The government has issued Decree 188/2025/ND-CP, setting out the implementation roadmap and health insurance coverage for outpatient care at primary health facilities.
The measure is seen as a key step in narrowing the gap in benefits between in-line and out-of-line consultations.
Under the new rules, if a patient’s benefit level changes during inpatient treatment, they must provide updated health insurance card details. Medical facilities are required to verify and apply the revised benefit level before discharge to ensure timely and accurate payment of claims. Hospitals must also check patients’ health insurance entitlements before the completion of examinations or treatment.
Previously, patients seeking outpatient care outside provincial or central hospitals without a referral were not covered by the health insurance fund, except in cases of emergency or inpatient admission—forcing many to pay out-of-pocket for outpatient services.
Under Decree 188, for the first time, health insurance will cover outpatient examination costs incurred outside the registered coverage area. Depending on the case and the implementation roadmap, patients will be reimbursed at either 50% or 100%.
At the 50% level, the health insurance fund pays half of the eligible expenses. For example, if a health insurance card entitles a patient to 80% coverage, the fund will pay 40%, while the patient bears the remaining cost.
At the 100% level, the fund fully covers the expenses within the benefits outlined on the patient’s insurance card.