Correct understanding of enjoying 100% provincial health insurance from January 1, 2021

Provincial health insurance: Not applicable to Central hospitals

Due to not understanding the hospital routes correctly, many people mistakenly think that the provincial route policy applies to all hospitals.hospitallocated in a province or centrally-run city of the whole country. This understanding is incorrect.

Currently, according to Circular 40/2015/TT-BYT, health examination and treatment facilities covered by health insurance are divided into 4 levels: Commune - District - Province - Central. The policy of connecting to the province only applies to medical facilities at the provincial level and not to hospitals at the central level.

Every day, Nghe An General Hospital receives dozens of stroke cases of all kinds. Photo courtesy of Thanh Cuong

Health insurance only pays for inpatient treatment outside the province.

Clause 3, Article 22, Law on Health Insurance 2008, amended and supplemented in 2014, clearly states:

In case of card holderhealth insuranceIf you go to the wrong medical facility for examination and treatment, the health insurance fund will pay according to the benefits when you go to the right medical facility for examination and treatment at the following rates:

At provincial hospitals: 100% of inpatient treatment costs nationwide from January 1, 2021.

Accordingly, health insurance participants who go to provincial hospitals for medical examination and treatment will be entitled to 100% of inpatient treatment costs nationwide at the same level as when going to the right hospital for medical examination and treatment.

Every year, Vinh City General Hospital receives nearly 20 emergency cases of CO poisoning. Photo courtesy of Thanh Chung

To be paid for health insurance when examining and treating outpatients at provincial hospitals, patients must have a referral letter from a lower-level hospital.Health Insurance FundPay for medical examination and treatment costs according to the benefit level of the health insurance participant.

Not everyone is covered for 100% of their inpatient treatment.

As mentioned above, people with health insurance cards who go to provincial hospitals for medical examination and treatment are entitled to 100% of inpatient treatment costs at the same level as in the correct hospital.

Currently, the level of health insurance benefits when receiving medical treatment at the right medical facility is regulated in Article 22, Law on Health Insurance 2008, amended in 2014 as follows:

- 100% of medical examination and treatment costs: Soldiers, police; people with revolutionary contributions, veterans; children under 6 years old; people from poor households; people who have participated in health insurance for 5 consecutive years and have the amount of co-payment for medical examination and treatment costs in the year greater than 6 months of basic salary...

Cochlear implant surgery to treat congenital hearing loss in children at Nghe An Obstetrics and Pediatrics Hospital. Photo courtesy of Thanh Chung

- 80% of medical expenses: Other subjects.

Accordingly, from January 1, 2021, if a patient is treated as an inpatient at a provincial hospital in a case of being out of line:

- Beneficiaries of 100% of in-line medical examination and treatment costs: 100% of inpatient treatment costs are paid;

- Beneficiaries of 95% of in-line medical examination and treatment costs: 95% of inpatient treatment costs are paid;

- Beneficiaries of 80% of in-line medical examination and treatment costs: 80% of inpatient treatment costs are paid.

Therefore, not everyone is paid 100% of the inpatient treatment cost when going to a hospital outside the province. Only those who are entitled to 100% of the cost of inpatient treatment in the right province are paid the entire cost of inpatient treatment in the wrong province. Other subjects are paid according to their right level.

On the morning of September 16, the inspection team inspected Vinh City General Hospital - a unit with a large number of patients coming for examination and treatment. Photo courtesy of Thanh Chung

Note: According to Official Dispatch 4055/BHXH-CSYT of the Social Insurance issued on December 23, 2020, inpatients who are not treated in the province will not be entitled to the non-co-payment regime for medical examination and treatment costs to be considered for 100% payment of medical examination and treatment costs for those who have participated in health insurance for 5 consecutive years.

At the same time, the co-payment portion of the patient in case of self-treatment at the wrong medical facility is not determined as a condition for granting a Certificate of non-co-payment in the year.

Therefore, in order for patients to fully enjoy health insurance benefits, including the right to not have to pay co-payments for medical examination and treatment costs, the Social Insurance agency encourages health insurance participants to go to the right medical examination and treatment center according to regulations.