Regulations on health insurance benefits and payments for outpatient examination and treatment

If during the inpatient treatment, there is a change in the benefit level, the patient is responsible for providing new card information, and the medical facility must check and apply the new benefit level before discharge. These regulations aim to ensure that health insurance payments are made fully and promptly in accordance with the patient's rights in all cases. The medical examination and treatment facility is responsible for checking the benefits and benefit levels of the health insurance participant before the end of the medical examination, treatment, and discharge.

Compared to before, when Decree 188 was not in place, patients who voluntarily went for outpatient examinations at provincial or central hospitals (without a referral letter) would not have their outpatient costs paid by the Health Insurance Fund, except in some cases of emergency or inpatient treatment at the wrong level (for example, the Health Insurance Fund only paid 40% of inpatient costs at the central level according to the Health Insurance Law 2014). This means that outpatients who go to the wrong level must pay all costs themselves.

The new regulation for the first time allows health insurance to pay for outpatient treatment costs at a rate of 50% or 100% depending on the case, according to the roadmap.

Level 50% means that the health insurance fund pays half of the cost within the benefit scope (for example, if the benefit is 80%, the health insurance pays 40%, the patient pays the rest).

Level 100% means the fund pays all costs according to the benefit rate stated on the health insurance card.

This is a big step forward: from 0% before, now outpatients who go to the wrong area are supported with 50-100% of the cost within the insurance scope, thereby narrowing the gap in benefits between in-line and out-of-line examinations, moving closer to the goal of equitable universal health insurance.

In addition, previously, the cost of medical examination services upon request was not covered by health insurance at all. Patients who chose the requested service (e.g., examination by a professor or service room) had to pay the entire amount themselves, health insurance only paid for the services in the standard list.

Now, the new regulation allows health insurance to pay part of the cost within the scope of benefits even when using medical services.

This change helps eliminate the previous “gap” in benefits for on-demand examinations, which are becoming more and more popular due to social needs. Patients benefit by still using their health insurance card to cover part of the cost of medical examinations and services, instead of losing their benefits completely as before.

Compared to before, the new policy is more beneficial for patients, giving more flexible options in medical examination and treatment thanks to the superiority of the health insurance policy.

The new provisions in Decree 188 have significantly expanded the benefits of people going to health insurance for medical examination and treatment (especially for outpatient examinations outside the coverage area and service examinations), and at the same time clarified the principles of benefits to better protect the legitimate rights of participants./.