In which cases are medical expenses covered by insurance?

How will medical expenses be covered when using the hospital's insurance guarantee service? According to a representative from Phu Tho General Hospital, the hospital will pay all medical expenses that the insurance company guarantees for the customer directly to the hospital.

Customers only have to pay the portion of the costs exceeding the limit or outside the scope of the insurance contract's guarantee to the hospital (if any).

The time frame for the insurance company to confirm the guarantee for a customer is 30 minutes for outpatient claims and within 24 hours for inpatient claims (unless further assessment is required, in which case the insurance company will notify the customer).

However, every step in the medical expense guarantee process will be directly assisted by our medical expense guarantee staff and will be carried out as quickly as possible to save you time.

In which cases are hospital fees not covered by insurance? Not all cases covered by insurance are eligible for hospital fee coverage.

There are certain cases where medical expenses are not covered, specifically: Failure to provide and present the required insurance card or relevant identification documents.

Cases where there is insufficient information to confirm coverage or where further verification is needed. Individuals using medical services at facilities not part of the hospital/clinic network that collaborates with the insurance company.

Patients receiving treatment for pre-existing medical conditions prior to enrollment. Services related to cosmetic procedures/cosmetic surgery. Accidents related to the use of alcohol and stimulants, and failure to comply with legal regulations.

Treatment for drug-related illnesses and substance abuse. Treatment costs for illnesses caused by natural disasters, war, etc.

According to statistics from the Ministry of Health, the number of people participating in health insurance is steadily increasing. As of December 2023, over 93 million people nationwide were covered by health insurance, achieving a coverage rate of 93.35% of the population.

The quality of medical examination and treatment under health insurance is constantly improving, allowing people to access modern medical technology and many new, highly effective medicines, helping many overcome illnesses and serious diseases.

The health insurance fund, which is always balanced and has a surplus, is becoming a fundamental source of funding for the operation of medical facilities and provides financial protection for health insurance participants when they fall ill and need examination and treatment. The health insurance policy has ensured the principle of risk sharing among health insurance participants.

From July 1st, the basic salary increased from 1.8 million VND to 2.34 million VND, therefore, the level of health insurance benefits for patients will change.

Specifically, regarding health insurance coverage, if a patient is admitted to the hospital or begins treatment before July 1st but is discharged or finishes treatment on or after July 1st, and receives medical examination and treatment in accordance with the Health Insurance Law with a cost of less than 351,000 VND (15% of the basic salary), then health insurance will cover 100% of the cost, meaning the patient receives free medical examination and treatment. This figure is an increase of 81,000 VND compared to the previous regulation.

Regarding direct payment, the regulations apply to cases where patients are admitted to the hospital or begin treatment before July 1st but are discharged or complete treatment on or after July 1st.

Specifically, in the case of outpatient examination and treatment, payment will be based on actual costs within the scope of coverage and the level of health insurance benefits as prescribed, but not exceeding 0.15 times the basic salary, equivalent to a maximum of 351,000 VND (previously 270,000 VND).

In the case of inpatient examination and treatment, payment will be based on actual costs within the scope of coverage and the level of health insurance benefits as prescribed, but not exceeding 0.5 times the basic salary at the time of discharge, equivalent to a maximum of 1,170,000 VND (previously 900,000 VND).

In cases of inpatient examination and treatment at provincial-level and equivalent facilities without a health insurance contract (except in emergency cases), payment will be based on actual costs within the scope of coverage and the level of health insurance benefits as prescribed, but not exceeding one time the basic salary at the time of discharge, equivalent to a maximum of 2,340,000 VND (previously 1,800,000 VND).

In cases where patients receive inpatient medical examination and treatment at central-level and equivalent facilities without a health insurance contract (except in emergency cases), payment will be based on actual costs within the scope of coverage and the level of health insurance benefits as prescribed, but not exceeding 2.5 times the basic salary at the time of discharge, equivalent to a maximum of 5,850,000 VND (previously 4,500,000 VND).

In addition, the Ministry of Health also stipulates that the total cost of medical supplies for a single use of a technical service shall not exceed 45 times the basic salary. Specifically, for patients admitted to the hospital from July 1st, this is equivalent to no more than 105.3 million VND, compared to 81 million VND previously.

In cases where a patient is admitted to the hospital or begins treatment before July 1st but is discharged or finishes treatment on or after July 1st, the total cost of medical supplies for a single technical service will be determined based on the time the technical service ends, and the cost will be calculated based on both time points.

Specifically, before July 1st: Payments must not exceed 81 million VND, and from July 1st onwards: Payments must not exceed 105.3 million VND.

Not only will health insurance benefits change, but the change in the base salary from July 1st will also lead to many policy changes, including health insurance contribution rates and benefits for health insurance participants.

Accordingly, the monthly health insurance contribution rates for households are as follows: The first person pays 4.5% of the basic salary; the second, third, and fourth persons pay 70%, 60%, and 50% respectively of the first person's contribution.

From the fifth person onwards, the contribution is 40% of the first person's contribution. For students, the monthly health insurance contribution is 4.5% of the basic salary (the State budget subsidizes 30%, and students pay 70%).

For students, the monthly health insurance contribution is 4.5% of the basic salary (the State budget subsidizes 30%, and students pay the remaining 70%).