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| Cases where health insurance premiums are paid directly. (Source: SKDS) |
1. Cases where health insurance medical examination and treatment costs are directly paid
Pursuant to Clause 2, Article 31 of the Law on Health Insurance 2008 (amended in 2014) and Clause 1, Article 4 of Circular 09/2019/TT-BYT, health insurance card holders are entitled to direct payment of medical examination and treatment costs in the following cases:
- At medical examination and treatment facilities without health insurance medical examination and treatment contracts;
- Medical examination and treatment not in accordance with regulations on medical examination and treatment procedures under health insurance;
- Patients who have participated in health insurance for 5 consecutive years or more and have co-paid medical examination and treatment costs in the year greater than 6 months of basic salary (except for cases of self-examination and treatment at the wrong medical facility) but have not yet received co-paid amounts greater than 6 months of basic salary;
- In case health insurance card data is not provided or incorrect health insurance card information is provided;
- In case the patient cannot present the health insurance card before being discharged from the hospital, transferred to another hospital during the day due to emergency, loss of consciousness or death, or the card is lost but has not been reissued.
2. Direct payment level for health insurance medical examination and treatment costs
Specifically, Article 30 of Decree 146/2018/ND-CP stipulates the level of direct payment for health insurance examination and treatment costs as follows:
- In case a patient comes to a district-level medical examination and treatment facility or equivalent without a health insurance medical examination and treatment contract (except in emergency cases), payment is as follows:
+ In case of outpatient medical examination and treatment, payment is made according to actual costs within the scope of benefits and health insurance benefits according to regulations, but not exceeding 0.15 times the basic salary at the time of medical examination and treatment;
+ In case of inpatient examination and treatment, payment is based on actual costs within the scope of benefits and health insurance benefits according to regulations, but not exceeding 0.5 times the basic salary at the time of discharge from the hospital.
- In case a patient comes to a provincial-level medical examination and treatment facility or equivalent without a health insurance medical examination and treatment contract (except in emergency cases), payment will be made according to the actual costs within the scope of benefits and health insurance benefits according to regulations, but not exceeding 1.0 times the basic salary at the time of discharge from the hospital.
- In case a patient comes to a central or equivalent medical examination and treatment facility for inpatient treatment without a health insurance contract (except in emergency cases), payment will be made according to the actual costs within the scope of benefits and health insurance benefits as prescribed, but not exceeding 2.5 times the basic salary at the time of discharge from the hospital.
- In case a patient goes to a medical examination or treatment place where he/she initially registered for medical examination or treatment not in accordance with the provisions of Clause 1, Article 28 of the Law on Health Insurance, the health insurance fund shall pay the actual costs within the scope of benefits and health insurance benefits, but not exceeding 0.15 times the basic salary at the time of medical examination or treatment for outpatient medical examination or treatment and not exceeding 0.5 times the basic salary at the time of discharge for inpatient medical examination or treatment.
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