What is the 5 year continuous period?
The period of 5 consecutive years is the time during which health insurance participants enjoy corresponding priority rights. However, this period is not the valid period of health insurance as many people think.
Clause 1, Article 3 of Decision 1313/QD-BHXH clearly states that a person who has participated in health insurance for 5 consecutive years is a person who has the words "Time of 5 consecutive years: From date …./…./….." printed at the end of the health insurance card, helping health insurance participants and medical facilities determine the period of health insurance payment.
Clause 5, Article 12 of Decree 146/2018/ND-CP guiding the Law on Health Insurance stipulates that a period of 5 consecutive years is the period of use recorded on the health insurance card, the next time following the previous time, in case of interruption, the maximum period cannot exceed 3 months.
Benefits of participating in health insurance for 5 consecutive years
When participating in health insurance as a household, student, or under a labor contract, the patient will only be paid a maximum of 80% of the medical examination and treatment costs by the health insurance fund.
However, when participating in health insurance for 5 consecutive years, patients can enjoy the additional benefit of 100% payment of medical examination and treatment costs when meeting the following conditions: going to the right medical facility for examination and treatment and the amount of co-payment for medical examination and treatment costs in the year is greater than 6 months of basic salary.
According to Clause 3, Article 27 of Decree 146/2018/ND-CP, in case a patient has a cumulative co-payment amount in a fiscal year at a medical facility greater than 6 months of basic salary, that medical facility will record and not collect the co-payment amount exceeding 6 months of basic salary.
The medical facility will then notify the patient and provide an invoice for the patient to go to the Social Insurance agency to obtain a certificate of non-co-payment in that year. With this certificate, the patient will be entitled to health insurance benefits to pay 100% of the medical examination and treatment costs for the following medical examinations in the fiscal year.
However, in case a health insurance participant goes to many places for medical examination and treatment, when the accumulated co-payment amount in the fiscal year is greater than 6 months of basic salary, the patient still has to pay the co-payment amount exceeding 6 months of basic salary.
After that, the patient proactively brings the documents to the Social Insurance agency to complete the procedure to pay back the excess co-payment amount that he/she has paid, and at the same time receives a certificate of no co-payment in that year.
Because when going to different places for medical examination and treatment, the medical facility will not know the time when the patient has a co-payment amount exceeding 6 months of basic salary. If the patient does not pay attention to this time, to get through the fiscal year, he will lose the right to be paid 100% of his health insurance.
According to Notice 2298/TB-BHXH dated November 14, 2018 of Vietnam Social Security, to enjoy the above non-co-payment benefits, patients prepare a dossier including the following documents: Health insurance card; ID card with photo (copy); invoice, hospital fee payment document (original). Then, patients submit the dossier to the Social Security agency (where they participate in health insurance) for settlement.
In case the patient's co-payment exceeds 6 months of basic salary calculated from January 1, the Health Insurance Fund will pay 100% of the medical examination and treatment costs within the patient's benefits from the time the patient has participated for 5 consecutive years until December 31 of that year.
Conditions for receiving health insurance for 5 consecutive years
Pursuant to Point c, Clause 1, Article 22 of the 2008 Law on Health Insurance, amended and supplemented in 2014, patients with health insurance cards are entitled to enjoy health insurance benefits for 5 consecutive years when meeting the following conditions:
1. Participate in health insurance for 5 consecutive years or more
That is, on the health insurance card there is the line: "Time of 5 consecutive years: From …/…/…".
2. The amount of money spent on co-payment of medical examination and treatment costs in the year is greater than 6 months of basic salary.
Currently, the basic salary is applied at 1,800,000 VND/month, so the co-payment amount must be greater than 6 x 1,800,000 VND = 10,800,000 VND.
3. Medical examination and treatment at the right place
Pursuant to Article 6 of Circular 30/2020/TT-BYT, on-line medical examination and treatment includes the following cases:
+ Health insurance participants who come for medical examination and treatment are recorded on the health insurance card;
+ Register for initial medical examination and treatment at the commune or district level and go to the same level facilities in the same province;
+ Emergency;
+ Health insurance participants are transferred;…
Minh Hoa (t/h)
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