Accordingly, from July 1, 2026, health insurance (HI) participants who self-go for outpatient examination and treatment at some basic and specialized medical facilities will be paid 50% of the benefit level by the HI fund for diseases and groups of diseases that have not been paid before.
This is an important new point, helping people with health insurance cards reduce some costs when they come for outpatient examinations not in the initial registered medical examination and treatment facility or do not comply with regulations on transferring patients.
However, according to Vietnam Social Security, the policy only applies to groups of medical facilities prescribed by law, not all hospitals nationwide.
Diseases outside the list are paid 50% of the health insurance benefit level
Before July 1, 2026, health insurance participants who self-go for outpatient examinations at some basic-level and specialized-level facilities will only be 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 and disease groups, patients who have not been paid outpatient examination and treatment costs by the health insurance fund.
From July 1, 2026, benefits for these cases are expanded to two levels:
- Diseases and disease groups included in the list issued with Circular No. 01/2025/TT-BYT continue to be paid 100% of the benefit level within the scope of enjoyment by the health insurance fund.
- For the remaining diseases and groups of diseases, the health insurance fund will pay 50% of the benefit level within the scope of benefit, instead of not paying as before.
Sharing about this issue, Ms. Nguyen Lan Huong - Deputy Head of the Health Insurance Policy Implementation Board, Vietnam Social Security - said: This change expands benefits according to the roadmap, helping health insurance participants to receive additional cost support in case of self-examination for outpatient visits.
However, the payment level of 50% of the benefit level does not apply to all cases but depends on the medical examination and treatment facility, the disease or group of diseases diagnosed and the scope of health insurance benefits of each person.
Type of medical examination and treatment facility applying a payment level of 50% of the health insurance benefit level to self-go for outpatient examination
The 50% payment level is applied when health insurance participants self-go for outpatient examinations at some groups of establishments as follows:
- First, basic level medical examination and treatment facilities that have been identified by competent authorities as provincial level, central level or equivalent to provincial level, central level before January 1, 2025.
- Second, medical examination and treatment facilities are ranked at the basic level, with a total professional competency assessment score from 50 to below 70 points according to regulations on technical professional ranking, except for facilities that have been identified by competent authorities as district level before January 1, 2025.
- Third, specialized level medical examination and treatment facilities that have been identified by competent authorities as provincial level or equivalent to provincial level before January 1, 2025.
How is the 50% payment calculated?
According to Ms. Nguyen Lan Huong, "50% benefit level" is not understood as the health insurance fund paying 50% of the total amount recorded on the medical examination and treatment invoice. This ratio is calculated based on each person's health insurance benefit level and only applies to costs within the scope of benefit, according to the price and health insurance payment conditions.
For example, for people with a health insurance benefit level of 80%, when falling into the case of being paid 50% of the benefit level, the health insurance fund pays equivalent to 40% of the costs within the scope of benefit.
People with a benefit level of 95% will be paid by the fund equivalent to 47.5% of the costs within the scope of benefit. People belonging to the 100% benefit group will be paid equivalent to 50%.
Part of the costs outside the scope of health insurance benefits, on-demand services or items that are not eligible for payment are still self-paid by patients.
Conditions for being paid 50% of the health insurance benefit level to self-examine for outpatient visits
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 fund.
The payment level is determined based on the technical expertise level that the medical examination and treatment facility has been ranked by a competent authority (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 ensure full rights, participants should go for examination at the initial medical examination and treatment registration facility or comply with regulations on transferring medical examination and treatment facilities. In case of needing to go for outpatient examination themselves, patients should contact a medical facility or social insurance agency to be informed about the group of facilities, scope and applicable payment level.
Expanding payment from 0% to 50% of the benefit level for the remaining diseases and groups of diseases contributes to reducing the cost burden, increasing access to health services and better ensuring the rights of health insurance participants.
