Health insurance benefits when having the latest referral paper

What is the level of health insurance benefits when having a referral letter? What are the procedures for medical examination and treatment under health insurance when having a referral letter? - Reader Hai Yen

Mức hưởng bảo hiểm y tế khi có giấy chuyển tuyến mới nhất

1. Latest regulations on health insurance referral papers

From December 3, 2023, the form of referral form for medical examination and treatment under health insurance (or health insurance referral form) prescribed in Decree 75/2023/ND-CP amending Decree 146/2018/ND-CP guiding the Law on Health Insurance (effective from December 3, 2023) will be applied.

DOWNLOAD: Latest health insurance referral form

2. Health insurance benefits when having the latest referral paper

According to Article 11 of Circular 40/2015/TT-BYT, the case of a health insurance participant being transferred to a health insurance medical examination and treatment facility according to regulations is one of the cases of correct medical examination and treatment.

Pursuant to Article 22 of the Law on Health Insurance 2008 (amended and supplemented in 2014), patients will enjoy health insurance payment levels when having a referral paper as follows:

- 100% of medical examination and treatment costs for the following subjects:

+ Officers, professional soldiers, non-commissioned officers, soldiers on active duty;...

+ People with revolutionary contributions, veterans;

+ Children under 6 years old;

+ People eligible for monthly social security benefits;

+ People from poor households; ethnic minorities living in areas with difficult socio -economic conditions; people living in areas with particularly difficult socio-economic conditions; people living in island communes and island districts;

+ Relatives of people with revolutionary contributions are biological fathers, biological mothers, wives or husbands, and children of martyrs; people who raised martyrs;

+ Patients who have participated in health insurance for 5 consecutive years or more and have the amount of co-payment for medical examination and treatment costs in the year greater than 6 months of basic salary,

- 95% of medical examination and treatment costs are covered by health insurance: People receiving monthly pensions and allowances for loss of working capacity; relatives of people with revolutionary contributions; near-poor households, etc.

- 80% of medical examination and treatment costs within the scope of health insurance payment: Remaining subjects.

3. Procedures for medical examination and treatment under health insurance when there is a referral

Accordingly, to enjoy health insurance coverage when having a referral paper, patients need to follow the correct procedures for health insurance examination and treatment in Article 15 of Decree 146/2018/ND-CP (amended and supplemented in Decree 75/2023/ND-CP). Accordingly, when referring to a medical examination and treatment facility, patients must present the following documents:

- Health insurance participants must present their health insurance card with photo or citizen identification card when seeking medical examination or treatment;

In case of presenting a health insurance card without a photo, it is necessary to present one of the following identification documents with a photo issued by a competent authority or organization, or a certificate issued by the commune-level police, or other documents certified by theeducational institution where the student is managed; other legal identification documents or documents with level 2 electronic identification as prescribed in Decree 59/2022/ND-CP.

- In case of referral for medical examination and treatment, health insurance participants must present the referral records of the medical examination and treatment facility and the referral paper according to Form No. 6 of the Appendix issued with Decree 146/2018/ND-CP.

In case the referral form is valid until December 31 but the treatment period has not ended, the referral form can be used until the end of the treatment period.

In case of re-examination upon treatment request, health insurance participants must have a re-examination appointment paper from the medical examination and treatment facility according to Form No. 5 of the Appendix issued with Decree 146/2018/ND-CP.

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