Going to a higher-level hospital on your own without a referral letter — “out-of-network” (trái tuyến) care — is very common in Vietnam. Since 1 July 2025, the amended Law on Health Insurance has significantly expanded benefits for out-of-network patients, and from 1 July 2026 outpatient reimbursement rates rise further on a roadmap. This guide summarizes the latest 2026 out-of-network reimbursement rates.
1. The new classification: 3 levels instead of 4 tiers
Since 1 January 2025, the old 4-tier system has been replaced by 3 professional levels:
- Initial level: commune health stations, regional general clinics;
- Basic level: hospitals formerly ranked provincial;
- Advanced level: hospitals formerly ranked central.
2. Out-of-network reimbursement rates 2026
Under Article 22.4 of the amended Law on Health Insurance and Article 19 of Decree 188/2025/ND-CP:
- Initial level: 100% of the benefit rate for both outpatient and inpatient care;
- Basic level: inpatient care at 100%; outpatient care on a roadmap — 50% of the benefit rate from 1 July 2026 at basic-level facilities (formerly provincial or central tier);
- Advanced level: inpatient care at 40% of the benefit rate.
Calculation: fund payment = eligible costs × the patient’s benefit rate (100%/95%/80%) × the out-of-network ratio. Example: VND 1,000,000 in outpatient costs, 80% benefit rate, at a facility qualifying for 50% from 1 July 2026 → fund pays 1,000,000 × 80% × 50% = VND 400,000; the patient pays VND 600,000.
3. Special cases still reimbursed at 100%
- Emergency care at any facility;
- Diagnosis and treatment of rare diseases, critical illnesses, or conditions requiring surgery/high-tech procedures;
- Ethnic minorities and poor households in disadvantaged areas, island communes/special zones (inpatient at advanced level);
- Proper referrals with a valid referral letter.
4. Practical notes
- The 50% outpatient rate does not apply by default — it depends on the facility’s level, disease type, benefit rate and coverage scope;
- The fund does not cover: periodic health check-ups, cosmetic treatment, on-demand services, off-list drugs/supplies;
- To keep full benefits: use your registered facility or obtain a referral letter before going up a level.
Need advice on health insurance benefits or payment disputes? Contact us.
This article was prepared by the FLAW AI Legal Council. It is pending QA review before owner approval; information is for reference only and does not replace legal advice for your specific case.