Question:
Are students participating in health insurance (HI) entitled to health insurance benefits when they go to non-public medical facilities for examination and treatment? - (buihoaxx@gmail.com)
Hanoi Social Insurance replied:
According to Article 24 of the 2008 Law on Health Insurance, amended and supplemented in 2014, a health insurance-covered medical examination and treatment facility is defined as a medical facility under the provisions of the Law on Health Insurance that has signed a health insurance contract with a health insurance organization.
If a private hospital signs a contract for health insurance, it is also considered a health insurance facility. Therefore, when people with health insurance cards visit these medical facilities, they will also be paid by the Health Insurance Fund at the same level as public health insurance facilities.
In case the private medical facility has not signed a medical examination and treatment contract with the health insurance organization, you must pay the medical examination and treatment costs to the private hospital in advance, then complete the procedures for the health insurance fund to pay later. Specifically, according to Clause 2, Article 31 of the Law on Health Insurance, the health insurance organization will pay the health insurance medical examination and treatment costs directly to the person with a health insurance card who goes for medical examination and treatment in the following cases:
Medical examination and treatment at district-level medical examination and treatment facilities and equivalent facilities that do not sign a health insurance medical examination and treatment contract with the Social Insurance agency:
Outpatient: payment based on 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 and treatment.
Inpatient: payment based on actual costs within the scope of benefits and health insurance benefits, but not exceeding 0.5 times the basic salary at the time of discharge.
Inpatient medical examination and treatment at provincial-level medical examination and treatment facilities and equivalent facilities that do not sign a health insurance contract with the social insurance agency: payment is based on actual costs within the scope of benefits and health insurance benefits, but not exceeding 1 time the basic salary at the time of discharge from the hospital.
Inpatient medical examination and treatment at central-level medical examination and treatment facilities and equivalent facilities that do not sign a health insurance medical examination and treatment contract with the social insurance agency: payment is based on actual costs within the scope of benefits and health insurance benefits, but not exceeding 2.5 times the basic salary at the time of discharge.
In emergency cases, patients participating in health insurance can receive medical examination and treatment at any medical facility (including private hospitals) and will be paid for actual costs within the scope of benefits and health insurance benefit levels according to regulations.
Thus, health insurance participants who go to private hospitals and clinics for medical examination and treatment will still be entitled to health insurance. Article 28 of Decree 146/2018/ND-CP stipulates that the application dossier for the district-level Social Insurance agency to pay health insurance premiums for medical examination and treatment in this case includes:
- Photocopies (with original for comparison) of documents: Health insurance card + identity card (ID card/CCCD); hospital discharge papers; medical examination form/Medical examination book of the medical examination requested for payment; invoices and related documents.
Note: Patients who go to private hospitals for medical examination and treatment will enjoy medical examination and treatment benefits according to the prices prescribed in Circular 22/2023/TT-BYT. The difference in services such as examination, testing, surgery, etc., must be paid by the health insurance card holder to the medical examination and treatment facility.
Source: https://kinhtedothi.vn/hoc-sinh-kham-tai-benh-vien-tu-co-duoc-huong-bhyt-khong.html
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