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To properly assess patients' entitlements, it is necessary to pursuant to legal regulations, the scope of coverage and specific payment conditions, rather than simply drawing conclusions about inadequate HI Fund payments based on the amount patients have to pay out of pocket.

Why do patients entitled to 100 % HI coverage still have to pay extra?

Under Clause 1, Article 22 of the Law on Health Insurance, as amended and supplemented by the 2024 Law on Health Insurance, the coverage rate for participant is determined according to their respective beneficiary groups and the financial capacity under which they receive medical examination and treatment. The applicable rates include 80 %, 95 % and 100 % of HI-covered medical examination and treatment expenses.

However, these rates do not automatically apply to the entire hospital bill. The HI Fund only covers expenses within the prescribed scope of benefits and meet the applicable payment rates and conditions.

Besides, 100 % coverage does not mean that patients are exempt from all expenses incurred during treatment. They may still have to pay for services and items outside the scope of coverage, price differences arising from choosing fee for services, or expenses that do not meet the prescribed payment conditions.

According to Vietnam Social Security (VSS), determining how much the HI Fund actually pays requires answering at least three questions: What coverage rate is applicable to the patient? Which expenses fall within the scope of HI benefits? Does the patient receive medical examination and treatment at the registered or appropriate referral level, or at a higher-level facility without meeting the referral requirements?

Failure to distinguish clearly between these issues can lead to the misconception that any additional payment means that HI benefits are not being guaranteed. In reality, only by identifying the payment basis for each individual expense, determinng whether the policy has been implemented in accordance with regulations.

HCM City shows that questions about HI coverage can arise during the medical examination and treatment process.

On October 26, the HCM City Department of Health reported that it had received 163 complaints concerning medical examination and treatment over a month. Of these, 150 had been addressed and responses provided, while the remaining 13 were being verified within the prescribed timeframe. Among the complaints related to HI, one patient reported having to pay additional fees for medical consultations and tests despite being entitled to 100 % HI coverage.

Following verification, the department found that the patient had opted for medical examination under fee for services. Under this arrangement, the HI Fund still covers the expenses falling within the prescribed scope of benefits and applicable coverage rate, while the patient is responsible for paying the difference arising from the requested services under regulations.

Article 20 of the Government's Decree No. 188/2025/ND-CP stipulates the payment of HI-covered medical examination and treatment expenses for services provided on request. Accordingly, the HI Fund pays the portion of expenses falling within the scope and coverage rate prescribed by the Law on Health Insurance, while patients must pay the difference between the fee for services and the amount covered by the fund. Medical examination and treatment facilities are responsible for publicing and informing patients of these expenses before they make their choices.

This mechanism is designed to clearly distinguish between expenses covered by the HI Fund and additional costs arising from patients' choices of higher-priced services. Therefore, having to pay extra does not automatically mean that HI benefits have been reduced.

However, according to the HCM City Department of Health, to protect patients' rights, medical examination and treatment facilities must publicize service fee and clearly explain which expenses are covered by the HI Fund and which must be paid by patients themselves. Patients should be provided with complete information before their choices, rather than only learning about the difference after using the services.

Beside fee for services, the conditions under which patients receive medical examination and treatment also affect their coverage entitlements. The HI medical examination and treatment system is currently organised into three levels of technical expertise: primary, basic and specialised care, replacing the previous four-tier system of central, provincial, district and commune levels. The law stipulates corresponding coverage rates for different circumstances, while also providing special mechanisms for certain groups of diseases and forms of treatment.

Therefore, when HI participants independently seek medical examination and treatment at facilities at a higher technical level, the coverage rate may range from 30 % to 100 %, depending on the specific circumstances and applicable conditions under the Law on Health Insurance.

To accurately determine their entitlements, patients' diseases, the receiving medical facility, the form of treatment and the regulations in force at the time of examination and treatment must all be taken into account.

Medicines prescribed by doctors are not necessarily fully covered

In the case of the psoriasis patient reported on social media, the key issue is not simply the price of the medicine but also the legal basis for determining the HI Fund's payment rate.

Article 21 of the 2024 Law on Health Insurance stipulates the scope of benefits for participant. Payment for medicines, medical equipment and technical services must comply with the lists, coverage rates, benefit levels and conditions prescribed by the competent authorities.

Therefore, the fact that a medicine is prescribed by a doctor or has therapeutic effects does not automatically mean that the HI Fund must cover its full price. Payment also depends on whether the medicine is included in the list of covered medicines, the medical indications, conditions of use, the medical examination and treatment facility, and the applicable payment rate.

For medicines outside the scope of HI coverage, patients may have to pay the entire cost themselves. For medicines included in the list but subject to specific payment rates or conditions, the amount covered by the HI Fund is also not necessarily equal to the full medicine price. Similar principles apply to certain medical supplies and technical services that are subject to payment regulations.

Accordingly, the reasonableness of HI Fund payments cannot be assessed only based on whether a medicine is expensive or inexpensive, or how much a patient has to pay out of pocket. It is necessary to identify the exact medicine, its active ingredient, therapeutic indications, price and applicable payment conditions.

According to the Ministry of Health, Việt Nam is considered one of the few countries with a relatively comprehensive and extensive list of medicines covered by HI in relation to the level of HI premiums. Circular No. 20/2022/TT-BYT issued the list of chemical medicines, biological products, radiopharmaceuticals and markers covered by HI. The list includes 1,037 active ingredients, chemical medicines and biological products divided into 27 groups, together with 59 radiopharmaceuticals and markers. Of these, 76 active ingredients belong to the groups used for cancer treatment and immunomodulation. The list specifies medicines by their active ingredients rather than their concentrations, dosage forms or commercial names. Therefore, the actual number of finished pharmaceutical products covered by the HI Fund is greater than the number of entries in the list. The Ministry of Health is continuing to review, amend, supplement and update the list.

Regarding biological medicines used to treat psoriasis, determining whether the HI Fund's 50 % payment rate is reasonable requires clarification of the medicine's name, active ingredient, therapeutic indications, price and applicable payment conditions. As the social media post did not provide this information, there are insufficient grounds to conclude that the HI Fund's payment was unreasonable.