In case the Social Insurance directly pays the cost of health insurance treatment for patients

The Lao Dong Newspaper Legal Consulting Office replied:

Article 54 of Decree No. 188/2025/ND-CP stipulates that social insurance agencies pay costs directly to health insurance participants according to the scope of benefits and the level of benefits according to the provisions of the law on health insurance in the following cases:

1. Patients in a state of emergency, loss of consciousness or death without presenting health insurance card information before being discharged from the hospital.

2. Health insurance participants under the management authority of the Ministry of National Defense and the Ministry of Public Security who have lost their health insurance cards but have not been reissued or the patient's health insurance card information is incorrect or incorrect and has not been corrected or corrected by the social insurance agency at the end of the medical examination, treatment, or discharge period.

3. Health insurance participants who are subjects whose health insurance is paid by the state budget but have not been issued a health insurance card, except for the cases specified in Clause 1, Article 50 of this Decree. Patients are paid the full cost of medical examination and treatment within the scope of benefits and the benefit level from the date of determination as a subject paid by the state budget but have not been paid because they have not been issued a health insurance card.

4. Patients who are admitted to the medical examination and treatment facility for emergency care do not have a health insurance medical examination and treatment contract. Patients are paid the entire cost of medical examination and treatment within the scope of benefits and the benefit level has not been paid according to the provisions of the law on health insurance.

5. In case of medical examination and treatment under health insurance for people who have changed and are in the group of subjects with higher health insurance benefits but have not been issued a new health insurance card, the Social Insurance agency will pay the difference in costs between the two direct benefits for health insurance participants.

6. In case the patient buys medicine and medical equipment himself according to the provisions of Articles 58 and 59 of this Decree. For subjects specified in Points a, b, c and d, Clause 3, Article 12 of the Law on Health Insurance, the payment of drug and medical equipment costs shall be implemented in accordance with the provisions of Decree No. 70/2015/ND-CP dated September 1, 2015 of the Government detailing and guiding the implementation of a number of articles of the Law on Health Insurance for the People's Army, People's Public Security and people working in secret services amended and supplemented by Decree No. 74/2025/ND-CP dated March 31, 2025 of the Government.

7. In case the health insurance participant examines and treats a disease during the period of revocation, temporary detention or temporary lockdown prescribed in Clauses 1, 2 and 3, Article 12 of this Decree without the fault of the health insurance participant, the patient shall be paid the entire cost of medical examination and treatment within the scope of benefits and the benefit level according to the correct subject.

Thus, the cases where the Social Insurance directly pays the cost of medical examination and treatment under health insurance for patients are regulated as above.