HOW HOSPITAL FEES ARE PAID IF PARTICIPATING IN HEALTH INSURANCE FROM 5 YEARS?

People participating in health insurance from 5 years can enjoy up to 100% of medical examination and treatment costs if they fully meet the prescribed conditions. Based on current law, how is this cost paid by the health insurance agency?

How to calculate the amount of co-payment for medical examination and treatment costs to determine whether or not eligible for payment of 100% by health insurance?

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%.

>> BENEFITS FOR MEDICAL EXAMINATION AND TREATMENT UNDER HEALTH INSURANCE AT APPROPRIATE MEDICAL FACILITIES https://linconlaw.vn/benefits-for-medical-examination-and-treatment-under-health-insurance-at-appropriate-medical-facilities/

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.

How are medical examination and treatment costs for patients participating in health insurance from 5 years?

If a patient makes co-payment for each visit or multiple visits for medical care at the same healthcare establishment which is greater than the base pay amount received during 6 months

That healthcare establishment shall not be allowed to collect the patient’s co-payment which is greater than the base pay amount that he/she has received during 6 months. The healthcare establishment shall be responsible for providing an invoice for the co-payment amount equal to the base pay amount during 6 months so that the patient can use it as a basis for requesting the health insurance agency to give its certification of exemption from making any co-payment in that year.

In case where the patient’s accrued amount of co-payments in a financial year at different healthcare establishments or at the same healthcare establishment is greater than 6 months’ base pay amount:

That patient may present evidencing documents to the social insurance agency issuing his/her health insurance card to pay the amount of co-payment greater than 6 months’ total base pay amount and receive the certification of exemption from co-payment in that year;

>> PROCEDURES FOR RECEIVING HOSPITAL FEES REFUND WHEN PARTICIPATING IN HEALTH INSURANCE FROM 5 YEARS https://linconlaw.vn/procedures-for-receiving-hospital-fees-refund-when-participating-in-health-insurance-from-5-years/

Note, in case where the patient’s co-payment amount is greater than the 6 months’ total base pay amount as from January 1, the health insurance fund shall cover 100% of costs incurred from healthcare services falling within the scope of a patient’s interests from the anniversary date of 5 consecutive years of health insurance participation to the end of December 31 in that year.

What to be noted about the order of payment of medical examination and treatment costs for patients participating in health insurance from 5 years, and for regular medical examinations and treatment that exceed 6 months of base salary but have not yet been paid immediately at the medical examination and treatment facilities?

To receive payment, patients need to comply with the following procedures with the social insurance agency:

– Step 1: Patients participating in health insurance from 5 years prepare and submit a payment request. 

– Step 2: The Social Insurance Agency receives and processes payment requests according to regulations.

– Step 3: Receive results, including payment for medical examination and treatment costs, at the Finance – Accounting Department/department.

Procedure processing time shall be no later than 40 days from the date of receipt of complete and valid documents.