Medical examination services are still covered by health insurance.

It seems paradoxical but it is a reality at many hospitals: when patients register for medical examination services, they are still covered for a part of the health insurance cost depending on the category.

Patients who receive medical examination and treatment on demand are paid by the health insurance fund according to the scope of benefits, which has increased the ability to access high-quality services at lower costs for patients - Photo: DUYEN PHAN

Since this policy took effect on July 1, the Law on Health Insurance requires hospitals to publicly disclose service costs and notify patients in advance of the difference in fees they must pay.

This policy, according to the Ministry of Health , will increase benefits for patients; at the same time, it will be transparent when patients clearly know the part of the cost covered by health insurance and the part they pay themselves, helping them to be proactive in choosing appropriate medical services.

To ensure transparency and reasonable use of resources to serve patients, medical facilities need to develop and publicly disclose clear fees, in accordance with the instructions and regulations of the Ministry of Health. Communication work must be implemented systematically, clarifying regulations on co-payment, self-payment, payment conditions and specific health insurance benefits.

Doctor Vo Hong Minh Phuoc (Deputy Director of Ho Chi Minh City Oncology Hospital)

Insurance covers more than 40,000 - 50,000 VND/visit for service examination

Faced with the reality of having to wait a long time for health insurance examinations, many patients, even though having health insurance, still choose to receive medical examination and treatment services to save time on travel, accommodation, etc. Many patients do not know about the option of registering for medical examination and treatment on demand and still being partially paid for by health insurance.

Recently, Ms. DTKD was advised by a doctor at a tertiary hospital in Ho Chi Minh City to undergo surgery due to an arm injury. However, due to the large number of patients, the health insurance surgery schedule was full, while her condition was not acute and the patient was told to wait half a month for health insurance surgery.

"If I register for surgery outside of working hours as requested, I will pay 8.5 million VND instead of only 3 million VND for surgery with health insurance. Of this, the additional service fee outside of working hours is calculated at 5.5 million VND, health insurance covers medicine and room fees," said Ms. D.

Having participated in health insurance since 2018, Ms. BN (30 years old, living in Ho Chi Minh City) decided to switch to the maternity service at Tu Du Hospital, after several health insurance check-ups here but having to wait too long.

When she gave birth at the end of 2024, she also chose the "business" service with a service bed costing 1 million VND/day.

Even though it was a service, the surprising thing when she was discharged from the hospital was that Ms. N. was still covered by health insurance for more than 2 million VND out of 18 million VND including all types of expenses. "When I was discharged from the hospital, I found out that even though I chose the service package for giving birth and staying in a bed, health insurance still covered nearly 15% of the total hospital bill," Ms. N. confided.

Mr. Pham Van Thang (34 years old, from Ninh Binh ) said that he has participated in health insurance for 4 years, although he has gone to the hospital many times for medical examination but has never used his health insurance card.

"Most of the time I choose to have medical examinations and treatments done by private medical services because the waiting time at the health insurance clinic is long. The service examinations are also paid for, even if it is a small part, it helps a bit, and there are more benefits when participating in health insurance," Mr. Thang said frankly.

According to Tuoi Tre 's research, the current service price paid by the health insurance fund at medical examination and treatment facilities ranges from 33,000 - 50,000 VND. For medical examination and treatment on demand, the price ranges from 200,000 - 400,000 VND depending on each medical examination and treatment facility, according to the level of expertise, and the choice of specialist.

For example, at Bach Mai Hospital (Hanoi), the health insurance examination fee is 50,600 VND/visit; the service examination fee upon request for masters and doctors is 300,000 VND/visit; for PhDs and specialist II is 350,000 VND/visit, and for professors, associate professors and senior doctors is 400,000 VND/visit.

Thus, when examining and treating patients on demand, health insurance participants who choose to see a specialist will be paid 50,600 VND/visit, the remaining difference in cost will be paid by the patient.

"That means if a master's examination costs 300,000 VND, the patient will have to pay 249,400 VND. In addition, for other technical services such as ultrasound, testing, surgery, hospital beds... the patient will also be covered by the health insurance fund according to regulations and must pay the remaining difference," a doctor analyzed.

Health insurance patients wait for medical examination in order at District 7 Hospital, Ho Chi Minh City, July 2, 2025 - Photo: TU TRUNG

How does health insurance pay?

Speaking with Tuoi Tre, Ms. Nguyen Thi Thu Hang, Deputy Director of Social Insurance Region 27, said that health insurance payment for medical examination services at medical examination and treatment facilities has existed before, but was only shown in circulars on health insurance payment prices.

Specifically, in 2024, social insurance payments will be based on Circular 22/2023/TT-BYT dated November 17, 2023. Article 5, Point 7 stipulates that in cases where there is a health insurance card and the use of medical examination and treatment services upon request, the health insurance fund will pay the costs within the scope of benefits and the benefit level according to the provisions of the Law on Health Insurance and implementing guidelines.

From January 1, 2025, Circular 22/2023/TT-BYT expires and this content is regulated by the Government in Decree 02/2025/ND-CP dated January 1, 2025, Article 1, Point 1 (effective from January 1, 2025).

People with health insurance cards who seek medical examination and treatment upon request will have the health insurance fund pay the cost within the scope of benefits (if any) as prescribed in Article 22 of the Law on Health Insurance. The difference between the price of medical examination and treatment services upon request and the payment level of the health insurance fund shall be paid by the patient.

Medical examination and treatment facilities are responsible for ensuring human resources, professional conditions, medical equipment, and the ability to provide services in accordance with the contract signed with the social insurance agency and publicly disclosing expenses that patients must pay outside the scope of benefits; as well as the health insurance benefit level, the difference in costs, and must notify patients in advance.

Sharing more about this issue, Ms. Vu Nu Anh, Deputy Director of the Department of Health Insurance (Ministry of Health), said that people with health insurance cards who go for medical examination and treatment as requested will have the health insurance fund pay part of the cost according to the scope of benefits, stipulated in Article 22 of the Law on Health Insurance.

In which the difference between the price of medical examination and treatment services upon request and the payment level of the health insurance fund is paid by the patient.

"This means that even if a health insurance participant receives medical examination and treatment upon request, the health insurance fund will still cover the cost according to the regulations on medical examination and treatment prices under health insurance. The difference between the price of medical examination and treatment on request and the health insurance will be paid by the patient himself/herself," Ms. Nu Anh stated.

Explaining this regulation in more detail, an expert from Hanoi Social Insurance said that currently, the health insurance payment level will be 40%, 80% or 100%. In the case of outpatient treatment, if the patient goes to a medical facility other than the initial medical facility listed on the card, he/she will not be paid. Only inpatient or emergency treatment will the health insurance cover a part.

If a patient goes to a specialized hospital (formerly a central hospital) for examination (without a valid referral) and has to be hospitalized for inpatient treatment, he/she will receive 40% of the inpatient treatment costs according to the benefit level on the health insurance card. In case of outpatient examination at a specialized hospital, the health insurance will not pay.

"Similarly, if you go to a primary hospital (formerly a provincial hospital) outside the province where you initially registered without a referral, you will only be covered by health insurance when you are an inpatient, with the correct payment level (usually 80% or 100% depending on the benefits listed on the card)," this expert stated.

Similar to health insurance medical examination and treatment, to be paid for medical examination and treatment upon request, patients also need to ensure the regulations on referral to a higher level to enjoy the highest payment level.

Summary: XM

Policy has been in place for many years

That is the assertion of the expert of the Health Insurance Department. Accordingly, Decree 85 of 2012 stipulates that people with health insurance cards are paid by the health insurance fund for medical examination and treatment costs at the prescribed rate. The difference between the examination cost and the payment level of the health insurance fund is paid by the patient.

In 2019, the Ministry of Health also sent a document to Vietnam Social Security requesting payment of health insurance medical examination and treatment costs when using on-demand services.

"The Ministry of Health has issued three documents guiding implementation. However, before that, some hospitals had difficulty in paying the social insurance agency, especially problems with the implantation machine, the machine owned by the whole people...

Therefore, in this revised Law on Social Insurance, the Ministry of Health has consolidated the documents and included them in the law so that the instructions are coherent and clear. This creates conditions for relevant parties to have a basis for implementation, ensuring the rights of the people," said this expert.

* Mr. Tang Chi Thuong (Director of Ho Chi Minh City Department of Health):

Breakthrough in scope, objects, and benefits

To ensure the rights of patients who use medical examination and treatment services and have health insurance cards, the Ministry of Health requires medical examination and treatment facilities to ensure human resources, professional conditions, medical equipment, and the ability to provide medical examination and treatment services in accordance with the contract signed with the social insurance agency.

In addition, it is also stipulated that medical examination and treatment facilities must ensure that the number of hospital beds providing services on demand at any one time does not exceed 20%; experts and good doctors of the unit spend a minimum of 70% of their time examining and treating health insurance patients.

I believe that the health insurance policy systems that came into effect on July 1 are groundbreaking in terms of scope, subjects, benefits and support mechanisms. People can enjoy many of these new services, but they also pose many challenges that require the health sector to prepare carefully and synchronously.

Patients using medical services are still partially covered by health insurance - Photo: TU TRUNG

Reduce financial burden, ensure the rights of both patients and hospitals

Speaking to Tuoi Tre , Dr. Vo Hong Minh Phuoc, deputy director of the Ho Chi Minh City Oncology Hospital, said that the fact that patients receive medical examination and treatment on demand and are paid by the health insurance fund according to the scope of benefits has increased the ability for patients to access high-quality services at lower costs.

"This policy creates peace of mind and allows individuals to proactively choose services that suit their personal finances. At the same time, it protects the rights of health insurance participants, especially those with chronic diseases and cancer who need treatment services," Dr. Phuoc affirmed.

According to Mr. Phuoc, the hospital has currently built a service price list according to the requirements in accordance with the instructions of the Ministry of Health, ensuring both suitability to reality and compliance with payment regulations.

Along with that, it is necessary to organize reasonable examination flow, arrange appropriate human resources, have a separate reception process for patients who enjoy health insurance but register for service examination, and notify patients in advance of the difference in costs.

In addition, the unit has also supplemented and signed an appendix to the contract with the social insurance agency on adjusting working hours and updating the practice time of doctors in accordance with the practice time on the registration system of the Department of Health.

The hospital also increased communication, instructions at the reception desk, posts on fanpages, short videos in areas inside the hospital... to help patients understand the regulations and make appropriate choices.

At Thong Nhat Hospital, Associate Professor Le Dinh Thanh, hospital director, said that for many years now, people who seek medical treatment at the hospital have been covered by the health insurance fund. And since July 1, this issue has been included in the Health Insurance Law, so it is clearer and more popular at medical facilities.

According to him, there is transparency between the examination areas at the hospital, including the staff examination area, the regular health insurance examination area and the service examination area. Every day, the hospital receives about 3,000 - 4,000 health insurance examinations and the service examination area usually fluctuates from 800 - 1,000. Among the health insurance examinations, he said that there are many patients with health insurance who choose to have service examinations.

According to regulations, when patients use health insurance services, the cost that health insurance covers will be deducted and they only need to pay the remaining difference.

"This regulation helps people access higher quality services but reduces the financial burden thanks to partial payment by health insurance," Mr. Thanh said.

The director of a hospital in Hanoi said that in the past, some hospitals had applied this form, allowing patients to use their health insurance cards when choosing a service examination area, but there were no clear regulations in the law. Therefore, many hospitals have not applied it, and patients when having an examination upon request often have to pay for everything themselves, including technical costs or medicine.

"For examination fees, the initial cost difference may be large, but when it comes to treatment, testing, surgery... the cost difference will not be too large. For patients who receive medical examination and treatment on demand, the payment level will be significantly reduced.

This new regulation will bring clear benefits to patients, especially those who have participated in health insurance but still want high-quality services. This is a big step forward," he said.

Not only beneficial for patients, according to many hospital directors, the new regulation will also benefit hospitals, as the number of patients choosing the service can increase thanks to the policy of "service examination still enjoying insurance". From here, hospitals will have more legal revenue from the difference in service.

The director of a tertiary hospital in Ho Chi Minh City affirmed that when this regulation is legalized, public hospitals will be able to implement it more transparently, which opens up opportunities to improve service quality through diversifying types of medical examination and treatment while still ensuring health insurance benefits.

In particular, promoting healthy competition between public and private facilities, forcing public hospitals to innovate and upgrade the quality of medical examination and treatment to meet the people's increasing expectations.

"The medical facility will also rebalance resources between the two forms of health insurance examination and service examination, avoiding overload in the health insurance area, ensuring the rights of both groups of patients in a fairer and more effective way," said the hospital director.

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Source: https://tuoitre.vn/kham-dich-vu-van-duoc-bao-hiem-y-te-chi-tra-20250707085536995.htm