Article 22 of the 2008 Law on Health Insurance (as amended and supplemented in 2014) specifies the health insurance benefit levels for services obtained within the network and out-of-network as follows:
Health insurance coverage for in-network care:
– 100% Coverage of Medical Costs for the Following Groups:
a) Officers, professional military personnel, non-commissioned officers, and active-duty soldiers.
b) Officers, non-commissioned officers, technical specialists serving in the People’s Public Security force, security academy trainees, and term-serving soldiers in the People’s Public Security.
c) Essential/Cyphering personnel receiving salaries equivalent to military personnel.
d) Cyphering trainees benefiting from policies applicable to military and security academy trainees.
đ) People with revolutionary merits and war veterans.
e) Children under 6 years old.
g) Individuals receiving monthly social protection allowances.
h) Individuals from poor households; ethnic minorities living in areas with difficult or particularly difficult socio-economic conditions; residents of island communes and island districts.
i) Relatives of people with revolutionary merits, including biological parents, spouses, children of martyrs, and those who raised martyrs.
j) Single-visit medical examinations/treatments with costs lower than the government-defined threshold, or visits at commune-level health stations.
k) Patients who have participated in continuous health insurance for 5 years or more, with an annual co-payment amount exceeding 6 months of base salary (except for self-referred off-line visits).
– 95% Coverage of Medical Costs for the Following Groups:
a) Pensioners and individuals receiving monthly loss-of-work-capacity allowances.
b) Relatives of people with revolutionary merits (excluding biological parents, spouses, children of martyrs, and those who raised martyrs).
c) Individuals from near-poor households.
– 80% Coverage of Medical Costs for:
Important Notes:
– The above benefit levels also apply to insured individuals registered for primary care at commune health stations, polyclinics, or district hospitals starting from January 1, 2016.
– If an individual falls under multiple coverage categories, they are entitled to the highest benefit level among their eligible categories.
Threshold Conditions for 100% Medical Cost Coverage
Pursuant to Point d, Clause 1, Article 14 of Decree 146/2018/NĐ-CP, where the cost of a single medical examination or treatment session is lower than 15% of the base salary, the patient shall have 100% of the medical examination and treatment costs covered by health insurance.
From now until June 30, 2019, if medical examination and treatment costs are 208,500 VND or less, the patient will have 100% of the cost covered by health insurance (equivalent to 15% of the base salary of 1.39 million VND/month).
However, starting from July 1, 2019, patients are entitled to the aforementioned benefit only if the medical examination and treatment costs are lower than VND 223,500 (equivalent to 15% of the base salary of VND 1.49 million per month).
Criteria for On-Line Medical Visits (Correct Route)
(1) Seeking medical examination and treatment at the primary healthcare facility registered on the health insurance card.
(2) Individuals whose health insurance cards are registered for primary care at a commune-level health station, polyclinic, or district hospital, seeking care at another commune health station, polyclinic, or district hospital within the same province.
Children who do not have a health insurance card due to pending birth registration may use their birth notification document for medical care.
(3) Admitted for emergency treatment at any healthcare facility.
(4) Transferred in accordance with official referral regulations, including:
– Referrals under Articles 10 and 11 of Circular 40/2015/TT-BYT dated November 16, 2015.
– Referrals under Clause 3, Article 14 of Decree 146/2018/ND-CP dated October 17, 2018.
– Referrals under Clause 2, Article 6 of Circular 04/2016/TT-BYT dated February 26, 2016.
(5) Presenting valid documentation proving stay in another locality during a business trip, mobile work, full-time study, or temporary residence, and seeking primary care at an equivalent facility (same administrative level) as the primary care facility registered on the health insurance card (pursuant to Clause 7, Article 15 of Decree 146/2018/ND-CP).
(6) Presenting a follow-up appointment slip in cases where the patient was previously transferred.
(7) Requiring immediate medical treatment after organ donation.
(8) Requiring immediate medical treatment right after birth.
Since January 1, 2021, health insurance covers 100% of inpatient treatment costs according to the beneficiary’s coverage rate for self-referred (off-line) visits at provincial-level medical facilities nationwide (Clause 1, Article 22 of the amended Law on Health Insurance).
