Decree No. 188/2025/ND-CP of the Government detailing the implementation roadmap and the rate of benefits when examining and treating outpatient diseases according to the provisions of the Law on Health Insurance.
If there is a change in the benefit level during inpatient treatment, the patient is responsible for providing new card information, and the medical facility must check and apply the new benefit level before discharging.
These regulations aim to ensure that health insurance payments are paid in full and on time in accordance with the rights of patients in all cases.
Medical examination and treatment facilities are responsible for checking the rights and benefits of health insurance participants before finishing the medical examination, treatment, and discharge.
Compared to before, when Decree 188 was not yet issued, patients who arbitrarily examined for outpatient treatment at provincial or central hospitals (without a referral letter) will not be covered by the health insurance fund for outpatient treatment, except for some cases of emergency care or outpatient treatment at the central level according to the Health Insurance Law 2014).
This means that outpatients on the other side of the line must pay all costs themselves.
However, according to the new regulations, patients are entitled to the following:
The new regulation allows from January 1, 2025, when outpatient medical examination and treatment at basic medical examination and treatment facilities reach a score of less than 50 points or are temporarily classified as basic level, health insurance participants are paid 100% of the benefit level by the health insurance fund, except for basic medical examination and treatment facilities that have been identified by competent authorities as provincial or central levels before January 1, 2025.
From July 1, 2026, when outpatient medical examination and treatment at basic medical examination and treatment facilities achieves a score of 50 points to less than 70 points, health insurance participants will receive 50% of the benefits from the health insurance fund.
From July 1, 2026, when examining and treating outpatients at basic medical examination and treatment facilities that have been identified by competent authorities as provincial or central levels or equivalent to provincial or central levels before January 1, 2026, health insurance participants will be paid 50% of the benefit level by the health insurance fund.
From July 1, 2026, when examining and treating outpatients at specialized medical examination and treatment facilities that have been identified by competent authorities as provincial level before January 1, 2025, according to Point h, Clause 4, Article 22 of the Law on Health Insurance, health insurance participants will be paid 50% of the benefit level by the Health Insurance Fund.
The new points stipulated in Decree 188 have significantly expanded the rights of people going for health insurance examination and treatment (especially for outpatient examination at the cross-led and service examination), while clarifying the principles of benefits to better protect the legitimate rights of participants.
