New regulations on submitting documents and direct payment for health insurance examination and treatment

Application for direct payment of medical examination and treatment costs under health insurance

Pursuant to Article 28 of Decree 146/2018/ND-CP, the application file for direct payment of health insurance medical examination and treatment costs includes:

- Documents are photocopies (with originals for comparison) including:

+ Health insurance card, identity card as prescribed in Clause 1, Article 15, Decree 146/2018/ND-CP;

+ Hospital discharge papers, medical examination form or medical examination book of the medical examination or treatment for which payment is requested.

- Invoices and related documents.

Submit application and directly pay for medical examination and treatment under health insurance

Pursuant to Article 29 of Decree 146/2018/ND-CP, the patient or the patient's relative or legal representative as prescribed by law shall directly submit the above-mentioned documents to the social insurance agency at the district level where they reside.

District social insurance is responsible for:

- Receive payment request documents from patients and issue receipts. Provide guidance on how to complete documents that are not complete according to regulations.

- Within 40 days from the date of receipt of the complete payment request, the health insurance assessment must be completed and the medical examination and treatment costs paid to the patient or the patient's relatives or legal representative must be paid. In case of non-payment, a written response must be given stating the reason.

Direct payment level for medical examination and treatment under health insurance

Pursuant to Article 30 of Decree 146/2018/ND-CP, the direct payment level for medical examination and treatment under health insurance is stipulated as follows:

(1) In case a patient comes to a district-level medical examination and treatment facility or equivalent without a health insurance medical examination and treatment contract (except in emergency cases), payment is as follows:

- In case of outpatient medical examination and treatment, payment is made according to actual costs within the scope of benefits and health insurance benefits according to regulations, but not exceeding 0.15 times the basic salary at the time of medical examination and treatment;

- In case of inpatient examination and treatment, payment is based on actual costs within the scope of benefits and health insurance benefits according to regulations, but not exceeding 0.5 times the basic salary at the time of discharge from the hospital.

(2) In case a patient comes to a provincial-level or equivalent medical examination and treatment facility for inpatient treatment without a health insurance contract (except in emergency cases), payment will be made according to the actual costs within the scope of benefits and health insurance benefits as prescribed, but not exceeding 1.0 times the basic salary at the time of discharge from the hospital.

(3) In case a patient comes to a central or equivalent medical examination and treatment facility for inpatient treatment without a health insurance contract (except in emergency cases), payment will be made according to the actual costs within the scope of benefits and health insurance benefits as prescribed, but not exceeding 2.5 times the basic salary at the time of discharge from the hospital.

(4) In case a patient goes to a medical examination or treatment place where he/she initially registered for medical examination or treatment that is not in accordance with the provisions of Clause 1, Article 28 of the Law on Health Insurance 2008 (amended in 2014), the Health Insurance Fund shall pay the actual costs within the scope of benefits and health insurance benefits, but not exceeding 0.15 times the basic salary at the time of medical examination or treatment for outpatient medical examination or treatment and not exceeding 0.5 times the basic salary at the time of discharge for inpatient medical examination or treatment.