Could you please provide a detailed explanation of health insurance coverage levels for both in-network and out-of-network medical examinations and treatments? This information would help my family and me make informed decisions when choosing healthcare services.

Reader Tran Anh

Health insurance coverage levels for in-network and out-of-network care are detailed in Articles 12 and 22 of the 2008 Health Insurance Law, amended in 2024.

For in-network medical examinations and treatments, health insurance coverage ranges from 80% to 100%.

1. 100% coverage for medical examination and treatment costs applies to the following cases and patient groups:

- Costs for a single medical examination or treatment that are less than 15% of the basic salary level (currently 2.34 million VND).

- Costs for medical examination and treatment at initial healthcare facilities, including:

: Health stations;

: Family medicine facilities;

: Military-civilian health stations, military-civilian clinics;

: Regional medical centers offering medical examination and treatment services, licensed as clinics;

: Healthcare facilities within agencies, units, and organizations as regulated by the Minister of Health;

: Initial healthcare facilities within the military and public security forces as regulated by the Minister of National Defense and the Minister of Public Security;

: Outpatient medical examination and treatment costs at regional general clinics.

A doctor examines a patient at the Hospital for Tropical Diseases, TP HCM, April 2023. Photo: Quynh Tran

- Officers and professional soldiers currently serving in the People's Army; professional officers and non-commissioned officers, and technical professional officers and non-commissioned officers serving in the People's Public Security forces; individuals engaged in cipher work receiving salaries equivalent to military personnel;

- Non-commissioned officers and soldiers currently serving in the People's Army; non-commissioned officers and conscripted soldiers in the People's Public Security forces; military academy students, public security academy students, and cipher academy students who are Vietnamese citizens receiving living allowances;

- Military academy students, public security academy students, and cipher academy students who are foreign citizens receiving living allowances;

- Reserve officer training students for three months or more who have not participated in social insurance or health insurance;

- Full-time militia members;

- Individuals with meritorious service to the revolution as stipulated by the Ordinance on Preferential Treatment for People with Meritorious Service to the Revolution; veterans;

- Children under six years old;

- Relatives of martyrs, individuals who nurtured martyrs as stipulated by the Ordinance on Preferential Treatment for People with Meritorious Service to the Revolution;

- Individuals belonging to poor households; ethnic minorities from near-poor households residing in communes and villages in ethnic minority and mountainous regions; ethnic minorities residing in areas with difficult socio-economic conditions; individuals residing in areas with particularly difficult socio-economic conditions; individuals living in island communes and districts;

- Individuals receiving monthly social assistance benefits; individuals receiving monthly nurturing allowances as stipulated by relevant laws; individuals receiving monthly survivor benefits who are also eligible for social assistance benefits;

- Individuals aged 75 and above receiving monthly survivor benefits, and individuals aged 70 to under 75 from near-poor households receiving monthly survivor benefits;

- Patients who have participated in health insurance for 5 consecutive years or more and whose co-payment amount for medical examination and treatment costs within the year, for visits as stipulated in clause 3, points a, b, c, d, and e of clause 4, clause 5 of Article 22, Article 26, and Article 27 of the 2008 Health Insurance Law, amended in 2024, exceeds 6 times the reference level.

2. 95% coverage for medical examination and treatment costs applies to the following patient groups:

- Individuals receiving monthly pensions or disability allowances;

- Relatives of individuals with meritorious service to the revolution, widows or widowers of martyrs who have remarried and are receiving monthly survivor benefits, and related individuals as stipulated by the Ordinance on Preferential Treatment for People with Meritorious Service to the Revolution, excluding relatives of martyrs and individuals who nurtured martyrs;

- Individuals belonging to near-poor households;

- Ethnic minorities living in communes no longer classified as having difficult or particularly difficult socio-economic conditions, who receive state budget support for health insurance contributions as regulated by the Government.

3. All other patient groups receive 80% coverage for medical examination and treatment costs.

Note: If an individual belongs to multiple health insurance participant categories, they will receive the highest applicable benefit level.

Click to continue reading: Health insurance coverage for out-of-network medical examination and treatment.