Scope and level of health insurance benefits

Based on the provisions of the Health Insurance Law 2008 and the revised Health Insurance Law 2014, LawFirm.Vn will provide necessary information on the issue of scope and level of health insurance benefits.

1. What is health insurance?

Clause 1, Article 1 of the 2014 Amended Health Insurance Law stipulates, Health insurance is a form of compulsory insurance applied to subjects prescribed by this Law for health care, not for other purposes. Profits are made by the State.

2. Scope of health insurance coverage

Article 21 of the 2008 Health Insurance Law and Article 1 of the 2014 Revised Health Insurance Law stipulate:

– Health insurance participants have the following costs covered by the health insurance fund:

+ Medical examination, treatment, rehabilitation, periodic prenatal examination, and childbirth.

+ Transporting patients from the district level to the higher level for subjects specified in Points a, d, e, g, h and i, Clause 3, Article 12 of the 2008 Health Insurance Law in case of emergency or while on medical treatment. Inpatient treatment requires referral to technical expertise.

– The Minister of Health presides over and coordinates with relevant ministries and branches to promulgate a list, rates, and payment conditions for drugs, chemicals, medical supplies, and medical technical services within the scope of benefits of health insurance participants.

3. Health insurance benefits

– When health insurance participants go for medical examination and treatment according to the provisions of Articles 26, 27 and 28 of the 2008 Health Insurance Law, the health insurance fund will pay the medical examination and treatment costs during the period of time. The scope of benefits is as follows:

+ 100% of medical examination and treatment costs for subjects specified in Points a, d, e, g, h and i, Clause 3, Article 12 of the 2008 Health Insurance Law. External medical examination and treatment costs The scope of health insurance benefits of the subjects specified in Point a, Clause 3, Article 12 of the 2008 Health Insurance Law is paid from the health insurance funding source for medical examination and treatment of this group of subjects. ; In case this funding source is not enough, it will be guaranteed by the state budget;

+ 100% of medical examination and treatment costs in cases where the cost for one medical examination and treatment is lower than the level prescribed by the Government and medical examination and treatment at the commune level

+ 100% of medical examination and treatment costs when the patient has participated in health insurance for 5 consecutive years or more and has the amount of money to pay for medical examination and treatment costs in the year greater than 6 months of basic salary. facility, except in cases where you go for medical examination or treatment at the wrong level;

+ 95% of medical examination and treatment costs for subjects specified in Point a Clause 2, Point k Clause 3 and Point a Clause 4 Article 12 of the 2008 Health Insurance Law;

+ 80% of medical examination and treatment costs for other subjects.

– In case a person belongs to many subjects participating in health insurance, they will receive health insurance benefits according to the subject with the highest benefit.

– In case a person with a health insurance card goes for medical examination or treatment at the wrong route, the health insurance fund will pay the benefit specified in Clause 1 of this Article at the following rate, except for the cases specified in Clause 5, Article 22 of the Health Insurance Law 2008:

+ At central hospitals, it is 40% of inpatient treatment costs;

+ At provincial hospitals, it is 60% of inpatient treatment costs from the effective date of this Law to December 31, 2020; 100% of inpatient treatment costs from January 1, 2021 nationwide;

+ At district hospitals, it is 70% of medical examination and treatment costs from the effective date of this Law to December 31, 2015; 100% of medical examination and treatment costs from January 1, 2016.

– From January 1, 2016, health insurance participants who register for initial medical examination and treatment at a commune-level medical station or polyclinic or district hospital are entitled to insured medical examination and treatment. Health care at a commune health station or polyclinic or district hospital in the same province has the benefit level as prescribed in Clause 1, Article 33 of the 2008 Health Insurance Law.

– Ethnic minorities and people from poor households participating in health insurance are living in areas with difficult socio-economic conditions, areas with extremely difficult socio-economic conditions; Health insurance participants living in island communes and island districts, when they go for medical examination and treatment at the wrong level, will have their medical examination and treatment costs paid by the health insurance fund at district and hospital hospitals. Inpatient treatment at provincial and central hospitals and benefits as prescribed in Clause 1, Article 22 of the 2008 Health Insurance Law.

– From January 1, 2021, the health insurance fund pays inpatient treatment costs according to the benefit level specified in Clause 1, Article 22 of the 2008 Health Insurance Law for health insurance participants when they go for self-examination. diseases and improper medical treatment at provincial medical examination and treatment facilities nationwide.

The Government specifically regulates the benefit levels for medical examination and treatment covered by health insurance in bordering areas; Cases of medical examination and treatment upon request and other cases not specified in Clause 1, Article 22 of the 2008 Health Insurance Law.

4. In cases where health insurance is not available

Article 23 of the 2008 Social Insurance Law and Article 1 of the 2014 Amended Health Insurance Law stipulate that the following cases are not eligible for health insurance:

– Expenses in the case specified in Clause 1, Article 21 have been paid by the state budget.

– Nursing and convalescence at nursing and convalescence facilities.

– Physical examination.

– Pregnancy testing and diagnosis are not for treatment purposes.

– Use assisted reproductive technology, family planning services, abortion, except in cases where pregnancy must be terminated due to fetal or maternal pathology.

– Use cosmetic services.

– Treatment of strabismus, nearsightedness and refractive errors of the eyes, except for children under 6 years old

– Use alternative medical supplies including artificial limbs, artificial eyes, artificial teeth, eyeglasses, hearing aids, and mobility aids in medical examination, treatment and rehabilitation.

–  Medical examination, treatment, and rehabilitation in case of disaster.

– Medical examination and treatment of drug addiction, alcohol addiction or other addictive substances

– Medical examination, forensic examination, forensic psychiatric examination.

– Participate in clinical trials and scientific research.