Regulations of benefits for health insurance participants

According to Article 21 of the Law on Health Insurance, health insurance participants are reimbursed by the health insurance fund for costs related to medical examination, treatment, rehabilitation, regular prenatal check-ups, and childbirth. Additionally, the fund covers medical examinations for screening and early diagnosis of certain diseases as prescribed.

In particular, for subjects who are officers, non-commissioned officers, people with meritorious services to the revolution, and children under 6 years of age, the health insurance fund also supports transportation costs from the district level to higher levels in cases of emergency or when inpatient treatment requires transfer for professional technical reasons.

Specific health insurance benefit levels

Health insurance participants, when undergoing medical examination and treatment in accordance with regulations, will be reimbursed by the health insurance fund at different levels, depending on the participant category.

The benefit level of 100% of medical examination and treatment costs applies to: Officers, professional and technical non-commissioned officers within the People’s Public Security force; People with meritorious services to the revolution; Children under 6 years of age. Additionally, cases where the cost of a single medical visit is lower than the limit prescribed by the Government, and medical examination and treatment at the commune level are also entitled to the 100% level.

The benefit level of 95% of medical examination and treatment costs applies to persons receiving monthly pensions, monthly allowances for loss of working capacity, and persons receiving monthly social protection allowances.

The benefit level of 80% of medical examination and treatment costs applies to other subjects not belonging to the above-mentioned groups.

Regulations regarding medical examination and treatment outside of designated referral systems.

In cases where health insurance cardholders voluntarily seek medical examination and treatment not at the prescribed professional technical level (off-line), the health insurance fund will pay costs according to the prescribed benefit levels (100%, 95%, or 80%, depending on the subject) but at a lower rate. Specifically, at central-level hospitals, it is 30% of inpatient treatment costs; at provincial-level hospitals, it is 50% of inpatient treatment costs; and at district-level hospitals, it is 70% of medical examination and treatment costs.

Cases not covered by health insurance

Participants should note several cases not covered by the health insurance fund under Article 23, including: Medical examination and treatment costs already paid by the state budget; nursing and convalescence at nursing facilities; regular health check-ups; prenatal testing and diagnosis not for treatment purposes.

Additionally, aesthetic services, corrective surgery, prosthetics (artificial limbs, eyes, teeth), and hearing aids are not within the scope of payment. Medical examination and treatment due to drug addiction, alcohol addiction, or other addictive substances, as well as medical assessment and forensic assessment, belong to the group not covered by health insurance.

MSc. Nguyen Nam Anh – Center for Support & Continuing Education