In what cases is health insurance not covered?

The revised Law on Health Insurance, effective from July 1, stipulates that health insurance will not cover medical examination and treatment costs in some cases.

People do health insurance procedures at Hanoi - Bac Giang International General Hospital (Bac Giang province) - Photo: HA QUAN

According to the Law on Health Insurance (HI) amended and supplemented with a number of articles, effective from July 1, the list of 12 cases not entitled to HI under the 2014 Health Insurance Law remains unchanged.

However, the 7th and 8th cases in this list have been revised and supplemented.

12 cases not covered by health insurance

Specifically, cases not covered by health insurance include:

1- Expenses paid by the state budget include:

- Medical examination, treatment, rehabilitation, regular pregnancy check-ups, childbirth

- Medical examination to screen and diagnose some diseases early

- Transporting patients from district level to higher level in emergency cases or when inpatient treatment requires technical transfer for some subjects. Specifically:

People with revolutionary contributions

People eligible for monthly social security benefits according to the law; people from poor households.

Ethnic minorities living in areas with difficult or extremely difficult socio -economic conditions; children under 6 years old; people from near-poor households.

2. Nursing and convalescence at specialized facilities.

3. Health check

4. Pregnancy testing and diagnosis are not for treatment purposes.

5. Use of assisted reproductive techniques, family planning services, abortion, except in cases of termination of pregnancy due to fetal or maternal illness.

6. Cosmetic services.

7. Treatment of strabismus and refractive errors of the eye for people 18 years of age and older (previously 6 years of age and older).

8. Use of alternative medical devices such as artificial legs, artificial arms, artificial eyes, dentures, eyeglasses, hearing aids, mobility aids in medical examination, treatment and rehabilitation (previously medical supplies).

9. Medical examination, treatment and rehabilitation in case of disaster.

10. Treatment of drug, alcohol or other substance addiction.

11. Medical examination, forensic examination, forensic psychiatric examination.

12. Participate in clinical trials and scientific research.

Expanding the scope of health insurance coverage

The amended Law on Health Insurance also adds a number of costs to be paid by health insurance from 2025, including:

Medical examination and treatment, including telemedicine, telemedicine support, family medicine, home medical examination and treatment, rehabilitation, regular pregnancy check-ups, childbirth.

Transporting patients belonging to the subjects specified in points a, b, c, d, đ, e, h, i, o, r, clause 3, article 12 of the 2008 Law on Health Insurance (amended by clause 10, article 1 of the 2024 amended Law on Health Insurance) in cases of inpatient treatment or emergency requiring referral according to the provisions of Article 27 of the 2008 Law on Health Insurance (amended by clause 22, article 1 of the 2024 amended Law on Health Insurance).

According to the draft circular guiding a number of articles of the amended Law on Health Insurance, the Ministry of Health proposes that the scope of benefits for patient transportation costs will be specifically regulated by the payment of transportation costs at a fixed rate: 0.2 liters of RON92 gasoline for 1km.

Specific regulations on payment of transportation costs in cases where medical examination and treatment facilities provide services. Patients must provide their own transportation.

The Fund will also cover the costs of using medical technical services, drugs, medical equipment, blood, blood products, medical gases, supplies, tools, and chemicals in medical examination and treatment within the scope of payment of the Health Insurance Fund.

In addition, people with health insurance cards who go for medical examination and treatment upon request will have the health insurance fund pay part of the medical examination and treatment costs within the scope of benefits, according to regulations.

The difference in cost between the price of medical examination and treatment services upon request and the payment level of the health insurance fund shall be paid by the patient to the medical examination and treatment facility.

Previously, patients were not covered for on-demand medical examination and treatment.

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Source: https://tuoitre.vn/truong-hop-nao-khong-duoc-chi-tra-bao-hiem-y-te-20250401154259649.htm