Learn about Health Insurance Law

Question: From January 1, 2015, the amended Law on Health Insurance comes into effect. So how are the health insurance benefits and payment methods for health insurance examination and treatment costs calculated?

Reply:

1.When health insurance participants go for medical examination and treatment according to the provisions of Articles 26, 27 and 28 of the Law on Health Insurance and Clause 4, Clause 5, Article 22 amended and supplemented by the Law on Health Insurance, the health insurance fund will pay for medical examination and treatment costs within the scope of benefits with the following benefits:

a)100% of medical examination and treatment costs for subjects specified in Points d, e, g, h and Point i, Clause 3, Article 12 amended and supplemented of the Law on Health Insurance;

b) 100% of medical examination and treatment costs and no limit on payment rates for certain drugs, chemicals, medical supplies and technical services as prescribed by the Minister of Health for: People participating in revolutionary activities before January 1, 1945; people participating in revolutionary activities from January 1, 1945 to the August 1945 uprising; Vietnamese heroic mothers; war invalids, people enjoying policies like war invalids, war invalids of type B, sick soldiers with a reduced working capacity of 81% or more; war invalids, people enjoying policies like war invalids, war invalids of type B, sick soldiers when treating wounds, recurring illnesses; children under 6 years old;

c)100% of medical examination and treatment costs at commune level;

d)100% of medical examination and treatment costs in cases where the cost for one medical examination and treatment is lower than 15% of the basic salary;

D)100% of medical examination and treatment costs for patients who have participated in health insurance for 5 consecutive years from the time they participate in health insurance to the time of medical examination and treatment and have the amount of co-payment for medical examination and treatment costs accumulated in the year greater than 6 months of basic salary, calculated from the time of participating in health insurance for 5 consecutive years, except in cases of self-examination and treatment at the wrong medical facility;

e)95% of medical examination and treatment costs for subjects specified in Point a, Clause 2, Point k, Clause 3 and Point a, Clause 4, Article 12 amended and supplemented of the Law on Health Insurance;

g)80% of medical examination and treatment costs for other subjects.

2.Health insurance participants, when going for medical examination and treatment at medical examination and treatment facilities bordering two provinces and centrally-run cities (hereinafter referred to as provinces and cities), shall be paid by the health insurance fund within the scope of benefits and levels as prescribed in Clause 1 of this Article, in the following cases:

a)Medical examination and treatment at commune health stations, polyclinics, and district hospitals;

b)Transfer technical expertise to commune, district and provincial levels.

3.Cases of medical examination and treatment upon request are paid by the health insurance fund within the scope of benefits and levels of benefits as prescribed in: a) Clause 1, Article 4 of this Decree for cases of medical examination and treatment as prescribed in Articles 26, 27 and 28 of the Law on Health Insurance and Clauses 4, 5 and Clause 6, Article 22, amendments and supplements of the Law on Health Insurance; the patient himself/herself pays the cost beyond the scope of benefits and levels of benefits; b) Clause 3, Article 22, amendments and supplements of the Law on Health Insurance for cases of self-examination and treatment at the wrong medical facility; the patient himself/herself pays the cost beyond the scope of benefits and levels of benefits.

Provincial Social Insurance – Nghe An Newspaper(Coordinate implementation)