Outpatient examination and treatment, examination upon request are still covered by health insurance

Decree 188 has significantly expanded the rights of people using health insurance for medical examination and treatment. (Photo: DO THOA)

These changes significantly expand benefits for health insurance participants, especially for outpatients and patients using on-demand services.

Compared to before, when Decree 188 was not available, patients who voluntarily seek outpatient treatment at provincial or central hospitals (without a referral letter) will not have their outpatient costs paid by the health insurance fund, except in some cases of emergency or inpatient treatment at a hospital at a hospital at a different level (for example, the health insurance fund only pays 40% of inpatient costs at a central hospital according to the 2014 Law on Health Insurance). This means that outpatients at a different level must pay all costs themselves.

However, according to the new regulations, patients are entitled to the following benefits: The new regulations allow that from January 1, 2025, when examining and treating outpatients at a basic medical examination and treatment facility with a score of less than 50 points or temporarily classified as basic, health insurance participants will be paid 100% of the benefit by the health insurance fund, except for basic medical examination and treatment facilities that, before January 1, 2025, were determined by competent authorities to be provincial or central level.

From July 1, 2026, when outpatient examination and treatment at a basic medical examination and treatment facility achieves a score from 50 points to less than 70 points, health insurance participants will be paid 50% of the benefit by the health insurance fund.

From July 1, 2026, when examining and treating outpatients at a basic medical examination and treatment facility that before January 1, 2025 was determined by a competent authority to be a provincial or central level or equivalent to a provincial or central level, health insurance participants will be paid 50% of the benefit by the health insurance fund.

From July 1, 2026, when examining and treating outpatients at specialized medical examination and treatment facilities that were identified by competent authorities as provincial level before January 1, 2025 according to regulations in Point h, Clause 4, Article 22 of the Law on Health Insurance, health insurance participants will be paid 50% of the benefit level by the health insurance fund.

The new provisions in Decree 188 have significantly expanded the benefits of people going for health insurance examination and treatment (especially for outpatient examinations outside the designated area and service examinations), while clarifying the principles of benefits to better protect the legitimate rights of participants.

Medical examination and treatment on demand are also covered by health insurance.

Decree 188 also clearly states the benefit level for health insurance participants who go for medical examination and treatment upon request.

Specifically, people with health insurance cards who go for medical examination and treatment upon request will have the health insurance fund pay part of the medical examination and treatment costs according to the scope of benefits and levels of benefits under the law on health insurance.

The difference between the cost of medical examination and treatment services upon request and the cost paid by the health insurance fund shall be paid by the patient to the medical examination and treatment facility.

Medical examination and treatment facilities are responsible for ensuring human resources and professional conditions, publicly disclosing expenses that patients must pay outside the scope of benefits and health insurance benefits, the difference in costs, and must notify patients in advance.

Previously, the cost of on-demand services was not covered by health insurance at all. Patients who chose the requested service (for example, seeing a professor or a service room) had to pay the full amount themselves, and health insurance only covered the services in the standard list. Now, the new regulation allows health insurance to cover the cost within the scope of benefits even when using on-demand services.

The addition of this policy is considered to eliminate the "gap" in benefits, helping patients have more flexible options and optimize health insurance card benefits.

Sharing about one of the major concerns of people when using on-demand examination services, how are health insurance benefits applied? Specialist Doctor II Tran Thai Son, Deputy Head of General Planning Department, Bach Mai Hospital said that in principle, when patients use on-demand examination services, health insurance will pay as follows: Part covered by health insurance: The health insurance fund will pay for costs within the scope of benefits (medicine, technical services, bed fees...) according to the price prescribed by health insurance.

Patient self-payment: The patient will pay the difference between the requested service price and the price specified by health insurance.

To illustrate easily for people, Dr. Son gave a specific example of examination fees: The examination fee according to health insurance regulations at Bach Mai Hospital is 50,600 VND/visit.

The cost of an on-demand examination (for example, a Master's or Specialist I examination) is 300,000 VND/visit. In that case, the patient will pay the difference: 300,000 VND - 50,600 VND = 249,400 VND.

For the remaining amount of VND 50,600, the health insurance fund will continue to pay according to the benefit level on the patient's health insurance card (for example, the benefit level is 80%, 95% or 100%). The patient only has to co-pay the remaining amount (if any).

"Regarding medicine, there is no concept of 'on-demand medicine'. If the medicine is on the list of medicines covered by the health insurance fund, the patient will enjoy full benefits according to regulations, regardless of whether the medicine is covered by health insurance or on-demand," Dr. Son emphasized.

DO THOA

Source: https://nhandan.vn/kham-chua-benh-ngoai-tru-kham-theo-yeu-cau-van-duoc-thanh-toan-bao-hiem-y-te-post901722.html