In which cases is health insurance covering 100% of medical examination and treatment costs?

Health insurance participants can have their medical examination and treatment costs paid 100% by the health insurance fund in many specific cases, according to regulations in current decrees.

People receiving health insurance medical examination and treatment in Hanoi - Photo: NAM TRAN

According to the current Law on Health Insurance (HI), the HI fund will cover all medical examination and treatment costs if the cost for one medical examination and treatment is lower than 15% of the basic salary.

According to Decree 73/2024/ND-CP, the current basic salary is 2,340,000 VND. Thus, if a patient's medical examination and treatment costs less than 351,000 VND/time (equivalent to 15% of the basic salary), the Health Insurance Fund will pay 100% within the scope of benefits.

This means that if the cost of medical examination/treatment is less than 351,000 VND, the patient does not have to pay a co-payment.

Not only low-cost medical examination and treatment cases, special groups of subjects are fully covered by the Health Insurance Fund, including:

Subjects as prescribed in Clauses 3, 4, 5, 8, 9, 11, 17 and 20, Article 3 of Decree 146 such as the poor, ethnic minorities living in difficult areas, people living in island communes, island districts, people with revolutionary contributions, the elderly, people with severe disabilities...

Some priority groups are covered 100% and have unlimited payment rates for drugs, supplies, and techniques, including:

Revolutionary activist before January 1, 1945.

Revolutionary activist from January 1, 1945 to before the August 1945 uprising.

Vietnamese heroic mother

War invalids (including type B war invalids recognized before December 31, 1993) and people enjoying the same policies as war invalids with a body injury rate of 81% or more.

War invalids and resistance fighters infected with toxic chemicals have a body injury rate of 81% or more.

Wounded and sick soldiers treated for wounds and recurring illnesses.

Children under 6 years old.

In addition to the above-mentioned groups, people who receive medical examination and treatment at the commune level are also covered 100% by the Health Insurance Fund, regardless of the subject.

Notably, people who have continuously participated in health insurance for 5 years or more, if the co-payment amount in the year exceeds 6 months of basic salary (ie 14,040,000 VND), will also have the health insurance fund pay 100% of the costs incurred exceeding the threshold, except in cases of self-examination and treatment at the wrong medical facility.

The remaining cases will be paid by the Health Insurance Fund at the rates of 40%, 60%, 80% according to current regulations.

Paying 100% of the costs in specific cases also contributes to increasing access to health services, encouraging people to participate fully and continuously in health insurance. To ensure their rights, people should clearly understand the information, keep full documents proving the time of participating in health insurance and perform medical examination and treatment at the right place and in accordance with regulations.

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Source: https://tuoitre.vn/truong-hop-nao-duoc-bao-hiem-y-te-chi-tra-100-chi-phi-kham-chua-benh-20250805100612437.htm