In case of medical examination and treatment on demand, it is covered by health insurance.

Ms. Vu Nu Anh, Deputy Director of the Department of Health Insurance ( Ministry of Health ), said that Decree 02/2025 of the Government supplements regulations for cases where health insurance participants go for medical examination and treatment upon request, the Health Insurance Fund will pay part of the medical examination and treatment costs according to the scope of benefits (if any) as prescribed in Article 22 of the Law on Health Insurance.

"The difference in cost 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 to the medical examination and treatment facility," Ms. Nu Anh affirmed.

Decree 02 also stipulates that medical examination and treatment facilities are responsible for publicly disclosing expenses that patients must pay outside the scope of benefits and health insurance benefits, the difference in costs, and must notify patients in advance.

According to the representative of the Department of Health Insurance, the above regulation aims to ensure transparency of information on costs within and outside the scope of patient benefits, helping patients clearly understand the costs within the scope of benefits and the costs that need to be paid.

Doctors at Viet Duc Friendship Hospital ( Hanoi ) examine a child patient receiving inpatient treatment. Photo: T.Thang

Speaking with VietNamNet on July 9, the director of a basic-level hospital in Hanoi (formerly provincial level) affirmed that this policy is not new.

In fact, in Decree 85/2012, the Government stipulates that people with health insurance cards are paid by the Health Insurance Fund for medical examination and treatment costs to medical examination and treatment facilities according to the level prescribed by the law on health insurance. The difference between the medical examination and treatment costs and the payment level of the Health Insurance Fund is paid by the patient to the medical examination and treatment facility.

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

"However, previous documents 'did not clearly stipulate' as in Decree 02, hospitals can implement or not implement. Many hospitals are 'hesitant' because many costs (such as bed fees) are very complicated and detailed, and they do not meet the information technology requirements to clearly separate the part that patients are entitled to under health insurance and the difference that must be paid. Therefore, hospitals have separate regulations for on-demand service examinations (often called voluntary) and health insurance examinations for convenience in settlement of payments", said this director.

Dr. Nguyen Van Thuong, Director of Duc Giang General Hospital - Hanoi (classified as basic level, grade I), affirmed that the policy of medical examination and treatment on demand paid by health insurance was implemented before 2020.

Currently, the medical examination fee paid by the health insurance fund at this hospital and other special and first-class hospitals such as Bach Mai, Viet Duc, and Xanh Pon... is 50,600 VND.

The price for on-demand examination at Duc Giang General Hospital is only 200,000 VND. At other hospitals, it ranges from 250,000 - 500,000 VND/visit depending on each facility, professional level, and choice of specialist (doctor, senior doctor, master, doctor, associate professor, professor...).

When having a medical examination upon request, the person with a health insurance card will be paid 50,600 VND/visit by the Health Insurance Fund according to the benefit rate (written on the card). Similarly, with other technical services upon request such as ultrasound, testing, surgery, hospital beds... the patient will also be paid according to regulations. The remaining difference in cost will be paid by the patient.

Conditions for health insurance fund to pay for medical examination and treatment upon request

However, not all patients with health insurance cards will be covered by the Health Insurance Fund when they go for medical examination and treatment as required, but it depends on whether they go to the right level and right route or not.

Currently, health insurance participants have 3 benefit levels recorded on the card: 80%, 95% or 100%.

For those who go to the right medical facility for examination, the Health Insurance will pay 50,600 VND. However, not everyone will be paid 100% of this 50,600 VND. The Health Insurance Fund will pay according to the benefit level on the patient's card (80-95-100%).

For example, a person with a benefit level of 80%, the Health Insurance Fund only pays nearly 40,500 VND, the patient will pay an additional 10,000 VND, in addition to the difference between the on-demand examination price and the Health Insurance price.

In case of self-examination and treatment (outside the designated area) at a specialized level (usually the former Central level hospital), health insurance will not be paid for; inpatient or emergency treatment will be paid for by health insurance according to regulations.

Specifically, if hospitalized for inpatient treatment, the patient will receive 40% of the treatment cost according to the benefit level stated on the health insurance card. For example, a person with a benefit level of 80%, if hospitalized for inpatient treatment, the health insurance fund will pay 32%.

In the case of self-examination and treatment at a basic-level hospital (usually a provincial-level hospital in the past), the patient is only entitled to health insurance when receiving inpatient treatment, with a payment level of 100% according to the benefit level.

Particularly at newly established medical examination and treatment facilities that are classified as basic level with a score of less than 50 points or are temporarily classified as basic level, when health insurance participants go for outpatient medical examination and treatment themselves, the Health Insurance Fund will pay 100% of the benefit amount.

Source: vietnamnet

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