Health insurance (HI) partially supports the cost of medical examination and treatment; but not everyone understands the issues related to the payment of health insurance and how much the health insurance pays? The following article of Lawyer X will share with readers the legal regulations on the maximum payment of health insurance. Hope this article brings a lot of useful things to you
Legal grounds
Law on Health Insurance Amended 2014
How much does health insurance pay?
According to the provisions at Point b, Clause 1 of Official Letter 4996/BHXH-CSYT dated December 17, 2014; on the application of the base salary in the payment of medical examination and treatment expenses covered by health insurance:
“b) In case a patient with a health insurance card that assigned to use high-cost technical services: While waiting for the Ministry of Health to issue a list and payment rates and conditions for medical services. Medical supplies, medical supplies within the scope of benefits of the participants of health insurance according to the provisions of Clause 14, Article 1 of the amended and supplemented Law on Health Insurance, the social insurance agency shall temporarily pay the costs of these technical services according to regulations. after:
– 80% of the cost, but not exceeding 40 months of the current base salary for single use of high-cost technical services, for subjects with health insurance cards bearing benefit code 4 as prescribed in Clause 2, Article 2 of Decision No. Decree No. 1314/QD-BHXH.”
Thus, at present, only the maximum payment level for one-time use of a high-cost service is 40 times the base salary (current base salary is 1,490,000 VND) equal to 59.6 million and for the use of other services, there is no regulation on the maximum amount to pay.
Current regulations regarding health insurance benefits
The right level of health insurance coverage
Clause 1, Article 22 of the Law on Health Insurance Amending and Supplementing 2014 stipulates that when health insurance participants go for medical examination and treatment at the right level, their expenses can pay by the health insurance fund within the scope of their benefits. benefit level:
– 100% of medical examination and treatment costs if they are soldiers or police; people with meritorious services to the revolution, veterans; children under 06 years old; people from poor households; a person who has participated in health insurance for 5 consecutive years and has a co-payment of medical examination and treatment expenses in the year greater than 6 months’ basic salary…
– 95% of medical examination and treatment costs if the person is entitled to a monthly pension or allowance for loss of working capacity; people from near-poor households…
– 80% of medical examination and treatment costs if they are other subjects.
Off-line health insurance coverage
According to Clause 3, Article 22 of the Law on Health Insurance 2008, amended and supplemented in 2014, in case a health insurance cardholder goes for medical examination and treatment off-line, the health insurance fund will pay according to his/her benefit rate when he/she receives a medical examination on the correct basis. The line at the following rate:
+ at the central hospital is 40% of the cost of inpatient treatment;
+ Besides, at provincial hospitals is 100% of inpatient treatment costs nationwide (previously 60%);
+ Then, at district hospitals is 100% of medical examination and treatment costs.
Thus, in 2021, if you have a health insurance card for inpatient treatment outside the provincial level, the health insurance fund will pay 100% of the cost of inpatient treatment nationwide.
Direct payment to health insurance cardholders
In 2021, it is expected that the base salary will still be 1.49 million VND/month as before. Therefore, the level of direct payment to the holders of the health insurance card according to the provisions of Article 30 of Decree 146/2018/ND-cp is as follows:
– Medical examination and treatment at the district level and the equivalent without a contract for medical examination and treatment covered by health insurance:
+ Outpatient: not more than 0.15 times the base salary at the time of medical examination and treatment; which means the direct payment is 223,500 VND.
+ Inpatient: not more than 0.5 times the base salary at the time of discharge, which means the direct payment is 745,000 VND.
– Treatment and inpatient medical examination at the provincial level and the equivalent without a contract for medical examination and treatment with health insurance; Not more than 1.0 times the base salary at the time of hospital discharge, equivalent to the payment level; directly, ie 1.49 million VND/month.
– Then, inpatient medical examination and treatment at the central level and equivalent without a contract for medical examination and treatment under health insurance: Not more than 2.5 times the base salary at the time of discharge, equivalent to direct payment, ie 3,725 million VND.
– Medical examination and treatment at the place of initial registration are not by regulations:
+ Outpatient: not more than 0.15 times the base salary at the time of medical examination and treatment; equivalent to direct payment, ie 223,500 VND.
+ Inpatient: not more than 0.5 times the base salary at the time of discharge, which means the direct payment is 745,000 VND.
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Frequently asked questions
According to Clause 1, Article 2 of the Law on Health Insurance 2008, amended and supplemented in 2014: Health insurance is a form of compulsory insurance applied to the subjects specified in this Law for health care, not for profit organized by the State.
Currently, there are two forms of health insurance participation: compulsory health insurance and voluntary health insurance. For compulsory health insurance, there are 6 groups of subjects participating in health insurance as defined in Decree 146/2018/ND-CP, which are: Groups paid by employees and employers. The group is paid by the social insurance agency. Besides, the group is paid by the State budget. The group is supported by the State budget. Then, the group participating in health insurance by household; The group is closed by the employer. According to the latest regulations in Decree 146/2018/ND-CP, the participants of voluntary health insurance are those who do not belong to 6 groups participating in voluntary health insurance.
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