Công văn 647/BYT-BH năm 2025 mức hưởng bảo hiểm y tế đối với trường hợp tự đi khám chữa bệnh và có chi phí cho 01 lần khám chữa bệnh thấp hơn 15% mức lương cơ sở do Bộ Y tế ban hành

To:

- Departments of Health of provinces and municipalities;
- Health facilities nationwide.

The Ministry of Health has received official dispatches from several Departments of Health and health facilities [1] requesting the provision of guidance on the health insurance (HI) reimbursement rate for participants who visit health facilities that are not their registered primary care providers or against regulations on referral with the medical cost of one medical examination/treatment occasion that is lower than 15% of the statutory pay rate. The Ministry of Health hereby provides the following clarification:

1. Regarding the HI reimbursement rate when the medical cost of one medical examination/treatment occasion is lower than 15% of the statutory pay rate

- According to clause 4, Article 22 of the Law on Health Insurance amended by Law No. 51/2024/QH15 (Law on Health Insurance), "In case a health insurance participant visits a health facility that is not the registered primary care provider or against regulations on referral prescribed in Article 26 and Article 27 of this Law, except for the cases specified in clause 3 and clause 5 of this Article, he/she will be reimbursed by the health insurance fund at the rates specified in clause 1 of this Article."

HI participants falling under clause 4, Article 22 of the Law on Health Insurance are entitled to all HI reimbursement rates prescribed in clause 1, Article 22, which includes the provision that: “100% of the medical costs if the cost of one medical examination/treatment occasion is lower than the level prescribed by the Government.”

- According to clause 3, Article 14 of Decree No. 146/2018/ND-CP amended by Decree No. 75/2023/ND-CP and Decree No. 02/2025/ND-CP, the medical cost of one medical examination/treatment occasion to be covered 100% by the health insurance fund as prescribed in point b, cause 1, Article 22 of the Law on Health Insurance is 15% of the statutory pay rate.

Thus, the provisions of clause 4, Article 22 of the Law on Health Insurance, which refers to the HI reimbursement rates prescribed in clause 1, Article 22 thereof, must be complied with in order to ensure the rights of HI participants.

...

...

...

Where the HI-covered medical cost of one medical examination/treatment occasion is equal to or exceeds 15% of the statutory pay rate, the HI reimbursement rate shall follow Article 22 of the Law on Health Insurance, except for point b, clause 1 thereof.

The Ministry of Health requests the Departments of Health of provinces and municipalities and relevant agencies and units to implement accordingly to ensure the rights of HI participants.

PP. MINISTER
DEPUTY MINISTER




Tran Van Tuan

[1] Official Dispatch No. 155/SYT-KHTC dated January 26, 2025 of Thai Binh Department of Health, Official Dispatch No. 387/SYT-NVY dated January 23, 2025 of Ca Mau Department of Health, Official Dispatch No. 223/BVDK-KHTH dated January 21, 2025 of Ninh Binh Provincial General Hospital.