State health insurance of citizens

State health insurance of citizens is a mandatory procedure. Due to this, free medical care is provided. The insurers are territorial or federal authorities.

Citizens are persons who have, and the insurer is a municipal or village budget. What is included in the free service if you have a compulsory medical insurance policy?

Professional assistance from medical workers can be obtained free of charge. Moreover, the planned examinations are carried out in the territory where the person is insured, that is, in order to receive the services of specialists, it is necessary to purchase a policy. Insurance calculations are based on contractual obligations. The policy is issued directly in organizations, enterprises or funds located in different areas.

For each locality, a register of medical services is approved. Any hospital or clinic has this list, agreed upon with municipal or regional authorities.

The modern program includes the following areas of assistance:

• first medical;
• specialized;
• ambulance;
• used in the treatment of pain in incurable pathologies.

These directions are defined by regulatory documents.

About types of assistance

Types of first aid and which specialists provide it:

1. Nurses provide health care support to the patient.
2. Paramedics or obstetrician-gynecologists provide pre-medical care.
3. Medical care is provided by local doctors, including therapists and pediatricians.

First aid is provided by medical staff in a clinic, directly at the patient’s home or in a day hospital.

The specialist's responsibilities include:

• reception of a citizen;
• prescribing procedures to clarify the diagnosis;
• determining the name of the disease;
• prescription of complex therapy;
• control over recovery.

Moreover, the purchase of medicines is not included in the list of free services.

Specialized medical care is provided when the patient is under observation in a day hospital.

This includes IVs, injections, massage, physiotherapy and surgery that does not require hospitalization.

Ambulance services are divided into:

1. Specialized and urgent. That is, the deterioration of a citizen’s well-being does not threaten his life as a whole.
2. Emergency urgent or emergency. The citizen's condition is dangerous to his life.

In the presence of acute diseases, hospitalization is prescribed, namely in case of:

• vascular hemorrhages;
• heart attack conditions;
• in case of poisoning;
• injuries;
• infectious pathologies.

According to the order of the Ministry of Health, in the next two years there will be a complete medical examination of all Russian citizens. As a result of this examination, each person will be assigned a specific health group.

If any chronic disease is detected, you will be required to undergo a medical examination as many times a year as necessary based on the diagnosis.

If a person misses this examination, he will receive a message about this in the form of an SMS message. According to the introduced rules, insurance companies will have to process requests and complaints from citizens and provide assistance in the event of controversial situations.

If a patient has doubts about the quality of medical services provided to him, insurance workers will have to order an examination.

Amendments will be introduced to the Labor Code that will legislate an additional annual leave day. This day will be provided to workers over 40 years of age to undergo a medical examination while maintaining their average earnings.

The policy can be issued in paper form, as before, or in the form of an electronic card, with which you will not need to present your passport at medical institutions. The temporary policy will be valid for 45 days.

Modern assistance programs provide for:

1. Providing free medicines to patients with chronic pathologies.
2. Surveys of workers employed in hazardous or difficult conditions, as well as whose activities are related to food.
3. Ensuring monitoring of the condition of young children, including those under guardianship or orphans.
4. Conducting examinations of pregnant women on the eve of childbirth.
5. Examinations of newly born babies for hereditary pathologies.

Maternity services

The policy provides women with the right to free qualified medical care while expecting a baby. The document provides for the possibility of choosing a clinic and a doctor for the expectant mother while she is expecting her baby.

When presenting the policy to the clinic, a woman has the right to a whole range of procedures and examinations, which include:

1. Treatments are therapeutic or preventive.
2. Visiting a visiting nurse at home.
3. Study of biomaterial in specialized laboratories.
4. Hospitalization, if necessary.
5. Diagnosis of pathologies of the unborn child.
6. Preparing for...
7. Rules and recommendations for breastfeeding.
8. Consultations with specialists of other profiles.
9. Choosing a gynecologist with the consent of the specialist himself.
10. Preventive, therapeutic and diagnostic measures in special organizations that have the right to engage in these activities.
11. Pain relief if surgery is necessary.
12. Ensuring the protection of health information.
13. Right to refuse assistance.
14. Presence of relatives or friends at the birth.

If a premature baby was born, then according to a free program, such children are nursed and operated on for organ transplantation.

Benefits in dentistry

Dentist services are quite expensive, so many people are confused about what kind of help they are entitled to receive without paying. To do this, you must have health insurance.

In each territory there is an individual Program according to which dental services are provided, and throughout Russia only provision of emergency care is provided.

Specialized dental care covers:

1. Treatment in regional clinics.
2. Treatment of children in children's clinics.

Moreover, each institution must approve a list of services, and the patient must be informed:

1. About the types of services.
2. About the working hours of specialists.
3. About telephone numbers and locations of insurers.
4. About the benefits provided.

Many private medical institutions also provide services without payment, and you can learn about this from the operators.

The following types of services are provided for children:

• restoration of tooth enamel not affected by caries;
• silver treatment and remineralization of teeth;
• orthodontic appointments and services.

Free service

Free adult service includes:

• doctor's appointment, specialist consultation and examination of the oral cavity;
• treatment of the pathology of periodontal disease and gingivitis, caries and pulpitis;
• elimination of exacerbation;
• building up hard tooth tissues with damaged roots;
• surgical interventions;
• cleaning teeth from stones;
• straightening the jawbone;
• removal of decayed teeth;
• radiography;
• treatment of salivary glands;
• physiotherapy;
• local and general anesthesia.

Medicines can be issued free of charge if they are on the list of free medicines approved at the regional level. Typically, these are domestically produced products.

Complaints about specialists

If controversial issues arise and conflict situations are brewing, you can file a complaint against the doctor.

The Constitution of the Russian Federation guarantees all citizens free medical care under the compulsory health insurance policy (CHI). Types of free assistance provided under the compulsory medical insurance policy:

• primary health care(outpatient clinic);
• emergency,
• specialized medical care(if a diagnosis is established, treatment of a specific disease is carried out)
• high-tech medical care(treatment of diseases using high-tech, complex, costly treatment methods).

The presence of a compulsory medical insurance policy confirms that the patient’s treatment in public and some private clinics will be paid for from the compulsory health insurance fund, which is formed from mandatory contributions from citizens.

Briefly about the compulsory medical insurance system

Payment for treatment in the compulsory medical insurance system occurs at specially formed tariffs for each disease, but does not depend on the method of treating this disease. Tariffs are the same for all medical institutions. The compulsory medical insurance tariff specifies how many and what procedures, tests and studies the clinic can and should perform in the treatment of a particular disease.

Tariffs are the same for all clinics, which means that the patient can choose a more high-tech and well-equipped clinic, regardless of the cost of treatment. The insurance company will handle settlements with the clinic.

Some expensive procedures within the compulsory medical insurance system can only be performed if strictly necessary, which the clinic must prove, otherwise they simply will not be paid for by the compulsory medical insurance fund. Therefore, treatment of patients in the compulsory medical insurance system, unfortunately, has its limitations.

Medical institutions are forced to work according to the rules established by the Compulsory Medical Insurance Fund for each disease. It is important to say that the provision of high-tech medical care (HTMC) to patients, the so-called “quota” treatment, is also paid for from the compulsory medical insurance fund and, accordingly, is carried out according to the algorithms prescribed above.

But the tariffs of the VMP system are higher and are designed specifically to provide complex, high-tech treatment, which allows the clinic staff to use all the power of modern treatment methods, advanced technologies and high-quality consumables.

Not all hospitals in Russia have the right to provide high-tech medical care. Every year, the Ministry of Health of the Russian Federation creates a list of clinics that can treat patients with VMP. Selected clinics receive a so-called assignment from the Ministry of Health, which determines the number of patients that the hospital can treat under VMP.

In medical centers of federal significance, only high-tech and specialized medical care is provided under the compulsory medical insurance policy. The Clinic of Coloproctology and Minimally Invasive Surgery is part of the First Moscow State Medical University named after. Sechenov, accordingly, the same requirements apply to her.

How to get medical care under the compulsory medical insurance policy?

Option 1. By referral from the clinic

The compulsory medical insurance policy itself is required. If it is not there, and you are a citizen of the Russian Federation, you need to contact an insurance company that works with the territorial compulsory medical insurance fund, write an application and immediately receive a temporary policy, and after about a month, a permanent compulsory medical insurance policy. After receiving the compulsory medical insurance policy, you need to be assigned to a clinic, which you can choose yourself. After this, you can qualify for high-tech medical care under the compulsory medical insurance policy.

Referral from the clinic to which the patient is attached (at his place of residence or at his choice). Such a referral to a city hospital or federal center is issued to a patient if the clinic doctors cannot independently diagnose the patient or provide treatment. A referral from the clinic allows the federal medical institution, which is the First Moscow State Medical University named after. Sechenov and our Clinic, provide the patient with primary, specialized and high-tech care.

At the clinic you can receive both a referral for a free consultation in our Clinic and a referral for free treatment.

Option 2. Referred by doctors from our Clinic.

In some cases, doctors at the Clinic of Coloproctology and Minimally Invasive Surgery can also issue referrals for treatment. The number of referrals is limited and applies to certain types of diseases or complications.

You can find out about the possibility of free treatment under the compulsory medical insurance policy during a face-to-face consultation with a doctor. In this case, you will bypass the stage of agreeing and receiving a referral at the clinic. Please note that referrals for compulsory medical insurance treatment, which are issued directly at our Clinic, have a limited number.

To make a referral under the compulsory medical insurance policy through a doctor at the KKMH Clinic, you will need:

1. compulsory medical insurance policy
2. independent visit to the clinic only for treatment (not carrying out a set of diagnostic measures) with an already established diagnosis

According to the adopted legislation, almost every person registered and living on the territory of the Russian Federation has the right assigned to him to apply to any medical institution to receive appropriate treatment if such a need arises. However, there is one important nuance - services of this kind, as well as the right to receive medications free of charge, that is, free of charge, are provided only if the citizen has a document such as a compulsory health insurance policy.

Who can receive free medical services?

Any citizen who owns the following has the right to use the services of medical institutions:

• Employed citizens. That is, the category of persons who regularly pay taxes to the state budget. That is, in essence, he pays for his treatment in advance.
• Unemployed citizens. In this case, payment of funds for the treatment of these persons also occurs at the expense of the federal budget.
• Children, teenagers, and who have not reached the age of eighteen and are not taxpayers.

If a person is officially employed, he has the right to register, as well as . If he is not employed, works unofficially, or has not reached the age of majority, you can apply for the specified document to any company that provides insurance services.

In the event that a citizen needs to see a specialist who is receiving treatment outside the locality where the specified individual lives, a referral from the attending physician is also required.

There is a certain list of medical services, the provision of which is free of charge. These include the following:

1. Emergency assistance, that is, the departure of an ambulance when a patient is called. This service is provided free of charge not only to persons who have, but also to those who do not have this document. In the recent past, there were unreliable rumors that if a person does not have a compulsory health insurance policy, he will have to pay about one and a half to two thousand rubles for calling emergency help. This is wrong. This service is provided absolutely free of charge in any case.
2. Ambulatory treatment in a medical institution that is part of the insurance system and includes a number of different manipulations: examination and diagnosis of the patient’s disease, performing the necessary procedures and prescribing adequate treatment. However, when a patient is under so-called outpatient, daytime or home treatment, all necessary medications must be purchased by him at his own expense, since there are no benefits in this case.
3. Working with the public to raise awareness of sanitary and hygienic issues. That is, holding various lectures, seminars and so on.
4. Diagnosis and treatment of the population using expensive innovative drugs and methods. For example, in some regions of the Russian Federation, in vitro fertilization is carried out free of charge.
5. Diagnosis of the disease followed by hospitalization.
6. in dental clinics and offices that have state status.

Free services under compulsory medical insurance policy

For example, while undergoing treatment in a state hospital, a citizen has the right to receive free services for the treatment of diseases of the following kind: support of pregnancy during its complicated course, as well as in the presence of pathologies of any kind, medical abortion, the presence of chronic diseases, or in case of exacerbation of the disease, poisoning , causing bodily harm and so on. In this case, the provision of medications necessary for adequate treatment is free of charge.

The diseases that, according to the list, are treated free of charge include the following:

1. Diseases of an infectious nature, with the exception of those categories classified as sexually transmitted infections.
2. Various diseases of the blood, vascular system, heart.
3. Diseases of the stomach, as well as the gastrointestinal tract in general.
4. Any disease caused by a nervous disorder.
5. Diseases of joints, bones, muscles and so on.
6. All kinds of defects in vision, hearing, speech.
7. Tumors of both benign and malignant nature.
8. Diseases of tissues and skin.
9. Diseases of the genitourinary area.
10. Diseases of the respiratory system.

What to do if treatment is denied if you have a policy?

Currently, not every citizen is fully aware of the rights that are granted to him in accordance with this law, which is often taken advantage of by unscrupulous workers in this field of activity, demanding payment of a certain fee for the provision of the necessary assistance.

What to do if your rights are violated

Every citizen of the Russian Federation who has insurance has the right to seek help from any medical institution located on the territory of the state. The specified institution is obliged to admit him and carry out appropriate diagnosis, treatment, as well as other manipulations that are necessary. However, it often happens that doctors, as well as hospital staff, refuse to admit the patient in such cases. This is not legal and violates human rights. It is important to produce.

To restore the violated right, a person who has been denied medical services must file a complaint with the medical service, whose employees will take appropriate measures. If such a case is detected, administrative penalties may be applied to medical service workers.

What can you expect with a compulsory medical insurance policy?

In order to know which services the compulsory health insurance policy gives you, you need to carefully read the list of services provided to the population free of charge.

It should be remembered that, in essence, these services are not at all free due to the fact that a certain amount intended specifically for this purpose is deducted from the salary of each employed citizen every month. Consequently, in this way, each individual pays in advance for his treatment in a state-type institution. In our other articles you can familiarize yourself with and .

The holder of a compulsory health insurance policy (CHI) can count on undergoing all necessary examinations within the framework of the current insurance program. According to Law No. 323-FZ of November 21, 2011 “On the fundamentals of protecting the health of citizens in the Russian Federation,” each insured person has the right to receive medical care in a guaranteed volume on a free basis in accordance with the terms of the insurance contract. Are all compulsory medical insurance tests free and what is included in this list?

Who pays for free tests?

Medical care under the compulsory medical insurance policy is free only for its owner. As for hospitals and clinics providing outpatient and inpatient treatment to insured persons, each of these medical institutions is required to pay the following costs:

• maintenance of special equipment and troubleshooting;
• remuneration of medical workers;
• purchase of necessary reagents, instruments and drugs.

All of the above insurance costs are covered by the Federal Compulsory Health Insurance Fund (MHIF).

Rules for receiving free tests

Receiving a particular medical service under a compulsory medical insurance policy must be justified. When there is a need to conduct any examinations, you need to proceed as follows:

• visit the clinic along with your compulsory medical insurance policy;
• contact a specialist of the required profile;
• receive a referral for free tests.

The patient cannot independently decide what tests need to be done - this is determined by the doctor. All activities prescribed by a specialist are done free of charge in the same clinic. If the clinic is unable to conduct some research, the patient is sent to another medical facility.

On a note! When undergoing a course of treatment in a hospital setting under the compulsory medical insurance program, the patient has the right to receive all medical services free of charge.

How to get tested in another region

The scope of medical services under a compulsory insurance contract has some territorial restrictions. Outside of their region, the insured receives medical care under the terms of the basic program, which is valid throughout the country. Within the borders of its region, it is served under a program approved by the territorial compulsory health insurance fund (TFOMS), which covers a wider range of services.

Rules for receiving medical care under compulsory medical insurance in another region:

• when leaving, you should have the policy with you - it’s better to take a photo of it and save the photo on your phone so that you can present it to the medical workers at least in this form;
• when they refuse to conduct a particular study free of charge, explaining that this is not provided for in the basic program, you need to look at Art. 35 Federal Law No. 326-FZ dated November 29, 2010 “On compulsory health insurance in the Russian Federation” (hereinafter referred to as Federal Law No. 326). If the basic program does not provide for this type of examination, then the refusal is legal;
• when a government agency refuses to provide service, call the regional TFOMS. The phone number can be found on the website of the Federal Compulsory Medical Insurance Fund. It is illegal;
• when health workers claim that they work only with specific insurers, this is also unlawful, since the policy is valid throughout the country.

Good to know! Tests are a preventive measure, which means an insured event. This is regulated by Art. 3 Federal Law No. 326. In accordance with the law, free studies to clarify the diagnosis must be carried out throughout the Russian Federation.

If an incomprehensible situation arises, call your insurance company - they will tell you what to do. The phone number is on the back of the policy.

What tests can be taken under compulsory medical insurance for free?

The problem is that there is no complete and exhaustive list of free studies on compulsory medical insurance. Sometimes specialists themselves do not know whether a particular study is covered by the insurance program. This is due to the fact that diagnosing various diseases sometimes requires an individual approach. To make a specific diagnosis, there is no need to rack your brains over this issue - just look at the standards of medical care.

Remark: standards of medical care are the selection of minimal effective measures for the diagnosis and treatment of a particular disease.

In order to find out whether some type of research is provided for by the compulsory medical insurance program, you must:

1. Look at Article 35 of Federal Law No. 326. For example, if it is necessary to diagnose or observe a disease of the eye and its adnexal apparatus (for example, astigmatism), this is included in the compulsory medical insurance program.
2. Next, we look for the standard of medical care for this disease on the website of the Ministry of Health of the Russian Federation. We select the subsection “Diseases of the eye and its adnexal apparatus” and look for the Order of the Ministry of Health “On approval of the standard of primary health care for astigmatism.” We open it and look for the desired position in the nomenclature list.

An approximate list of standard tests for compulsory medical insurance 2020:

You can see the full list of compulsory medical insurance tests in 2020.

According to eco

Approximately one-seventh of married couples in the Russian Federation cannot conceive a child through natural fertilization. This is often due to the peculiarities of the physiological structure of the reproductive organs or the banal incompatibility of partners. Fortunately, the state offers to solve this problem by providing a quota for IVF, which includes representatives of both sexes who suffer from infertility.

In order to become parents through in vitro fertilization under the compulsory medical insurance program, you must undergo a medical examination.

List of required tests for IVF according to compulsory medical insurance 2020:

• General and biochemical blood test and urinalysis;
• fluorographic examination;
• blood sampling to determine the Rh factor and group;
• hysteroscopy and pipel biopsy;
• taking smears for the composition of microflora from the vagina and urethra;
• hemostasiogram;
• blood test for homocysteine;
• hormonal panel: study of hormone levels: prolactin, TSH, T4, in case of menstrual dysfunction - FSH, cortisol (important to exclude stress factors), estradiol, metanephrine and normetanephrine.
• blood sampling to detect TORCH infections (syphilis, HIV, hepatitis, herpes);
• PCR of vaginal discharge for herpes virus and cytomegalovirus;
• microbiological analysis for chlamydia, mycoplasma, ureaplasma is also included in the compulsory medical insurance policy for IVF;
• cytology of smears from the cervix and cervical canal;
• detection of antibodies to the rubella virus;
• Ultrasound of the pelvic organs and thyroid gland;
• Ultrasound of the mammary glands - up to 35 years, mammography - after 35 years;

Research for men:

• blood test for TORCH infection;
• spermogram;
• PCR of urethral discharge for herpes virus and cytomegalovirus;
• the compulsory medical insurance policy also includes culture or PCR for chlamydia, ureaplasmosis, mycoplasmosis;
• taking smears for flora from the urethra;
• blood sampling for Rh factor and group.

The shelf life of the results of the above studies is from 3 months to one year. If there were unsuccessful IVF attempts or interrupted pregnancies before the procedure, partners are recommended to undergo a blood karyotype test.

Everything is discussed in detail in separate articles on our website.

During pregnancy

Expectant mothers also have the right to undergo tests under the compulsory medical insurance policy. To do this, you need to register with the antenatal clinic and regularly visit your obstetrician-gynecologist.

The list of standard studies includes:

• clinical blood and urine tests;
• blood chemistry;
• tests for allergens (in the presence of skin and mucous reactions)
• studies to identify infectious diseases;
• detection of antibodies to viral infections - measles and rubella;
• blood sampling for Rh factor and group;
• blood sampling for TORCH infection;
• hormonal panel: hCG, estrogen, progesterone, prolactin.

If the doctor sees the need to conduct some additional studies, they are carried out on a paid basis only when the clinics providing services under the compulsory medical insurance program do not have the appropriate equipment, instruments or reagents.

Refund Policy

It happens that the insured person undergoes a series of tests on his own initiative, so as not to waste time visiting the clinic. Accordingly, payment for the research carried out is made from his own pocket. In such a situation, it is extremely difficult to justify the need to provide medical services free of charge. There is still a chance to get your money back, but to do this you need to do the following:

• keep all receipts for payment for medical services provided on a paid basis;
• bring them to the insurance company and find out whether this study falls under the compulsory medical insurance program;
• If the tests taken are included in the list of free tests, you need to write an application for a refund and indicate in it the details of your bank account for a refund.

The above algorithm will only take effect when the patient has a referral from a doctor for paid tests. Otherwise, it is almost impossible to return the spent funds, because the state cannot pay for all studies conducted without direction, and only on the basis of the insured person’s own initiative.

Important! In order to prove that you are right, you first need to know your rights. If a doctor or insurer insists that the required analysis is not included in the compulsory medical insurance program, this can be checked on the website of the territorial Compulsory Medical Insurance Fund or refer to regulations. Some unscrupulous health workers deliberately refer patients for paid tests, and then receive their share for this.

Conclusion

Summarizing the above, the following conclusion suggests itself: almost all tests that are prescribed by a doctor can be carried out free of charge, because there is simply no exhaustive list. The specialist acts in accordance with generally accepted norms and standards - if a certain study needs to be carried out to confirm the diagnosis and this is supported by legislation, then this does not contradict the terms of the compulsory insurance program.

The patient, in turn, must: know his rights as an insured person, be able to find information of interest in the legislative framework and on websites, have a policy with him and resolve all controversial issues with the insurer.

You can learn more about the system and your rights from our next article.

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