Many new regulations on referral of medical examination and treatment under health insurance
In 2025, the health sector has many new policies and changes in health insurance referrals. Through that, health insurance patient benefits are increasingly expanded, making it more convenient for patients to go for medical examination and treatment.
62 patients were transferred directly, 141 patients were transferred by year
On January 2, 2025, the Ministry of Health held a workshop to disseminate the contents of Circular 01/2025/TT-BYT, detailing and guiding the implementation of a number of articles of the Law on Health Insurance. This Circular guides the registration of initial health insurance examination and treatment and referral of health insurance examination and treatment for more than 13,000 medical examination and treatment facilities nationwide. The Circular aims to overcome difficulties and obstacles in the past, at the same time, creating a synchronous legal corridor to effectively implement health insurance policies in the new period.
According to Circular 01, a list of 62 rare diseases, critical diseases, or diseases requiring surgery and high technology are allowed to go directly to specialized or basic medical facilities without having to go through referral procedures. These diseases include: infections, cancers, metabolic disorders, neurological diseases, cardiovascular diseases, congenital malformations and special conditions such as anti-tuberculosis drug resistance, organ transplants, war sequelae, post-cardiac surgery syndrome... Patients in this group can go directly to specialized facilities for treatment and enjoy full health insurance benefits according to regulations.
In addition, the Circular also stipulates a list of 167 diseases or groups of diseases that are examined and treated at primary health facilities, and a list of 141 diseases that are referred to other hospitals within 1 year from the date of signing the form. Previously, this list only included 62 diseases, but now it has increased to 79 diseases. For diseases in the list of 141 diseases, the referral form is valid for 12 months from the date of signing, instead of only valid until the end of the calendar year as before.
For example, under the old regulations, referral letters were only valid until December 31st regardless of when the patient applied for the letter, forcing them to reapply at the beginning of the new year. Under the new regulations, referral letters will be valid for a full 12 months. So, if a patient applies for a referral letter on December 1st of this year, the letter will be valid until December 1st of next year.
The list of 141 diseases referred annually includes diseases such as: chromoblastomycosis (color fungus) infection and abscess caused by phaeomyces; anemia, hereditary hemolytic anemia; bone marrow failure; disseminated intravascular coagulation (fibrinolytic syndrome); purpura; hemophagocytic syndrome associated with infection; chronic renal failure,...
According to the Law on Medical Examination and Treatment, the current medical examination and treatment system is divided into 3 professional levels: initial, basic and specialized (previously including 4 levels: Central, provincial, district, communal). Health insurance participants enjoy different levels of support: 80% at specialized facilities, 95% at basic facilities and 100% at primary facilities. In 2024, the Ministry of Health guided the decentralization of expertise and techniques at medical facilities. Specialized hospitals are usually central-level hospitals (such as Bach Mai Hospital, K Hospital, E Hospital, Viet Duc Hospital, Dermatology Hospital...) and some highly specialized provincial hospitals (such as Nghe An General Hospital, Nghe An Oncology Hospital).
Circular 01 also states: Participantshealth insuranceenjoy 100% support when examining and treating at a medical facility other than the place of initial medical examination and treatment registration, regardless of administrative boundaries. In case of changing the place of residence or temporary residence (such as students who go to school and then return to their hometown for Tet or summer holidays), health insurance participants need to register temporary residence or notify the authorities of the change of residence, and update information on the VNeID application.
Increase patient rights
According to Professor, Dr. Tran Van Thuan - Deputy Minister of Health, Chairman of the National Medical Council, the regulation on limiting cross-level medical services aims to rationally divide the flow, reduce the burden on specialized medical facilities, and avoid affecting the rights of seriously ill patients or emergency cases. At the same time, this policy also helps to balance the Health Insurance Fund more effectively.
The new points in Circular 01 are particularly significant in improving the quality of medical examination and treatment, ensuring that patients have access to and timely treatment for diseases requiring specialized expertise that basic or primary health care facilities are not qualified to provide. The new policy contributes to reducing referral procedures, saving travel costs and other related costs, including the cost of transporting patients and supporting relatives during the care and treatment process. Thereby, helping to significantly reduce household expenses related to medical examination and treatment, and at the same time, using the Health Insurance Fund more effectively.
Information from Nghe An Department of Health said that recently, the industryMedicalNghe An has directed medical examination and treatment facilities to strictly implement regulations on referrals and hospital transfers according to Circular 37/2014/TT-BYT dated November 17, 2014 of the Ministry of Health. At the same time, facilities are required not to “keep” patients, ensuring maximum patient benefits.
The Nghe An Health and Social Insurance sector has also issued guidelines for referrals for health insurance examination and treatment in the area to create more favorable conditions for patients. Specifically, the sector has assessed the capacity of each medical facility in the province, thereby providing general guidelines for referrals, especially for specific diseases. For example, cancer patients are transferred directly to the Oncology Hospital, psychiatric patients are transferred directly to the Mental Hospital, and intensive diabetic patients are transferred to the Endocrinology Hospital, with referral papers valid for 1 year.
The health sector is actively implementing communication, consultation, and guidance activities so that health insurance participants can clearly understand the list of 62 diseases that are allowed to be transferred to other hospitals and 141 diseases that are granted a hospital transfer certificate valid once a year. At the same time, patients are advised to go to appropriate medical facilities to receive the best support and ensure maximum benefits. Nghe An Department of Health has also directed medical facilities to fully prepare facilities and human resources to meet the increasing demand for medical examination and treatment under the new policy.
Dr. Le Thi Hoai Chung - Director of Nghe An Department of Health
To address the shortcomings in referrals and ensure the rights of patients, Nghe An Health Department has been implementing synchronous solutions. This includes directing medical facilities to increase the application of information technology and digital transformation to quickly resolve procedures for patients. In addition, programs, projects and plans to improve the capacity and quality of medical examination and treatment, along with improving the spirit and service attitude of medical staff are also promoted. These efforts aim to improve the quality of medical services, thereby creating satisfaction and trust for patients in the health system.