Sending a question to the Social Insurance agency, reader T asked: After merging administrative units, Ms. T.T. T (Ninh Binh) took her child for medical examination and treatment at Nam Dinh Children's Hospital, but the Hospital still announced that her child's case was an out-of-zone examination and did not fully enjoy health insurance benefits as prescribed.
Currently, the province has been merged, so is the enjoyment of health insurance (HI) between medical facilities in the same province considered to be in accordance with the line?
Is the hospital's determination to be out-of-line in this case correct? If it has not been applied uniformly, what is the official time to implement policies related to health insurance after the merger? " - Ms. T asked.
Regarding this issue, Ninh Binh Provincial Social Insurance answers as follows:
Based on the 2008 Health Insurance Law; Law No. 46/2014/QH13 amending and supplementing a number of articles of the Health Insurance Law Law No. 51/2024/QH15 amending and supplementing a number of articles of the Health Insurance Law;
Based on Decree No. 188/2025/ND-CP dated July 1, 2025 of the Government detailing and guiding the implementation of a number of articles of the Health Insurance Law;
From January 1, 2025, Nam Dinh Children's Hospital is ranked as basic level and before January 1, 2025, it is identified as provincial level.
Based on Clause 1, Article 19 of Decree No. 188/2025/ND-CP: "From January 1, 2025, when outpatient medical examination and treatment at a basic level medical examination and treatment facility reaches a score below 50 points or is temporarily ranked as basic level, health insurance participants are paid 100% of the benefit level by the health insurance fund, except for basic level medical examination and treatment facilities that have been identified by competent authorities as provincial or central levels before January 1, 2025".
Based on point 6, clause 15, Article 1 of Law No. 46/2014/QH13: "From January 1, 2021, the health insurance fund shall pay inpatient treatment costs according to the benefit level specified in clause 1 of this article for health insurance participants when they self-go for medical examination and treatment not in accordance with the tuyến at provincial-level medical examination and treatment facilities nationwide".
Thus, at the time Ms. T's child went for outpatient examination at Nam Dinh Children's Hospital (examined in the wrong place registered for initial examination and treatment), it was not within the scope of payment of the health insurance fund.
From July 1, 2026, implementing the provisions of Clause 2, Clause 3, Article 19 of Decree No. 188/2025/ND-CP, if her child goes for outpatient examination at Nam Dinh Children's Hospital (or other provincial-level hospitals), the health insurance fund will pay 50% of the benefit level.
