Regulations and list of critical illnesses eligible for benefits

What is a critical illness? List of 42 critical illnesses eligible for benefits, critical illness health insurance – Procedures for applying for critical illness health insurance.

What is a terminal illness?

Up to now, there has not been any unified document regulating the concept of critical illness. This content has only been defined in the following legal documents:

➧ Pursuant to Clause 4, Article 3 of Decree 140/2021/ND-CP, a person with a serious illness is a person suffering from one of the diseases that can be life-threatening such as: 

• HIV infection has progressed to AIDS;
• Stage 4 kidney failure or higher;
• Heart failure grade 3 or higher;
• Cirrhosis of the liver;
• Drug-resistant tuberculosis;
• Leprosy, paralysis;
• Terminal cancer;
• Other diseases confirmed as critical illnesses by medical facilities from district level or higher.

➧ Pursuant to Resolution No. 02/2018/NQ-HDTP regulating cases of serious illness, as follows:

• People serving suspended sentences have life-threatening illnesses that are difficult to treat, such as: HIV that has turned into AIDS, kidney failure stage 4 or higher, severe drug-resistant tuberculosis stage 4, heart failure stage 3, cirrhosis with ascites, end-stage cancer, and they are unable to take care of themselves, with a high risk of death;
• Diagnosis and conclusion are carried out by provincial hospitals and military hospitals at military region level or higher.

So, simply put, critical illnesses are illnesses that endanger the patient’s life, confirmed by a provincial hospital or a military hospital at the military region level or higher. These illnesses are very difficult to treat, requiring advanced treatment techniques, the use of high-quality chemicals and drugs, and a long treatment regimen such as: late-stage cancer, cirrhosis with ascites, paralysis, grade 4 tuberculosis, grade 3 heart failure, grade 4 kidney failure, HIV that has turned into AIDS, etc.

List of 42 critical illnesses eligible for benefits and health insurance under Decree 134

Decree No. 134/2016/ND-CP lists 42 critical illnesses eligible for benefits, specifically as follows:

In addition, based on Circular No. 26/2014/TT-BQP, the list of critical illnesses is divided into 9 main groups of illnesses, including:

1. Cancer;
2. Diseases of the nervous system;
3. Liver diseases;
4. Diseases of the urinary system;
5. Metabolic diseases;
6. Respiratory diseases;
7. Circulatory system diseases;
8. Diseases of the musculoskeletal system;
9. Acquired immunodeficiency syndrome.

Subsidy regime, health insurance benefits for people with serious illnesses

People with critical illnesses included in the list of critical illnesses will receive the following benefits:

• The health insurance fund will pay for expenses within the scope of benefits when going to the right and wrong medical facility for examination and treatment;
• Other critical illness support and allowances.

1. Level of health insurance benefits for critical illness

According to the provisions of the Law on Health Insurance 2008, people with serious illnesses who participate in health insurance will have their costs covered by the health insurance fund within the scope of benefits when going for medical examination and treatment. Depending on whether the patient is examined at the same or different level, the severity of the illness, and which group of subjects they belong to, the regulations on the level of health insurance benefits for serious illnesses will be different.

Below, fdiinvietnam.com will share details about this content.

1.1. Level of health insurance benefits for critical illness when examining and treating at the right medical facility

Pursuant to Article 14 of Decree 146/2018/ND-CP, depending on each group of patients, there will be different levels of health insurance benefits and payment for medical examination and treatment of serious illnesses, specifically:

• Group 1: Group of subjects participating in health insurance enjoys 100% health insurance (limited payment rate for drugs, chemicals, medical supplies and technical services);
• Group 2: Group of subjects participating in health insurance enjoys 100% health insurance (no limit on payment rate for drugs, chemicals, medical supplies and technical services);
• Group 3: Group of subjects participating in health insurance enjoys 95% health insurance;
• Group 4: Group of people participating in health insurance enjoy 80% health insurance.

The specific subjects of each group receiving critical illness insurance are as follows:

➧ Group 1: Group of subjects entitled to 100% limited health insurance

• Veteran;
• People with revolutionary contributions;
• People from poor households;
• People eligible for monthly social security benefits according to the provisions of law;
• Ethnic minorities living in areas with difficult socio-economic conditions;
• People living in island districts, island communes or areas with particularly difficult socio-economic conditions;
• Relatives of people with revolutionary contributions: biological parents, wife, husband, children and people who raised martyrs;
• People aged 80 and over are receiving monthly pension benefits.

➧ Group 2: Group of subjects entitled to 100% health insurance without limit

• Children under 6 years old;
• Heroic Vietnamese Mother;
• Revolutionary activist before January 1, 1945;
• Revolutionary activist from January 1, 1945 to August Revolution;
• War invalids, people enjoying policies like war invalids, war invalids of type B, sick soldiers with reduced working capacity of 81% or more;
• War invalids, people enjoying policies like war invalids, war invalids of type B, sick soldiers when treating wounds;
• Resistance fighters exposed to toxic chemicals have a labor capacity reduction rate of 81% or more.

>> See more: Conditions for 100% health insurance.

➧ Group 3: Group of subjects entitled to 95% health insurance

• People from near-poor households;
• People receiving monthly pension and disability benefits;
• Relatives of people with revolutionary contributions, including: biological father, biological mother, wife/husband, children from 6 years old to under 18 years old or 18 years old or older who are still in school or have disabilities of people with revolutionary contributions;
• People in multidimensionally poor households (households that meet the criteria of low income and lack of basic social services), also known as the state of not being able to meet basic needs in life at a minimum level. 

➧ Group 4: The group of subjects entitled to 80% health insurance are the remaining subjects.

Note:

1) In addition to the 4 basic groups above, health insurance also covers critical illnesses with a benefit rate of 100% for the following 3 cases: 

• People who examine and treat patients at commune-level facilities;
• The cost of one medical examination and treatment for health insurance participants is lower than 15% of the basic salary;
• Patients who have participated in health insurance for 5 consecutive years and the amount paid for medical examination and treatment is 6 times the basic salary of 1 month (not applicable to cases of out-of-network examination).

2) If a person belonging to many health insurance groups has a serious illness, he/she will receive the health insurance level of the highest group.

See also: 

>> Regulations on basic salary;

>> Benefits of participating in health insurance for 5 consecutive years.

1.2. Health insurance benefits for out-of-line medical examination for serious illness

The health insurance card records the initial health insurance medical examination and treatment facility of the cardholder. Performing medical examination and treatment at the right facility will help patients receive support for medical examination and treatment costs within the scope of benefits with the highest level of health insurance benefits. 

However, due to the danger and complexity of serious illnesses, many people decide to seek treatment outside the facility’s lines (higher levels such as provincial and central health facilities) and only a few people choose to receive treatment at district-level facilities.

The level of critical illness health insurance for cases where patients seek medical examination and treatment at the wrong medical facility (also known as cross-line medical examination and treatment) is specifically regulated as follows:

Medical treatment facility	Health insurance benefit level
District hospital	100% of medical examination and treatment costs
Provincial hospital	100% of inpatient treatment costs
Central hospital	40% of inpatient treatment costs

In addition, for patients who are treated through the provincial health insurance system and have a health insurance card when going to a provincial medical facility for examination and treatment, the health insurance fund will pay the same benefits as going to the correct medical facility for examination and treatment at a rate of 100% of the cost of inpatient treatment nationwide, specifically:

2. Other critical illness support regimes

Along with the level of health insurance benefits from the health insurance fund for people with serious illnesses as fdiinvietnam.com has presented above, the Government currently also has a policy of using the reduced state budget for hospitals to buy and support the purchase of health insurance cards.

In addition, people from poor households and people in communes with difficult socio-economic conditions also receive other support such as:

➧ Meal allowance

Applicable to inpatients at state-run medical facilities from district level and above, the support level is at least 3% of the general minimum wage/person/day.

➧ Travel allowance

Support for travel expenses from home to hospital, from hospital to home or transfer to hospital (*) or in emergency cases, death or serious illness, family members wish to take the patient home but are not supported by health insurance.

➧ Pay one-way shipping costs

Applicable to cases where the means of transport of state medical facilities are not used, the subsidy is 0.2 liters of gasoline/km (calculated according to the distance of transport and the price of gasoline at that time).

➧ Support part of the cost of medical examination and treatment under health insurance

In case the subjects have to pay together from 100,000 VND or more.

➧ Support a portion of the hospital fees that the patient must pay to the state medical facility (from 1,000,000 VND or more) in case there is no health insurance

Applicable to cases where people with cancer, heart surgery, kidney dialysis or other diseases have difficulty paying due to high costs and cannot afford hospital fees. In cases where patients choose their own medical facility, they must pay hospital fees according to regulations.

Note:

(*): Only applicable to inpatient treatment at state-owned medical examination and treatment facilities from district level and above.

Documents and procedures for applying for critical illness benefits (critical illness health insurance)

To proceed with the procedure for critical illness health insurance, follow these 4 steps:

➧ Step 1 : Prepare documents to apply for critical illness health insurance

➧ Step 2: Submit application to Social Insurance agency

You submit your application to the Social Security Agency. Then, you wait to sign in the applicant box on the application receipt and make an appointment to return the results of the reissue of the health insurance card.

➧ Step 3: Receive the application receipt and appointment letter for the health insurance card issuance result

After checking the declaration and adjusting the information, the One-Stop Department of the provincial and district Social Insurance agency will issue a receipt of the application and an appointment to return the results of the health insurance card issuance. At this time, you sign in the box for the person submitting the application.

➧ Step 4: Receive health insurance card

Within 10 days from the date of receiving a complete and valid application, the health insurance organization must transfer the health insurance card to the agency or organization managing the subject or transfer it directly to the person requesting the card.

Regulations on registration for medical examination and treatment of critical illness health insurance

To enjoy health insurance benefits when going for medical examination and treatment of serious illnesses, patients need to pay attention to the regulations on the following issues:

• Place of initial registration for health insurance examination and treatment;
• Transfer of treatment, examination and treatment under health insurance;
• Procedures for registering for health insurance examination and treatment.

1. Regulations on initial health insurance examination and treatment registration place

Health insurance participants have the right to register for initial health insurance examination and treatment facilities according to their own needs at commune-level, district-level or equivalent health insurance examination and treatment facilities. The name of the initial health insurance examination and treatment facility is recorded on the health insurance card.

Note:

• Health insurance participants can change their initial medical examination and treatment registration facility at the beginning of each quarter;
• Health insurance participants will not be entitled to register for initial medical examination and treatment facilities in cases where they are registered for medical examination and treatment at provincial and central level facilities according to regulations of the Minister of Health.

2. Regulations on referral for treatment, examination and treatment of health insurance for serious illnesses

Treatment referral is the transfer of a patient from one medical facility to another, either from lower to higher levels or from higher to lower levels or between facilities at the same level.

Regulations on conditions and cases of referral for treatment, examination and treatment under health insurance are specifically as follows:

➧ Case 1: Transferring medical examination and treatment facilities from lower level to higher level

• The disease is not suitable for the diagnostic and treatment capacity and technical list of the primary medical examination and treatment facility or the medical examination and treatment facility is not qualified to diagnose and treat;
• In case the upper-level medical examination and treatment facility adjacent to the initial medical examination and treatment facility does not have suitable technical services, the patient will be transferred to a higher level of treatment;
• Before transferring to another hospital, the patient must be consulted and have a referral indication (not applicable to clinics or level 4 medical examination and treatment facilities).

➧ Case 2: Transferring medical examination and treatment facilities from upper level to lower level appropriately

Patients diagnosed with remission and treated through the emergency phase can continue treatment at lower levels.

➧ Case 3: Transferring medical examination and treatment facilities between facilities of the same level

• The disease is not suitable for the list of medical examination and treatment techniques of the medical examination and treatment facility or the facility does not have sufficient conditions for diagnosis and treatment;
• The disease is suitable for the list of medical examination and treatment techniques of the medical examination and treatment facility of the same level expected to be transferred to.

➧ Case 4: Transferring medical examination and treatment facilities between facilities and neighboring areas

• The Director of the Department of Health provides specific instructions on referrals for medical examination and treatment facilities in border areas within provinces and centrally run cities, while ensuring management authority;
• Directors of the Departments of Health shall unify and coordinate to provide specific instructions on referrals for medical examination and treatment facilities in border areas between provinces and centrally run cities, ensuring management authority.

Note:

1) The cases of route transfer mentioned above by fdiinvietnam.com are considered correct route transfer. Cases of route transfer not following the above regulations are considered off-route transfer. 

2) If a health insurance participant goes on a business trip, studies in a concentrated form of training, works mobile (flight attendant, pilot, tour guide, etc.) or temporarily resides in another locality, he/she will receive initial medical examination and treatment at a suitable medical facility and at the place where he/she is working mobile or temporarily residing.

3. Documents to prepare when registering for health insurance examination and treatment for critical illness

Depending on each case, the documents required to prepare when registering for health insurance examination and treatment for critical illnesses are different, specifically as follows: 

➧ Case 1: Health insurance participant goes for first medical examination and treatment

• Adult: 
  • Present health insurance card with photo;
  • If the health insurance card does not have a photo, additional identification documents such as citizen identification card, family register, etc. must be attached.
• Children under 6 years old: 
  • Show health insurance card;
  • If you do not have a health insurance card, you must present a copy of the birth certificate or a copy of the birth certificate. In case the child needs treatment immediately after birth and does not have a birth certificate, the head of the medical examination and treatment facility, the father or mother or guardian of the child must sign the medical record and be responsible for this confirmation.

➧ Case 2: Health insurance participants are waiting for re-issuance or replacement of health insurance cards.

Present the appointment paper for reissuance or exchange of health insurance card issued by the competent authority and a type of identification document.

➧ Case 3: Health insurance participants who have donated body parts come for medical examination and treatment

• Present health insurance card with photo (if health insurance card does not have photo, it is necessary to present additional identification documents such as citizen identification card, household registration book, etc.);
• Present documents proving organ donation issued by a competent authority and some types of personal identification documents;
• In case the donor must undergo treatment immediately after donation, the head of the medical examination and treatment facility where the person donated the body part and the patient or the patient’s relative must sign the confirmation in the medical record and be responsible for this confirmation.

➧ Case 4: Health insurance participant must seek emergency care

Present the documents as prescribed in case 1 or case 2 (depending on which case the health insurance participant belongs to).

➧ Case 5: Health insurance participant transfers treatment

• Health insurance participants must have a hospital transfer record or a referral letter from a medical facility (*);
• In case of re-examination upon treatment request, health insurance participants must have a re-examination appointment paper from the medical examination and treatment facility.

(*): In case the treatment referral paper is valid until December 31 of the calendar year but the treatment period has not ended, the patient can still use that paper until the end of the treatment period.

➧ Case 6: Health insurance participants go for re-examination as required for treatment

Health insurance participants must have a re-examination appointment from the medical facility.

➧ Case 7: Health insurance participants go on business trips, study in a concentrated training format, or work on the go.

• Present the documents as prescribed in case 1 or case 2 (depending on which case the health insurance participant belongs to);
• Submit original or copy of one of the following documents:
  • Business paper;
  • School transfer papers;
  • Proof of temporary residence registration;
  • Decision to send to study or student card.

Frequently asked questions about critical illness, critical illness health insurance

1. What is a critical illness?

Critical illness is a disease that is confirmed by a provincial hospital or military hospital at the military region level or higher to be life-threatening and difficult to treat, such as: end-stage cancer, cirrhosis with ascites, paralysis, severe tuberculosis level 4, heart failure level 3, kidney failure level 4, HIV that has turned into AIDS, etc.

>> See details: What is a critical illness?

2. What are the list of critical illnesses?

Pursuant to Circular No. 26/2014/TT-BQP, the list of critical illnesses includes 42 diseases:

1. Cancer;
2. First myocardial infarction;
3. Coronary artery surgery
4. Heart valve replacement surgery;
5. Aortic surgery;
6. Stroke… 

>> See details: List of critical illnesses of Decree 134.

3. What is the correct health insurance payment level for people with serious illnesses?

Pursuant to Article 14 of Decree 146/2018/ND-CP, depending on which group of people participating in health insurance with serious illness belong to, the level of payment for medical examination and treatment costs of the health insurance fund will be different, ranging from 80% – 100%.

>> See details: Critical illness insurance benefits when treated at the right facility.

4. What documents do people with serious illnesses need to prepare when going for health insurance treatment?

Depending on which of the 7 cases mentioned below the person with a serious illness registers for health insurance examination and treatment, the regulations on the documents that need to be prepared will be different:

• Health insurance participants go for medical examination and treatment for the first time;
• Health insurance participants are waiting for re-issuance or replacement of health insurance cards;
• Health insurance participants who have donated body parts come for medical examination and treatment;
• Health insurance participants must have emergency care;
• Health insurance participants transfer treatment;
• Health insurance participants go for re-examination as required for treatment;
• Health insurance participants go on business trips, study in the form of training, or work on the move.

 >> See details: Application form for health insurance examination and treatment for serious illness.

5. Who is entitled to 100% critical illness health insurance?

Groups of subjects entitled to 100% health insurance for critical illnesses include:

• Limited groups of beneficiaries of 100% health insurance: veterans, people with revolutionary contributions, people from poor households…;
• Groups of subjects entitled to 100% unlimited health insurance: children under 6 years old, revolutionary activists before January 1, 1945, heroic Vietnamese mothers…;
• Other cases not belonging to specific target groups: the cost of one medical examination and treatment for health insurance participants is lower than 15% of the basic salary, people receiving medical examination and treatment at commune-level facilities…

>> See details: Level of health insurance benefits for critical illness.

6. Can district insurance cover provincial health examination?

Yes. District-level health insurance can still provide medical examination and treatment at provincial level, this is called cross-line medical examination and treatment. According to the provisions of Clause 15, Article 1 of the 2014 amended Law on Health Insurance, in case a person with a health insurance card goes to a non-line medical examination and treatment, the health insurance fund will pay according to the following benefits:

• At central hospitals: 40% of inpatient treatment costs;
• At provincial hospitals: 60% of inpatient treatment costs;
• At district hospital: 100% of medical examination and treatment costs.

7. What is out-of-network health insurance examination?

Cross-border health insurance examination is the case where a health insurance participant uses the health insurance card to examine and treat at a facility other than the one initially registered for medical examination and treatment.

8. Are people with serious illnesses entitled to any subsidies or cost support?

Yes. People with serious illnesses will receive:

• The Health Insurance Fund pays for expenses within the scope of benefits when going to the right and wrong medical facility for examination and treatment;
• Enjoy other benefits and support for serious illnesses such as food and travel expenses…

>> See details: Critical illness benefit regime.

9. Are people with serious illnesses covered by health insurance?

Yes. People with serious illnesses can absolutely apply for health insurance according to the following instructions:

• Step 1: Prepare documents and procedures to apply for critical illness health insurance;
• Step 2: Submit application to Social Insurance agency;
• Step 3: Receive the application receipt and appointment letter for the health insurance card issuance results;
• Step 4: Receive health insurance card.

>> See details: Procedures for critical illness insurance.

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