“From Tomorrow, Avail 100% Health Insurance Coverage for Out-of-Network Medical Examinations.”

The 2024 Amendments to the Health Insurance Law (effective from July 1st) expand benefits for health insurance participants when seeking medical examination and treatment out of network, meaning they do not go to the initially registered facility or fail to follow the prescribed referral procedures.

According to regulations, the health insurance fund will cover 100% of the entitlement in the following specific cases:

Examination and treatment at basic or specialized facilities for diagnosis, treatment of rare diseases, critical illnesses, diseases requiring surgery or advanced techniques as prescribed by the Ministry of Health.

Ethnic minorities, poor households in difficult or extremely difficult socio-economic regions, and those living on island communes or districts receiving inpatient treatment at specialized facilities.

– Examination and treatment at the initial designated health facility (i.e., in-network).

– Inpatient treatment at basic-level facilities.

– Examination and treatment at basic or specialized facilities that were classified as district-level before January 1st, 2025.

– Inpatient treatment at specialized facilities that were classified as provincial-level before January 1st, 2025.

– Examination and treatment at any facility in emergency cases.

Patients with critical illnesses can go directly to higher-level facilities for treatment.

The Ministry of Health stipulates that patients with 62 critical illnesses, rare diseases, or those requiring surgery or advanced techniques can go directly to specialized facilities for examination and treatment without a referral.

This list includes serious conditions such as malignant cancers (pancreatic cancer – C25, thymoma – C37, brain tumor – C71…); metabolic disorders, congenital malformations, neonatal diabetes – P70.2; stage 3 or 4 heart failure…

However, to be eligible for this benefit, cancer patients (codes C00-C97) must meet two conditions: being under 18 years old and having a specified treatment regimen (without a specified treatment, they will not be eligible for the out-of-network benefit).

Similarly, diabetic patients who are insulin-dependent (E10.7) or non-insulin-dependent (E11.7) can only go out of network if they have stage 2 foot ulcers, stage 3 or higher chronic kidney disease, or at least two complications (cardiovascular, eye, neurological, or vascular).

Tran Thi Trang, Director of the Health Insurance Department (Ministry of Health), said that the list of rare and critical illnesses is constantly being reviewed and updated to ensure timely access to treatment for the population.

According to the Ministry of Health, the current healthcare system is divided into three levels: primary (commune health stations, polyclinics), basic (district hospitals, provincial-level specialized or general hospitals), and specialized (mainly central-level hospitals or some provincial-level hospitals with advanced specialties).

This classification forms the basis for regulations on out-of-network and in-network referrals, ensuring a rational allocation of healthcare resources and benefits for health insurance participants.