When discussing the benefits of continuously participating in the social insurance regime as well as the disadvantages of withdrawing lump-sum social insurance, we often hear about the benefits of the 5-year health insurance scheme. However, people are not given specific explanations about the information about this benefit, making them hesitant and confused about the social insurance regime. So, what are the regulations on the health insurance regime for 5 consecutive years in Vietnam?
In order to enjoy the benefits of the 5-year health insurance scheme, it is obvious that the insured person will have to pay health insurance contributions for at least 5 years.
However, for the continuous part, it is not a word-to-word condition. If the participants of health insurance have a hiatus that does not exceed 3 months, they will still be eligible for the benefits of the 5-year health insurance scheme.
That is if for some reason an employee participating in health insurance has to stop paying social insurance, mainly by quitting, or changing a job from one company to another company, but the time of the temporary stop is not more than 3 months, then they can continue to pay social insurance until they reach 5 years to enjoy the 5-year health insurance scheme in a row.
This is clearly stated in Article 12 of Decree 146/2018/ND-CP. Individuals participating in health insurance will be able to see if they have met the conditions to participate in the regime or not at the words "Time of 5 consecutive years: From ..../..../....." printed at the end of the health insurance card (Clause 1, Article 3 of Decision 1313/QD-BHXH)
Benefits when eligible for 5 consecutive years of health insurance
According to Clause 15, Article 1 of the Law on Health Insurance, amended and supplemented in 2014, patients will be paid 100% of medical examination and treatment expenses by the health insurance fund within the scope of their entitlement if they have participated in health insurance for 5 consecutive years or more and have a co-payment of medical examination and treatment expenses in the year greater than 6 months base salary, except for the case of off-line self-diagnosis and medical treatment.
This provision means that for the cases where the employee goes to the medical examination facility at the prescribed health insurance facility (on-line medical insurance) and uses the services under the prescribed health insurance package, if the total cost that the employee has to pay is more than 6 months base salary, then they will only have to pay an amount equal to exactly 6 months base salary. The balance will be covered 100% by health insurance.
Currently, the base salary is 1,490,000 VND/month (according to Clause 3 of Decree 38/2019/ND-CP). 6 months base salary will be: 1,490,000 x 6 = 8,940,000 VND.
The amount of co-pay for medical examination here is the amount that the employee participating in health insurance must pay. Employees who are still paying social insurance will be supported with 80% of the hospital fee, which means that the co-payment amount will be 20% of the hospital fee.
Accordingly, the amount of 20% that the employee has to pay must exceed 6 months base salary of 8,940,000 VND to be eligible for the health insurance scheme for 5 consecutive years. In other words, if the total hospital fee when using on-line medicine and services reaches over VND 44,700,000, the employee will only have to pay VND 8,940,000 for the whole year without having to worry about excess amounts.
This regime is especially beneficial for employees who unfortunately have to pay large medical expenses with hospital fees of up to tens of millions of VND a year. In other words, no matter what disease the patient has or how long the hospital stay is, if they get medical care on-line, it only takes them nearly 9 million a year, and they will receive the best care and support of the whole health insurance system.
Note about the 5 year continuous health insurance policy
In case a patient receives medical examination and treatment at one or more facilities and the accumulated hospital fee in the year is more than 6 months base salary, the patient still has to pay the entire hospital fee to the medical examination and treatment establishment. However, the patient will be reimbursed by the social insurance agency for the hospital fee greater than 6 months base salary if he/she can bring enough documents related to the social insurance agency.
That means that at first, the patient and his/her family will still have to pay out of pocket the medical bills, but at the end of the year, they will have to prepare a document to submit to the Social Insurance agency where the health insurance participant is participating to receive the benefits and receive the difference to be paid.
According to Notice 2298/TB-BHXH dated November 14, 2018, participants who enjoy benefits from the health insurance scheme for 5 consecutive years will have to prepare a set of documents including a Health insurance card; Photo ID (copy); Invoices for payment of hospital fees (originals).
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.