From July 1, 2023, what are the conditions for health insurance to cover 100% of medical examination and treatment costs? How will the conditions for receiving health insurance for 5 consecutive years change? See now.
Conditions for 100% health insurance for medical examination and treatment costs
According to health insurance payment regulations, health insurance participants will enjoy 100% of medical examination and treatment costs if the cost for one medical examination and treatment is less than 15% of the basic salary.
Accordingly, from July 1, 2023, the basic salary has been adjusted to increase from VND 1,490,000/month to VND 1,800,000/month. With this adjustment, the contribution level, regime and benefits of health insurance when examining and treating diseases will also change.
Specifically:
- With the basic salary before July 1, 2023 (VND 1,490,000/month), the health insurance medical examination and treatment benefit is under VND 223,500;
- With the basic salary from July 1, 2023 (1,800,000 VND/month), the maximum health insurance payment for one medical examination and treatment is 270,000 VND.
➨ Thus, people with health insurance cards who go to medical examination and treatment in accordance with the provisions of the Law on Health Insurance with a total cost of one medical examination and treatment of less than 270,000 VND will be covered 100% by health insurance.
See also:
>> How to look up the validity and validity of health insurance card;
>> 3 ways to replace paper health insurance cards when going to see a doctor.
Change the conditions for health insurance benefits for 5 consecutive years
To enjoy social insurance for 5 consecutive years, health insurance participants must meet the following 3 conditions:
- Health insurance participation period of at least 5 consecutive years;
- Medical examination and treatment in the right place;
- The co-payment cost of medical examinations and treatments during the year is greater than 6 months of the basic salary (ie greater than 10,800,000 VND).
However, due to the adjustment of the basic salary, there has been a change in the conditions for receiving health insurance for 5 consecutive years. Specifically, there has been a change in the co-payment costs for medical examinations and treatments during the year.
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Details of each condition and changes in co-payment costs for medical examinations during the year are as follows:
1. Health insurance participation period of at least 5 consecutive years
The period of participating in health insurance for 5 consecutive years is recorded directly on the health insurance card. Accordingly, people participating in health insurance for medical examination and treatment from this point on will enjoy health insurance benefits for 5 consecutive years.
>> See more: Benefits of paying health insurance for 5 consecutive years.
2. Go to the right medical facility for treatment
Pursuant to Article 6 of Circular 30/2020/TT-BYT, there are 8 cases of medical examination and treatment under health insurance in the right place. Specifically, including the following cases:
- Newborns must be treated immediately after birth;
- Organ donors must seek treatment immediately after donation;
- People with a re-examination appointment in case of referral according to regulations;
- Health insurance participants receive medical examination and treatment at the medical examination and treatment facility listed on the health insurance card;
- Health insurance participants are transferred to health insurance examination and treatment facilities according to regulations;
- Health insurance participants in emergency situations can go to any medical facility nationwide for emergency treatment;
- Health insurance participants register for primary medical examination and treatment at commune level or general clinic or district level hospital to go to other facilities of the same level in the province;
- Health insurance participants with documents proving that they are in another locality during the period of time, working on a mobile basis, on business, temporarily residing… go to a medical examination and treatment facility at the same level or equivalent to the initial registration facility recorded on the health insurance card.
3. Co-payment costs for medical examinations and treatments during the year are greater than 6 months of basic salary
➤ What is a co-payment?
Co-payment cost (also known as co-payment cost) is the amount of money that the patient pays with the Social Insurance agency according to the % rate of the health insurance card.
For example:
Mr. A has a health insurance card with a benefit rate of 80%. Mr. A went to the hospital and the total cost covered by health insurance was 1,000,000 VND. At this time, Mr. A was paid 800,000 VND by health insurance, and Mr. A paid 200,000 VND himself.
Thus, this amount of 200,000 VND is the co-payment cost.
➤ Changes in co-payment costs for medical visits during the year
From July 1, 2023, due to changes in the basic salary (increased from VND 1,490,000/month to VND 1,800,000/month), the co-payment level for medical examinations and treatments during the year will also be adjusted. Specifically, it will increase from VND 8,940,000 to VND 10,800,000 (equivalent to 6 basic salaries).
In summary, from July 1, 2023, people who have participated in health insurance for 5 consecutive years or more must have co-payment costs for medical examinations and treatments in the year greater than VND 10,800,000 (equivalent to 6 months of basic salary) to enjoy health insurance benefits for 5 consecutive years.
5 groups of people covered by 100% health insurance (medical examination and treatment costs)
Below are cases that are entitled to 100% health insurance for medical examination and treatment costs at the right facility (latest update 2023).
➤ Group 1:
This group includes:
- Veteran;
- Subjects eligible for monthly social security benefits;
- People aged 80 and over who are receiving monthly pension benefits;
- Relatives of martyrs: biological parents, spouse, children of martyrs, people who raised martyrs;
- People with revolutionary contributions according to the Ordinance on Preferential Treatment of People with Revolutionary Contributions;
- Poor households;
- Ethnic minorities living in areas with difficult socio-economic conditions;
- Subjects living in island communes, island districts or in areas with particularly difficult socio-economic conditions.
Note:
Subjects entitled to 100% health insurance coverage for medical examination and treatment costs in this group are subject to payment rate limits for certain drugs, chemicals, technical services and medical supplies.
➤ Group 2:
Group 2 includes the following subjects:
- Children under 6 years old;
- Heroic Vietnamese Mother;
- Revolutionary participants:
- Before January 1, 1945;
- From January 1, 1945 to the August 1945 General Uprising.
- Resistance war participants infected with toxic chemicals have a labor capacity reduction rate of 81% or more;
- War invalids, category B war invalids, people enjoying the same policies as war invalids and sick soldiers when treating wounds, recurring illnesses or having a labor capacity reduction rate of 81% or more.
Note:
Health insurance participants in this group will enjoy 100% of medical examination and treatment costs and there is no limit on the payment rate for drugs, chemicals, technical services and medical supplies.
➤ Group 3: Health insurance participants receive medical examination and treatment at commune-level medical facilities.
➤ Group 4: Health insurance participants have a cost for one medical examination and treatment lower than 15% of the basic salary (equivalent to less than 270,000 VND).
➤ Group 5: People who have participated in health insurance for 5 consecutive years or more and have a co-payment amount for medical examination and treatment costs in the year greater than 6 months of basic salary (excluding cases of medical examination and treatment under health insurance outside the designated health facility).
>> See more: Enjoy health insurance benefits from voluntary social insurance.
Frequently asked questions about conditions and beneficiaries of 100% health insurance
1. Conditions for medical examination and treatment covered by 100% health insurance?
From July 1, 2023, people with health insurance cards who go to the right medical facility for examination and treatment in accordance with the provisions of the Law on Health Insurance with a total cost of one medical examination and treatment of less than VND 270,000 (less than 15% of the basic salary) will be covered 100% by health insurance.
2. Conditions for receiving health insurance for 5 consecutive years?
To receive social insurance for 5 consecutive years, health insurance participants must meet the following 3 conditions:
- Health insurance participation period of at least 5 consecutive years;
- Medical examination and treatment in the right place;
- Co-payment costs for medical examinations and treatments during the year are greater than 6 months of basic salary.
3. Regulations on the amount of co-payment for medical examination and treatment during the year for people participating in health insurance for 5 consecutive years
Since from July 1, 2023, the basic salary will increase to 1,800,000 VND/month, people who have participated in health insurance for 5 consecutive years or more must have a co-payment amount for medical examination and treatment costs in the year greater than 10,800,000 VND (equivalent to 6 months of basic salary) to enjoy health insurance benefits for 5 consecutive years.
4. What cases are eligible for 100% health insurance?
There are 5 groups of people whose medical examination and treatment costs are covered by health insurance, including:
- Group 1: veterans, people with revolutionary contributions, people eligible for monthly social security benefits…;
- Group 2: children under 6 years old, heroic Vietnamese mothers, people participating in revolutionary activities before January 1, 1945…;
- Group 3. Health insurance participants receiving medical examination and treatment at commune-level medical facilities;
- Group 4: Health insurance participants whose cost for one medical examination and treatment is lower than 15% of the basic salary;
- Group 5: People who have participated in health insurance for 5 consecutive years or more and have the amount of co-payment for medical examination and treatment costs in the year greater than 6 months of basic salary.
>> See details: 5 groups of people whose medical examination and treatment costs are covered by health insurance.
5. What cases are considered proper medical examination and treatment?
Cases considered to be medical examination and treatment under health insurance in the right place include:
- Newborns must be treated immediately after birth;
- Organ donors must seek treatment immediately after donation;
- People with a re-examination appointment in case of referral according to regulations;
- Health insurance participants go to the correct initial medical facility listed on the health insurance card;
- Health insurance participants are transferred to health insurance examination and treatment facilities according to regulations;
- …
>> See more: 8 cases of health insurance examination and treatment in the right place.