Scope of Benefits for Health Insurance Participants

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

In particular, for specific groups such as officers, non-commissioned officers, people with meritorious services to the revolution, and children under 6 years old, the health insurance fund also supports transportation costs from the district level to higher levels in cases of emergency or when transferring between professional and technical levels during inpatient treatment.

Specific Health Insurance Benefit Levels

When health insurance participants seek medical examination and treatment in accordance with regulations, the health insurance fund will reimburse costs at different levels, depending on the participant category.

A 100% reimbursement rate for medical costs applies to: Professional and technical officers and non-commissioned officers of the People’s Public Security forces; People with meritorious services to the revolution; and children under 6 years old. Furthermore, cases where the cost of a single medical visit is lower than the Government’s prescribed threshold, or treatments conducted at the commune level, are also eligible for 100% coverage.

A 95% reimbursement rate applies to retirees, individuals receiving monthly loss-of-working-capacity benefits, and those receiving monthly social protection allowances.

An 80% reimbursement rate applies to other groups not mentioned in the above categories.

Regulations on Out-of-Network Medical Examination and Treatment

In cases where health insurance cardholders seek medical examination or treatment at a level higher than their designated professional and technical route without a referral, the health insurance fund will reimburse costs based on the prescribed benefit levels (100%, 95%, or 80% depending on the subject) but at a lower percentage. Specifically: 30% for inpatient treatment costs at central-level hospitals; 50% for inpatient treatment costs at provincial-level hospitals; and 70% for medical costs at district-level hospitals.

Cases Not Covered by Health Insurance

Participants should note several cases where the health insurance fund does not provide coverage according to Article 23, including: Medical costs already covered by the state budget; nursing or convalescence at nursing facilities; routine physical examinations; and pregnancy tests or diagnostics not intended for treatment purposes.

Additionally, services related to aesthetics, orthopedics, prosthetic limbs, glass eyes, dentures, and hearing aids are not within the scope of coverage. Medical examinations and treatments resulting from addiction to drugs, alcohol, or other addictive substances, as well as medical and forensic examinations, are also excluded from health insurance benefits.

MSc. Nguyen Nam Anh – Continuous Training and Support Center