No. 01/2025/TT-BYT, patients are still paid 100% of the benefit level within the scope of benefits by the health insurance fund.
For diseases and groups of diseases outside this list, the health insurance fund will pay 50% of the benefit level within the scope of enjoyment, instead of not paying as before.
Types of medical examination and treatment facilities are applied with a payment rate of 50%
Health insurance participants are only paid 50% of the benefit level by the health insurance fund when they self-go for outpatient examination at the following groups of medical examination and treatment facilities:
First, basic level medical examination and treatment facilities that have been identified before January 1, 2025 as provincial level, central level or equivalent to provincial level, central level.
Second, basic level medical examination and treatment facilities with a total professional competency assessment score from 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.
Third, specialized level medical examination and treatment facilities that have been identified as provincial level or equivalent provincial level before January 1, 2025.
How is the 50% payment calculated?
Many people misunderstand that 50% of the benefit level means that the health insurance fund pays half of the total cost of medical examination and treatment. In fact, this rate is calculated based on the health insurance benefit level of each person and only applies to costs within the scope of payment by the health insurance fund.
For example:
People with a health insurance benefit level of 80% will be paid by the health insurance fund equivalent to 40% of the medical examination and treatment costs within the scope of benefit.
People with a benefit level of 95% will be paid equivalent to 47.5% of expenses.
People belonging to the group entitled to 100% health insurance will be paid equivalent to 50% of the cost.
For expenses outside the scope of health insurance benefits, on-demand services or expenses that are not eligible for payment, patients still have to pay themselves.
Conditions for being paid 50% of the health insurance benefit level when undergoing outpatient examination outside the tuyến.
The new regulation does not mean that from July 1, 2026, people with health insurance cards can go for outpatient examinations at any hospital and will be paid 50% of the benefit level by the health insurance fund.
The determination of the payment level will be based on many factors, including: professional technical level of the medical examination and treatment facility (initial level, basic level or specialized level); disease or group of diseases diagnosed; health insurance benefit level of patients and scope of costs paid by the health insurance fund.
To fully enjoy benefits, health insurance participants should still have an examination at the initial medical examination and treatment registration facility or comply with regulations on referrals. In case of needing to go for outpatient examination, patients should contact the medical facility or social insurance agency in advance to be guided on the group of facilities to be applied, the scope of payment and specific payment levels.
