Which insurance company to choose to obtain a compulsory medical insurance policy. How do compulsory medical insurance companies differ from each other? Working hours of the health insurance company

The compulsory health insurance system provides insured citizens with free medical care.

The role of insurance companies in compulsory medical insurance

In 2011, a new law “On Compulsory Health Insurance” was adopted. With its introduction, the powers assigned to medical insurance organizations (HMOs) expanded.

The functions of insurance organizations now include:

• protection of the rights of insured citizens;
• registration of insurance policies;
• organization and financing of medical care;
• determination of tariffs for services provided by medical institutions;
• quality control of services;
• representing the interests of insured persons in court.

CMOs conduct consultations and explanatory work among insured persons about the regulations governing the provision of medical care.

To monitor the quality of services, HMO experts are sent to medical institutions and sociological surveys are conducted among citizens.

To carry out the activities of the company, it is necessary to obtain a license. Then notify the territorial MHIF of your intention to work in the compulsory medical insurance system. Documents must be submitted to the Federal Compulsory Compulsory Medical Insurance Fund no later than September 1 of the year preceding the start of the provision of services.

The insurance organization is responsible for financing medical care within the framework of the basic budget and reports to the Federal Compulsory Medical Insurance Fund for compliance with the law on compulsory medical insurance.

Information about medical insurance organizations is posted on the Internet in the public domain.

Differences between companies

All CMOs operating in Russia are commercial organizations operating on the basis of a license issued by the state.

Such companies have equal opportunities at the beginning of their work, but function differently.

Companies differ in their approach to working with clients:

• response time to complaints;
• support for insured persons (24 hours a day, during business hours);
• information about free services;
• accessibility of branches;
• employee preparedness.

Another difference is the number of clients. The more people are insured, the more funding the company receives from the health insurance fund.

If there is a lack of funding, the insurance organization will not be able to spend enough money on examination, consultation and legal support of the insured persons. This can ultimately lead to a decrease in the quality of services and loss of customers.

CMOs also differ in the scope of insurance services. If a company offers voluntary health insurance services in addition to compulsory health insurance, then it is interested in improving the quality of service to attract customers and generate additional profit.

Insured persons have the right to change insurance at will, but not more than once a year. To do this, you must submit an application to the company - the new insurer no later than November 1 of the current year.

Only citizens over 18 years of age can exercise this right. For children under 18 years of age, the decision to change insurance company is made by parents.

An exception is a change of place of residence, provided there are no branches of the insurance company in the territory of residence, or the closure of an insurance company.

Ratings of insurance organizations

The assessment is carried out according to the following criteria:

• financial stability;
• infrastructure;
• quality of services.

Based on the results of the analysis, an opinion is formed on the ability of the insurance organization to fulfill its obligations under the compulsory medical insurance.

You can find information about the reliability of insurers on the official website of Expert RA - https://raexpert.ru/ratings/insurance/.

The data presented by the FFOMS are an objective assessment of activities, since the organization was created to implement state policy in the field of compulsory medical insurance.

You can get acquainted with the opinion of the FFOMS on the official website of the organization - http://ffoms.ru/system-oms/analyst-ratings/.

At the same time, on the page you can evaluate insurance organizations in each region according to the selected evaluation criterion.

However, if a large number of people leave negative reviews, this is a reason to think about the quality of services.

How to choose a CMO

The volume of medical care within the framework of compulsory medical insurance is the same for all subjects of the Russian Federation. It does not depend on the insurance company, but the CMO interacts with medical institutions and the Federal Compulsory Compulsory Medical Insurance Fund.
The comfort, time spent and health of the insured will depend on how “well” the insurance company does its job.

You need to choose from organizations operating in your region. Please note whether there is an office or collection points in your city. The presence of an office and a multi-line telephone allow you to quickly contact the CMO for advice.

You can find out more information about the company on the official website of the medical insurance organization or from the media:

• active work with clients;
• activity information;
• rating;
• Availability of hotline numbers.

What else should you pay attention to when choosing insurance for compulsory medical insurance?

• Company size
  Small regional health care organizations will not be able to control the provision of medical care outside the location of the departments. Federal CMOs cover the entire country and open branches in every city.

  Federal-level insurance organizations more often provide clients with 24-hour telephone support and have greater opportunities to protect the rights of insured persons in court.

• Specialist level
  Availability of specialists in various fields: doctors, lawyers, experts. This will allow you to defend the client’s interests in the event of controversial situations.

The quality of medical care in Russia depends on the efficiency of the medical insurance organization, which is the link between territorial health insurance funds, medical institutions and consumers of insurance services. Every citizen of Russia has the right to choose and change a medical insurance organization in the compulsory medical insurance system, which is enshrined in law. These companies have a lot in common, but there are also nuances that affect the final attractiveness for a potential client.

General characteristics of medical insurance organizations

The employer acts as the insurer for working citizens, and the local administration for the unemployed. Self-employed persons, which include individual entrepreneurs, lawyers, farmers, etc., must independently decide on the issue of concluding an insurance contract. If a citizen is not satisfied with the services provided by an insurance medical organization, then he has the right to enter into an agreement with another company. Each medical insurance organization:

• Operates under a license to provide compulsory medical insurance services and carry out measures to control the quality of medical care;
• Concludes standard agreements with Territorial Compulsory Medical Insurance Funds and medical institutions;
• Pays for medical services provided to insured persons by medical organizations at a single rate. It is approved for each subject of the Russian Federation;
• Works only in the field of compulsory or compulsory and additional health insurance;
• Receives the same amount of funds from the Territorial Fund per insured person;
• Has an authorized capital of 10 million rubles. (with additional provision of medicines - from 30 million rubles).

A medical insurance organization is obliged to protect the interests of insured citizens, including in court, by filing claims against medical institutions for material compensation for physical or moral damage caused to the insured person through their fault. Medical insurance organizations advise and inform insured citizens about regulatory legal acts on issues of compulsory health insurance.

Differences between medical insurance organizations

Equal conditions for the start of work of medical insurance organizations do not mean that they will function equally. Differences can be traced in the organization of work with a specific client. Companies that enter into contracts with large enterprises and institutions operate more efficiently. Negative employee reviews and constant complaints can lead to termination of the insurance contract, which means the simultaneous loss of a large number of insured persons and funds. In the process of interaction between an insured citizen and an insurance medical organization, it is important how quickly controversial issues and conflicts can be resolved: is it possible to communicate with consultants around the clock, the territorial accessibility of the branch, the competence and ability of employees to adequately respond to complaints.

The difference can also be seen in the list of insurance services. When a company provides additional medical insurance, it is beneficial for it that the insured is satisfied with the service. In this case, there is a chance that the client will want to conclude an agreement on additional medical insurance, which will have a beneficial effect on the organization’s budget. The number of clients also significantly influences the funds provided by the Territorial Fund, which are also spent on conducting medical examinations in response to complaints from insured persons. If an insurance company has more than 100 thousand clients, then the chance of a full-fledged expert assessment of the quality of medical care is higher.

The level of customer awareness varies from organization to organization. An informal approach to the advisory work of insurance company employees allows the client to better navigate the list of free medical services, the rights and capabilities of the insured person. The client's complaint must be considered within a month (with a written application). When the insured person is denied services if he has a policy, the insurance company is obliged to respond within 3 days: take measures to eliminate the problem, and if these are not taken, then explain the reasons to the client in writing.

The largest medical insurance companies in Russia for 2017

In 2017, the insurance market continued to show positive dynamics, although the growth rate decreased relative to 2016. According to official statistics of the Central Bank of the Russian Federation, 316 billion rubles of insurance premiums were collected for all types of insurance in the first quarter of 2017, which is 5.3% or 16 billion rubles more than in the same period in 2016. According to RIA Rating, the TOP 3 largest medical insurance companies include SOGAZ, Rosgosstrakh and MAKS-M.

Limited Liability Company "Rosgosstrakh-Medicine"

From 2011 to 2017, this company included several medical insurance organizations (Ikar, Ecofond, Lipetsk-Health), including the Closed Joint Stock Company Capital Medical Insurance. "Rosgosstrakh-Medicine" was officially registered in 2002, today its authorized capital is 210 million rubles, it works only with compulsory health insurance policies. The main office is located in Moscow, there are 42 regional branches, the total number of insured persons is more than 22 million. Company employees provide telephone consultations around the clock.

Closed Joint Stock Company "MAKS-M"

It has been operating since 1994, has representative offices in 24 constituent entities of the Russian Federation, and has an authorized capital of 220 million rubles. About 18.5 million clients are insured; the company operates only in the field of compulsory health insurance. The main office is located in the capital, there are 80 regional branches. There is a hotline and a contact center. In 2017, the company acquired a full stake in the insurance company Astro-Volga-Med, which was one of the largest in the Volga region.

Joint Stock Company SK SOGAZ-Med

It has been operating since 1998, serving 40 constituent entities of the Russian Federation, 640 regional branches. Authorized capital – 123 million rubles. The company's clients are about 18.8 million Russians; work is carried out in two directions: compulsory and voluntary health insurance. The consultation center is open 24/7. In 2003, the Gazprommedstrakh company became part of JSC SK SOGAZ-Med.

Conclusion

All medical insurance organizations in the Russian Federation operate under state licenses and receive funds from territorial funds, which assume the obligations of policyholders in the event of bankruptcy. The insured person has the right to change the insurance company if the quality of its services is unsatisfactory. The choice of the optimal company depends on a number of factors: organization of work, availability of information, number of clients, etc.

Compulsory medical insurance is compulsory health insurance. With its help, absolutely every citizen of the Russian Federation has the right to restore their health completely free of charge. It is noteworthy that the main advantage of the program is to ensure equal conditions for receiving medical care for residents of different regions of the country.

In other words, those services that should be provided to citizens free of charge according to compulsory medical insurance do not depend on the place of registration of the population. But the quality of these services directly depends on the choice of insurer. Let's look at how not to make a mistake with your choice and conclude a profitable contract.

It should immediately be noted that the program involves the provision of the same services to citizens of the Russian Federation. But when choosing a suitable insurance company, you need to pay attention to the extent of coverage of the territory it can guarantee. This is the most important point, which will directly determine where exactly a person can receive the necessary medical care. The differences are as follows:

• regional medical insurance organizations will be able to guarantee the provision of medical care only within the location of their own offices. For example, if there are no company offices in Krasnodar, then a person will not be able to receive medical care;
• Federal companies are more profitable in terms of cooperation, since they can provide qualified medical care throughout the entire Russian Federation. In other words, they do not and cannot have any obstacles, which is very convenient. Especially for people who have to travel frequently or go on business trips;
• It is easier for large companies to protect client rights that have been violated. The same applies to issues related to the settlement of disputes that have arisen.

To make it easier for Russians to make their final choice, a special official website of the FFMS was created. This site provides ratings of insurance companies and all the necessary information about them. But most importantly, the page also has a section with reviews from real people who have worked with such companies. Having familiarized yourself with this information, choosing the most suitable insurer becomes much easier.

How to avoid becoming a victim of scammers?

Insurance fraud is not uncommon. And therefore, Russians need to exercise maximum caution when signing a contract with an insurer, so as not to ultimately become another victim of deception. It should be remembered that:

• Every company that issues insurance policies has a license. Before signing the contract, be sure to ask to see a document proving that such a license has been obtained. This information can also be found on the MHIF page;
• companies never require the client to pay for concluding a contract or issuing a policy. This is a completely free service;
• the company always attaches to the contract a list of those medical services that will be provided free of charge. If a representative demands payment for printing this list, he is a common scammer;
• immediately after concluding an agreement with the company, a temporary policy is issued. Since a permanent one is issued within 60 days. Consequently, no one can immediately issue a permanent one. The exception is scammers;
• the list of documents required to obtain insurance is clearly indicated in the regulatory documents. Only scammers can demand that you provide them with some additional papers.

TOP 10 insurance companies

Representatives of the official department insist that Russians should choose a company with which they will cooperate in the future, focusing on a special rating. This will help you protect yourself from scammers and choose a reputable insurer. This rating was formed based on data on the number of insured clients.

1. LLC "Rosgosstrakh-Medicine"
2. JSC "MASK MASK-M"
3. OJSC SK SOGAZ-Med
4. VTB MS LLC
5. Alfa Insurance MS LLC
6. LLC "VTB-Medicine"
7. LLC "RESO-MED"
8. LLC "Ingosstrakh-M"
9. JSC SMK "ASTRAMED-MS"
10. CJSC "Spasskiye Vorota-M"

Moscow insurance companies

Residents of the capital can choose a suitable company using the list below:

1. "Health insurance"
2. Insurance company "UralSib"
3. "MAX-M"
4. LLC "MEDSTRAKH"
5. "Spassky Gate - M"
6. "RESO-MED"
7. "SOGAZ-Med"
8. "Ingosstrakh-M"
9. "Rosgosstrakh-Medicine"

Change of insurance company

The state provides every citizen with the opportunity to renew an insurance contract with another company in the future. This guarantees that if a person nevertheless makes a mistake and enters into a contract that is unfavorable for him, he will be able to terminate it. Indeed, sometimes it happens that, having studied other market offers, a citizen finds something more attractive. And then the need arises to renegotiate the contract. According to current legislation, replacement of insurance is possible only once per calendar year, not more often. But in some cases there may still be exceptions:

• relocation - if a citizen has changed his place of registration, he may think about concluding an agreement with another insurance company. This is especially true if cooperation was envisaged with a regional organization;
• change of personal data - according to the law, a citizen of the Russian Federation can change his last name, first name and even in some cases patronymic. If this happens, then you are given the opportunity to renew the insurance contract;
• The closure of an insurance company is an extremely undesirable event, but it does not threaten any losses for citizens, since they can immediately terminate the contract and enter into a new one.

In all of the above cases, a citizen can contact the company and conclude a new contract.

List of documents

In order for the company to issue an insurance policy, the client must provide a certain package of documents. As mentioned above in the article, the law establishes a list of documents that Russians are required to provide to the insurer. And it includes:

• application - it should be written according to the template provided by the company representative;
• passport (including national), residence permit, documents confirming temporary registration;
• SNILS (if available).

Please note that persons who have not yet determined their citizenship are required to provide proof of identity. Refugees must present a document that confirms their status. Since minor children can be enrolled in this program, additional paperwork may be required. In this case, you must attach their birth certificate and parent’s passport to the application.

Refusal to take out a policy: what to do?

By law, a company cannot refuse a citizen to issue a policy if all the necessary documents have been provided. But if this happens, you should receive a written refusal from the company and then inform the MHIF about what happened. If no measures are taken on this issue in the future, then the only way out is to file a statement of claim.

Sometimes citizens receive a partial refusal. That is, the company refuses to include in the policy those medical services that are required by law. In this case, you must first file a claim. It should, of course, indicate the exact details of the company to which the citizen has claims. There are two ways to find them out:

• by policy number on the FFOMS website;
• request information to the CMO.

Once the data is received, you can submit a claim.