12 cases are not covered by health insurance even though they are examined at the right clinic

From July 1, 2025, according to Clause 18, Article 1 of the Law amending and supplementing the Law on Health Insurance 2024, 12 cases of patients not entitled to health insurance of the Law on Health Insurance 2014 will remain unchanged, however, 2 cases of the old Law will be amended and supplemented.

Specifically, 12 cases will not be covered by health insurance for medical examination and treatment costs from July 1, 2025, including:

- Services that have been paid for by the state budget include: Regular pregnancy check-ups, childbirth, screening, early diagnosis, rehabilitation, and costs of transporting patients from district level to higher level.

- In case of nursing and convalescence at nursing and convalescent facilities.

- Go for a medical checkup.

- When performing tests, pregnancy diagnosis is not for treatment purposes.

- When using assisted reproductive techniques, family planning services, abortion, or curettage. Note, except in cases where pregnancy must be terminated due to pathological causes of the fetus or the mother.

- Patients using cosmetic services.

- Patients with strabismus, myopia and refractive errors of the eye, except for those under 18 years old.

Compared to current regulations (effective before July 1, 2025), only children under 6 years old who are treated for strabismus, myopia and refractive errors of the eye are covered by health insurance. However, according to the new amended and supplemented Law on Health Insurance in 2024, from July 1, the age of health insurance coverage for treatment of these problems will be raised from 6 to 18 years old.

There are four common types of refractive errors of the eye: nearsightedness, farsightedness, astigmatism and presbyopia. According to the Ministry of Health 's calculations, when expanding benefits to people under 18 years old, each year it is estimated that health insurance needs to pay 734.2 billion VND for refractive error treatment; 12.5 billion VND for strabismus treatment; 3.4 billion VND for ptosis treatment.

- Use of alternative medical devices including prosthetic legs, artificial arms, artificial eyes, dentures, eyeglasses, hearing aids, and mobility aids in medical examination, treatment, and rehabilitation.

According to the new regulations that will come into effect soon, the patient in section 8 previously "using medical supplies" will now be replaced by "using medical equipment".

- Patients receive medical examination, treatment and rehabilitation in case of disaster.

- Patients examined and treated for drug addiction, alcoholism or other addictive substances.

- Conduct medical examination, forensic examination, forensic psychiatric examination.

- Patients participating in clinical trials or scientific research.

Thus, when people go to see a doctor or get treatment in the above cases, they will not be covered by health insurance, which means they will have to pay all medical examination and treatment costs themselves.

According to the new Law on Health Insurance, in case a health insurance participant receives medical examination and treatment upon request, the health insurance fund will only pay the portion of the cost within the scope of benefits (if any) as prescribed.

The difference in cost between the requested service price and the health insurance fund payment level shall be paid by the patient to the medical facility.

According to the Department of Health Insurance (Ministry of Health), the limitation of coverage is to ensure the effective and fair use of the health insurance fund, and to focus on the main goal of medical examination and treatment. Services that are not intended to treat diseases, such as beauty or general health check-ups, will not use resources from the fund.

In reality, many people mistakenly believe that all they need to do is have a health insurance card and go to the right place to get the full cost covered. However, health insurance only covers medical examination and treatment services that are listed and have clear medical indications.

DO THOA

Source: https://nhandan.vn/12-truong-hop-khong-duoc-huong-bao-hiem-y-te-du-kham-dung-tuyen-post888879.html