Organization of compulsory health insurance oms. What is compulsory health insurance (compulsory health insurance). Does it work now and in which regions

29.05.17 265 495 15

The doctors were shocked when I showed ...

On weekends, I lay at home with an impossible sore throat and a temperature of 39.6.

Throwing in not the first dose of paracetamol for the day, I called the ambulance. They told me that it was a sore throat and that I called the district police officer on Monday. The ambulance didn't come.

Zhenya Ivanova

was treated and recovered

I typed in the search bar: "What to do if the ambulance refuses to go." At the forum I saw the advice: “Tell me threateningly that now call the insurance company. They will come right away. " I did so. The ambulance arrived. After that, I twice threatened the doctors with a call to the insurance company and once actually called the number indicated on the policy. It helped every time.

Insurance Company protects my rights and really guarantees free treatment. But if you do not know the laws, then unscrupulous doctors can deceive you, refuse treatment, and demand additional payment.

I recovered and decided to figure out what your compulsory health insurance guarantees you.

Meet: your compulsory medical insurance policy

Most likely, you already have a compulsory health insurance policy. Your parents made it to you immediately after birth. It is either in your passport or in the box with everyone important documents.

If you don't have a policy, drop everything and go to register

Without a policy, you will not get any free treatment. Fortunately, you can get or exchange the policy in any city without registration and registration. To do this, take your passport and SNILS with you and go to an insurance company convenient for you, which draws up these policies.

If there is no SNILS, go first with a passport to the insurance company, then wait 21 days and only then get the policy.

Citizens of the Russian Federation, foreign citizens, refugees and stateless persons permanently or temporarily residing in the territory of the Russian Federation, can obtain a policy. Citizens Russian Federation the policy is issued without limitation of the validity period. By law, even if you have an old-style policy and it is expired, the insurance will still work. Only until you change your passport data: name, surname, place of residence.

If you came to the clinic with an old expired policy and you are denied treatment, it is illegal. You must be accepted. In clinics, everyone is asked to change policies for documents of a new type, but so far this is only a recommendation. Of course, it is better to heed this recommendation: when a law comes out that terminates the old-style policies, it will not take you by surprise.

What insurance companies provide compulsory medical insurance policies

Compulsory medical insurance is an insurance program, that is, everyone pays a little into the common boiler, and then from it they pay those who need it. A common pot is collected by the state from entrepreneurs and distributes funds through an extensive system, which, in turn, pay to hospitals. And an insurance company is an intermediary manager that connects you, the hospital and the state.

Insurance companies make money on compulsory medical insurance in the same way as on other services. They are also responsible for the quality of services and discipline in the system. Your first point of contact is an insurance company.

Each region has its own registers of companies that make CHI policies. Just google it.

Where can you be treated with a compulsory medical insurance policy

To get to a clinic in another city or area, you need:

1. Choose a clinic. Any, not necessarily the one that is closer to home.
2. Find out at the reception which insurance companies work with this clinic. If you have a choice, look at the description of the company on the CMO website. Everyone has the same insurance, but some have more offices, and some have round-the-clock support.
3. Come to the insurance company with a passport and SNILS, fill out an application to replace the policy.
4. Obtain a temporary certificate. It works like a policy for a month.
5. Return to the clinic. Say the code phrase "I want to attach to your clinic" in the registry. Receive an application form, fill it out and return it to the registry.

Now you can get treatment in this clinic for free.

If your insurance company serves the clinic to which you are going to attach, then you do not need to change the policy. But you need to inform the insurance company that you have moved and want to be treated elsewhere. Otherwise, the new clinic will not receive money for your treatment.

Why do you need to attach to the clinic

It is necessary to attach to the clinic, because in our country there is a system of per capita financing. Money for your treatment is given only to the institution to which you are assigned. Therefore, you cannot attach to several clinics at once. You can also officially change the clinic no more than once a year. Previously, this can only be done if you have moved. In this case, in the new clinic, you will be asked to write an application addressed to the head physician.

You cannot attach to a research institute or a hospital, only to a district clinic. And already there, your local therapist will write out referrals to narrow-profile specialists: an eye surgeon, a cardiologist, a chiropractor. Without a referral from a doctor or an ambulance specialist in specialized clinics, you can only be admitted for a fee.

What is UMIAS

In Moscow, the data of all patients are entered into the UMIAS - a unified medical information and analytical system. This simplifies the process of making an appointment with specialists: you can get a ticket to a doctor, cancel or postpone an appointment, get a written prescription at in electronic format... UMIAS even has mobile app.

Please note: if you have moved and decided to attach to a new clinic, then you cannot just take it and do it through the system. You need to write an application addressed to the chief physician and wait until the bureaucratic apparatus approves it. It may take 7-10 business days. If you are registered on the portal of Moscow state services, then you can submit an application in electronic form. They promise to consider it in 3 working days.

When I faced such a problem, I needed help urgently. And according to the law, they are obliged to help me without any multi-day delays. But in the polyclinic they are afraid that if they treat me before the clumsy car enters new data into the UMIAS, they will not receive money for me from the insurance company.

Right in front of the hospital administrator on duty, I called the insurance company, after which I received the necessary consultations at the hospital for free. I was also examined by a whole commission of department heads, and to this day everyone treats me very carefully.

What is included in the compulsory medical insurance treatment

The Compulsory Health Insurance Act entitles all of us to receive treatment free of charge. And even if your policy has expired, you can still use it.

If you do not have the policy with you, you can still make an appointment with a doctor, they have no right to refuse you.

Although for nurses this is an additional concern, therefore, most likely, they will try to convince you that this is not possible. If this happens, just call the insurance company.

In any unclear situation, call the insurance

The minimum amount of assistance is described in the basic compulsory health insurance program. Whether to add something else to this list, each region decides on its own. The exact list of insured events can be found at any clinic or on the website of the Ministry of Health in your region.

In any case, you can apply the following rule: if something threatens your life and health, it is treated free of charge. If you are generally healthy, but want to feel even better, then most likely you can only do it for money. If the state can help you, but the level of this assistance seems too low for you, you will have to put up with it or pay extra.

Examples of what can and cannot be done under the compulsory medical insurance policy

It is impossible	Can
Teeth whitening is an aesthetic procedure	To brush your teeth, because it is the prevention of tooth decay
Get imported Japanese adult diapers by choosing a brand yourself	Get diapers for an elderly person
Remove a couple of extra pounds. Your figure is not insured by the state	Remove boil
Wait on exercise therapy for exercises from hatha yoga or a modern gym	Go to physiotherapy exercises
Consult a dermatologist if you are worried about simply increased oily skin of the face	See a dermatologist for a serious skin rash
Make a denture	Remove the tooth

Teeth whitening is an aesthetic procedure

Brushing your teeth because it is caries prevention

Get imported Japanese adult diapers by choosing a brand yourself

Get diapers for an elderly person

Remove a couple of extra pounds. Your figure is not insured by the state

Remove boil

Wait on exercise therapy for exercises from Hatha Yoga or the modern gym

Go to physiotherapy exercises

Consult a dermatologist if you are worried about simply increased oily skin of the face

See a dermatologist for a serious skin rash

Make a denture

Remove the tooth

When something hurts, you can get an appointment with a therapist free of charge, who will write a referral to a specialist. If indicated, the therapist should write referrals to any doctors who work in government clinics.

Without a referral, you can make an appointment with a surgeon, gynecologist, dentist and a dermatologist at a dermatovenerologic dispensary. Or make an appointment with a child psychiatrist, surgeon, urologist-andrologist or dentist. The OMS does not guarantee free tests and examinations without a referral from the attending physician.

Once every three years, you can undergo a free medical examination and find out if everything is in order with your health. Clinical examination is carried out for each every three years - that is, if this year you turn 21, 24, 27 years old, and so on.

The compulsory medical insurance program also includes free pain relief and rehabilitation after illnesses and injuries. But for one or two, it will not work out in which case you are entitled to free insurance assistance, and where you have to pay on your own. There are a lot of nuances in this matter. If you have a rare disease or difficult situation, contact the Federal Compulsory Medical Insurance Fund.

What exactly is not included in the CHI program

The state will not pay for:

1. Any treatment without a doctor's prescription.
2. Conducting surveys and examinations.
3. Home treatment at will, not on special indications.
4. Vaccinations outside government programs.
5. Spa treatment if you are not a sick child or pensioner.
6. Cosmetology services.
7. Homeopathy and traditional medicine.
8. Dentures.
9. Superior rooms - with special meals, personalized care, TV and other pleasures.
10. Medicines and medical devices if you are not in hospital.

If the hospital asks for money for services that are not on this list, just in case, call the insurance company and ask if it is legal.

Privileges

People with disabilities, orphans, large families, participants in hostilities and other citizens who are supposed to social benefits, the state is ready to pay more medical services... Each category has its own lists of benefits, you can find them in the department social protection or find it on the internet.

Sometimes you are legally entitled to free treatment, but doctors just shrug their shoulders. There may be a queue of up to several months for free rehabilitation, and there may simply not be any pain relievers in your local hospital. It's illegal, but it's a fact of life.

Extortion

Doctors are people too, and nothing human is alien to them. Like any person, getting a lot of money from you right now is more interesting for some doctors than getting a little less money from the insurance and much later. Therefore, a whole illegal practice of extortion of money for treatment under compulsory medical insurance has grown in Russia.

This extortion is based on legal illiteracy. It is enough for the doctor to pretend to be smart and take a stern tone for the frightened patients to start throwing money at him. But the slightest sign that the doctor is legally savvy patient - and the tone changes. Therefore, it is very useful to know which medical services are obliged to provide you for free.

Remember that the treatment is free only for you. The hospital and the doctor will receive money for this treatment from the health insurance fund. This money was paid to the fund by entrepreneurs, including your employer.

You do not need to pay a second time out of your pocket for what the state guarantees you. Moreover, the doctor is likely to receive payment from the fund anyway, even if you are forced to pay.

You do not pay for the treatment, but the hospital will receive money for it.

If you know for sure that you should and can be treated for free, but the doctor offers to pay, call the insurance company. The insurance number is written on your policy, specialists hotline they will help you.

If you cannot do this, ask your doctor to write a written refusal to provide free medical care. If the doctor is behaving provocatively, you can turn on the recorder, it is legal. If even this does not help, call the department for the protection of citizens' rights in the CHI system.

7 499 973-31-86 - telephone of the department for the protection of citizens' rights in the CHI system

Emergency help is always free

If something really bad happened - you lost consciousness, broke your leg or feel acute pain - you should be helped in any state clinic, even if you don't have any documents with you and you have never received a policy.

The hospital does not have the right to refuse assistance to newborns and children under the age of one year, even if the child's parents do not have a policy and registration. Pregnant women cannot be denied - they can contact any antenatal clinic and any maternity hospital, even without documents.

All participants in the health care system are just people: acquaintances, friends, brothers, matchmakers and godfathers. They have parents and children. They are all Russians and they work just like any of us.

• If a surgeon demands a bribe for pain relief, then this is not the health care system, it is this particular surgeon, his parents and teachers. This means that his father, somewhere in his childhood, gave him an example that a bribe is normal. How do you feel about bribes yourself?
• If a hospital says that it has no money for medicines, it is not Putin's fault, but some officials who do not know how to draw up budgets. Or the head physician who does not know how to manage money. You have a lot of people you know who do the same things in their jobs.
• After all, when you get your salary in an envelope, it’s your employers who are underpaid to the health insurance fund. Where will the money for your medicines come from, if you have allowed not to pay for them?

It turns out mild schizophrenia: the same person supports gray salary and complains about insufficient funding for hospitals.

Putin, Navalny, Medvedev, Tinkov or Trump will not solve our health problems. We will solve this problem ourselves if we give our children an example of conscientious attitude to work and the law. To skip classes at the institute was not a feat, but a shame. It was a shame to pass tests for money. To give bribes was against our principles. To know and defend their rights was a duty, not a superpower.

In short: no one will fly in and provide us with free medicine as in paid Israeli clinics. All the hell that we see in hospitals is not hospitals, it is ourselves. And me too.

Let's start by paying taxes and fees. I have everything, thanks. Sorry for the moralizing tone, but I just got fed up with this nagging.

Remember

1. If you don't have a policy, drop everything and go to register.
2. With a compulsory medical insurance policy, you should be treated free of charge in any state clinic throughout Russia.
3. Treatment is free only for you. The hospital and the doctor will receive money for this treatment from the health insurance fund.
4. The policy works even if it has expired. If you come to the clinic with an old policy and you are denied treatment, it is illegal.
5. In any unclear situation, call your health insurance company. The number is on the policy. Write it down to your phone right now.
6. If the insurance company does not save you, call the Federal Compulsory Health Insurance Fund: +7 499 973-31-86.
7. If you have spent money on treatment, which should be free of charge by law, write a statement to the insurance company - you must return the money.
8. Emergency assistance is always free, even if you have no documents.

Final qualifying work

Introduction

economic health insurance

Health insurance is a set of types of insurance that provide for the obligations of the insurer to make insurance payments in the amount of partial or full compensation for the additional costs of the insured caused by the insured's appeal to medical institutions for medical services included in the health insurance program.

In legal terms, this type of insurance is based on the law that defines the legal, economic and organizational foundations of health insurance for the population of Russia. The law ensures the constitutional right of Russian citizens to medical assistance.

The relevance of the topic lies in the fact that medical insurance in the Russian Federation is a form of social protection of the interests of the population in health protection.

Object of study- the CHI system in the Russian Federation

Subject of study- activities of the insurance company "Ak Bars-Med" LLC in the compulsory medical insurance system.

Purpose of the study- study of the essence and structure of compulsory health insurance in the Russian Federation.

Based on the purpose of the work, the following were set tasks:

1.Consider and study the compulsory health insurance system in the Russian Federation.

2.Identify the main participants in the compulsory health insurance system and its financing.

.Analyze the activities of the insurance company LLC "Ak Bars-Med"

To solve the tasks, the following were applied research methods: analysis of scientific and methodological literature; observation; analysis, synthesis, comparison.

1. Theoretical foundations of the compulsory health insurance system in the Russian Federation

.1 Economic essence the system of compulsory health insurance in the Russian Federation

According to Art. 2 ФЗ dated 27.11.1992 No. 4015-1 (revised from 21.07.2005) "On the organization of insurance business in the Russian Federation": "Insurance is a relationship to protect 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 ”.

The compulsory health insurance system (MHI) is one of the forms of social protection of the interests of the population. It is based on two laws: "The Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens' Health" and the Law of the Russian Federation "On Medical Insurance of Citizens in the Russian Federation".

Compulsory health insurance is an integral part of the state social insurance and provides all citizens of the Russian Federation with equal opportunities in obtaining medical and drug assistance provided at the expense of compulsory medical insurance in the amount and on conditions that correspond to compulsory medical insurance programs (Article 1 of the Law of the Russian Federation of June 28, 1991 No. 1499-1 "On medical insurance of citizens in the Russian Federation").

The purpose of compulsory health insurance is to guarantee the citizens of the Russian Federation in the event of insured event receiving medical care from the accumulated funds and financing preventive measures. An insured event in health insurance is understood not only as the appearance of a disease, but the very fact of providing medical assistance for a disease. Insurance compensation here it acquires the form of payment for medical care provided to the population, consisting of a set of specific medical services (diagnostics, treatment, prevention). Medical insurance is carried out at the expense of deductions from the profits of enterprises or personal funds of the population by concluding appropriate agreements. A health insurance contract is an agreement between the policyholder and the health insurance company. The latter undertakes to organize and finance the provision of medical care of a certain type and quality to insured persons (or other services in accordance with compulsory or voluntary health insurance programs). Medical insurance on the territory of the Russian Federation is carried out in two types: compulsory and voluntary. Compulsory insurance is carried out by virtue of the law, and voluntary insurance is carried out on the basis of an agreement concluded between the policyholder and the insurer. Each of these forms of insurance has its own characteristics.

You should take care of your health and the sooner the better. In countries with developed market economy health insurance is one of the most important elements of the health maintenance system.

Figure 1 - Subjects of compulsory health insurance

The CHI is based on the following basic organizational, economic and legal principles:

Universality. All citizens of the Russian Federation, regardless of gender, age, health status, place of residence, level of personal income, have the right to receive medical services included in the territorial compulsory health insurance programs.

Statehood. Compulsory health insurance funds are state property of the Russian Federation, they are managed by the Federal and Territorial MHI funds. Specialized insurance medical organizations. The state acts as a direct insurer for the non-working population and exercises control over the collection, redistribution and use of compulsory health insurance funds, ensures the financial stability of the compulsory health insurance system, and guarantees the fulfillment of obligations to insured persons.

Non-commercial in nature. All profits from compulsory health insurance operations are used to replenish the financial reserves of the compulsory health insurance system.

Obligation. Local executive authorities and legal entities(enterprises, institutions, organizations, etc.) are obliged to make deductions at the established rate of 3.6% of the wage fund to the territorial CHI fund and in a certain order, and in addition bear economic responsibility for violation of the terms of payment in the form of a penalty and / or fine.

Public solidarity and social justice... All citizens have equal rights to receive medical care at the expense of the compulsory medical insurance funds. Insurance premiums and payments for compulsory medical insurance are transferred for all citizens, but the demand for financial resources is carried out only when applying for medical help (the principle of "healthy pays for the sick"). The range and volume of services provided do not depend on the absolute size of contributions to compulsory medical insurance.

1.2 Mechanism for the implementation of the compulsory health insurance system in the Russian Federation

In accordance with this Law, compulsory medical insurance in Russia is state and universal for the population. This means that the state, represented by its legislative and executive bodies, determines the basic principles of CHI organizations, sets tariffs for contributions, a circle of policyholders and creates special government funds to accumulate contributions for compulsory health insurance. The universality of the compulsory medical insurance is to provide all citizens with equal guaranteed opportunities to receive medical care in the amount established by government programs OMS.

The main goal of the compulsory medical insurance is to collect insurance premiums and provide medical care at the expense of the collected funds to all categories of citizens on legally established conditions and in guaranteed amounts. therefore compulsory medical insurance system should be viewed from two points of view. On the one hand, it is an integral part state system social security along with pension, social insurance and unemployment insurance. On the other hand, OMC is financial mechanism securing additional budgetary allocations Money to finance health care and pay for medical services. It should be noted that the scope of compulsory medical insurance includes only medical services for the population. Reimbursement of earnings lost during illness is carried out within the framework of another state system - social insurance and is not subject to compulsory medical insurance.

On the basis of the Basic Program, territorial CHI programs are being developed in the constituent entities of the Russian Federation, the volume of medical services provided, which cannot be less than the volume established by the Basic CHI Program. However, in practice, the cost of territorial programs has to be determined proceeding not from the criteria laid down in the Basic Program, but from the amount financial resources collected by territorial funds for the implementation of compulsory medical insurance in a given territory of a constituent entity of the Russian Federation.

The system of compulsory health insurance was created to ensure the constitutional rights of citizens to receive free medical care, enshrined in Article 41 of the Constitution of the Russian Federation.

Medical insurance is a form of social protection of the interests of the population in health protection.

The most important regulatory legal act governing compulsory health insurance is the Law of the Russian Federation "On health insurance of citizens in the Russian Federation", adopted in 1991. From that moment, the beginning of the development of a new health care industry - insurance medicine was laid.

The law established the legal, economic and organizational foundations of health insurance for the population in the Russian Federation, identified the means of compulsory health insurance as one of the sources of financing for medical institutions and laid the foundation for the creation of an insurance model for financing health care in the country.

Compulsory health insurance is an integral part of state social insurance and provides all citizens of the Russian Federation with equal opportunities to receive medical and pharmaceutical care provided at the expense of compulsory health insurance in the amount and on terms consistent with compulsory health insurance programs.

For implementation public policy In the field of compulsory health insurance of citizens, the Federal and territorial compulsory health insurance funds have been created.

How are compulsory medical insurance funds formed to finance medical care?

The financial resources of the compulsory health insurance fund are formed from a part of the unified social tax at the rates established by the legislation of the Russian Federation, a part of the unified tax on imputed income for certain types of activities in the amount established by law, insurance premiums for compulsory medical insurance of the non-working population paid by the executive authorities of the constituent entities Of the Russian Federation, local government, taking into account the territorial programs of compulsory medical insurance within the funds provided for in the respective budgets for health care, other revenues provided for by the legislation of the Russian Federation.

Sources of financing for medical care.

Federal Law of the Russian Federation of December 29, 2006 No. 258-FZ "On Amendments to Certain Legislative Acts of the Russian Federation in Connection with Improving the Delineation of Powers" from January 1, 2008 specifies the list of types of medical care provided to citizens within the framework of state guarantees. Now it includes primary health care, emergency medical care, emergency medical care, including specialized (air ambulance), specialized medical care, including high-tech. The law defines the sources of funding.

At the expense of compulsory medical insurance funds are paid for medical care provided in accordance with the basic compulsory medical insurance program, which is an integral part of the State Guarantee Program and provides for primary health care, specialized (except for high-tech) medical care, as well as the provision of necessary drugs in accordance with the legislation Of the Russian Federation in cases of diseases (with the exception of sexually transmitted diseases, tuberculosis, HIV infection and acquired immunodeficiency syndrome), injuries, poisoning, congenital anomalies (malformations), deformities and chromosomal diseases, during pregnancy, childbirth, the postpartum period, abortion , certain conditions arising in children in the perinatal period.

Through budgetary allocations federal budget provided:

1.Specialized medical care provided in federal medical institutions, the list of which is approved by the executive body authorized by the Government of the Russian Federation;

2.High-tech medical care provided in medical organizations in accordance with the state assignment, formed in the manner determined by the Ministry of Health and Social Development of Russia;

.Medical assistance provided federal laws for certain categories of citizens, provided in accordance with the formed state assignment and in the manner determined by the Government of the Russian Federation;

.Additional measures for the development of the preventive direction of medical care (clinical examination of children staying in inpatient institutions - orphans and children in difficult life situations, additional medical examination of working citizens, immunization of citizens, early diagnosis of certain diseases) in accordance with the legislation of the Russian Federation;

5.Additional medical care provided by district general practitioners, district pediatricians, general practitioners (family doctors), district nurses, district general practitioners, district nurses, district pediatricians, nurses of general practitioners (family doctors) of federal state institutions run by the Federal Biomedical Agency;

6.Additional medical care provided by district general practitioners, district pediatricians, general practitioners (family doctors), district nurses, district general practitioners, district nurses, district pediatricians, nurses of general practitioners (family doctors) of healthcare institutions municipalities providing primary health care (and, in their absence, by the relevant health care institutions of the constituent entity of the Russian Federation), subject to the placement in these institutions of a municipal order for the provision of primary health care;

.Emergency medical care, as well as primary health care and specialized medical care provided by federal state institutions subordinate to the Federal Medical and Biological Agency, employees of organizations included in the list of organizations of certain industries with particularly hazardous working conditions, as well as to the population of closed administrative-territorial formations, science cities of the Russian Federation, territories with physical, chemical and biological factors dangerous to human health, with the exception of costs financed from compulsory medical insurance funds;

.Medicines intended for the treatment of patients with malignant neoplasms of lymphoid, hematopoietic and related tissues, cystic fibrosis, pituitary dwarfism, Gaucher disease, multiple sclerosis, as well as after organ transplantation and (or) according to the list of medicines approved by the Government of the Russian Federation.

It should be noted that the provision of high-tech medical care to citizens is carried out at the expense of the federal budget in accordance with the established state task and in the manner determined by the executive authority authorized by the Government of the Russian Federation in any, regardless of the form of ownership and level of subordination, specialized medical organizations. In accordance with part 6 of article 51 of the Federal Law of November 29, 2010 No. 326-FZ "On compulsory medical insurance in the Russian Federation", financial support of high-tech medical care is carried out at the expense of compulsory medical insurance funds from January 1, 2015.

In accordance with part 5 of article 51 of the Federal Law of November 29, 2010 No. 326-FZ "On compulsory medical insurance in the Russian Federation", the financial support of emergency medical care (with the exception of specialized (airborne) emergency medical care) is carried out at the expense of compulsory medical insurance from January 1, 2013. The procedure for the transfer of budgetary allocations from the budgets of the budgetary system of the Russian Federation to the budgets of the compulsory medical insurance fund for the financial provision of emergency medical care (with the exception of specialized (sanitary and aviation) emergency medical care) is established by federal law that determines the rate of the insurance premium for compulsory medical insurance of the non-working population.

The expenditures of the budgets of the constituent entities of the Russian Federation include:

Specialized (air ambulance) emergency medical care. Specialized medical care provided in oncological dispensaries (in terms of content), in dermatovenerologic, anti-tuberculosis, narcological dispensaries and other specialized medical institutions of the constituent entities of the Russian Federation included in the nomenclature of healthcare institutions approved by the Ministry of Health and social development Russian Federation, for sexually transmitted diseases, tuberculosis, HIV infection and acquired immunodeficiency syndrome, mental and behavioral disorders, including those associated with the use of psychoactive substances;

High-tech medical care provided in medical institutions of the constituent entities of the Russian Federation in addition to the state assignment formed in the manner determined by the Ministry of Health and Social Development of Russia;

Medicines according to:

1.With a list of population groups and categories of diseases, with outpatient treatment which medicines and medical devices are dispensed on prescriptions of doctors free of charge, including the provision of citizens with medicines intended for patients with hemophilia, cystic fibrosis, pituitary dwarfism, Gaucher disease, malignant neoplasms of lymphoid, hematopoietic and related tissues, multiple sclerosis, as well as after organ transplantation and (or) tissues, taking into account the medicinal products provided for by the list approved by the Government of the Russian Federation;

2.With a list of population groups, for outpatient treatment of which drugs are dispensed by prescriptions of doctors with a 50% discount from free prices.

.At the expense of budgetary allocations of local budgets, with the exception of municipalities, medical assistance to the population of which, in accordance with the legislation of the Russian Federation, is provided by federal state institutions subordinate to the Federal Medical and Biological Agency, are provided:

.Ambulance, with the exception of specialized (air ambulance);

.Primary health care provided to citizens for sexually transmitted diseases, tuberculosis, mental disorders and behavioral disorders, including those associated with the use of psychoactive substances.

In accordance with the legislation of the Russian Federation, the expenses of the respective budgets include the provision of medical organizations with medicines and other means, medical products, immunobiological preparations and disinfectants, donor blood and its components.

In addition, at the expense of budgetary investments of the federal budget, the budgets of the constituent entities of the Russian Federation and local budgets, medical care and other services are provided in the prescribed manner in medical institutions included in the nomenclature of health care institutions approved by the Ministry of Health and Social Development of the Russian Federation, as well as in medical organizations. that do not participate in the implementation of the territorial CHI program.

Who manages the CHI funds.

Compulsory health insurance funds are managed by the Federal Mandatory Medical Insurance Fund and the territorial compulsory medical insurance funds, which were created on the basis of the "Regulations on the Federal Mandatory Medical Insurance Fund" and "Regulations on the Territorial Compulsory Medical Insurance Fund", approved by the Resolution of the Supreme Council of the Russian Federation No. 4543-1 dated February 24. 93 years old.

The provisions on compulsory health insurance funds are based on a legal structure that takes into account world experience in the most effective protection of public funds from their misuse. The creation of compulsory medical insurance funds makes it possible to provide financial conditions for maintaining free medical care for citizens.

Financing of the compulsory health insurance system in the Russian Federation.

Figure 1 - Financial flows in the compulsory health insurance system

The financial resources of the state compulsory medical insurance system are formed at the expense of targeted compulsory payments of policyholders:

Funds are deducted from the budgets of the constituent entities of the Russian Federation for compulsory medical insurance for the non-working population (children, students, students, pensioners, unemployed, etc.). Organs government controlled in the regions, they are responsible for making payments.

Payers of insurance CHI contributions employers are for working citizens. Insurance premium rates are set at the federal level. Until 2001, they accounted for 3.6% of the wages of the insured. Since 01.01.2002 insurance premiums for compulsory health insurance of working citizens are included in the unified social tax, which also combines employers' contributions to Pension Fund and the Social Security Fund.

For calculus tax rate(contribution to compulsory medical insurance) use the so-called regressive scale, in accordance with which the procedure for determining tax base for every employee. This takes into account the size of the organization (enterprise), the employee's income, etc. However, for most workers with an average income of up to 100,000 rubles. per year, contributions to compulsory medical insurance remained unchanged: 3.6% of wages - 3.4% - to the territorial fund and 0.2% to the Federal fund of compulsory medical insurance.

Figure 3 - Dynamics of the share of assets of organizations and insurance premiums

Medical insurance organizations pay for the provision of medical care (under the CHI program) to the insured provided medical institutions working in the CHI system.

Currently, several methods are used to pay for medical services.

To pay for treatment in hospitals, they use:

1)payment according to the cost estimate;

2)the average cost of the treated patient;

)for the treated patient according to clinical and statistical groups (CSG) or medical and economic standards (MES);

)by the number of bed days;

Payment for treatment in outpatient clinics is made by:

)according to the cost estimate;

2)according to the average per capita standard;

)for individual services;

)for the treated patient;

)combined payment method.

Currently, there is no single system of payment for medical services in the CHI system. This situation is typical for the transition period in the organization of compulsory medical insurance. Most effective way payment for medical services today, experts consider payment for a treated patient, i.e. completed case of treatment.

The practice of introducing CHI in the constituent entities of the Russian Federation shows that at present it has not yet been possible to achieve full compliance of the functioning territorial CHI systems with the requirements of the legislation.

1.3 Main participants in the compulsory health insurance system

Compulsory health insurance is 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 compulsory health insurance funds within the territorial compulsory health insurance program and in cases established by this Federal Law within basic program compulsory health insurance;

The subjects of health insurance are: insured persons, policyholders and the Federal Fund.

Insured persons are citizens of the Russian Federation, foreign citizens permanently or temporarily residing in the Russian Federation, stateless persons (with the exception of highly qualified specialists and their family members in accordance with Federal Law No. 115-FZ of July 25, 2002 "On legal status foreign citizens in the Russian Federation "), as well as persons entitled to medical assistance in accordance with the Federal Law" On Refugees "(See Appendix 4):

) working, according to employment contract or a civil law contract, the subject of which is the performance of work, the provision of services, as well as under a copyright contract or a license contract;

) who are members of peasant (farmer) households;

) non-working citizens:

g) other citizens who do not work under an employment contract and are not specified in subparagraphs "a" - "f" of this paragraph, with the exception of military personnel and persons equated to them in the organization of medical care (See Appendix 4).

Policyholders:

b) organizations;

6) individual entrepreneurs, notaries in private practice, lawyers.

The insurers for non-working citizens specified in clause 5 are the executive authorities of the constituent entities of the Russian Federation, authorized by the supreme executive bodies of state power of the constituent entities of the Russian Federation. These policyholders are payers of insurance premiums for compulsory health insurance of the non-working population.

Federal fund.

The insurer for compulsory health insurance is the Federal Fund within the framework of the basic compulsory health insurance program.

Federal Fund is a non-profit organization created by the Russian Federation in accordance with this Federal Law to implement the state policy in the field of compulsory health insurance.

Participants of the CHI system:

) Territorial funds.

Territorial funds - non-profit organizations created by the constituent entities of the Russian Federation in accordance with Federal Law No. 326-FZ dated November 29, 2010 "On Compulsory Health Insurance in the Russian Federation" (hereinafter referred to as the Federal Law) to implement the state policy in the field of compulsory health insurance in the territories of the constituent entities of the Russian Federation.

Carry out:

but) separate powers of the insurer regarding the implementation of territorial compulsory health insurance programs within the basic compulsory health insurance program in accordance with this Federal Law.

b) management of compulsory medical insurance funds on the territory of a constituent entity of the Russian Federation, intended to ensure guarantees of free provision of medical care to insured persons within the framework of compulsory health insurance programs and in order to ensure the financial stability of compulsory medical insurance on the territory of a constituent entity of the Russian Federation.

The territorial fund exercises the following powers of the insurer:

.participates in the development of territorial programs of state guarantees for the free provision of medical care to citizens and the determination of tariffs for payment for medical care in the territory of the subject of the Russian Federation;

2.accumulates and manages compulsory health insurance funds, provides financial support for the implementation of territorial compulsory health insurance programs in the constituent entities of the Russian Federation, forms and uses reserves to ensure the financial stability of compulsory health insurance in the manner prescribed by the Federal Fund;

.ensures the rights of citizens in the field of compulsory health insurance, including by monitoring the volume, timing, quality and conditions of providing medical care, informing citizens about the procedure for ensuring and protecting their rights in accordance with this Federal Law;

.exercises control over the use of compulsory medical insurance funds by medical insurance organizations and medical organizations, including conducting inspections and audits;

.collects and processes data of personalized accounting of information about insured persons and personalized accounting of information about medical care provided to insured persons in accordance with the legislation of the Russian Federation.

The territorial fund at the place of providing medical care makes payments for medical care provided to insured persons outside the territory of the constituent entity of the Russian Federation, in which the policy of compulsory medical insurance was issued, in the amount established by the basic program of compulsory medical insurance, no later than 25 days from the date of submission of the medical invoice. organization, taking into account the results of the control of volumes, terms, quality and conditions for the provision of medical care. The territorial fund of the constituent entity of the Russian Federation, in which the policy of compulsory medical insurance was issued, shall reimburse funds to the territorial fund at the place of medical care delivery no later than 25 days from the date of receipt of the invoice presented by the territorial fund at the place of medical care, in accordance with the tariffs for payment of medical care, established for the medical organization that provided medical care, taking into account the results of the control of volumes, terms, quality and conditions for the provision of medical care.

Medical insurance organizations operating in the field of compulsory health insurance.

Medical insurance organizations (CMO) licensed federal body executive power, exercising the functions of control and supervision in the field of insurance activities. The specifics of licensing the activities of medical insurance organizations are determined by the Government of the Russian Federation.

Carry out:

but) separate powers of the insurer in accordance with the Federal Law and the agreement on financial support of compulsory medical insurance concluded between the territorial fund and the medical insurance organization.

b) its activities in the field of compulsory health insurance on the basis of an agreement on financial support of compulsory health insurance, an agreement for the provision and payment of medical care for compulsory health insurance, concluded between an insurance medical organization and a medical organization.

For a more complete implementation of the tasks laid down in the proposed draft law, it is necessary to harmonize the regulatory and legal framework of the federal and regional levels in the health care system and its financing. The system should also be improved financial control and streamline the reporting system. Finally, arbitration and mediation mechanisms should be established to resolve conflicts between insured citizens, compulsory health insurance organizations and health care providers.

No. Directions Years of implementation Expected results 1. Phased transition to a new system of compulsory health insurance: ( transition period 2005-2008): Introduction of a new CHI system: 2005-2008 Balancing the income of the CHI system and its obligations to provide guaranteed medical care to insured citizens in those constituent entities of the Russian Federation that conclude multilateral agreements; ensuring equal accessibility of citizens to medical care within the framework of the basic compulsory medical insurance program; ensuring transparency of financial flows and rational use of the resources of the CHI system; creation of a unified system of personified accounting with the formation of individual personal accounts; determination of a single insurance premium rate for unemployed citizens in an amount that ensures the fulfillment of the state's obligations under the basic compulsory medical insurance program for the provision of free medical care; in 25 constituent entities of the Russian Federation that have concluded multilateral agreements on co-financing of the unemployed population; 2005 in 47 constituent entities of the Russian Federation of the Russian Federation that have concluded multilateral agreements on the co-financing of the non-working population; 2006 in 69 constituent entities of the Russian Federation of the Russian Federation that have entered into multilateral agreements on the co-financing of the non-working population; 2007 all constituent entities of the Russian Federation 2008 Monitoring of healthcare institutions 2004 Preparation of proposals for the phased optimization of the network of medical organizations, changes in organizational and legal forms. 3. on optimization of the network of medical organizations. 2004-2008 Reduction of institutions that do not provide high-quality medical services, transfer to inpatient replacement technologies, re-profiling. to reduce and reorientate about 15% of ineffectively operating hospitals, bringing the rate of bed availability per 100 thousand of the population in 2004-2006 from 113-110; in 2007-2008 - up to 90-100, and by 2010 up to 80-85 beds; Transformation of the status of a significant part of medical institutions into state (municipal) non-profit organizations, autonomous non-profit organizations. This will make it possible to switch from the system of channeling funds for the maintenance of medical facilities to payment for the volume of medical care for a specific patient. Gradual formation competitive environment , rationalizing costs and improving the quality of services, ensuring the availability of high-quality medical care for all citizens of the country. Changing the organizational and legal form of the main part of state (municipal) institutions 2005-20074. Improving the structural efficiency of the health care system, creating and introducing a system of inpatient replacement technologies. Changes in the structure of health care expenditures with a shift in emphasis to outpatient care 2004-2010 This will allow: to reduce the volume of inpatient medical care in 2005-2006 by 3-5%, in 2007-2008 by 10-15%, in 2009-2010 to 30 - 35 percent; to increase the volume of outpatient care for the above stages, respectively 5-9%; 18-26%; up to 55 percent, with a corresponding redistribution of funding for these types of medical care. Differentiation of hospital beds depending on the intensity of the treatment and diagnostic process. 5. Staged introduction of medical and economic standards in the new system of compulsory health insurance 2005-2008 Introduction of medical and economic standards of medical care that define a socially acceptable and technologically sound minimum of medical care for each disease, will optimize the costs of the CHI program; Phased recalculation of compulsory medical insurance programs as medical and economic standards are introduced. Efficiency and transparency of the use of financial resources of the CHI system. 6. Development of primary health care. 2004-2008 Introduction of general medical practices (family doctor), development of health care. 7. Introduction of new mechanisms for combining voluntary and compulsory health insurance. 2006-2007 Attraction of additional sources of funding to pay for medical services. 8. Transfer of benefits for drug provision of certain categories of the population to targeted social assistance. 2005-2006 Reduction of budgetary expenditures. 9. Widespread introduction of a formulary system of drug provision of medical institutions. 2005-2007. Reduction of costs in hospitals. 10 .Transition to a system of state and municipal orders for the provision of medical care by healthcare organizations to the population within the framework of the budgetary part of the State Guarantee Program. 2005-2008 Approval of the procedure for the formation of state and municipal plans-orders for medical mi organizations. Improving the efficiency of using financial, material and labor resources, developing a competitive environment. 11. Introduction of new methods of remuneration medical professionals 2005-2007 Transformation of medical institutions into other organizational and legal forms will increase wages 12. Development of the sector of paid services in health care. 2004-2007 Creation of conditions conducive to an increase in the volume and development of the market for high-tech medical services. Participation of citizens in co-financing of medical

2. Applied aspects of the implementation of the compulsory health insurance system in the Russian Federation on the example of the insurance company AK Bars-Med LLC

2.1 a brief description of insurance company LLC "Ak Bars-Med"

Insurance company AK BARS-Med LLC was founded in 2004. The main areas of activity are compulsory and voluntary health insurance. Authorized capital companies 150 million rubles. Since 2004, more than 3.2 million people have entrusted their health to the company's partners - medical organizations participating in the implementation of the Territorial Compulsory Medical Insurance Program in the Republic of Tajikistan.

45 branches and representative offices of the Company are successfully operating in all administrative districts of the Republic of Tatarstan.

The insurance company has concluded contracts and cooperates with all medical and preventive institutions of the Republic of Tatarstan participating in the implementation of the Territorial MHI program in the Republic of Tajikistan.

The main tasks of the insurance company are:

1)issuance of compulsory medical insurance policies to insured persons residing in the territory of the Republic of Tatarstan;

2)conclusion of contracts with medical organizations for the provision and payment of medical care for compulsory medical insurance;

)control of volumes, terms, quality and conditions for the provision of medical care in accordance with the terms of the contract. Conducting scheduled inspections of the quality of medical care for the insured (LLC IC "AK BARS-Med" introduced a new approach to assessing the quality of medical services using the automated technology examination of the quality of medical care (ATE KMP) for various medical profiles). Examination of the quality of medical care provided (EKMP) based on written applications from insured citizens. It is carried out mainly in two cases: when solving issues of reimbursement of unreasonable expenses of citizens during the period of their diagnosis and treatment in a hospital and in the presence of claims to the quality of medical care provided to citizens in a medical and preventive institution.

)protection of the rights and interests of the insured: rendering assistance to the insured in solving problems arising when receiving medical services in medical institutions participating in the implementation of the Territorial program of compulsory medical insurance of the Republic of Tajikistan;

)advising and promptly solving problems arising from the receipt of medical care by insured citizens in the system of compulsory medical insurance by calling the 24-hour dispatch service.

)conclusion of contracts of voluntary medical insurance with the issuance of medical insurance policies;

)conclusion of contracts for the provision of medical, health and social services to citizens on voluntary medical insurance with any medical and other institutions.

In order to meet the needs of insured citizens in effective methods of treatment, specialists of the insurance company have developed a number of voluntary health insurance programs. Contracts have been concluded with private clinics, leading medical institutions in Russia, near and far abroad.

The Company successfully operates a powerful expert service - 120 freelance doctors-experts of the highest category in various medical profiles regularly conduct examinations of the quality of medical care provided.

The insurance company "AK BARS-Med" is a member of the All-Russian Union of Insurers, the Interregional Union of Medical Insurers, and the Union of Insurers of Tatarstan.

In 2008, the insurance company "AK BARS-Med" became a laureate in the nomination "Best medical company" - the nomination of the Volga national prize in the field of insurance "Silver Umbrella"

In 2010 he is nominated and becomes the winner in the nomination

"Best Medical Insurance Organization".

In 2011 he also became a nominee for the title of "Best Regional Insurance Company 2011".

At present, AK BARS-Med LLC has good potential, significant human, financial and administrative resources. The company has high credit the trust of its shareholders, partners and customers, is dynamically developing.

In the segment of medical insurance, LLC AK BARS-Med, according to the results of 2013, took the 251st place, having collected insurance premiums in the amount of 86 million rubles.

Economic environment in which the Group operates The Republic of Tatarstan is a large donor region, industrial, commercial, cultural and scientific center. There are many industrial enterprises, trade is developed. All this creates the preconditions for the existence of a rapidly developing insurance market. It is important to emphasize that the insurance market of the Republic of Tatarstan is the most developed among the 14 regions of Russia included in the Volga Federal District. For a number of years, the republican insurance market has been confidently leading in the Volga federal district... One of the objective indicators of the development of one or another insurance market stands for the amount of collected insurance premiums.

Economic indicators Tatarstan at the end of 2014 speaks of the successful development of the republic. So, gross regional product grew by 2.3% and amounted to 1.520 trillion. rubles.

In 2014, the foreign trade turnover of the Republic of Tatarstan is estimated at 26 billion US dollars, an increase of 102.3%. The interregional trade turnover of the Republic of Tatarstan is estimated at 600 billion rubles, an increase of 112%.

The above facts testify to the investment attractiveness of Tatarstan for the development of the insurance business.

The regional insurance market is a subordinate part of the region's economy. Potential demand for insurance services, both among individuals and legal entities are determined by social and economic potential region. So, the population of the region gives an idea of ​​the possible volume of development of the insurance market, the share of the urban population indirectly reflects the degree of perception by the population of new types of insurance, average level per capita income is taken into account when planning the development of voluntary types of insurance, the volume of industrial production characterizes the level of property interests, etc. ...

The company receives income from a compulsory health insurance contract, which is classified as a service contract, as it does not contain a material insurance risk... Under the agreement concluded with the Territorial Fund for Compulsory Medical Insurance (hereinafter - TFOMS), IC AK BARS-Med LLC takes part in the compulsory medical insurance program in order to provide citizens of the Russian Federation with free medical care with the help of a number of appointed insurers. The company receives prepayments from TFOMI and, in turn, makes prepayments to medical institutions for services provided by these institutions under the TFOMI program. Earmarked funds received from TFOMI, but not transferred to medical institutions for reporting date, are reflected as liabilities for earmarked financing under compulsory medical insurance. For these services, the Company receives a commission, which is reflected in the consolidated statement of comprehensive income as commission income from compulsory health insurance.

Unearned premium reserve.

The unearned premium reserve is created in the amount of the part of the accrued premium under the insurance contract related to the remaining term of the insurance contract as of the reporting date and is calculated in proportion to the remaining period of the contract based on the amount of the accrued gross premium, that is, excluding acquisition costs.

Compulsory health insurance.

Free medical services under the compulsory medical insurance policy:

Emergency medical assistance (ambulance).

Outpatient care, including the implementation of measures for the diagnosis and treatment of diseases in the clinic, at home and in the day hospital, if necessary, provide emergency care on weekends and holidays(drug provision for outpatient treatment is not included in the compulsory medical insurance program).

Inpatient care for:

)acute diseases and exacerbations of chronic diseases, poisoning, injuries requiring intensive care, round-the-clock medical supervision and isolation of the patient according to indications.

)pathology of pregnancy, childbirth, abortion.

)planned hospitalization for treatment and rehabilitation, requiring round-the-clock medical supervision, in hospitals, departments and day wards.

High-tech medical care, which includes a range of medical and diagnostic services carried out in a hospital using complex and unique medical technologies.

Sanitary and hygienic education of the population, measures for diagnostics, prevention, medical rehabilitation.

Not included in free medical services under the compulsory medical insurance policy:

Diagnostics, research, procedures, consultations carried out at home (except for persons who, for health reasons, cannot visit medical institutions).

Conducting consultations of specialists on the basis of personal initiative of citizens, medical examination and examination, medical support of private events.

Hospitalization in a dedicated bed. Additional services, stay in a superior ward, individual post of a medical worker, care and additional food, telephone, TV, etc.

Treatment and examination for concomitant disease in the absence of an exacerbation that does not affect the severity of the underlying disease.

Examination, treatment, observation at home (except for cases when the patient is unable to visit a medical institution for health reasons and the nature of the disease).

Anonymous medical services (except for cases stipulated by the legislation of the Russian Federation).

Carrying out preventive vaccinations at the request of citizens (with the exception of vaccinations carried out under state programs).

Spa treatment (except for the treatment of children and treatment in specialized sanatoriums).

Cosmetology services.

Homeopathic services.

Dental prosthetics (with the exception of persons for whom it is provided by the current legislation).

Treatment of sexological pathology.

Citizens' rights in the field of compulsory medical insurance:

In accordance with the Federal Law of the Russian Federation of November 29, 2010 No. 326-FZ "On compulsory medical insurance in the Russian Federation", insured persons have the right to:

Free provision of medical care to them by medical organizations in the event of an insured event:

but) throughout the territory of the Russian Federation in the amount established by the basic compulsory health insurance program;

b) on the territory of the constituent entity of the Russian Federation in which the policy of compulsory medical insurance was issued, in the amount established by the territorial program of compulsory medical insurance;

Choosing an insurance medical organization by submitting an application in the manner prescribed by the rules of compulsory medical insurance;

Replacement of an insurance medical organization, in which a citizen was previously insured, once during a calendar year no later than November 1, or more often in the event of a change of residence or termination of the contract on financial provision of compulsory health insurance in the manner prescribed by the rules of compulsory health insurance by filing applications to the newly selected medical insurance organization;

Selection of a medical organization from medical organizations participating in the implementation of the territorial compulsory health insurance program in accordance with the legislation of the Russian Federation;

Choosing a doctor by submitting an application in person or through his representative addressed to the head of a medical organization in accordance with the legislation of the Russian Federation;

Receiving from the territorial fund, medical insurance organization and medical organizations reliable information about the types, quality and conditions for the provision of medical care;

Protection of personal data required for maintaining personalized records in the field of compulsory health insurance;

Reimbursement by an insurance medical organization of damage caused in connection with non-fulfillment or improper fulfillment by it of its obligations to organize the provision of medical care, in accordance with the legislation of the Russian Federation;

Reimbursement by a medical organization of damage caused in connection with non-fulfillment or improper fulfillment by it of its obligations to organize and provide medical care, in accordance with the legislation of the Russian Federation;

Protection of rights and legitimate interests in the field of compulsory health insurance.

2.2 The main tasks of the CHI system on the example of the insurance company LLC "Ak Bars - Med"

Compulsory health insurance is 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 compulsory health insurance funds within the territorial compulsory health insurance program and in the cases established by the Federal Law of November 29, 2010 No. 326-FZ "On compulsory medical insurance in the Russian Federation" within the framework of the basic compulsory medical insurance program.

1.For the non-working population - the executive bodies of the constituent entities of the Russian Federation, authorized by the supreme executive bodies of state power of the constituent entities of the Russian Federation.

2.For the working population - persons who make payments and other remuneration to individuals (organizations, individual entrepreneurs, individuals not recognized as individual entrepreneurs), individual entrepreneurs in private practice, notaries, lawyers.

The compulsory health insurance policy is a document certifying the right of the insured person to free medical care throughout the Russian Federation in the amount provided for by the basic compulsory health insurance program.

Table 2 - The number of insured persons under the compulsory health insurance system in the period from 2012 to 2014.

Number of people insured under the CHI system Year Number of insured persons, thousand people.As of 01.01.2012 448 640 As of 01.01.2013 454 482 As of 01.01.2014 456 406

Figure 4 - Dynamics of changes in the number of insured persons under the CHI system in IC LLC "Ak Bars - Med".

It can be seen from the presented diagram that the number of people insured under the CHI system is practically equal in all periods.

2.3 Evaluation of the efficiency of the IC LLC "Ak Bars-Med"

Table 3 - Initial data on the profits and losses of an insurance medical organization under the compulsory health insurance system on the targeted use of funds for 2012, 2013, 2014

For 2014 For 2013 For 2012 The balance of earmarked funds at the beginning of the reporting year 806 662 363 35 810 145 ReceivedFunds received from the territorial fund for the financial support of the CHI in accordance with the agreement on the financial support of the CHI 25 404 45 522 034 81616070185 Funds received from the medical organization as a result of the application of sanctions against them for violations revealed during the control of the volume, timing, quality and conditions of the provision of medical care 763 58245 37058 974 Including: As a result of medical and economic control 709 2742313 As a result of an examination of the quality of medical care 21 86322 41130 051 As a result of payment for honey. organization of fines for failure to provide medical care for untimely provision of inadequate medical care 8283 011620 Funds received from legal entities Or physical. Persons who have caused harm to the health of the insured 3312 466 Other receipts of earmarked funds 4920 5231 198 466 UsedPayment for honey. assistance to insured persons under compulsory medical insurance agreements 29 009 13021 715 53016 169 069 Aimed at the income of insurance honey. organizations 15 97811 88911 428 Including: From the funds received from medical organizations as a result of the application of sanctions against them for violations revealed during the control of the volumes, terms, quality and conditions of medical care 15 97811 88911 428 As a result of the examination of the quality of medical care 6 4924 6976 884 As a result medical and economic expertise 9 0805 7044 234 Funds received from legal entities Or physical. Persons who have caused harm to the health of the insured — As a result of payment for honey. organization of fines for failure to provide medical care for untimely provision of medical care of inadequate quality 4061 506310 Other earmarked funds used – 1 222 973

Figure 5 - Dynamics of funds received and used

As of January 1, 2015, the number of citizens insured under compulsory health insurance in the Company was 3,181,144 people.

Figure 6 - Dynamics of insurance payments and premiums under the compulsory medical insurance agreement.

2.4 Prospects for the development of the CHI system in the Russian Federation

In the face of tough budget deficit the organization of the system of compulsory health insurance (CHI) was an effective political and economic decision, which marked the beginning of the formation of a fundamentally new system of legal and financial relations in the provision of medical care to the population, as well as a more rational use of available health care resources.

For 5 years, the system of compulsory health insurance has been organizationally formed and functions throughout the country from scratch. It consists of 90 territorial CHI funds, 1176 branches, 424 medical insurance organizations (HMI).

More than 82% of the population of the Russian Federation is provided with compulsory medical insurance policies. A system for collecting insurance contributions, accounting and registration of payers of contributions has been created and is functioning, the number of which amounted to 3.7 million.

In less than 5 years of implementation of the law on health insurance, more than 90 billion rubles have been collected. Of this amount, insurance premiums for workers amounted to almost 56 billion rubles, payments from the budget for compulsory medical insurance of the non-working population - over 21 billion rubles. Due to the collection of fines, penalties from payers, income from the use of temporarily available funds attracted almost 13 billion rubles.

In total, over 84 billion rubles have been allocated to the health care system over 5 years in addition to budget funds, which is more than 30% of all health care costs. The bulk of the funds (72.4 billion rubles) was used to finance medical care within the framework of territorial compulsory medical insurance programs. Over the past three years, more than 50% of these funds have been spent by health care institutions for the salaries of medical workers, more than 18% - to pay for medicines.

In the current year alone, the Federal MHI Fund provided financial assistance in the form of subventions to 88 constituent entities of the Russian Federation for a total amount of more than 900 million rubles. In addition, given the particular complexity and uniqueness of federal healthcare institutions, they received over 107 million rubles of assistance.

The main strategic direction of the work of the Federal and Territorial Funds has been and remains to ensure the implementation of the Law of the Russian Federation "On Health Insurance of Citizens".

One of the strategic tasks in the CHI is to ensure the constitutional right of citizens to free medical care. To this end, the government of the Russian Federation has approved the Program of State Guarantees for Providing Citizens of the Russian Federation with Free Medical Care. This program for the first time at the regulatory document the concept of a per capita standard of health care financing is introduced.

The implementation of territorial programs in the constituent entities of the Russian Federation will make it possible to start a real restructuring of medical care.

The deficit of funds for financing compulsory health insurance is increasing every year. As a result of an acute shortage of funds, the actual financing of territorial compulsory health insurance programs amounted to 9 months. 1998, only 37.5% of the approved annual volume.

It should be noted that in the context of a threatening increase in the financial deficit of the compulsory medical insurance system, out of 17 territorial funds, in which, during the checks of the KRU of the Federal Fund, misuse of funds was revealed, only one fund fully restored the spent money. From now on, the federal fund will strictly control territorial funds for the return of compulsory medical insurance funds for inappropriate spending.

The main reasons for the current financial situation are:

1)failure of the executive authorities of the constituent entities of the Russian Federation to comply with the law regarding the transfer of payments for compulsory medical insurance of the non-working population;

2)destabilization of the financial and economic situation in the country;

)low rate of insurance premium for compulsory health insurance of working citizens (3.6% with a need of 7.2%).

One of the options for solving the above problem could be the approval of a differentiated standard and the granting of the right to the constituent entities of the Russian Federation to approve the tariff of the insurance premium within the minimum and maximum size.

About payments. Of particular concern is the situation with payments for compulsory medical insurance of unemployed citizens of the Russian Federation.

Taking into account that non-working citizens exceed 60% of the total population of the Russian Federation, payments directed to compulsory medical insurance funds for insurance of non-working citizens should be at least 60-70% of all income of the system. The real situation is the opposite: admission budget funds not only in the compulsory medical insurance, but in general it is constantly decreasing, and the insurance premiums of workers instead of additional ones are becoming the main ones.

The solution of these problems is facilitated by the formation of a new information and analytical support of the CHI system on the basis of a comprehensive program of informatization of the industry.

The main tasks of the Federal Compulsory Medical Insurance Fund are:

Improving the financial and credit mechanism for the sustainability of the CHI system.

Improvement legislative regulation in the provision of medical care to the population at the federal and regional levels, the implementation of measures to implement the law on health insurance in the constituent entities of the Russian Federation.

Improvement of measures to improve the quality and availability of medical care for the population.

Implementation of the main directions of informatization of the CHI system.

In conclusion, it is necessary to note the importance and relevance of educational support for the reorganization of the medical care system as a compulsory medical insurance. For the public, including the medical one, the goals and ways of transition to compulsory medical insurance are still largely unclear. It is necessary to change the situation as soon as possible, to be heard and understood by millions Russian citizens in all Russian regions without exception. Ordinary citizens, public organizations and associations that represent their interests, political parties and movements, representatives of federal government bodies and, above all, Russian legislators should, with our help, understand: why the compulsory medical insurance is the real driving force behind the health care reform, why it is impossible to take seriously without the compulsory medical insurance protect the interests of citizens in the field of health protection.

Conclusion

1.Having studied the system of compulsory health insurance in the Russian Federation, we came to the conclusion that the system of compulsory health insurance (CHI) is one of the forms of social protection of the interests of the population. It is based on two laws: "The Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens' Health" and the Law of the Russian Federation "On Medical Insurance of Citizens in the Russian Federation". The purpose of compulsory medical insurance is to guarantee that the citizens of the Russian Federation, in the event of an insured event, will receive medical assistance from the accumulated funds and to finance preventive measures. Medical insurance is carried out at the expense of deductions from the profits of enterprises or personal funds of the population by concluding appropriate agreements.

2.The main participants in the compulsory health insurance system and its financing are: insured persons, policyholders and the Federal Fund.

Insured persons are citizens of the Russian Federation, foreign citizens permanently or temporarily residing in the Russian Federation, stateless persons (with the exception of highly qualified specialists and their family members in accordance with Federal Law No. 115-FZ of July 25, 2002 "On the legal status of foreign citizens in Russian Federation "), as well as persons entitled to medical assistance in accordance with the Federal Law" On Refugees ":

) working under an employment contract, or a civil law contract, the subject of which is the performance of work, the provision of services, as well as under a copyright contract or a license contract;

) independently providing themselves with work (individual entrepreneurs, notaries in private practice, lawyers);

) who are members of peasant (farmer) households;

) who are members of the family (clan) communities of the indigenous small-numbered peoples of the North, Siberia and the Far East of the Russian Federation, living in the regions of the North, Siberia and the Far East of the Russian Federation, engaged in traditional economic sectors;

) non-working citizens:

but) children from birth until they reach the age of 18;

b) non-working pensioners, regardless of the basis for granting a pension;

in) citizens studying full-time in educational institutions initial vocational, secondary vocational and higher vocational education;

d) unemployed citizens registered in accordance with the employment legislation;

e) a parent or guardian who takes care of the child until the child reaches the age of three;

6)able-bodied citizens caring for disabled children, disabled people of group I, persons who have reached the age of 80;

7)other citizens who do not work under an employment contract and are not indicated in subparagraphs "a" - "e" of this paragraph, with the exception of military personnel and persons equated to them in the organization of medical care.

Policyholders:

)persons making payments and other remuneration to individuals:

2) organizations;

)individual entrepreneurs;

)individuals who are not recognized as individual entrepreneurs;

)individual entrepreneurs in private practice, notaries, lawyers.

The insurers for non-working citizens specified in clause 5 are the executive authorities of the constituent entities of the Russian Federation, authorized by the supreme executive bodies of state power of the constituent entities of the Russian Federation. These policyholders are payers of insurance premiums for compulsory health insurance of the non-working population.

Federal fund.

The insurer for compulsory health insurance is the Federal Fund within the framework of the basic compulsory health insurance program.

Participants of the CHI system

Territorial funds are non-profit organizations created by the constituent entities of the Russian Federation in accordance with Federal Law No. 326-FZ of November 29, 2010 "On Compulsory Health Insurance in the Russian Federation" (hereinafter referred to as the Federal Law) for the implementation of state policy in the field of compulsory health insurance in the territories of the constituent entities of the Russian Federation Federation.

3.In the context of a severe budget deficit, the organization of the compulsory health insurance (MHI) system was an effective political and economic solution, which laid the foundation for the formation of a fundamentally new system of legal and financial relations in the provision of medical care to the population, as well as a more rational use of available health care resources.

1.On health insurance of citizens in the Russian Federation: Law of the Russian Federation of July 28, 1991 No. 1499-1 Vedomosti of the Congress of People's Deputies of the Russian Federation and the Supreme Soviet of the Russian Federation. 1991. No. 27. Art. 920.

2.On the procedure for financing compulsory medical insurance of citizens for 1993: Resolution of the Supreme Soviet of the Russian Federation dated February 24, 1993 No. 4543-1 Vedomosti of the Congress of People's Deputies of the Russian Federation and the Supreme Soviet of the Russian Federation. 1993. No. 17. Art. 591.

.On measures to implement the Law of the Russian Federation "On Amendments and Additions to the Law of the RSFSR" On Medical Insurance of Citizens in the RSFSR ":

.Resolution of the Council of Ministers - Government of the Russian Federation dated October 11, 1993 No. 1018 Collection of acts of the President and the Government of the Russian Federation. 1993. No. 44. Art. 4198.

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Compulsory health insurance system in the Russian Federation

The Russian system of compulsory health insurance (MHI) has recently undergone major changes

A number of significant innovations and reforms were implemented jointly by the Ministry of Health of the Russian Federation and the Federal Compulsory Medical Insurance Fund. The modernization of the CHI system and the underlying CHI law adopted in 2010 have been warmly welcomed by many experts and government officials. According to T.A. Golikova: “The adoption of the law on compulsory health insurance is important stage in the modernization of healthcare. We are moving to a competitive model in which the patient and the quality of medical care come to the fore. " Unfortunately, over time, some experts and officials began to publicly criticize those basic principles modern system OMS, in the development and implementation of which they themselves were directly involved.

So what has the modernization of the compulsory medical insurance system brought to the Russians? How do insurance medical organizations (HMO) and territorial CHI funds interact today? MK understood this.

The compulsory health insurance system was introduced in the 90s with the main goal of saving healthcare in the face of shrinking budgets and guaranteeing free medical care to Russians. The CHI coped with these tasks, but they were replaced by new ones: modernization of the medical industry, the introduction and provision of widespread availability of new treatment technologies, the transition from medical care mainly in emergency situations to health preservation, disease prevention and prevention of development. heavy forms dangerous diseases. Recently, the Ministry of Health and the MHIF have done a lot to develop the MHI system in these areas. Today, at the expense of the compulsory medical insurance, a program of medical examination of the population is carried out and high-tech medical assistance is provided in the treatment of complex diseases.

In addition, the procedure for the operation of the compulsory medical insurance system is being improved: more effective methods of paying for medical services are being introduced, new mechanisms are being created to control the quality of medical care and protect the rights of insured citizens. Thus, a single compulsory medical insurance policy has been introduced, according to which every citizen can receive medical care in any corner of the country. The Russians received the right to independently choose clinics and an insurance medical organization.

There is enormous competition in the HIO market today. There is a real struggle for patients, which means that there are more and more incentives to expand the range of services and improve their quality.

Registration of the insured and issuance of the policy

According to the law, a patient can change the HMO at least every year. What if you decide to change the insurer or change the old-style policy to a new one? You should contact one of the regional branches of insurance companies. Regardless of which company you prefer, the insurer will tell you about the procedure for obtaining an OMI policy, your rights in the OMI system, answer all your questions, accept your application and inform you about the terms and procedure for obtaining the policy.

What happens then? If you change old policy for a new one, the insurer will check your data with the database, immediately print and issue you a temporary certificate (acts as an OMI policy until the latter is received), update its register of insured persons, and send the data to the territorial CHI fund on the same day. In turn, the territorial fund collects all applications received during the day from all insurers in the region and checks whether the information is duplicated at the level of the regional health insurance organization. Then the fund sends the received data to the general database of the Federal Mandatory Health Insurance Fund with an application for a new policy. FFOMS, on the other hand, is already verifying the received data for duplication throughout the country and orders the production of a personal compulsory medical insurance policy on a secure form in Goznak. As soon as it is ready, FFOMS will send the policy to the territorial fund, where it will be handed over to the insurer. The latter will inform the citizen about the readiness of the policy and, accordingly, issue it. In general, the production and delivery of the policy takes no more than 30 working days.

This procedure not only makes it possible to receive medical care for each insured person in any locality of the country and prevents duplication of costs, but also ensures reliable accounting and proportional financing. federal programs by region.

Professional patient support

As already mentioned, today insurance medical organizations are interested in providing the highest quality services to their insured. The patient can contact his health care center for almost any issue related to the provision of medical care. For example, if you are asked to wait a long time for a doctor's appointment or are dragged out with a study, if it seems to you that medical care was provided to you of poor quality, or suddenly they demanded money for what you are entitled to for free, feel free to contact your insurer. In any of these situations, the CMO is not only obliged, but also interested in helping you. The insurer will explain to you what needs to be done to resolve the issue, join in solving the problem, call the head doctor of your clinic or hospital where you are being treated.

If the insurer deems it necessary or at your request, an assessment of the quality of the medical care provided to you will be carried out. If in the course of this inspection violations are revealed, the medical organization may be fined. CMO will provide you with consulting and legal support. Now these types of control have become a constant practice: for example, in the period 2014-2015, insurance organizations reviewed more than 60 million complaints from patients. However, if it seems to you that insurers are evading their duties, you can turn to the territorial CHI fund with a complaint - and then the insurers themselves will be inspected.

It is worth dwelling in more detail on the medical and economic examination and examination of the quality of the medical care provided. Today it is not only main function the insurer, but also the only mechanism for non-departmental control of medical organizations. Under the law, insurers have the right to impose sanctions on clinics or hospitals if they provided poor quality medical care. In some cases, this turns out to be a serious incentive for improving the quality of medical services. Such examinations are now carried out by expert doctors, both full-time and freelance. So that such examinations are not carried out for show, there is a selective control by the TFOMI, which can conduct a re-examination. And if it turns out that the initial examination of the insurance company was carried out poorly, the territorial CHI fund will fine the insurer itself. In order to avoid a conflict of interest, to conduct an examination in mandatory doctors are involved who do not work in those organizations that are subject to verification. And in especially difficult cases, insurers (usually federal) carry out examinations by experts from other entities and with higher qualifications from the country's leading medical organizations. In 2014-2015, according to the results of medical and economic control, 42.6 million accounts were identified, containing 52.6 million violations.

Payment for medical services

And a few more words about how medical care rendered to Russians is paid for today. All the money is accumulated in the FFOMS, from where it is transferred to the TFOMS, which distribute it to their “wards” health insurance companies, depending on the number of insured persons and a number of other indicators. All medical organizations in each Russian region collect monthly bills for all services and send them to insurers. For example, in the Tula region, where there are more than 60 medical organizations that are part of the compulsory medical insurance system, they all form registers of accounts for payment of medical care provided, depending on the insurance belonging of patients and send registers to those present at local market branches of the CMO. Insurance companies, before paying bills, conduct medical and economic control to establish the legality of payment (for example, whether the insured company is the right company, whether the service is included in the compulsory medical insurance, etc.). This is done to ensure that government money is used for its intended purpose.

At the end of the inspection, medical organizations receive payment from insurers. However, if the invoice was rejected due to a technical error, the clinic or hospital may issue a second invoice - the insurer is obliged to check it again and, if everything is correct, pay. The money to pay the bills of medical organizations appears on the accounts of medical organizations from TFOMS within a strictly designated period and only for 3 working days: during this time, insurers must accept and process all bills, pay them, and return the balance of funds (if any) to TFOMS. Violation of the deadlines threatens with strict sanctions from the TFOMS, which monitors the quality of the HIO's work. The TFOMI independently carry out only inter-territorial settlements (when the insured in one region of the Russian Federation received medical assistance in another region). However, the volume of such payments is negligible in comparison with the local ones, carried out by the CMO forces.

The system of interaction between the participants of the CHI system, built today, where funds and healthcare organizations ensure the functioning of the entire system and the possibility of realizing the rights of citizens to high-quality and free medical care, experts recognize as optimal and logical. Of course, this does not mean that there is absolutely nothing more to improve. Changes in this area are ongoing. For example, on the initiative of the Ministry of Health, an institute of insurance representatives has been created and has already begun its work, whose task is to raise the awareness of patients about their rights, to protect their interests even more closely.

And yet, a lot today depends on the activity of the patients themselves, on their desire to take care of their health, and for this - to constructively interact with insurers and protect their rights. If we all demand that medical services be provided to us with high quality, it is in our power to bring the level of health care to a level that we can rightfully be proud of.

When receiving medical care under the compulsory medical insurance policy, patients may face such inconveniences as long queues, insufficient volume of free services, and poor quality of service.

To avoid these troubles, the OMC + program was developed.

Background

In early 2015, the Ministry of Health developed a new project as part of the strategy for the development of the Russian health care system for the next 15 years.

The project was named "OMS +", and its essence was to create additional health insurance.

Patients who want to receive a package of medical services that is larger than the obligatory package can purchase the “MHI +” policy. All paid procedures that were previously carried out through the cashier's office of the clinic, thanks to this program, can only be provided under the new policy.

With the help of the policy, it was planned to achieve an increase in funding for the health care system, since all hidden payments could now be carried out only through the "CHI +".

The creation of such a program does not imply a reduction in services for an ordinary policy. OMC + acts as a supplement. The purchase of the policy is not imposed.

The program was not implemented throughout Russia, but only pilot versions of the project were launched in five regions: Tyumen, Lipetsk, Kirov, Belgorod regions, the Republic of Tatarstan. A limited number of insurance companies and hospitals were involved in the project.

What is CHI +

Compulsory health insurance plus is an additional package of services to the compulsory health insurance program. The insurance company does not provide additional financing within the framework of compulsory insurance.

The patient must purchase the OMS + policy and the insurance company, due to this policy, will pay the cost of additional services. Usually, patients pay for them themselves at the clinic's cash desk.

Citizens actively using additional services in regular polyclinics were considered as the target audience of the program. Such people got the opportunity to pay in advance with a discount for specific medical services or assistance of specialists at home, and not in the clinic.

In the scope of the “OMS +” policy, such services should have become cheaper for the end user than paid locally.

The project does not imply the intrusive distribution of health insurance services to individual organizations. The price of the packages depends not only on the number of services included in it, but also on the degree of responsibility of the citizen for his health. Responsibility depends on the regularity of medical examinations, medical examinations, general health, etc.

OMC + includes 16 programs. The project participants calculated their tariffs and prices themselves, based on the content and direction. With the help of this program, the Ministry of Health is trying to replenish the financial support of healthcare.

Insufficient funds to ensure not only the quality of medical care, but also to improve the level of service.

Patients who want to improve the quality of service often pay extra to doctors and staff without any guarantees. The innovation is an attempt to bring shadow payments to the official level.

The first pilot programs launched in several areas fell short of expectations. This happened for a number of reasons:

1. The economic situation in the country
   The development of the project fell on a period with a more stable economy, and its implementation began at the time of regression in the economy. The expected demand for the innovation did not follow.
2. No understanding of the principles of work
   The creators failed to draw a clear line between the MHI policy and the MHI + package. Citizens did not fully understand the need for additional costs. Some of the services within the package may seem optional to patients.
3. Lack of human and time resources
   There are no staff in medical institutions to provide more medical services. The compulsory medical insurance plus package provides for a long-term doctor's appointment. To fulfill it, it is necessary either to shorten the time of admission under the compulsory medical insurance (which cannot be done), or to hire more specialists, but the project does not involve funding an increase in staff.
4. Inconsistency of some conditions
   OMS + has a limitation on the number of laboratory tests. Help within compulsory insurance- not. It turned out that the paid package contains less services than the free one.
5. Lack of specific information
   Citizens do not want to buy a service that they do not understand.

OMC + or LCA

At first glance, the OMS + package may seem like voluntary health insurance. In fact, this is one of its forms, which differs from the standard VHI policy as follows:

The program is similar to those developed by insurance companies licensed for compulsory and voluntary insurance at the same time.

The Ministry of Health tried to combine the two policies, creating something in between. Such a program turns out to be cheaper than software, but gives a little more opportunities than compulsory insurance.

But, if you make out a VHI policy, you can be sure of the validity of your spending, then there are still many questions around the “plus program”.

Does it work now and in which regions

A trial version of the OMC + program was launched in 5 regions: Tatarstan and Tyumen, Lipetsk, Belgorod, Kirov regions.

Later, private clinics in Moscow and the Moscow region joined the project.

During the first year in all regions participating in the project, only a few hundred policies were sold.

Residents of the Tyumen region can arrange programs for newborns with medical assistance at home. The packages are divided into 3 levels depending on the number of medical services. Insurance companies also offer programs for adults with video receptions.

Pediatrics and dentistry programs for children have been launched in the Lipetsk region.

In Kirovskaya there are programs for newborns.

In Belgorodskaya - for adults and children.

In Tatarstan, 2 programs were introduced: "Heart under control" and "Patient care". The largest number of policies was sold in the republic.

The price of the policy varies from 2,000 rubles to 50,000 rubles.

The network of clinics "Doctor Ryad" in Moscow issues OMC + policies at a cost of 7,000 rubles or more.

Clinics "ABC-Medicine" also use the innovation.

Some insurance companies create almost identical VHI products. For example, a program from VTB Insurance.

On the this moment you can apply for an OMC + policy through the VHI Selection Center. On the site you can calculate approximate price, compare different types programs and get expert advice.

The first unsuccessful experience allowed the Ministry of Health to analyze and continue to improve the "CHI +". Therefore, the final version of the project does not yet exist.

The CHI system in Russia consists of subjects and participants, which are individuals and legal entities, as well as government agencies. Every citizen of the Russian Federation who has received insurance becomes a subject of this system. You should know more about your rights, as well as about interaction with other participants.

There are two types of health insurance in the Russian Federation: voluntary and compulsory. The purpose of the first is to provide citizens of the Russian Federation with an additional list of honey. services. Payment for the procedures is carried out from the fund, which is replenished by the owner of the insurance policy.

The second type of insurance is compulsory. When the insured person needs the help of doctors, he can go to the hospital and use the services of doctors free of charge. Compulsory insurance allows you to contact any clinic throughout the country. You will first need to get a foothold for one of them. This can be done by phone or at the reception.

Features of insurance in the field of medicine

Since insurance in the Russian Federation is a compulsory norm, you should learn more about what compulsory medical insurance is.

Under the law of the Russian Federation are required to insure

• citizens of the Russian Federation;
• foreigners permanently or temporarily living in the country;
• persons who do not yet have citizenship;
• refugees from other countries.

Payment for services provided to insurance holders is carried out from the state budget.

The sources of its formation are:

• employers' contributions for officially employed workers;
• fixed payments for self-employed and individual entrepreneurs;
• receipts from local budgets of the constituent entities of the Russian Federation.

With insurance, you can:

• get an ambulance;
• take part in treatment and prevention activities;
• contact narrowly specialized specialists;
• use the services provided by the insurance company.

Subjects participating in the insurance process

The legislation of the Russian Federation defines 3 subjects of insurance. Policyholders are legal entities authorized to issue policies. These are representatives of insurance companies. In some cases, the state itself acts as this subject.

Insured persons - citizens of the Russian Federation and other persons who have received insurance. This document equips them with the right to receive a range of services from public hospitals free of charge.

The federal fund regulates the relationship between the two previous subjects. FFOMS protects the rights of both insurers and policyholders.

In addition to the subjects, other participants are included in the CHI system. The funds of the constituent entities of the Russian Federation make contributions to the budget, from which the services provided to the owners of the policies are paid.

Also involved are medical insurance organizations and hospitals. The former are licensed issuing agencies VHI policies and. The second - provide honey. services are free.

Subjects and participants constantly interact with each other. The relationship between them is governed by Russian legislation.

Article 41 of the Constitution of the Russian Federation: what is it about

The article talks about the right of citizens of the state and other policyholders to receive medical care from hospital institutions on a free basis. Payment for services provided by doctors is made from the state. the country's budget.

Also, the Constitution contains information about the development of the system. In Russia, funding is being provided for programs aimed at creating new public and private foundations.

Article 41 states that the government undertakes to encourage the activities of organizations that will function to improve the health of the whole society as a whole and of every person who applies.

According to one hundred. 41 persons who deliberately conceal the fact of a threat to the health or life of Russian citizens will be obliged to be punished for this action. This is also supported by federal state laws.

Types of compulsory medical insurance

The policy of compulsory medical insurance of Russia can be presented in three types:

• paper containing a barcode;
• plastic, in the form of a card with a chip;
• electronic, with an individual number.

Medical insurance system

Subjects and participants interact with each other, creating a system. In the process of functioning of the structure, the issues of the formation of funds are resolved, from which payments are made in the future. Also, in the process of interaction, the distribution of finances occurs.

The bulk of medical care for the population of Russia is paid from the state budget. The Federal Compulsory Medical Insurance Fund deals with the regulation of cash flows.

Rights of persons who have received insurance

The insured has a number of rights provided for by the legislation of the Russian Federation:

• receive medical assistance throughout the state or within the entity where the policy was issued, on a free basis;
• choose an insurer by sending a statement to the company in accordance with the rules of state legislation;
• replace the insurance company no more than 1 time in 365 (366) days, if the term of the contract with the insurer has expired or you changed your place of residence (the choice should be made before November 1);
• choose a medical institution from those that will be offered to the insured by the agent;
• choose the attending physician by indicating him in the application addressed to the head of the hospital (independently or through an official representative);
• receive from the regional fund and honey. institutions truthful information about the quality and conditions of the procedures carried out by doctors;
• require doctors to protect personal data;
• receive from insurance and medical organizations compensation for damage in case of non-performance or improper performance of their services;
• demand protection of the rights and interests provided for by the legislation of the Russian Federation.

Responsibility of medical institutions

Hospitals and clinics are required to provide free medical care. services to insured persons. At the same time, the procedures performed by doctors should be of proper quality, and the prescribed medications should relieve the symptoms of the disease.

Honey. institutions are accountable to the Federal Foundation by submitting reports to it in the proper form.

Also, hospitals are required to:

• keep records of services rendered;
• provide insurers with information about the honey provided to their clients. help;
• post on the official website and other resources reliable information about the working hours, types of services, as well as inform the Federal Fund and patients about this;
• use medicines and consumables that were provided by the state;
• inform patients about the availability of paid services, if any, but not force them to purchase.

In case of violation by honey. institutions, the patient has the right to demand an examination. Within its framework, specialists carry out independent assessment the work of one or more doctors, as well as the entire hospital as a whole (if necessary).

Monitoring the provision of medical care

The main problem of compulsory medical insurance in Russia is the provision of medical services. institutions of inadequate quality. To determine the fact of violation based on the results of the procedure, independent expertise ILC in order to assess:

• the actions of the doctor and the treatment prescribed by him or the functioning of the hospital as a whole;
• compliance of the doctor with the level of his qualifications;
• the quality and safety of the care provided from one of four points of view (in an emergency, on the part of the patient, with and without deviation from technology);
• observance by the doctor of standards, procedures, requirements of legal acts in the provision of honey. help.

If, according to the results of the examination, a violation is revealed on the part of a doctor, several doctors or a medical institution as a whole, then an opinion will be issued to the insured person. On its basis, the policyholder will be able to draw up and file a claim in court for damages.

Scheme of work

To find out how honey works. insurance in Russia, you should consider the scheme of the functioning of the system.

For 2019-2020, its main link is the distribution of budget funds between the subjects:

• compulsory health insurance is not intended for payments to the population in cash or non-cash forms;
• payment of honey. services are made directly to the account of the treated institution;
• there is no payment for working days in which the policyholder was incapacitated;
• an important point is making contributions individually for each insured person;
• contributions to the budget are made by both the state and the employer;
• employees are not sources of budget financing.

Regional programs

The prospect for the development of compulsory medical insurance in Russia lies in the development by the subjects of their own insurance programs. According to them, the insured will be able to receive honey. assistance only in the territory where he received the policy. The services received will be paid directly from the fund of the subject.

Top 10 policy issuing companies

The development of compulsory medical insurance in Russia allows you to choose an insurer. You should pay attention to the rating, which is annually compiled by the FFOMS and uploaded on its official website. The table shows the top 10 insurance companies for 2019.

OMS contract

In addition to the basic data (who signed it, from what year and by what date it is valid, etc.), the contract specifies the obligations of both parties. The insurance company undertakes:

• provide the owner of the compulsory medical insurance policy with information about the rights and obligations of the insured;
• inform the policyholder in writing within 3 working days about the occurrence of the fact of insurance and the receipt of the policy;
• issue a compulsory medical insurance policy in accordance with the federal legislation of Russia.

The policyholder is obliged:

• make payments to the fund in a timely manner (the amount and timing of contributions are stipulated by law);
• turning to honey. an organization for help, to submit a compulsory medical insurance policy (except for cases when the appeal is urgent);
• personally or through an official representative, following the established rules, submit an application confirming the choice of an insurance company;
• send the insurer information about changing the passport or moving within a month from the date the changes come into force;
• when changing permanent residence within a month, select a new insurer.

The compulsory medical insurance system for citizens of Russia and other persons with insurance provides for the provision of services by medical institutions on a free basis. It consists of three main entities: the insurer, the insured and the FFOMS. The latter acts as a regulator of the relationship between the first two.