Health insurance will pay 50% when outpatient examination is not in the designated area

Sharing about this issue, Ms. Vu Nu Anh, Deputy Director of the Department of Health Insurance (Ministry of Health), said that Decree 02 of the Government has just amended and supplemented a number of articles of Decree 146 detailing and guiding measures to implement the amended and supplemented Law on Health Insurance.

This Decree guides the implementation roadmap and health insurance benefit rates for cases of medical examination and treatment not at the original registered facility or not in accordance with regulations on patient transfer.

Specifically, at newly established medical examination and treatment facilities classified as basic level (scoring less than 50 points according to the Ministry of Health's scale or temporarily classified as basic level), health insurance participants when receiving outpatient medical examination and treatment will be paid 100% of the benefit level by the health insurance fund from January 1, 2025.

At basic medical examination and treatment facilities (scoring from 50 to under 70 points), health insurance participants will receive 50% of the benefit from the health insurance fund when receiving outpatient medical examination and treatment from July 1, 2026.

At basic medical examination and treatment facilities, before January 1, 2025, which have been identified by competent authorities as provincial or central level or equivalent to provincial or central level, health insurance participants when receiving outpatient medical examination and treatment will have health insurance pay 50% of the benefit level from July 1, 2026.

At specialized medical examination and treatment facilities that before January 1, 2025 were determined by competent authorities to be provincial level or equivalent to provincial level according to regulations, health insurance participants when receiving outpatient medical examination and treatment will be paid 50% of the benefit level by the health insurance fund from July 1, 2026.

The regulations on implementation roadmap and benefit rates for outpatient examination and treatment at basic medical examination and treatment facilities have contributed to concretizing the provisions of the Law on Health Insurance.

The Ministry of Health believes that this regulation will gradually help increase access to medical examination and treatment services, increasing the rate of health insurance participants from July 1, 2026 when they go to basic medical examination and treatment facilities, which are currently provincial medical examination and treatment facilities, to 50%.

According to current regulations, health insurance participants who receive outpatient treatment in cases where medical examination and treatment are not provided to the provincial or central level will not be covered by the health insurance fund. If outpatient treatment is provided to the district level, they will be entitled to 100%.

This regulation also ensures convenience for patients when examining and treating with health insurance by only needing to read the health insurance code or ID number and not having to carry any documents after fully integrating into the level 2 electronic identification on the VNeID application.

For children under 6 years old who come to see a doctor, they only need to present their health insurance card. In case the child has not been issued a health insurance card, they must present a copy of the birth certificate or a copy of the birth certificate; in case they need to be treated immediately after birth and do not have a birth certificate, the head of the medical examination and treatment facility and the child's father, mother or guardian must present the following documents: