When is medical examination and treatment at the final level covered by health insurance?

Health insurance is an important social security policy, contributing to sharing medical costs, reducing the financial burden for patients. However, in reality, many people are still confused and do not clearly understand their rights.

People pay for health check-ups at Bach Mai Hospital, Hanoi - Photo: NGUYEN KHANH

So when do people get health insurance at the final hospital? If using the on-demand examination service, how will health insurance pay and what documents need to be prepared?

Documents to bring when going for health insurance examination

Answering these questions, Dr. Tran Thai Son, Deputy Head of the General Planning Department, Bach Mai Hospital, said that according to current regulations, people need to present information about their health insurance card in one of the following forms: citizen identification card or level 2 electronic identification account on the VNeID application that has integrated health insurance information.

In case of not being integrated, the patient needs to bring the health insurance card or health insurance number along with an identification document with photo (such as ID card, passport, personal identification certificate...).

For children under 6 years old, only need to present health insurance card or birth certificate. For cases in the process of reissuing or changing cards, need to bring the appointment paper for results and one of the identification documents.

When can I enjoy health insurance at a tertiary hospital?

According to Dr. Son, as a specialized central hospital, Bach Mai only accepts outpatient health insurance payments for patients in specific cases such as those with a referral letter from a lower-level medical facility and the letter is still valid. Those with a re-examination appointment card issued by Bach Mai Hospital.

In particular, according to the new regulations of the Ministry of Health , people with one of the 62 special diseases/disease groups according to Appendix 1 of Circular 01/2025/TT-BYT can go directly to the specialized level. However, Dr. Son noted that some diseases in this list also have accompanying conditions to enjoy health insurance.

For example, if there is no note "patients are entitled to benefits immediately during the medical examination and treatment session with confirmed disease results", the patient is only entitled to health insurance benefits after being diagnosed by a medical examination and treatment facility with a disease on the list.

Therefore, to ensure the right to health insurance treatment, in these cases, patients must bring prescriptions or discharge papers from previous medical facilities as evidence.

For patients who are covered by health insurance in the right hospital, if they come for a follow-up examination at Bach Mai Hospital or other tertiary hospitals, they must bring an appointment slip issued by the hospital itself.

The appointment slip must be in the prescribed form and still valid. If there are any unusual signs, the patient can still come before the appointment date.

In case you cannot return for a follow-up examination on time due to objective reasons, you should contact the hospital again for support in arranging a suitable time so as not to interrupt your benefits.

Examination on demand, at home still paid, but with conditions

Doctor Son specifically instructed that the Health Insurance Fund will pay for expenses within the scope of benefits (medicine, technical services, bed fees...) according to the prescribed Health Insurance price.

The patient will pay the difference between the requested service price and the health insurance price. For example, the health insurance examination fee is 50,600 VND/visit, but if the patient chooses to see the requested doctor at a price of 300,000 VND/visit, he/she will pay 249,400 VND.

For the remaining part, health insurance still pays the corresponding part to the benefit level (80%, 95% or 100%), the patient only co-pays the remaining part (if any).

As for treatment drugs, health insurance will still pay in full if the drug is on the list covered by the fund, regardless of whether it is a regular or required examination.

In addition, this expert also instructed that the current health insurance policy allows payment for medical examination and treatment services at home, a humane approach, especially useful for the elderly, paralyzed people or people with difficulty moving.

However, the implementation requires close coordination to avoid abuse of health insurance funds and ensure treatment quality.

"Home examinations are not yet widely implemented. Doctors recommend that people should prioritize visiting highly specialized medical facilities to ensure full diagnosis and treatment. Home examinations should only be used when absolutely necessary to maintain continuous treatment and avoid the disease becoming severe and requiring hospitalization," Dr. Son shared.

WILLOW

Source: https://tuoitre.vn/khi-nao-kham-chua-benh-o-tuyen-cuoi-duoc-chi-tra-bao-hiem-y-te-20250708215211985.htm