1. Definition:
- Out-of-pocket sum/copayment: This is the monetary amount that an insured patient must pay in collaboration with social insurance agencies at the rate (%) of entitlement to insurance covers specified in each health insurance card.
Example: Mr. A holding a health insurance card prescribing 80% of health insurance cover has to make the out-of-pocket payment accounting for 20% of total medical costs covered by his health insurance policy.
- The consecutive period of health insurance participation refers to the date subsequent to the previous date of issue inscribed on a health insurance card; in case of an interval, it must be less than 03 months.
2. Benefit entitlement requirements:
- The health insurance card shows the line “Date of celebration of 5 consecutive years of participation: from dd/mm/yy”.
- The insured's out-of-pocket payment made for medical costs within a year is greater than 6 months’ base pay (6 months’ base pay calculated from July 1, 2019 is equal to 8,940,000 dong) from the date of celebration of 5 consecutive years' participation in health insurance.
- The insured is referred to appropriate health establishments.
3. Right of entitlement
The insured meeting the abovementioned requirements will be entitled to covers equaling 100% of medical costs covered by health insurance benefits, specifically including the following circumstances:
- If a patient’s single or multiple out-of-pocket payment(s) when visiting once or more times at medical establishments is greater than 06 months' base pay, then:
+ Health establishment will not collect the sum of out-of-pocket payment greater than 6 months’ base salary.
+ Health establishment is required to provide the invoice proving the sum of out-of-pocket payment equaling 6 months’ base pay amount so that the patient may request a social insurance agency to confirm that he/she does not have to make any more out-of-pocket payment within the year in question.
- If an insured patient's accrued amounts of out-of-pocket payments at health establishments are different or such amounts at the same health establishment are greater than 6 month’s base pay, then the patient may submit evidencing documents to the social insurance agency where he/she is issued health insurance card in order to make copayment which is greater than 6 months' base pay and receive the written certification of exemption from out-of-pocket payment within the year in question.
- In case where the patient's co-payment amount is greater than the 6 months’ total base pay amount as from January 1, the health insurance fund can cover 100% of costs incurred from healthcare services falling within the scope of a patient’s interests from the anniversary date of 5 consecutive years of health insurance participation to the end of December 31 in that year.
4. Examples
Example 1:
- Mr. A has participated in health insurance for 5 years on December 31, 2018 (This is the date of commencement of calculation of difference used as a basis to pay any refund).
- His aggregate copayment cost accruing from January 1, 2019 to August 1, 2019 is 20,000,000 dong.
According to the abovementioned information, when Mr. A arrives with his invoices at the designated social insurance agency, Mr. A will be refunded 20,000,000 dong – 8,940,000 dong = 11,060,000 dong and will be granted certification of exemption from copayment within the year from August 1, 2019.
After obtaining certification of exemption from copayment within the year in question, if he visits appropriate health establishments, the patient may show it to exempt himself or herself from copayment required previously.
Example 2:
- Mr. B has participated in health insurance for 5 consecutive years on May 31, 2019.
- His aggregate copayment cost accruing from January 1, 2019 to August 1, 2019 is 20,000,000 dong. Including: Out-of-pocket payment sum calculated from January 1, 2019 to May 31, 2019 is 5,000,000 dong; from June 1, 2019 to August 1, 2019 is 15,000,000 dong.
According to the abovementioned information, when Mr. B arrives with his invoices at the designated social insurance agency, Mr. B will be refunded 15,000,000 dong – 8,940,000 dong = 6,060,000 dong and will be granted certification of exemption from copayment within the year from August 1, 2019.
5. Entitlement procedures
Persons eligible for refund may be required to submit the following documents to the social insurance agency:
- Health insurance card showing the line “Date of celebration of 5 consecutive years of participation: from dd/mm/yy” and photo-attached travel documents (duplicate).
- Medical invoices (original).
** Legal bases:
- Clause 15 of Article 1 in the 2014 amended Law on Health Insurance.
- Point dd of clause 1 of Article 14 and clause 3 of Article 27 in the Decree No. 146/2018/NĐ-CP dated October 17, 2018.
- Notice No. 2298/TB-BHXH in 2018 regarding direct payment of medical costs covered by health insurance and out-of-pocket payment greater than 6 months' base pay, issued by Ho Chi Minh city's Social Insurance Agency.
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