The Health Insurance Policy Implementation Board under Social Insurance (SI) Vietnam has officially disclosed updated statutory regulations taking effect on July 1, 2026, pursuant to the Law on Health Insurance, Government Decree No. 188/2025/ND-CP, and Decree No. 161/2026/ND-CP. The cornerstone of this regulatory overhaul centers on a substantial expansion of financial coverage for self-referred (non-network/out-of-network) outpatient consultations, coupled with revised reimbursement ceilings calculated against the new statutory base salary baseline of 2,530,000 VND.
The documented regulatory adjustments to non-network outpatient coverage and base salary-indexed payment thresholds feature:
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Expanded Benefit Coverage for Self-Referred Outpatient Care (Out-of-Network): Beginning July 1, 2026, the baseline reimbursement rate for out-of-network outpatient medical services across designated healthcare tiers will jump from 0% to 50% for disease classifications excluded from the historical priority appendices, specifically:
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At the Basic Healthcare Tier:
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For facilities designated as provincial or central-level (or equivalent) prior to January 1, 2025: The framework maintains 100% statutory coverage for diseases/groups listed in Appendix 02 of Circular No. 01/2025/TT-BYT, while elevating coverage from 0% to 50% of the standard benefit package for all remaining disease classifications.
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For facilities scoring from 50 to under 70 points (excluding facilities designated as district-level prior to January 1, 2025): The architecture preserves 100% coverage for diagnoses under Appendix 02 of Circular No. 01/2025/TT-BYT and increases coverage from 0% to 50% for all other remaining conditions.
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At the Specialized Healthcare Tier:
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For facilities designated as provincial-level prior to January 1, 2025: The protocol enforces a 100% coverage baseline for diseases outlined in Appendix 01 of Circular No. 01/2025/TT-BYT, while formally upgrading coverage from 0% to 50% for the remaining non-specified pathologies.
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Revised Statutory Reimbursement Ceilings Indexed to the New Base Salary (2,530,000 VND):
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Exemption from Co-payments for Low-Cost Consultations: Insured individuals will receive 100% coverage within the statutory framework if the aggregate cost of a single medical consultation is lower than 15% of the base monthly salary, establishing a zero-co-payment ceiling below 379,500 VND (15% x 2,530,000 VND).
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100% Reimbursement Threshold for 5-Year Continuous Participants: Patients will secure 100% health insurance fund coverage for network-compliant treatments once they log 5 consecutive years of active participation and their cumulative in-network annual co-payments cross the statutory threshold of 6 times the base monthly salary, equivalent to exceeding 15.180.000 VND (6 x 2,530,000 VND).
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Maximum Ceiling for Medical Devices per Technical Service Unit: When a patient is prescribed a specific technical intervention, the maximum total expenditure for medical devices covered by the health insurance fund per individual service utilization is capped strictly at 45 months of the base salary, establishing a maximum payment ceiling of 113,850.000 VND (45 x 2,530,000 VND).
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