According to the Ministry of Health, adjustments to health insurance (BHYT) focus on broadening participant benefits and updating coverage and contribution levels in line with the new base salary of 2,530,000 VND per month. These new policies, effective from July 1, are expected to provide greater benefits to BHYT participants, reduce medical examination and treatment costs, and enhance access to quality healthcare services nationwide.

50% outpatient costs covered for out-of-network care

One significant change is that BHYT cardholders seeking out-of-network outpatient care at basic-level medical facilities with a ranking score of 50 points or higher, facilities provisionally classified as basic-level, or specialized-level facilities previously ranked as provincial-level before 1/1/2025, will receive 50% of their eligible costs covered by the Health Insurance Fund.

Previously, patients receiving out-of-network outpatient care at many provincial-level hospitals had to cover the entire cost themselves. Therefore, starting July 1, this financial burden will be significantly reduced.

For example, a patient in the group eligible for 100% BHYT coverage incurs a total outpatient cost of 1,000,000 VND at a basic-level hospital. The Health Insurance Fund will pay: 1,000,000 VND x 100% x 50% = 500,000 VND. The patient will only need to pay 500,000 VND.

For a patient in the group eligible for 80% BHYT coverage, the insurance payment will be: 1,000,000 VND x 80% x 50% = 400,000 VND. The patient will pay the remaining 600,000 VND. This is known as the co-payment mechanism.

According to the managing agency, this marks a substantial expansion of benefits, offering people greater flexibility in choosing their healthcare providers.

Elderly people receiving medical examinations at Cau Ong Lanh ward health station, TP HCM on 5/4. Photo: Thanh Tung

Health insurance covers 100% for medical bills under 379,500 VND

Another new point is that cases where the total cost of a single medical examination or treatment is less than 15% of the base salary, equivalent to under 379,500 VND, will benefit from a more favorable policy. For in-network care, the Health Insurance Fund will cover 100% of the eligible costs across all technical and professional levels of medical facilities, from initial and basic to specialized.

For out-of-network care, patients will receive coverage according to the rates specified in the BHYT Law. However, the new calculation method is more advantageous as it no longer applies the benefit ratio for each patient group in certain situations.

For instance, a patient has a total medical examination and treatment cost of 370,000 VND. If this patient is eligible for 100% coverage for certain rare diseases, severe illnesses, or conditions requiring surgery or high-tech procedures, the Health Insurance Fund will pay the entire 370,000 VND. The patient will not have to pay any additional amount. Under the old calculation, if the patient belonged to the 80% coverage group, they would be subject to co-payment, with BHYT covering 296,000 VND and the patient having to pay an additional 74,000 VND.

Similarly, if a patient is eligible for 40% coverage for inpatient treatment at a specialized-level medical facility, the Health Insurance Fund will pay: 370,000 VND x 40% = 148,000 VND. The patient will pay 222,000 VND.

If the previous calculation method, which included an additional 80% benefit ratio, were applied, the BHYT payment would be 118,400 VND, nearly 30,000 VND less.

A representative from the Ministry of Health stated that to determine their BHYT benefits, people need to consider the technical and professional level of the medical facility. Information regarding hospital levels and ranking scores is publicly available on the official websites of healthcare management agencies, provincial health departments, and hospitals. This is a mandatory responsibility for these units to help people easily look up information before seeking care. Understanding the hospital's professional level will help people choose appropriate facilities and maximize their BHYT benefits.

Increased benefits for those with 5 years of continuous health insurance

The new policy also benefits individuals who have participated in BHYT for 5 consecutive years or more. Accordingly, BHYT participants with 5 or more consecutive years of contributions will have 100% of their eligible medical examination and treatment costs covered by the Health Insurance Fund once their total annual co-payment exceeds six months' base salary. The current threshold is set at: 6 x 2,530,000 VND = 15,180,000 VND.

For example, a person in the 80% BHYT coverage group has undergone multiple in-network treatments during the year, and their total co-payment has surpassed 15,180,000 VND. From the moment this threshold is exceeded until the end of the fiscal year, the Health Insurance Fund will cover 100% of their eligible medical examination and treatment costs, eliminating the need for further 20% co-payments as before.

For critically ill patients requiring high-tech interventions, BHYT has increased the maximum payment for medical equipment to 113,850,000 VND per procedure, an increase of over 8,500,000 VND from the previous limit.

This policy is regarded as a "financial safety net" for individuals with severe illnesses, chronic conditions, or those requiring long-term, high-cost treatment.

A representative from the BHYT managing agency announced plans to develop a centralized information portal for BHYT benefits. The portal will enable people to quickly look up their coverage levels and benefits for various medical examination and treatment scenarios. It will also provide utilities for medical facilities, businesses, and regulatory agencies. If implemented, this tool will support people in accessing BHYT policies more easily, reducing instances where they are unaware of their rights when seeking medical care.

Le Nga