Information on health insurance examination and treatment: When do you not need a referral to a specialized hospital?

On March 30, Master - Doctor Nguyen Thai Hoc, Deputy Head of the Health Insurance Department, University of Medicine and Pharmacy Hospital, Ho Chi Minh City shared that according to Article 5, Circular 01/2025/TT-BYT dated January 1, 2025 of the Minister of Health, there are instructions on cases of diagnosis, treatment of some rare diseases, serious diseases, diseases requiring surgery or using high technology at Point a, Clause 4, Article 22 of the Law on Health Insurance. Accordingly, issued with this Circular are lists of some rare diseases, serious diseases, diseases requiring surgery or using high technology that are entitled to 100% of the benefits according to the provisions of Point a, Clause 4, Article 22 of the Law on Health Insurance.

"This Circular stipulates that patients are entitled to benefits immediately during their medical examination and treatment with a confirmed diagnosis of the disease, then the patient is entitled to benefits immediately according to that regulation. In cases where the disease in the appendixes has regulations on conditions or disease status, the patient is only entitled to benefits when meeting those conditions or disease status," shared Master Hoc.

People exchange information about health insurance examination and treatment with staff at Ho Chi Minh City University of Medicine and Pharmacy Hospital

PHOTO: LE CAM

If another disease is discovered during the examination, will I be covered by health insurance?

In example 2 of Article 5, Circular 01/2025/TT-BYT dated January 1, 2025 of the Minister of Health detailing and guiding the implementation of a number of articles of the Law on Health Insurance "In case of definitive diagnosis and treatment of a number of rare diseases, serious diseases, diseases requiring surgery or using high technology at Point a, Clause 4, Article 22 of the Law on Health Insurance", a person with 1 of 62 serious diseases according to Appendix 1, Circular 01/2025/TT-BYT when going to any specialized hospital (no need for a referral to a medical examination and treatment facility) is entitled to health insurance as follows:

"A patient who is initially or basically diagnosed with pancreatic cancer - disease code C25 by a hospital A at the same level, and then goes to a specialized hospital B for examination and treatment, is entitled to the benefits prescribed in this Article as follows:

Case 1: Hospital B is a specialized hospital that examines and diagnoses a patient with a malignant tumor of the pancreas - disease code C25, then the patient is entitled to benefits according to regulations for examination and treatment of malignant tumors of the pancreas at Hospital B. During the examination and treatment of malignant tumors of the pancreas at Hospital B, if another disease or accompanying disease is discovered, the patient is also paid for the cost of examination and treatment of the other disease or accompanying disease discovered according to the scope of benefits and the level of benefits prescribed by the law on health insurance for cases of examination and treatment in accordance with the order and procedures prescribed by the law on health insurance.

Case 2: Hospital B is a specialized hospital that examines and diagnoses the patient and determines that he/she does not have pancreatic cancer - disease code C25. The patient is still entitled to benefits as prescribed in this article for that examination and diagnosis at Hospital B.

People waiting to see a doctor at a specialized hospital in Ho Chi Minh City.

PHOTO: LE CAM

Case 3: When going to hospital B, a specialized hospital, for examination and treatment of malignant tumors in the pancreas - disease code C25, and the patient also requests examination and treatment of other diseases, he/she will only enjoy the benefits prescribed in this Article for examination and treatment of malignant tumors in the pancreas at hospital B and will not enjoy the benefits prescribed for examination and treatment of other diseases at hospital B".

"Thus, in addition to serious illnesses, when examined and discovered to have other illnesses, health insurance is still available when examined and treated for other illnesses, following the correct procedures. In case the patient requests to be examined for other illnesses, he/she will only be entitled to health insurance benefits for serious illnesses and will not be entitled to health insurance for other illnesses," shared Master Nguyen Thai Hoc.

See details of the list of 62 rare and serious diseases

HERE

Source: https://thanhnien.vn/thong-cap-kham-chua-benh-bhyt-khi-nao-den-benh-vien-chuyen-sau-khong-can-giay-chuyen-185250328103901294.htm