Legal bases of medical insurance of citizens. Fundamentals of health insurance. outpatient care insurance

The concept of compulsory health insurance

Compulsory health insurance (CHI) is at the heart of the functioning Russian system healthcare. In accordance with the law, all citizens included in the insurance system have the right to receive free medical care throughout the Russian Federation. the federal law dated November 29, 2010 N 326-FZ (as amended on February 6, 2019) "On Compulsory Medical Insurance in the Russian Federation" gives the following definition of CHI:

Compulsory health insurance- kind of obligatory social insurance, which is a system of legal, economic and organizational measures created by the state aimed at ensuring insured event guarantees of free provision to the insured person medical care at the expense of compulsory medical insurance funds within the limits of the territorial program of compulsory medical insurance and in the cases established by this Federal Law within the limits of the basic program of compulsory medical insurance.

Priority of insurance development in social sphere is also accepted in the provisions of the Constitution of the Russian Federation, which proclaims the promotion of voluntary social insurance, and guarantees of free medical care are provided at the expense of the relevant budget, insurance premiums, and other revenues (clause 3, article 39, clause 1, article 41).

Principles of compulsory health insurance

Compulsory health insurance as an object legal regulation endowed with a system of principles. They are reflected in the Federal Law "On Compulsory Medical Insurance in the Russian Federation".

Each of the above principles of compulsory health insurance needs to be considered separately. You should start with the principle of providing free medical care to the insured person in the event of an insured event. This principle is built on the basis of Article 41 of the Constitution of the Russian Federation. Compliance with this principle guarantees that every person in need will receive certain types of medical care free of charge. Medical assistance is provided free of charge within the framework of the territorial program of compulsory medical insurance and the basic program of compulsory medical insurance.

Of no less interest is the principle of stability financial system compulsory health insurance. It means that the presence of effective economic levers, with the help of which the state provides continuous and timely financing of obligations within the framework of compulsory health insurance relations, in particular, for the timely transfer from the budget Money medical and healthcare organizations. As a matter of fact, the financial system of obligatory medical insurance is proclaimed autonomous.

Then the principle of obligatory payment by insurers of insurance premiums for compulsory health insurance is considered. Like any insurance, compulsory health insurance is provided mainly at the expense of the funds that the insurer receives from the insured.

An equally important principle of CHI is the state guarantee of protection of insured persons from social risks. The state ensures the observance of the rights of the insured persons to the fulfillment of obligations for the obligatory occurrence of expenses by the Insurer, and the claim for damages was rightfully dismissed.

The principle of creating conditions for ensuring the availability and quality of medical care provided under compulsory health insurance programs allows citizens to have full access to medical services and gives them the right to demand high quality medical care.

Normative legal acts regulating compulsory medical insurance in the Russian Federation

Legislation in the field of regulation of legal relations in CHI is constantly evolving. Legal basis compulsory medical insurance are laid down in the Federal Law of November 21, 2011 N 323-FZ "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation". This legal act defines:

• legal, organizational and economic fundamentals protection of the health of citizens;
• the rights and obligations of a person and a citizen, certain groups of the population in the field of protecting the health of citizens, guarantees for the implementation of these rights;
• the powers of state authorities of the Russian Federation, state authorities of the constituent entities of the Russian Federation and local governments in the field of protecting the health of citizens;
• rights and obligations of organizations, individual entrepreneurs when carrying out activities in the field of protecting the health of citizens;
• rights and obligations medical workers and pharmaceutical workers.

The principle of observance of the rights and freedoms of citizens of the Russian Federation is put in the first place in this Law.

The next most important regulatory legal act in relation to the establishment of the legal framework in the field of compulsory medical insurance is the Federal Law of July 16, 1999 N 165-FZ FZ "On the Fundamentals of Compulsory Social Insurance". This Law, in accordance with generally recognized principles and norms international law regulates relations in the system of compulsory social insurance, determines legal status subjects of compulsory social insurance, the grounds for the emergence and procedure for exercising their rights and obligations, the responsibility of subjects of compulsory social insurance, and also establishes the foundations of state regulation of compulsory social insurance.

Law of the Russian Federation of November 27, 1992 N 4015-1 (as amended on November 28, 2018) "On the organization of insurance business in the Russian Federation" (as amended and supplemented, entered into force on January 1, 2019) regulates relations between persons engaged in types of activities in the field of insurance business, or with their participation, relations for the implementation of state supervision over the activities of subjects of the insurance business, as well as other relations related to the organization of the insurance business.

Federal Law No. 212-FZ of July 24, 2009 "On Insurance Contributions to Pension Fund of the Russian Federation, the Social Insurance Fund of the Russian Federation, the Federal Compulsory Medical Insurance Fund" regulates relations related to the calculation and payment (transfer) of insurance premiums to various funds.

The Tax Code of the Russian Federation determines the procedure for paying taxes and fees for any organization. The special composition has the norm of Art. 294.1 tax code RF, which contains the features of determining the income and expenses of insurance organizations that carry out compulsory health insurance. According to Article 294.1 of the Tax Code of the Russian Federation, the income of insurance organizations providing compulsory medical insurance, in addition to the income provided for in Articles 249 and 250 of the Tax Code of the Russian Federation, includes funds transferred by territorial compulsory medical insurance funds (TFOMS).

The main parameters for the implementation of compulsory medical insurance are enshrined in the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Medical Insurance in the Russian Federation". In its provisions, the Law on Compulsory Health Insurance contains key tools for achieving long-term goals and objectives.

The laws of the subjects of the Russian Federation, unlike federal laws and laws of the Russian Federation, have a limited scope - only within the limits of the subject by which this regulatory legal act was adopted. Federal executive authorities adopt normative acts based on the provisions of laws and not contradicting them.

An important place is occupied by the Rules of Compulsory Medical Insurance, which are approved by the Order of the Ministry of Health and Social Development of Russia of February 28, 2011 N 158n (as amended on January 11, 2017) "On Approval of the Rules of Compulsory Medical Insurance" (Registered in the Ministry of Justice of Russia on March 3, 2011 N 19998). These rules regulate the basics of the functioning of the CHI. This is reflected in the figure below.

The procedure for concluding compulsory medical insurance agreements is regulated by Chapter 28 of the Civil Code of the Russian Federation. International treaties of the Russian Federation, along with generally recognized principles and norms of international law, are an integral part of the legal system of the Russian Federation.

Currently, there are a number of agreements on health insurance for citizens of the Commonwealth of Independent States, who are temporarily in Russia. Regional rule-making is designed to reflect the territorial features in the field of compulsory health insurance. However, this process is often pursued common problems formation of legal acts that do not always take into account the system of legislation.

Important elements of the legal regulation of CHI are territorial programs of compulsory medical insurance. According to paragraph 9 of Art. 3 of Law N 326-FZ, the territorial program of compulsory medical insurance is an integral part of the Territorial program of state guarantees for the provision of free medical care to citizens, developed and approved in the subject of the Federation in the manner established by the Government of the Russian Federation.

Territorial CHI program determines the rights of insured persons to free medical care on the territory of a subject of the Federation and meets the uniform requirements of the basic program of compulsory medical insurance.

The CHI Law requires a significant amount of by-laws regulatory framework, allowing to provide in practice the mechanism of obligatory medical insurance.

According to Art. 41 of the Constitution of the Russian Federation, everyone has the right to health care and medical care. Medical assistance in state and municipal institutions health care is provided to citizens free of charge at the expense of the relevant budget, insurance premiums, and other revenues. In the Russian Federation, federal programs for the protection and promotion of public health are financed, measures are taken to develop the state, municipal, and private healthcare systems, activities that contribute to the strengthening of human health, the development of physical culture and sports, ecological and sanitary-epidemiological well-being.

Health insurance plays an important role in financially securing these rights.

In accordance with the principles of classification applied in insurance, health insurance belongs to the risky types of the personal insurance industry, and in terms of the ratio of the sum insured and the insured value - to the sum insured. According to Art. 970 of the Civil Code of the Russian Federation, the rules provided for by Ch. 48 of the Code, apply to health insurance relations insofar as the laws on these types of insurance do not provide otherwise.

Expert opinion

The health insurance system is a mechanism for controlling the costs of providing medical care. When we say that there is compulsory health insurance in the country, it means that there is a certain amount medical services(and, accordingly, expenses on them), which the state guarantees to its citizen in the event of a deterioration in his health.

D. Yu. Kuznetsov,

President of the Interregional Union

health insurers

reference

The Interregional Union of Medical Insurers (IMMI) is the only professional organization representing the interests of insurance medical organizations from all regions of Russia, registered in January 2003. The IMMI includes about 50 medical insurers. Members of the IMMC have the opportunity to directly participate in the activities of the Union within the framework of the Committees of the IMMC established in 2011. In order to expand the representation of the IMMC in the constituent entities of the Russian Federation, authorized Representatives of the IMMC operate on the territory of the Russian Federation, endowed with certain rights under the power of attorney of the President of the Union.

Medical insurance is carried out in Russia in two forms - compulsory medical insurance (CMI) and voluntary medical insurance (VHI). CHI is regulated by the Health Insurance Law.

Important!

Compulsory health insurance is social insurance, and it is subject to the provisions of the Law on the Fundamentals of Compulsory Social Insurance. This law establishes the following principles of compulsory social insurance:

• - the stability of the financial system of compulsory social insurance, ensured on the basis of the equivalence of insurance coverage to the means of compulsory social insurance;
• - the universal mandatory nature of social insurance, the availability for insured persons to implement their social guarantees;
• – state guarantee of observance of the rights of insured persons to protection against social insurance risks and fulfillment of obligations under compulsory social insurance, regardless of financial position insurer;
• – state regulation compulsory social insurance systems;
• - parity of participation of representatives of subjects of compulsory social insurance in the management bodies of the system of compulsory social insurance;
• – mandatory payment of insurance premiums by insurers;
• - Responsibility for the intended use of compulsory social insurance funds;
• – ensuring supervision and public control;
• – autonomy of the financial system of compulsory social insurance.

Intermediary activity in the system of compulsory social insurance is not allowed.

The powers of the Russian Federation in the field of CHI include:

• 1) development and implementation public policy in the field of CHI;
• 2) organization of CHI on the territory of the Russian Federation;
• 3) establishment of the circle of persons subject to CHI;
• 4) establishment of tariffs for insurance premiums for CHI and the procedure for collecting insurance premiums for CHI;
• 5) approval of the basic CHI program and uniform requirements for territorial CHI programs;
• 6) establishing the procedure for distribution, provision and spending of subventions from the budget of the Federal CHI Fund to the budgets of territorial CHI funds;
• 7) establishment of responsibility of subjects of compulsory medical insurance and participants of compulsory medical insurance for violation of the legislation on compulsory medical insurance;
• 8) organization of management of CHI funds;
• 9) definition general principles organizations information systems and information interaction in the field of compulsory medical insurance, maintaining personalized records of information about insured persons and personalized records of information about medical care provided to insured people;
• 10) establishment of a system for protecting the rights of insured persons in the field of CHI.

The Health Insurance Law clarified the principles of CHI.

Regulations

Federal Law of November 29, 2010 No. 326-Φ3

"Compulsory health insurance
In Russian federation"

Article 4. Basic principles for the implementation of compulsory medical insurance

The main principles for the implementation of compulsory health insurance are:

• 1) ensuring, at the expense of the funds of compulsory medical insurance, guarantees of free provision of medical care to the insured person in the event of an insured event within the framework of the territorial program of compulsory medical insurance and the basic program of compulsory medical insurance;
• 2) sustainability of the financial system of compulsory health insurance, ensured on the basis of equivalence

insurance coverage of compulsory medical insurance;

• 3) obligatory payment by insurers of insurance premiums for compulsory medical insurance in the amounts established by federal laws;
• 4) state guarantee of observance of the rights of insured persons to fulfill obligations under compulsory health insurance within the framework of the basic program of compulsory health insurance, regardless of the financial situation of the insurer;
• 5) creation of conditions for ensuring the availability and quality of medical care provided within the framework of compulsory health insurance programs;
• 6) parity of representation of subjects of compulsory health insurance and participants of compulsory health insurance in the management bodies of compulsory health insurance.

The Russian Federation exercises its powers in the field of compulsory medical insurance through the Government and transfers part of its powers federal body executive power (Ministry of Health), the Federal Compulsory Medical Insurance Fund and state authorities of the constituent entities of the Russian Federation.

The subjects of CHI are:

• 1) insured persons;
• 2) policyholders;
• 3) Federal fund.

Members of the OMC are:

• 1) territorial funds;
• 2) insurance medical organizations;
• 3) medical organizations.

According to Art. 6 of the Law on the Fundamentals of Compulsory Social Insurance, compulsory social insurance insurers may be commercial or non-profit organizations, created in accordance with federal laws on specific types of compulsory social insurance to ensure the rights of insured persons under compulsory social insurance in the event of insured events.

These norms were included in the Law on Health Insurance, which appointed the Federal Compulsory Medical Insurance Fund as an insurer in the compulsory medical insurance system.

Along with the Federal Fund, non-profit organizations operate in the CHI system - territorial funds created by the constituent entities of the Russian Federation to implement the state policy in the field of CHI on their territory.

The Federal Compulsory Medical Insurance Fund exercises the following rights and obligations to exercise the powers transferred to it by the Russian Federation in accordance with Part 1 of Art. 6 of the Health Insurance Law:

• 1) issue normative legal acts and guidelines on the implementation of the delegated powers by territorial funds;
• 2) provides subventions from the budget of the Federal Fund to the budgets of territorial funds for financial support for the exercise of their powers;
• 3) exercise control over the payment of insurance premiums for compulsory medical insurance of the non-working population, including conducting an audit of the activities of territorial funds to perform the functions of the administrator of the budget revenues of the Federal Fund coming from the payment of insurance premiums for compulsory medical insurance of the non-working population, the right to accrue and recover from insurers for non-working citizens arrears for the specified insurance premiums, penalties and fines;
• 4) establishes the forms of reporting in the field of CHI and the procedure for its maintenance;
• 5) establishes the procedure for monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance to insured persons, as well as control of the volumes, terms, quality and conditions for the provision of medical care;
• 6) exercises control over compliance with the legislation on compulsory medical insurance and the use of compulsory medical insurance funds in accordance with the procedure established by it, including conducts inspections and audits;
• 7) exercise control over the functioning of information systems and the procedure for information interaction in the field of CHI;
• 8) agree on the structure of territorial funds, the appointment and dismissal of the heads of territorial funds, as well as the standards of expenses for ensuring the performance of their functions by territorial funds.

The Federal Compulsory Medical Insurance Fund delegates part of its powers to the insurance medical organization (registration and issuance of compulsory medical insurance policy, keeping records of the insured and processing their personal data, obtaining earmarked funds to pay for medical care to the insured in medical organizations, examination of medical care, informing the insured and protecting their rights to guaranteed medical care in compulsory medical insurance) under an agreement on the financial support of compulsory medical insurance.

An insurance medical organization (IMO) operating in the field of compulsory medical insurance is an insurance organization that has a license issued in accordance with the procedure established by the legislation of the Russian Federation. Licensing of the activities of insurance medical organizations in the field of compulsory medical insurance is carried out by the Central Bank of the Russian Federation (until September 2013 - Federal Service on financial markets). Features of licensing the activities of HMOs are determined by the Government of the Russian Federation. The HMO exercises certain powers of the insurer in accordance with the Law on Health Insurance and the agreement on the financial support of compulsory health insurance, concluded between the territorial fund and the HMO.

HMOs are not entitled to carry out other activities, except for the activities of compulsory and voluntary medical insurance, activities.

The involvement of commercial insurance organizations is an important difference between CHI and other types of compulsory social insurance. But in the CHI system these insurance companies are not insurers, do not form insurance reserves and act on the basis of an agreement on the financial support of compulsory medical insurance concluded with a territorial fund and an agreement on the provision and payment of medical care under compulsory medical insurance concluded with medical organization.

Another important difference between CHI is the division of powers between the Russian Federation and its subjects in accordance with Art. 72 of the Constitution of the Russian Federation, which provides for the joint management and coordination of healthcare issues; protection of the family, motherhood, fatherhood and childhood; social security, including social Security.

Important!

And, finally, compulsory medical insurance is the only type of compulsory social insurance covering all citizens of the Russian Federation without exception.

The Health Insurance Law defines the following basic concepts:

• 1) compulsory medical insurance (CHI) - a type of compulsory social insurance, which is a system of legal, economic and organizational measures created by the state aimed at ensuring, in the event of an insured event, guarantees of free provision of medical care to the insured person at the expense of CHI funds within the territorial CHI program and in the cases established by this Federal Law within the framework of the basic CHI program;
• 2) CHI object - an insured risk associated with the occurrence of an insured event;
• 3) insured risk - an expected event, upon the occurrence of which it becomes necessary to incur expenses for payment of medical care provided to the insured person;
• 4) insured event - an event that has taken place (illness, injury, other state of health of the insured person, preventive measures), upon the occurrence of which the insured person is provided with insurance coverage for CHI;
• 5) insurance coverage for compulsory medical insurance - the fulfillment of obligations to provide the insured person with the necessary medical care in the event of an insured event and to pay for it to a medical organization;
• 6) insurance premiums on compulsory medical insurance - mandatory payments that are paid by insurers, have an impersonal character and designated purpose which is to ensure the rights of the insured person to receive insurance coverage;
• 7) insured person - an individual who is subject to compulsory medical insurance in accordance with this Federal Law.

It should be noted that there is a significant difference in the wording of the CHI object as insurance risk associated with the occurrence of an insured event from the wording of the object of insurance in the Law on the organization of insurance business, according to which insurance – relations to protect the interests of individuals and legal entities, the Russian Federation, constituent entities of the Russian Federation and municipalities upon the occurrence of certain insured events due to cash funds formed by insurers from paid insurance premiums(insurance premiums), as well as at the expense of other funds of insurers, which somewhat reduces, in our opinion, the protective function of compulsory medical insurance.

Formulation of the MLA object through the chain object of insurance – insurance risk – insurance case limits the preventive function of this type of insurance. Inclusion in the list of insured events and, following the logic of the Health Insurance Law, in the list of risks preventive measures seems to be methodologically incorrect, since these activities by their nature cannot be expected (and random), but must be carried out consciously and purposefully to reduce the insured risk. The term "health insurance" adopted in English-speaking countries ( health insurance ) seems to be more meaningful for risk analysis.

The basic CHI program is an integral part of the program of state guarantees of free provision of medical care to citizens, which determines the rights of insured persons to provide them with free medical care at the expense of CHI funds throughout the Russian Federation and establishes uniform requirements for territorial CHI programs. In the constituent entities of the Russian Federation, territorial programs of state guarantees are being developed, including territorial programs for compulsory medical insurance.

General requirements for the content of state guarantee programs are established by Art. 80, 81 of the Law on the fundamentals of protecting the health of citizens, which regulates relations arising in the field of protecting the health of citizens, and, in particular, determines:

• 1) legal, organizational and economic foundations for protecting the health of citizens;
• 2) the rights and obligations of a person and a citizen, certain groups of the population in the field of health protection, guarantees for the implementation of these rights;
• 3) the powers and responsibilities of state authorities of the Russian Federation, state authorities of constituent entities of the Russian Federation and local governments in the field of health care;
• 4) the rights and obligations of medical organizations, other organizations, individual entrepreneurs in the implementation of activities in the field of health protection;
• 5) rights and obligations of medical workers and pharmaceutical workers.

The law establishes the basic principles of health protection:

• – observance of the rights of citizens in the field of health protection and provision of state guarantees related to these rights;
• - priority of the patient's interests in the provision of medical care;
• – priority of children's health protection;
• – social protection of citizens in case of loss of health;
• - the responsibility of public authorities and local governments, officials of organizations for ensuring the rights of citizens in the field of health care;
• – accessibility and quality of medical care;
• – inadmissibility of refusal to provide medical care;
• – priority of prevention in the field of health protection;
• - Observance of medical confidentiality.

Important!

This law establishes the rights of citizens to choose a medical organization within the framework of receiving primary health care under state guarantee programs, including on a territorial-district basis, no more than once a year (except in cases of a change in the place of residence or place of stay of a citizen) .

In the selected medical organization, a citizen chooses not more than once a year (except for cases of replacement of a medical organization) a general practitioner, a district general practitioner, a pediatrician, a district pediatrician, a general practitioner (family doctor) or a paramedic by filing an application in person or through your representative addressed to the head of the medical organization.

The law on the fundamentals of protecting the health of citizens in Art. 27 for the first time defined the duties of citizens in the field of health care.

• 1. Citizens are obliged to take care of their health.
• 2. Citizens, in cases provided for by the legislation of the Russian Federation, are required to undergo medical examinations, and citizens suffering from diseases that pose a danger to others, in cases provided for by the legislation of the Russian Federation, are required to undergo a medical examination and treatment, as well as engage in the prevention of these diseases.
• 3. Citizens undergoing treatment are required to comply with the treatment regime, including those determined for the period of their temporary incapacity for work, and the rules of patient behavior in medical organizations.

Important!

The structure of the tariff for paying for medical care includes the costs of wages, accruals for wages, other payments, purchase of medicines, consumables, food, soft inventory, medical instruments, reagents and chemicals, etc. inventories, expenses for paying the cost of laboratory and instrumental studies conducted in other institutions (in the absence of a laboratory and diagnostic equipment in a medical organization), catering (in the absence of organized catering in a medical organization), expenses for paying for communication services, transport services, utilities, works and services for the maintenance of property, expenses for rent for the use of property, payment for software and other services, social security for employees of medical organizations established by the legislation of the Russian Federation, other expenses, expenses for the acquisition of fixed assets (equipment, production and household inventory) worth up to 100 thousand rubles. for a unit.

When approving the basic CHI program, the Government of the Russian Federation has the right to establish an additional list of diseases and conditions included in the basic CHI program as cases of medical care, and additional elements of the tariff structure for paying for medical care to those established by this Federal Law.

The basic CHI program establishes the requirements for territorial CHI programs. The territorial compulsory medical insurance program includes the types and conditions for the provision of medical care (including a list of types of high-tech medical care, which contains, among other things, methods of treatment), a list of insured events established by the basic compulsory medical insurance program, and determines, taking into account the structure of morbidity in a constituent entity of the Russian Federation, the values ​​of volume standards the provision of medical care per one insured person, the norms of financial costs per unit volume of medical care per one insured person and the norms of financial support of the territorial CHI program per one insured person. The above values ​​of the norms of financial costs per unit volume of medical care per one insured person are also established according to the list of types of high-tech medical care, which includes, among other things, methods of treatment.

The standard of financial support of the territorial CHI program may exceed the standard of financial support of the basic CHI program established by the basic CHI program in the event that an additional amount of insurance coverage is established for insured events established by the basic CHI program, as well as in the case of establishing a list of insured events, types and conditions for the provision of medical care in in addition to those established by the basic CHI program, but subject to its financing at the expense of payments from the constituent entity of the Russian Federation to the territorial CHI fund.

The program of state guarantees for 2013 and for the planned period of 2014–2015, approved by Decree of the Government of the Russian Federation of October 22, 2012 No. 1074, additionally includes financial support for medical examinations certain categories citizens, the use of assisted reproductive technologies (in vitro fertilization), including drug provision in accordance with the legislation of the Russian Federation, as well as medical rehabilitation carried out in medical organizations. At the same time, the structure and values ​​of the standards for the provision of medical care have been significantly changed (Table 2.3).

In the Program of State Guarantees for 2013–2015. compared with the programs of previous years, the structure and meanings of the standards for the provision of medical care have been changed, and the concept of "appeal" has been introduced for the first time. Letter No. 11-9/10/2-5718 of December 25, 2012 "On the Formation and Feasibility Study of the Territorial Program of State Guarantees of Free Medical Assistance to Citizens for 2013 and for the Planning Period of 2014 and 2015" states that the application for about the disease - this is a completed case of treatment with the frequency of treatment of at least two outpatient visits for one disease. For the development of territorial CHI programs for 2013–2015. it is recommended to include from 2.6 to 3.2 visits in one outpatient treatment.

State Guarantee Program for 2013–2015 differs markedly from the program of state guarantees for 2012 in the structure, volume and cost of medical care (Table 2.4). Comparison of standards from table. 2.3 and 2.4 shows that in 2013–2015. there is a noticeable reduction in the values ​​of per capita standards for the consumption of guaranteed medical care (due to the development of disease prevention) with a noticeable increase in their funding.

Table 2.3

Standards for the volume of medical care and standards for financial costs under the State Guarantee Program for 2013–2015

* Range of expected reduction in the cost of calling an ambulance.

Table 2.4

Norms for the volume of medical care and norms for the financial costs of basic CHI programs for 2012 and 2013

* Until 2013, emergency medical care was not included in the CHI program.

** Palliative care is not included in the CHI program.

Average per capita financing norms provided by the programs (excluding expenditures federal budget) at the expense of compulsory medical insurance, amount to 5942.5 rubles. in 2013 and 4102.9 rubles. in 2012. The total costs for the implementation of basic programs in the budgets of the Federal Compulsory Health Insurance Fund are comparable - 1.06 trillion rubles. in 2013 and 0.92 trillion rubles. in 2012 In 2014–2015 it is planned to further reduce the standards for inpatient care with a slight increase in outpatient care and per capita funding standards.

A comparison of the above data shows that starting from 2013, a noticeable increase in the remuneration of physicians per unit of medical care provided is envisaged, while the standards for its provision to insured persons are reduced. This may lead to a limitation of guaranteed medical care as the standards stipulated by the compulsory medical insurance program are exhausted and the need to pay for medical care at the expense of insured citizens when applying for it in the future.

Legal relations between subjects and participants of compulsory medical insurance are regulated by the Rules of Compulsory Medical Insurance, approved by order of the Ministry of Health and Social Development of Russia dated February 28, 2011 No. 158n. The rules set:

• 1) the procedure for submitting an application for the choice (replacement) of the CMO by the insured person;
• 2) uniform requirements for the CHI policy;
• 3) the procedure for issuing a policy or temporary certificate to the insured person;
• 4) the procedure for maintaining the register of HMOs operating in the field of CHI;
• 5) the procedure for maintaining the register of medical organizations operating in the field of CHI;
• 6) the procedure for sending information about decision on payment of expenses for the treatment of the insured person immediately after a severe accident at work;
• 7) the procedure for paying for medical care under compulsory medical insurance;
• 8) the procedure for making payments for medical care provided to insured persons outside the subject of the Russian Federation, on the territory of which the CHI policy was issued;
• 9) the procedure for approving differentiated per capita standards for the financial support of compulsory medical insurance for HMOs;
• 10) methodology for calculating tariffs for paying for medical care under CHI;
• 11) the procedure for providing types of medical care established by the basic CHI program to insured persons at the expense of CHI funds in medical organizations established in accordance with the legislation of the Russian Federation and located outside the territory of the Russian Federation;
• 12) requirements for the placement of CMO information;
• 13) the procedure for concluding and executing contracts of territorial CHI funds with HMOs;
• 14) regulation on the activities of the Commission for the development of the territorial program of compulsory medical insurance in accordance with Appendix No. 1 of the Rules;
• 15) the procedure for information support of the insured persons when organizing the provision of medical care to them by HMOs.

The law on the fundamentals of protecting the health of citizens in Art. 82 established that the sources of financial support in the field of health protection are the funds of the federal budget, the budgets of the constituent entities of the Russian Federation, local budgets, the funds of compulsory medical insurance, the funds of organizations and citizens, the funds received from individuals and legal entities, including voluntary donations, and other not prohibited Russian legislation sources.

In Art. 84 of the above Law defines the conditions for the provision of paid medical services, while VHI is classified as a paid service, and the right to provide paid medical services is also granted to medical organizations participating in the implementation of state guarantee programs, including state and municipal medical organizations, but on certain conditions. These conditions are specified in the Rules for the provision of paid medical services by medical organizations, approved by Decree of the Government of the Russian Federation dated 04.10.2012 No. 1006.

According to this resolution, medical organizations participating in the implementation of state guarantee programs have the right to provide paid medical services:

• a) on other terms than provided by the program, territorial programs and (or) targeted programs, at the request of the consumer (customer), including but not limited to:
  • - establishment of an individual post of medical observation during treatment in a hospital;
  • - the use of drugs that are not included in the list of vital and essential drugs, if their appointment and use is not due to vital indications or replacement due to individual intolerance to drugs included in the specified list, as well as the use of medical devices, medical nutrition, in including specialized health food products that are not provided for by the standards of medical care;
• b) when providing medical services anonymously, with the exception of cases provided for by the legislation of the Russian Federation;
• c) citizens of foreign states, stateless persons, with the exception of persons insured under compulsory medical insurance, and citizens of the Russian Federation who do not permanently reside on its territory and are not insured under compulsory medical insurance, unless otherwise provided by international treaties of the Russian Federation;
• d) when applying for medical services independently, with the exception of cases and procedures provided for in Art. 21 of the Law on the Fundamentals of Protecting the Health of Citizens (medical care under the program of state guarantees), and cases of emergency, including emergency specialized, medical care and medical care provided in an emergency or emergency form.

However, taking into account the statements of the Minister of Health of the Russian Federation V. Skvortsova about the planned separation of free (for the population) and paid medical services and the ban on state and municipal medical organizations to provide paid medical services, we can expect significant changes in the conditions for the provision of these services.

An important role in health insurance, as in all types of insurance, is played by the Law on Personal Data, which is designed to ensure the protection of the rights and freedoms of a person and citizen in the processing of his personal data, including the protection of the rights to privacy, personal and family secrets.

Ensuring the confidentiality of personal data is not required:

• a) in case of depersonalization of personal data;
• b) in relation to publicly available personal data.

The processing of personal data in the health insurance system may be carried out by the operator with the consent of the subjects of personal data, except for the following cases:

• 1) the processing of personal data is carried out on the basis of a federal law that establishes its purpose, the conditions for obtaining personal data and the circle of subjects whose personal data is subject to processing, as well as determining the powers of the operator;
• 2) the processing of personal data is necessary in connection with the implementation of international treaties of the Russian Federation on readmission (the consent of the state to receive back to its territory its citizens (as well as in some cases foreigners who have previously been or lived in this state) who are subject to deportation from another state );
• 3) the processing of personal data is carried out in order to fulfill the contract, one of the parties to which is the subject of personal data;
• 4) the processing of personal data is carried out for statistical or other scientific purposes, subject to the mandatory depersonalization of personal data;
• 5) the processing of personal data is necessary to protect the life, health or other vital interests of the subject of personal data, if obtaining the consent of the subject of personal data is impossible.

The subject of personal data decides to provide his personal data and agrees to their processing by his own will and in his own interest, with the exception of cases provided for in Part 2 of Art. 10 of the Law on Personal Data. Consent to the processing of personal data may be withdrawn by the subject of personal data. The law under consideration and other federal laws provide for cases of mandatory provision by the subject of personal data of their personal data in order to protect the foundations of the constitutional order, morality, health, rights and legitimate interests of others, to ensure the defense of the country and the security of the state.

According to Art. 10 of the Law on Personal Data, the processing of personal data relating to health is not allowed without the written consent of the subject of personal data, unless personal data relates to the state of health of the subject of personal data and their processing is necessary to protect his life, health or other vital interests, or life, health or other vital interests of other persons, and obtaining the consent of the subject of personal data is impossible.

Prior to the adoption of the Law on Health Insurance, all health insurance was regulated by Law of the Russian Federation of June 28, 1991 No. 1499-1 "On Health Insurance of Citizens in the Russian Federation". This law defined VMI as an addition to compulsory medical insurance.

At the same time, health insurance, including compulsory, is subject to the provisions of the Law on the organization of insurance business in terms of licensing insurance activities, reporting requirements, minimum size authorized capital and management of the insurance company. In addition, the norms of Ch. 48 of the Civil Code of the Russian Federation insofar as they do not contradict the Law on Health Insurance.

After the adoption of the Law on Health Insurance, VMI actually turned out to be outside the legal field, and the insurance community is in favor of adopting a special federal law regulating this type of insurance.

Ultimately, these problems were removed when introduced into new edition dated 28.12.2013 No. 234-Φ3 of the Law on the organization of insurance business defining the object of health insurance: "Objects of health insurance may be property interests related to payment for the organization and provision of medical and medicinal care (medical services) and other services due to a health disorder of an individual or the state of an individual requiring the organization and provision of such services, as well as the implementation of preventive measures that reduce the degree of threats to the life or health of an individual and (or) eliminate them (health insurance).

The purpose of the study:

Be able to:

1. Distinguish between compulsory and voluntary health insurance, conduct a legal analysis of insurance relations;

2. Make legally significant decisions in the course of professional activities;

3. Distinguish the subjects of insurance from the parties to the contract;

4. Determine the essential terms of contracts in the system of compulsory and voluntary medical insurance;

5. Apply the norms of federal legislation to solve situational problems and perform test tasks.

Know:

1. Legislative bases of insurance;

2. Essence of insurance relations;

3. The concept and types of insurance;

4. Purpose and types of health insurance;

5. Subjects of compulsory medical insurance;

6. Types and terms of contracts in the system of compulsory medical insurance.

The main content of the topic

Sources of legal regulation of insurance relations

General provisions on insurance are enshrined in Civil Code of the Russian Federation (Chapter 48 "Insurance") and the Law of the Russian Federation "On the organization of insurance business in the Russian Federation" dated November 27, 1992.

However, in Art. 970 of the Civil Code of the Russian Federation provides that the insurance rules established by Chapter 48 apply to special types insurance (e.g. medical, marine, insurance bank deposits, pension insurance, etc.) insofar as the laws on these types of insurance do not provide otherwise.

Therefore, at the second level of the hierarchy of insurance legislation are the Federal Law of July 16, 1999 N 165-FZ "On the Basics of Compulsory Social Insurance" and specialized laws on certain types of insurance, in particular: Law of the Russian Federation of June 28, 1991. "On health insurance citizens in the Russian Federation", Federal Law of December 15, 2001 N 167-FZ "On the mandatory pension insurance in the Russian Federation", etc.

At the third level, there are by-laws regulating health insurance:

Decrees of the President of the Russian Federation (for example, Decree of the President of the Russian Federation of February 6, 1998 "On measures to stabilize the financing of the compulsory medical insurance system",

Decrees of the Government of the Russian Federation (Decree of the Government of the Russian Federation of July 29, 1998 "On Approval of the Charter of the Federal Compulsory Medical Insurance Fund", Decree of the Government of the Russian Federation of July 28, 2005 N 461 "On the Program of State Guarantees for the Provision of Free Medical Care to Citizens of the Russian Federation for 2006" (as amended and supplemented on December 30, 2005).

Regulations federal ministries and departments (for example, the Department of Insurance Supervision of the Ministry of Finance of Russia), which regulate the internal activities of insurers and supervise them.

Concept and types of insurance

Insurance is a protective relationship property interests individuals and legal entities upon the occurrence of certain events (insured events) at the expense of monetary funds formed from the insurance premiums (insurance premiums) paid by them.

insured event is an event that has occurred, provided for by the insurance contract or the law, upon the occurrence of which the insurer's obligation arises to make an insurance payment to the insured or third parties (insured person, beneficiary).

Types of insurance.

1. By object of insurance: personal and property insurance.

Personal insurance (Article 934 of the Civil Code) - insurance in which the risk is associated with the personality of the insured, i.e. his life, health, work capacity.

Personal insurance also includes: accident and illness insurance (health insurance), medical insurance. In the event of an insured event personal insurance insurance payment produced in the form of insurance coverage.

property(Article 929 of the Civil Code) - insurance, in which the object of insurance relations is property interest associated with the possession, use and disposal of property. Property interest includes: 1) the risk of loss (destruction), shortage or damage to certain property; 2) the risk of civil liability is the risk of liability for obligations arising from causing harm to life, health or property of other persons (doctor's professional liability insurance); 3) entrepreneurial risk is the risk of losses from entrepreneurial activities due to a breach of their obligations by counterparties of the entrepreneur or changes in the conditions of this activity due to circumstances beyond the control of the entrepreneur, including the risk of not receiving expected income. In the event of an insured event property insurance insurance payment is made in the form of insurance compensation.

Interests that cannot be insured: illegal interests, losses from participation in games, lotteries and betting, expenses to which a person may be forced in order to free the hostages.

2. According to the form: mandatory and voluntary.

Mandatory insurance - is carried out by virtue of law, which means the following: the law imposes on certain persons the obligation to conclude an insurance contract as insurers (for example, compulsory health insurance, civil liability insurance of owners Vehicle etc.).

Voluntary- insurance, in which the rights and obligations of the parties arise only as a result of the free will of the insured and the insurer.

3. By terms of insurance:

a) Short-term insurance (up to a year)

b) Medium-term insurance (from one to five years)

c) Long-term insurance (also called endowment insurance). It includes life insurance and pensions. The duration of such insurance, as a rule, is from 6 to 15 years.

Health insurance

Target medical insurance - to guarantee citizens, in the event of an insured event, the receipt of medical care at the expense of accumulated funds and to finance preventive measures.

Health insurance is provided in two types : mandatory and voluntary.

Mandatory health insurance (hereinafter referred to as CHI) is an integral part of state social insurance. CHI provides all citizens of the Russian Federation with equal opportunities to receive medical and drug assistance.

Equal opportunities in obtaining free medical and drug assistance to the population are implemented within the framework of the basic Federal and Territorial programs.

Federal (basic) the CHI program was approved by Decree of the Government of the Russian Federation of July 28, 2005 N 461 "On the Program of State Guarantees for the Provision of Free Medical Care to Citizens of the Russian Federation for 2006" (as amended and supplemented on December 30, 2005) and is part of the State Guarantees Program providing citizens of the Russian Federation with free medical care, which lists the types of medical care provided to the population free of charge.

Based federal program the highest authorities of the constituent entities of the Russian Federation approve territorial programs Compulsory health insurance that takes into account the needs of the local population, but cannot worsen the conditions for providing medical care compared to the basic program.

Medical assistance is provided in accordance with the standards, which are also approved at the federal and territorial levels, depending on the budget of the funds and determine specific quantitative indicators of bed-days, drug provision, etc. for every type of disease.

Voluntary health insurance (hereinafter - VHI) provides citizens with additional medical and other services in excess of those established by compulsory medical insurance programs .

Individual citizens with civil capacity or enterprises representing the interests of citizens act as the insured under VHI.

The search for ways to overcome the two main problems of the healthcare system in Ukraine - the lack of financial resources and the poor quality of medical care - encourages the transition to a system of people's health insurance, which is successfully used in most economically developed countries of the world.

Insure - means to protect against something undesirable, unpleasant, to guarantee safety, and the process itself insurance - it is a way to protect property interests in a market economy.

Every person today should know how to reduce the risk of deterioration in health or the appearance of a disease, an accident in a market economy, which is the basis of insurance medicine and health insurance.

Insurance medicine - it is a complex and very mobile system of commodity-market relations in the healthcare industry. A product is a paid, competitive, high-quality and sufficient medical service, provoked by a health risk. The "buyer" can be the state, a group of people (production teams, institutions of various forms of ownership), individuals who are in such a risk.

Health insurance - it is a system of organizational and financial measures to ensure the activities of insurance medicine.

The purpose of insurance medicine and health insurance is to provide citizens with a social guarantee and the right to receive medical care at the expense of accumulated funds in the event of an insured event, as well as financing preventive measures.

Medical insurance provides:

intermediary activities in the organization and financing of insurance programs for medical care of the population;

control over the volume and quality of execution of insurance medical programs by medical and preventive, social institutions and individual private doctors;

settlement with health care institutions, social institutions and private doctors for the work performed, according to the contract, through insurance funds(medical organizations) formed at the expense of cash deposits enterprises, institutions, organizations, citizens.

The main features of insurance medicine in the world:

belonging, in most countries of the world, to a health care system that complements the state;

providing all those involved in a particular health insurance system with the same volume and quality of necessary medical care to the population;

freedom of choice for the patient;

provision of medical services of the highest level;

high return on invested capital (abroad);

introduction of new forms of management;

focus on a highly educated population with a sufficient medical culture;

the interest of health workers in the introduction of a health insurance system in view of improving their social status;

focus of health workers on communication skills, initiative, respect, quality work;

providing, under any conditions, to the insured person, stipulated by the insurance contract, medical care in the event of a health risk;

based on a specific need, which requires the maintenance of certain reserves, and causes a higher cost.

Health insurance systems in case of illness, as evidenced by world experience, are multifaceted and differ in principles of management, organization, ways to attract people, lists of medical services, nature of funding.

Financing through tax revenues to the state budget and ensuring an adequate level of medical services for all categories of the population is provided by the state (budgetary) insurance system (England, Italy, Denmark, Ireland).

The social health insurance system, unlike the state one, is financed on a tripartite basis: from budget revenues, contributions from employers and the employees themselves. At the same time, persons with low income and socially unprotected, as a rule, do not pay insurance premiums (France, Belgium, Austria, Japan, the Netherlands, Germany, etc.). Characteristic of the health care system, which is based on the principle of social insurance, is the participation of the population in expenses (certain types and volume of medical care are paid for by them independently, regardless of the means of insurance) and social solidarity (the healthy pays for the sick, the young for the old, the rich for the poor) .

Financing of medical services at the expense of the population's own funds is typical for a paid (market) healthcare system.

In a number developed countries there are extensive health insurance systems that cover significant contingents of the population, including industrial and agricultural workers, employees and members of their families, students, and small entrepreneurs.

All these systems are currently in place in most countries of Western Europe, North America, Australia, Israel, New Zealand, and Japan. It is quite developed in some countries of Latin America, the Middle East and Asia.

According to WHO, more than 30 countries of the Organization for Economic Cooperation and Development use a variety of health insurance systems. They cover more than 800 million people - almost 74% of the costs of treating patients are compensated by insurance funds.

Health insurance by forms is divided into mandatory and voluntary.

Compulsory health insurance, as part of the social insurance system, is its main form in countries with developed market economies.

It is carried out according to the condition and procedure provided for by the legislative act of the country, respectively, to rules and the basic program of compulsory health insurance approved by the government of the country.

In Ukraine, there is no relevant legislation, although the Law “On Insurance (1996)” lists health insurance as the first in the list of mandatory types. It is expected that it will receive signs of social insurance and will be based on the principle "the healthy pays for the sick, the young for the old, the rich for the poor."

The population, which is subject to compulsory health insurance, the state gives an equal right to a guaranteed volume of medical care, regardless of the amount of the insurance premium actually paid. The insured person can receive medical assistance in accordance with the program throughout the state, including beyond the permanent place of residence, with further mutual settlements between insurance organizations at approved rates.

The state gives the right to the insured within the place of residence to choose a health facility and a doctor, subject to their participation in the compulsory medical insurance programs of the medical organization where the particular citizen is insured.

The specific amount of the insurance premium for compulsory insurance for enterprises of various forms of ownership (as a percentage of the wage fund or profit) are established by the executive structures, taking into account the size of the basic contribution, price indexation, as well as the degree of adverse impact of the working environment on the health of workers.

Compulsory medical insurance of the non-working population is carried out by insurance organizations under an agreement with the territorial administration.

Insurance medical organizations (companies, funds) implement compulsory insurance medical program under an agreement with health care facilities (regardless of ownership), private practitioners and general practitioners (family), licensed and accredited in the manner prescribed by law on the provision of services to the insured party in the amount provided for by the approved basic program.

The activities of medical institutions, personnel, individual doctors involved in compulsory insurance are paid by the insurance company at established rates for services or standard financing per person in accordance with the agreement with the insurance organization. It discusses the volume and quality of medical care on the basis of approved clinical and statistical groups. They are controlled by the insurance company.

Voluntary health insurance is considered as additional if there is compulsory health insurance in the country, or as an independent one. The greatest development of voluntary health insurance in commercial basis reached in countries with liberal market economies.

In Ukraine, according to the Decree of the Cabinet of Ministers "On Insurance" No. 4793 dated 10.05.93. and the Law "On Insurance" dated 07.03.96. introduced voluntary health insurance.

Unlike mandatory, which is funded by targeted taxes, voluntary health insurance is an important type of financial and commercial activity, which is regulated by the relevant law.

In case of voluntary medical insurance, legal entities and individuals can act as the insured party. It is carried out on the basis of an agreement between the insured and the insurance company, applies to those legal entities and individuals who do not fall under compulsory insurance and want to be insured.

The content of voluntary insurance programs is determined by the situation in the healthcare industry, associated with scarce types of medical and preventive care, the volume and level of medical care guaranteed by the compulsory medical insurance program. Appropriate insurance programs are coordinated with the territorial health authorities and in a certain way stimulate the development of the most promising forms and directions. voluntary insurance.

In modern voluntary health insurance, differentiated programs are distributed, which, at the choice of the insured, include life insurance in case of rehabilitation, permanent and temporary disability, preventive insurance to pay for preventive and sports and recreational services.

Table 1

Features of compulsory and voluntary medical insurance.

The basis of health insurance are programs, which largely determine the activities of medical institutions.

Basic program of compulsory health insurance(hereinafter - the basic program) according to the law is processed by the Ministry of Health of Ukraine, approved by the government and guarantees the population of the country a minimum amount of medical care. These are scientifically substantiated proportions of outpatient and inpatient care in certain medical specialties that require material, personnel and financial support.

According to the basic program, government bodies approve territorial programs. The volume and conditions for the provision of medical care, which are provided for by the territorial programs, cannot be less than those established by the basic program.

Health insurance programs should be reviewed depending on the need for medical care that is guaranteed to the population, the material and financial capabilities of society in the healthcare industry.

Insurance medical organizations implement mandatory programs under contracts with health care facilities (regardless of ownership), private doctors or general practitioners (family doctors) who are licensed and accredited. Medical assistance to the insured party is provided in the amount provided for by the approved basic program.

Voluntary medical insurance program finalized by insurance organizations and includes, as a rule, medical services that were left without attention of the compulsory insurance program.

For their implementation, medical insurance organizations involve on a contractual basis medical, social, health-improving institutions of any form of ownership with the determination of fees for specific services.

The medical facilities involved in the programs bear legal and economic responsibility to the insurance organization for the provision of medical services to the insured party, stipulated by the contract, regarding the volume and quality. If a medical institution violates the standard of providing medical care to the insured, the insurance organization has the right not to partially or completely pay the cost of services.

Medical institutions have the right to apply penalties to their doctors for medical services provided in violation of the standard. Their sizes are stipulated by contracts. Keep in mind that not all medical services can be funded by health insurance programs.

The state should finance healthcare institutions and pay for expensive medical services, socially important types of medical care, state medical programs, the activities of research institutes and medical educational institutions.

It is advisable to consider health insurance as a system of economic relations between the medical support industry and the following composite (subjects): Insurance Company, policyholder, insured person and medical institution.

Insurers - these are legal entities (medical insurance organizations, funds) that are established and operate in the form of companies and carry out insurance activities in accordance with the license obtained.

Obligations of the insured:

drawing up an agreement with accredited healthcare facilities, independently working doctors in the prescribed manner to provide a guaranteed amount of assistance with compulsory medical insurance;

drawing up an agreement with accredited or licensed medical, special institutions and individuals to provide voluntary insurance services to their clients;

drawing up contracts (without the right to refuse), in accordance with the current insurance rules;

quality control of medical care provided to the insured party;

control of expediency of use of insurance means by producers of medical services;

economic responsibility to the insured for the provision of medical services;

creation of reserve (reserve) and preventive funds to ensure the stability of insurance activities.

Insurance medical organizations have the right to receive compensation on a claim from enterprises and citizens for violation of sanitary and environmental legislation to reimburse the costs of medical, preventive, sanitary and hygienic and anti-epidemic measures.

Policyholder (of the insured) – this entity, an able-bodied citizen who has drawn up an insurance contract with the insured or is one in accordance with the legislative acts of the country.

Under compulsory health insurance, the non-working population is insured by local administrations, while the employed population is insured by enterprises and employers. Individuals who are self-employed pay mandatory health insurance contributions on their own. Employees of non-profit organizations are provided with funds from the financial resources of the budget or founders.

Under medical insurance, enterprises, civil, charitable organizations, foundations, other legal entities, as well as capable citizens who pay insurance premiums, act as the insured.

The insured is obliged:

in accordance with the contract, make insurance premiums (payments) in accordance with the established procedure;

take measures depending on him to avoid adverse factors affecting the health of the insured;

provide insurance companies with information about the health, working and living conditions of the contingents of the population that are subject to insurance;

draw up third-party insurance contracts with insurance companies.

Policyholders have the right to choose insurance companies, appoint citizens or legal entities to receive insurance amounts (insurance compensation) and change them before the occurrence of an insured event when drawing up insurance contracts.

Violation of the terms of the contract by the party in the part that depends on it may entail full or partial payment of the costs of medical services at the expense of own funds the insured person (violation of safety rules, violation of the regime, diseases provoked by alcohol, tobacco, physical inactivity, overeating).

Insured - is a person who takes part in personal insurance. His life, health and ability to work are the object of insurance protection.

The insured has the right to:

compulsory and voluntary medical insurance;

the choice of an insurance medical organization, a medical institution and a doctor in accordance with the contract for compulsory and voluntary medical insurance;

receiving medical care throughout the country, including beyond the line of permanent residence;

obtaining medical services that meet the contract in terms of quality and volume;

filing a claim by an insured, an insurance medical organization, a medical institution, including for material compensation for losses.

With private voluntary health insurance, the insured person who pays his insurance premiums acts as the insured. For some types of personal insurance, these subjects may not coincide. For example, when insuring children, the insurers are the parents, and the children are the insured.

The insured person is obliged not to meaningfully create a risk of loss of his own and the health of other citizens, to reliably inform the medical institution and the insured about his condition and possible existing risks of deterioration, to adhere to the rules of the medical institution in which he receives assistance.

The insured person is liable for intentional concealment of an existing disease when drawing up a voluntary health insurance contract.

An important feature that distinguishes health insurance from others is that this is the only type of insurance when compensation for losses to the insured in the event of an insured event is carried out not with money, but with medical services. They are provided, usually by the fourth subject of health insurance - medical institution and its employees.

Institutions have the right to issue documents that confirm the temporary disability of the insured, to receive payment from the insured for the cost of medical services provided to the insured in accordance with medical and economic standards; at the request of consideration of the commission's claims with the participation of independent experts.

Health care institutions are obliged to provide the insured person with assistance and services in accordance with the standards in the volumes, types and forms indicated in the insurance program; submit reports to the insured about the amount of medical care provided to the insured.

Subjects of health insurance in Ukraine will build their activities in accordance with the agreements drawn up.

With voluntary health insurance, two types of contracts are drawn up:

an agreement between the insured and the insurance medical organization (HIO) in favor of a citizen (if the insured is a legal entity, then in favor of an employee of this enterprise, a relative of an employee) (U1);

an agreement between HMOs and medical institutions, to which, in the presence of an insured event, a citizen has the right to apply (U2).

Picture 1.

Thus, in case of voluntary health insurance, the main source of financing assistance is the money of the insured, and additional - the profit from the investment temporarily. free funds, securities, deposits, investments, etc.

Compulsory health insurance (CMI) provides for the drawing up of certain agreements on the relevant relationships between its subjects:

agreements on financing between the insured, the territorial CHI fund and HMOs in favor of a citizen to pay for medical care under the territorial CHI program (the role of the insured will be: for the working population - employers, for employees public sector and non-working - local administrations);

agreements between an insurance medical organization and medical institutions on payment for services within the limits of compulsory medical insurance.

As the experience of a number of countries where it has been introduced shows, insurance premiums for the working population constitute the basis for the receipt of funds into the funds.

Figure #2

A citizen with compulsory and voluntary medical insurance will be issued an insurance policy with a guarantee for receiving medical services in accordance with insurance programs that will operate on the territory of Ukraine. The financial flows of compulsory health insurance will pass through different subjects of the health care system. This will create a problem of control over them and, more importantly, will require an assessment of their effective use.

In this way, insurance medicine and medical insurance is an independent system of commodity-market relations in the healthcare system, aimed at improving the medical provision of all insured people.

Its introduction in Ukraine is not so much a change in the number of funding sources as: a) transition to new forms of organization and management of the healthcare system; b) wages for work performed; c) change of priorities in medical care from inpatient to outpatient care; d) high quality of medical services and their compliance with the social guarantees of the insurance policy; e) free choice by the patient of the doctor and health facility.

For this, intermediary and organizational and managerial structures (insurance organizations, funds, cash desks), specially trained medical personnel and a more responsible attitude towards one's health are already needed today.

2. Characteristics of the contract of compulsory and voluntary medical insurance.

3. General characteristics of the contract for organization and financing

health insurance services.

4. Grounds for the emergence of relations between citizens and medical institutions in the provision of medical care.

1. The concept and types of health insurance.

The law of the Russian Federation "On medical insurance of citizens in the Russian Federation" introduced a system of insurance medicine in Russia as a form of social protection interests of the population in the protection of health. The law defines the types of health insurance, the subjects of relations, their rights and obligations, sources of funding and other aspects of insurance medicine.

The purpose of health insurance is to guarantee citizens, in the event of an insured event, receiving medical care at the expense of accumulated funds and to finance preventive measures.

The financial resources of the state system of compulsory medical insurance are formed at the expense of deductions from insurers for compulsory medical insurance. Insurance premiums of enterprises, organizations, institutions are directed to compulsory health insurance of citizens in excess of the allocations approved for health care.

To collect insurance premiums for compulsory medical insurance, the Federal and Territorial Funds for Compulsory Medical Insurance have been established as independent non-profit financial and credit institutions. The financial resources of the mandatory medical insurance funds are in the state ownership of the Russian Federation, are not included in the budgets, other funds and are not subject to withdrawal. Thus, insurance premiums for compulsory health insurance are transferred by the insured to the Federal and territorial funds, and only then - to the insurance medical organization.

There are two types of health insurance: compulsory and voluntary. For a citizen to receive medical care under the system of compulsory medical insurance, it is necessary to conclude 3 contracts:

compulsory medical insurance contracts;

contracts for the organization and financing of medical services for health insurance;

contracts for the provision of medical care.

The structure of relationships and the procedure for settlements depends on who the patient is: With compulsory health insurance for the working population, the following contracts are concluded:

compulsory health insurance contract between the insured

and insurance medical organization;

an agreement on the organization and financing of medical services between an insurance medical organization and a medical institution;

contract for the provision of medical care between a medical institution and a citizen (patient).

The rights and obligations of subjects of compulsory medical insurance (CHI) are fixed Model rules of CHI. The subjects of compulsory medical insurance are the insured, the policyholder, the insurer and the medical institution.

Citizens of the Russian Federation and stateless persons can be insured under the CHI system. Medical insurance of foreigners who are temporarily in Russia is carried out in accordance with the order established by the order of the Ministry of Health of the Russian Federation dated January 29, 1999 No. 27 "On medical insurance of foreign citizens temporarily staying in the Russian Federation." Foreigners permanently residing in Russia have the same rights as citizens of the Russian Federation, unless otherwise provided by an intercity agreement.

Let's take a closer look at these 3 contracts.