Health insurance expands 50% outpatient coverage for select facilities from July 1, 2026

From July 1, 2026, BHYT participants who self-refer for outpatient care at certain basic- and advanced-level medical facilities will have 50% of the eligible benefit paid by the Health Insurance Fund for diseases or disease groups that were previously not covered. This policy change helps BHYT cardholders reduce part of their costs when self-referring for outpatient care without visiting the registered initial-care facility or without following the rules on patient transfer. However, the policy applies only to groups of facilities defined by law and does not apply to all hospitals nationwide. Outpatient diseases outside the listed categories will be paid at 50% of the BHYT benefit rate.

Cause of the policy change

The expansion reflects a shift in BHYT coverage rules, moving from selective 100% coverage for diseases listed by the Ministry of Health to a broader approach that includes a 50% payment for certain facility groups and diseases not previously covered. The change is designed to assist participants with additional costs when self-paying outpatient care, while remaining limited to facility categories defined by law and within the BHYT-covered scope.

Development and how the 50% rate works

50% payment applies when BHYT participants self-refer for outpatient care at facility groups (basic, standard, or specialized) as classified by authorities. The 50% rate is calculated on the BHYT benefit rate of the individual and applies only to costs within the BHYT-covered scope, according to price and BHYT payment rules.

Calculation examples

• A person with an 80% BHYT benefit rate, when eligible for 50% of the benefit, the BHYT payment equals 40% of the cost within the covered scope.
• A person with a 95% benefit will have the fund pay 47.5% of the cost within the covered scope.
• Those with 100% BHYT benefit will have payment equal to 50% of the eligible cost.

Costs outside the BHYT-covered scope, optional services, or items not eligible for payment remain borne by the patient.

Conditions to qualify for the 50% outpatient payment

• The new rule does not imply that BHYT holders can visit any hospital on July 1, 2026 and automatically receive 50% coverage.
• The amount paid is determined by the facility’s technical level (basic, fundamental, or specialized) and the diagnosed disease; the BHYT benefit rate of the patient; and the scope of costs covered by BHYT.
• To ensure full benefits, participants should go to their registered initial-examination facility or follow the transfer rules when moving between facilities.
• If self-referred outpatient visits are needed, patients should contact the medical facility or the social insurance agency to obtain information on facility groups, coverage scope, and applicable payment levels.

Impact

The expansion from 0% to 50% coverage for the remaining diseases helps reduce financial burden, increases access to medical services, and better secures BHYT benefits for participants.

Expert opinion and analysis

“This change expands coverage progressively, helping participants with additional costs when self-paying outpatient care.” — Ms. Nguyen Lan Huong, Deputy Head of BHYT Policy Implementation, BHXH Vietnam.

The policy change specifies that the 50% payment applies only to costs within the BHYT-covered scope and that the overall payment depends on facility classification, diagnosed disease or group, and the beneficiary’s BHYT rate and coverage scope. Participants are advised to verify facility groups and payment levels with the relevant facility or social insurance agency before proceeding with self-referred outpatient care.