CO-PAYMENT OF HOSPITAL FEES BEYOND 10.8 MILLION, THE HOSPITAL FEES CAN BE REFUND?

Health insurance participants, when examined and treated according to regulations, will have the medical examination and treatment costs paid by the health insurance fund. The payment scope by the insurance agency for hospital fees is different depending on the insured person, the level of insurance payment, the duration of insurance participation, the level of expenses paid… In which, in case the insured person has the co-payment of hospital fees beyond 10.8 million if meeting full conditions, health insurance can pay up to 100% of medical examination and treatment costs. Is this right?

Health insurance participants with co-payment of hospital fees beyond 10.8 million, if meeting the conditions, can enjoy up to 100% of medical insurance

Regulations at Point c, Clause 1, Article 22 of the Health Insurance Law 2008 (Amended Health Insurance Law 2014) on health insurance benefits when the insured person having medical examination and treatment:

“… c) Total medical examination and treatment expenditures with regard to the at least 5-year-insured whose medical examination and treatment expenditures exceed the total amount of the base salaries in 6 months, except for the insured who go to the hospitals different from the registered hospitals;“

Thus, people participating in health insurance may enjoy the above insurance level of 100% if they fully meet the following conditions:

– Regarding insurance participation period: from 5 consecutive years;

– Regarding the amount of co-payment on hospital fees (calculated from January 1 to December 31 of the calendar year): the amount is greater than 6 months of base salary.

Of which, 6 months of base salary is equivalent to VND10.8 million (currently applied salary is VND1,800,000 /month, based on Decree 24/2023/ND-CP).

Note, the co-payment amount is the amount of money that medical examination and treatment people are paying together with the health insurance agency, determined by the percentage corresponding to each group in the section below. This cost is only calculated from January 1 to December 31 of the calendar year.

– Regarding medical examination and treatment route: correct route, including cases of medical examination and treatment at a medical facility recorded on the health insurance card and referral to medical examination and treatment according to regulations.

>> WHAT IS MEDICAL EXAMINATION AND TREATMENT UNDER HEALTH INSURANCE AT APPROPRIATE MEDICAL FACILITIES https://linconlaw.vn/what-is-medical-examination-and-treatment-under-health-insurance-at-appropriate-medical-facilities/

>> HOW HOSPITAL FEES ARE PAID IF PARTICIPATING IN HEALTH INSURANCE FROM 5 YEARS? https://linconlaw.vn/how-hospital-fees-are-paid-if-participating-in-health-insurance-from-5-years/

The amount of co-payment for medical examination and treatment costs is determined based on the insurance benefit level corresponding to each group of subjects

The payment scope of hospital fees is specified for specific groups of subjects and cases in Article 22 of the Law on Health Insurance 2008 (amended Law on Health Insurance 2014):

– In case of medical examination and treatment at the appropriate medical examination and treatment facilities, the benefit levels include 100%, 95%, 80% of medical examination and treatment costs respectively.

– In case of medical examination and treatment at the inappropriate medical examination and treatment facilities, the benefit levels include 100%, 70%, 60% and 40% of medical examination and treatment costs.

The costs not covered by the insurance fund will be paid by the medical examination and treatment facilities. For example, in the case of a medical examination and treatment person who is eligible to receive 95% of hospital fees from the insurance fund, the amount paid by the medical examination and treatment person here is 5%.

Note, the benefit level according to the above mentioned subjects can be looked up in the second box – denoted by number on the health insurance card; or the Health Insurance Benefits Information section on the digital social insurance application – VSSID.