Mr. Nhat Anh asked, is that correct? If not, then in case the doctor denies your health insurance benefits, how can you get it resolved?
The Social Insurance Department of Quang Ninh province answers this issue as follows: The following:
Health insurance is a form of compulsory insurance applied to subjects according to the provisions of the Health Insurance Law for health care, not for profit purposes. The profit is organized by the State, in which the insured person will be supported by the insurance agency in part or all of the medical examination and treatment costs when going for examination and treatment at a medical facility.</p >
The level of health insurance benefits depends on the insured person and the form of medical examination and treatment at the right or wrong level of the insured person.
Article 6 of Circular No. 30/2020/TT -The Ministry of Health regulates cases of medical examination and treatment covered by health insurance at the right level as follows:
1. Health insurance participants come for medical examination and treatment at the original medical examination and treatment facility written on the health insurance card.
2. Health insurance participants who register for initial medical examination and treatment at a commune-level medical examination and treatment facility or polyclinic or district hospital are entitled to medical examination and treatment covered by health insurance at a commune-level medical station or polyclinic or district hospital. other districts in the same province. In cases where children do not have a health insurance card because they have not yet completed birth registration procedures, they can use the birth certificate to go for medical examination and treatment at the medical examination and treatment facility specified in this Clause.
3. Health insurance participants in an emergency situation can receive emergency treatment at any medical examination and treatment facility nationwide.
4. Health insurance participants are referred to health insurance for medical examination and treatment according to the provisions of: Article 10 and Article 11 of Circular No. 40/2015/TT-BYT; Clause 3 Article 14 Decree No. 146/2018/ND-CP; Clause 2, Article 6, Circular No. 04/2016/TT-BYT.
5. Health insurance participants have documents proving that they are staying in another locality while on a business trip, mobile work, intensive study in the form of training, temporary residence training program and initial medical examination and treatment at the same medical examination and treatment facility. or equivalent to the initial medical examination and treatment registration facility recorded on the health insurance card as prescribed in Clause 7, Article 15 of Decree No. 146/2018/ND-CP. The medical examination and treatment facility is responsible for saving copies of the documents specified in this point in the patient’s medical treatment record.
6. People with a re-examination appointment in case they have been referred as prescribed in Clause 5, Article 15 of Decree No. 146/2018/ND-CP.
7. The person who donated his or her body parts must receive treatment immediately after donating the body parts.
8. Newborns must be treated immediately after birth.”
If they do not fall into the cases specified in Article 6 of Circular No. 30/2020/TT-BYT listed above, the patient will determined to be medical examination and treatment at the wrong route
Clause 3, Article 22 of the 2014 Amendments and Supplements to the Health Insurance Law stipulates: In cases where a person with a health insurance card goes for medical examination and treatment at the wrong route, the health insurance fund will pay at the appropriate rate. entitled to the provisions in Clause 1 of this Article according to the following ratio:
“a) At central hospitals, it is 40% of inpatient treatment costs;
b) At central hospitals, it is 40% of inpatient treatment costs;
b) Provincial hospitals are 60% of inpatient treatment costs from the effective date of this Law to December 31, 2020; 100% of inpatient treatment costs from January 1, 2021 nationwide;
c) At district hospitals, 70% of medical examination and treatment costs from the effective date of this Law until December 31, 2015; 100% of medical examination and treatment costs from January 1, 2016″.
So if you do not fall into the cases identified in Article 6 of Circular 30/2020/TT-BYT above, then when Going for medical examination and treatment at Vietnam Sweden Hospital – Uong Bi will be determined to be out of line. Vietnam – Sweden Hospital Uong Bi is a provincial level I hospital. If you receive inpatient treatment, you will be paid by the health insurance fund. 100% of inpatient treatment costs. In case you only come for examination and then go home or have outpatient treatment, you will not be entitled to health insurance.
In case you have a health insurance card and meet 1 of the following cases: specified in Article 6 of Circular No. 30/2020/TT-BYT or when you are receiving inpatient treatment at Vietnam Sweden Hospital – Uong Bi and the doctor denies your benefits, you can call the phone number hotline of the medical examination and treatment facility for resolution.
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