When Not to Transfer to a Specialist Hospital
Vietnam Health Insurance Coverage for Serious Illnesses Clarified
Table of Contents
- Vietnam Health Insurance Coverage for Serious Illnesses Clarified
- Vietnam Health Insurance Coverage for Serious Illnesses Clarified
- introduction: New Regulations on Health Insurance in Vietnam
- What Serious Illnesses Are Covered by Health Insurance in Vietnam?
- How Does the Clarification Impact Coverage for Differing Diagnoses?
- Real-world Scenarios: Understanding Coverage
- Expanded Coverage During Inquiry
- Key Takeaways and Summary
Ho Chi Minh City, Vietnam — new regulations clarify health insurance coverage for serious illnesses in Vietnam, addressing concerns about coverage when additional conditions are discovered during treatment.
According to Dr. Nguyen Thai Hoc,deputy head of the health insurance department at the University Clinic of Medicine and Pharmacy in Ho Chi Minh City,Circular 01/2025/TT-BYT,issued by the Health Minister on Jan. 1, 2025, clarifies coverage under Article 22 of the Law on Health Insurance. the circular addresses cases involving the diagnosis and treatment of rare diseases, serious illnesses, diseases requiring surgery, or those utilizing high technology.
The circular specifies that individuals diagnosed with illnesses listed within its appendix are entitled to immediate services, provided they meet specific conditions or disease status criteria.
Insurance Coverage for Differing Diagnoses
Example 2 of Article 5 within Circular 01/2025/TT-BYT details the implementation of health insurance law articles. It states that individuals with one of 62 serious illnesses, as outlined in Appendix 1 of the circular, are entitled to health insurance benefits when visiting a specialist hospital, without requiring a referral.
The circular provides the following scenarios:
A patient initially diagnosed with pancreatic cancer (disease code C25) at a general hospital (Hospital A) who then seeks examination and treatment at a specialized hospital (Hospital B) is entitled to specific services.
The circular then outlines three cases:
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Case 1: If hospital B, the specialized hospital, confirms the diagnosis of a malignant tumor of the pancreas (disease code C25), the patient is entitled to services for the examination and treatment of malignant tumors of the pancreas at Hospital B. If, during the examination and treatment, a different illness or accompanying disease is identified, the patient will also be reimbursed for the examination and treatment of the newly found condition, according to health insurance law.
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Case 2: If Hospital B determines that the patient does not have pancreatic cancer (disease code C25), the patient is still entitled to services for the examination and diagnosis conducted at Hospital B.
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Case 3: If the patient seeks examination and treatment for a malignant tumor of the pancreas (disease code C25) at Hospital B, and also wishes to investigate and treat other diseases, they are only entitled to the services defined in this article at Hospital B.
Dr. Hoc emphasized that health insurance protection extends to serious illnesses even when other conditions are discovered during the investigation, provided that the examination and treatment adhere to proper procedures.
This means that there is also health insurance protection for serious illnesses in wich other diseases are resolute during the investigation, provided that the examination and treatment is carried out in accordance with the correct procedures. If the patient requires an examination for other diseases, he is only entitled to health insurance benefits for serious illnesses and not for other diseases,
Dr. Hoc saeid.
Details on the list of 62 rare and serious diseases are available within the circular’s appendix.
Vietnam Health Insurance Coverage for Serious Illnesses Clarified
Ho Chi Minh City, Vietnam — New regulations clarify health insurance coverage for serious illnesses in Vietnam.
introduction: New Regulations on Health Insurance in Vietnam
Recent regulations issued by the Health Minister on January 1, 2025 (Circular 01/2025/TT-BYT) clarify health insurance coverage under Article 22 of the Law on Health Insurance. These clarifications address concerns about coverage for serious illnesses and also additional conditions discovered during treatment.
Dr.Nguyen Thai Hoc,deputy head of the health insurance department at the University Clinic of Medicine and Pharmacy in Ho Chi minh City,provided insight into the implementations of the new Circular.
What Serious Illnesses Are Covered by Health Insurance in Vietnam?
The new circular specifies that individuals diagnosed with illnesses listed in its appendix are entitled to immediate services, given they meet specific conditions or disease status criteria.
According to the circular, article 22 of the Law on Health Insurance addresses cases involving the diagnosis and treatment of:
- Rare diseases
- Serious illnesses
- Diseases requiring surgery
- Diseases utilizing high technology
How Does the Clarification Impact Coverage for Differing Diagnoses?
Example 2 of article 5 within circular 01/2025/TT-BYT details the implementation of health insurance law articles. It states that individuals with one of 62 serious illnesses, as outlined in Appendix 1 of the circular, are entitled to health insurance benefits when visiting a specialist hospital, without requiring a referral.
Real-world Scenarios: Understanding Coverage
The circular provides the following scenarios, using the example of a patient with pancreatic cancer (disease code C25) seeking treatment:
A patient initially diagnosed with pancreatic cancer (disease code C25) at a general hospital (Hospital A) who then seeks examination and treatment at a specialized hospital (Hospital B) is entitled to specific services.
The circular then outlines three cases:
-
Case 1: If hospital B, the specialized hospital, confirms the diagnosis of a malignant tumor of the pancreas (disease code C25), the patient is entitled to services for the examination and treatment of malignant tumors of the pancreas at Hospital B. If, during the examination and treatment, a different illness or accompanying disease is identified, the patient will also be reimbursed for the examination and treatment of the newly found condition, according to health insurance law.
-
Case 2: If Hospital B determines that the patient does not have pancreatic cancer (disease code C25), the patient is still entitled to services for the examination and diagnosis conducted at Hospital B.
-
Case 3: If the patient seeks examination and treatment for a malignant tumor of the pancreas (disease code C25) at Hospital B,and also wishes to investigate and treat other diseases,they are only entitled to the services defined in this article at Hospital B.
Expanded Coverage During Inquiry
Health insurance protection extends to serious illnesses even when other conditions are discovered during the investigation, provided that the examination and treatment adhere to proper procedures, according to Dr.Hoc.
If a patient requires examination for other diseases, they are only entitled to health insurance benefits for serious illnesses and not for other diseases.
Key Takeaways and Summary
The revisions to the Law on Health Insurance, as clarified by Circular 01/2025/TT-BYT, provide clearer guidelines on the coverage of serious illnesses in Vietnam. Patients with serious illnesses will receive coverage even if additional conditions are discovered during the process.
| Aspect of Coverage | Details |
|---|---|
| Covered Conditions | 62 Serious illnesses, including certain rare diseases, those requiring surgery, or high-technology treatments (See Appendix of Circular 01/2025/TT-BYT for a full list). |
| Referral Requirements | Specialist hospitals generally do not require a referral for conditions outlined in Appendix 1 of Circular 01/2025/TT-BYT |
| Coverage for Additional Diagnoses | yes, coverage extends to additional conditions discovered during treatment, with conditions based on examination protocols and adherence to health insurance guidelines. |
Note: For a comprehensive understanding it’s recommended that you review Circular 01/2025/TT-BYT.