Eliminate direct payment procedures for health insurance participants for 5 consecutive years

The Ministry of Health has just issued a document guiding the implementation of Decree 188/2025/ND-CP of the Government detailing and guiding the implementation of a number of articles of the Law on Health Insurance. One of the important contents of Official Dispatch 6872/BYT-BH is the guidance on direct payment of health insurance costs for participants who have participated for 5 consecutive years...

From July 1, 2025, people who have participated in health insurance for 5 consecutive years will no longer have to make direct payments.

Resolve direct payment cases by July 1, 2025

said, according to Point b Clause 3 Article 27 Decree 146/2018/ND-CP detailing and guiding measures to implement a number of articles of the Law on Health Insurance, patients with a cumulative co-payment amount in the fiscal year greater than 6 months of basic salary will be paid this excess directly at the Social Insurance agency, specifically:

In case the patient has a cumulative co-payment amount in the fiscal year at different medical examination and treatment facilities or at the same medical facility greater than 6 months of basic salary, the patient shall bring the documents to the Social Insurance agency that issued the health insurance card to pay the co-payment amount greater than 6 months of basic salary and receive a certificate of no co-payment in that year.

However, this regulation will cease to be effective from July 1, 2025 according to Clause 4, Article 70 of Decree 188/2025/ND-CP, when the new Decree officially takes effect and replaces Decree 146/2018/ND-CP.

After July 1, 2025, there will be no more direct payment procedures.

The Ministry of Health said that according to Article 54 of Decree 188/2025/ND-CP, the regulation on direct payment of medical examination and treatment costs under health insurance no longer includes cases where participants have participated for 5 consecutive years and have a co-payment amount greater than 6 months of basic salary.

Social Insurance agencies and medical examination and treatment facilities guarantee benefits and payments to patients according to regulations; patients do not have to carry out direct payment procedures.

The Social Insurance Agency is responsible for synthesizing and regularly updating information on the cumulative co-payment amount in the patient's fiscal year, the time when the patient participates in health insurance for 5 consecutive years or more, and notifying it on the Vietnam Social Insurance Data Portal.

Medical examination and treatment facilities shall base on the accumulated co-payment amount and the time when the patient has participated in health insurance for 5 consecutive years or more to determine the time when the patient is eligible for co-payment exemption during the patient's medical examination and treatment.

Instead, the Social Insurance agency and medical examination and treatment facilities are responsible for ensuring the rights of patients and making internal payments; patients do not have to make direct payment procedures as before.

Thus, from July 1, 2025, health insurance participants who have participated in health insurance for 5 consecutive years will no longer have to submit their own direct payment documents, but the identification and exemption from co-payment will be done automatically through the data system between the Social Insurance agency and the medical examination and treatment facility.

Medical examination and treatment facilities and Social Insurance agencies are responsible for properly implementing regulations on determining costs within the scope, health insurance benefits and co-payment costs of patients, sending payment data, and publishing complete, accurate and timely information on the Social Insurance agency's Data Receiving Portal as prescribed.

Clearly define co-payment costs for health insurance participants for 5 consecutive years

According to Point b, Clause 2, Article 18 of Decree 188/2025/ND-CP, the Social Insurance agency is responsible for synthesizing information on the cumulative co-payment amount in the patient's fiscal year, the time when the patient participates in health insurance for 5 consecutive years or more and notifies on the Data Receiving Portal of Vietnam Social Insurance.

Medical examination and treatment facilities shall base on the accumulated co-payment amount and the time the patient has participated in health insurance for 5 consecutive years or more to determine the time when the patient is eligible for co-payment exemption during the patient's medical examination and treatment.

The Ministry of Health emphasized that in case a medical examination and treatment facility determines costs within the scope, health insurance benefits and co-payment costs of the patient or sends payment data that is not in accordance with regulations, affecting the rights of health insurance participants, the medical examination and treatment facility must bear responsibility.

In case the Social Insurance agency fails to disclose information fully, accurately and promptly as prescribed to serve as a basis for reference, the Social Insurance agency must bear responsibility.

nhandan.vn

Source: https://baolaocai.vn/bo-thu-tuc-thanh-toan-truc-tiep-cho-nguoi-tham-gia-bao-hiem-y-te-du-5-nam-lien-tuc-post884294.html