PROCEDURES FOR RECEIVING HOSPITAL FEES REFUND WHEN PARTICIPATING IN HEALTH INSURANCE FROM 5 YEARS

People participating in health insurance from 5 years consecutively and have the co-payment for medical examination and treatment costs in the year greater than 6 months of base salaries can enjoy up to 100% of medical examination and treatment costs. In case the patient has paid hospital fees at the hospital, this amount will be paid by the health insurance agency according to the prescribed order. So, what is the procedure to receive a refund of hospital fees in this case?

People participating in health insurance from 5 years, if satisfying the specified conditions, may receive up to 100% of medical examination and treatment costs

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 from 5 years may enjoy the above 100% insurance level 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 (equivalent to VND 10.8 million).

– 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.

>> 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/

>> WHEN MUST VALUE ADDED TAX BE DECLARED? https://linconlaw.vn/when-should-value-added-tax-be-declared/

Medical examination and treatment costs for patients participating in health insurance from 5 years can be settled directly at the medical examination and treatment facilities or paid later by the social insurance agency.

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.

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.

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.

Procedures for requesting payment of medical examination and treatment costs if the patient is eligible but have not received benefits immediately at the medical examination and treatment facility

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

(i) Originals of relevant invoices and documents (invoices, hospital fee receipts and related documents).

(ii) Copies of the following documents (attached originals for comparison): Health insurance card and one of the documents proving identity with a valid photo (ID card, Citizen ID card, Passport , Party membership card, People’s Police card, Military card, Trade union membership card, Student card, Student card, Veterans card, Driver’s license or another valid photo document) if Health insurance card does not have a photo; Copy of birth certificate or birth certificate in case children under 6 years old do not have a health insurance card; Hospital discharge certificate, medical examination card or medical examination book of the medical examination and treatment requested for payment;

– Step 2: The Social Insurance Agency receives and processes payment requests according to regulations. Applications are received through one of the following methods:

+ Submitting through electronic transactions;

+ Sending documents via post;

+ Submitting directly to the application receiving department of the Social Insurance agency at the provincial and district levels or at the Public Administration Service Center at all levels.

– 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.