How is health insurance paid for out-of-network medical examination and treatment?

(Baonghean) - Recently, Nghe An Social Insurance has received many concerns from people in the province about health insurance. To help people better understand this issue. This issue's Understanding the Law on Social Insurance and Health Insurance will publish people's concerns and answers from provincial Social Insurance officials about related issues.

Mr. Nguyen Dinh Phuoc, residing in Hong Son ward, Vinh city asked:I initially registered for health insurance at Nguyen Minh Hong Private General Hospital. Can I go to Vinh City General Hospital or Nghe An Provincial General Hospital for medical examination and treatment?

Reply:Pursuant to Clause 4, Article 22 of the Law on Amending and Supplementing a Number of Articles of the Law on Health Insurance, it is stipulated that: From January 1, 2016, health insurance participants who register for initial medical examination and treatment at commune-level health stations or polyclinics or district-level hospitals are entitled to receive health insurance-covered medical examination and treatment at commune-level health stations or polyclinics or district-level hospitals in the same province.

Thus, if you initially register for medical examination and treatment at Nguyen Minh Hong Private General Hospital and go to Vinh City General Hospital (district level), you will be paid for medical examination and treatment under health insurance in the right line. If you go to Nghe An Provincial General Hospital (provincial level), you will be considered to have crossed the line.

Minister of Health Nguyen Thi Kim Tien mentioned the issue of health insurance payment.

Ms. Tran Thi An, residing in Nghi Phu commune, Vinh city asked:I have a health insurance card registered for initial medical examination and treatment at 115 General Hospital. If I give birth at Nghe An General Hospital or Nghe An Maternity and Pediatrics Hospital, how will I be entitled to health insurance benefits?

Reply:Pursuant to Clause 4, Article 22 of the Law on Amending and Supplementing a Number of Articles of the Law on Health Insurance, it is stipulated that: In case a person with a health insurance card goes to a medical examination or treatment facility that is not in the right line, the health insurance fund shall pay according to the benefit level prescribed in Clause 1 of this Article at the following rate, except for the case prescribed in Clause 5 of this Article:

a) At central hospitals, 40% of inpatient treatment costs;

b) At provincial hospitals, 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;

c) At district-level hospitals, 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.

Thus, if she gives birth at Nghe An General Hospital or Nghe An Maternity and Pediatrics Hospital (provincial level), the Health Insurance Fund will pay 60% of the health insurance medical examination and treatment costs according to the prescribed benefit level (except in emergency cases).

Mr. Bui Minh Tri makes recommendations on the issue of health insurance payment.

Ms. Nguyen Thi Dung, Hong Son ward, Vinh city asked:I initially registered for health insurance at Vinh City General Hospital, moved to Ho Chi Minh City to live and work, and went to District 12 Hospital for prenatal check-ups. What benefits will I receive?

Reply:Pursuant to Clause 8, Article 8 of Joint Circular No. 41/2014/TTLT-BYT-BTC dated November 24, 2014 of the Ministry of Health - Ministry of Finance guiding the implementation of health insurance, it is stipulated that: Health insurance participants who come for medical examination and treatment but are not in an emergency situation during business trips; mobile work; concentrated study in training forms, training programs, or temporary residence shall be entitled to initial medical examination and treatment at a medical facility of the same technical level or equivalent to the facility registered for initial medical examination and treatment stated on the health insurance card and must present the documents specified in Clause 1 or Clause 2 or Clause 3, Article 8 of Joint Circular No. 41/2014/TTLT-BYT-BTC and one of the following documents (original or copy): work permit, decision to send to study, document proving temporary residence registration.

Overview of the online conference to evaluate the work of making a list of health insurance participants from Nghe An bridge point.

Ms. Nguyen Thi Cuong, residing in Ha Huy Tap Ward, Vinh City asked:I have a health insurance card registered for initial medical examination and treatment at Dong Au General Hospital. Can I receive medical examination and treatment at any medical examination and treatment facilities in Vinh city and still enjoy the health insurance regime as at Dong Au General Hospital?

Reply:Pursuant to Clause 4, Article 22 of the Law amending and supplementing a number of articles of the Law on Health Insurance, it is stipulated that: From January 1, 2016, health insurance participants who register for initial medical examination and treatment at commune-level health stations or polyclinics or district-level hospitals are entitled to receive health insurance-covered medical examination and treatment at commune-level health stations or polyclinics or district-level hospitals in the same province.

Thus, in Vinh city, in addition to Dong Au General Hospital, you can receive medical treatment at the following hospitals and still enjoy the health insurance regime as at Dong Au General Hospital: Vinh City General Hospital, 115 General Hospital, Vinh International Hospital, Cua Dong General Hospital, Nguyen Minh Hong General Hospital, Thanh An General Hospital, Thai An General Hospital, Thai Thuong Hoang Dental Hospital, Saigon Eye Hospital, other medical stations, polyclinics and district hospitals in the province.

Social Insurance of Nghe An province