The ability of citizens to receive medical care free of charge depends on the content of the basic and territorial compulsory health insurance system. They contain a list of specific types of assistance, services and procedures that insured persons can count on. In this article we will look at what differences exist between these compulsory medical insurance programs, what are the features of the territorial program, as well as by whom and why it is being developed.

The difference between the territorial program and the basic one

The basic compulsory medical insurance package contains a detailed list of diseases and ailments that are classified as insured events, a classification of types and standards for the volume of assistance provided, the principle of calculating the tariff, payment methods, etc. It operates throughout the Russian Federation. This means that if, for example, a resident of Moscow felt unwell during his trip to Novosibirsk and went to the local clinic, then medical care will be provided to him exactly in accordance with the basic plan.

The territorial program, in turn, applies only to a specific region and provides the opportunity to use the services included in it only to residents of this region. The document contains the following points:

• List of insured events and the procedure for providing medical care (it will necessarily include the entire list from the basic program, but may contain additional provisions);
• Financial calculations of the cost of services provided in proportion to one insured person;
• Indicators of accessibility and quality of medical care provided in the region.

Thus, the main difference between these health insurance systems is based on territoriality and the list of types of medical services. Nevertheless, the territorial part of the compulsory medical insurance must comply with the general principles and conditions of the basic system and contain all the rights guaranteed to citizens.

The basic purpose of regional programs is the formation of an expanded list of areas of medical assistance available to residents of a specific constituent entity of the Russian Federation, as well as tariff indicators and the procedure for its provision. Therefore, the content of regional medical care lists may vary significantly depending on different regions.

What functions does it perform?

The main purpose of the territorial program is the development of the healthcare system in a particular region, taking into account its specifics and characteristics. The thing is that the Russian Federation is a very large state with different standards of living, climate, nature, and the number of medical workers in each region. Therefore, for the full functioning of the healthcare sector, insurance services must be adapted to the characteristics of the constituent entity of the Russian Federation. For example, a certain disease may be virtually unknown in most of the state, and therefore not included in the general policy. However, in one specific region, disease epidemics are constant, and as a result, the corresponding insured event will be included in the territorial program.

The same applies to the financing of health insurance - the gender and age composition of insured persons, the number of medical institutions and the tariffs for services provided differ in different regions. Moreover, if for an identical (compared to the basic program) insured event the financial support is greatly overestimated, then the document should detail the list of areas for which additional funds are planned to be allocated.

The procedure for developing and approving the territorial compulsory medical insurance program

Reimbursement to medical institutions for the cost of medical care provided is carried out according to the rules and tariffs regulated in the territorial part of the compulsory medical insurance program. Financing is provided from the budget funds of the Territorial Compulsory Medical Insurance Fund, which is formed in the following ways:

• Through contributions paid by employers for employees;
• At the expense of contributions paid by a constituent entity of the Russian Federation for non-working persons;
• Due to subsidies from the federal and regional budgets aimed at equalizing the conditions for financing TFOMS of various constituent entities of the Russian Federation.

The design development of the territorial part of the compulsory medical insurance program is carried out independently in each constituent entity of the Russian Federation by creating a special commission. It must include:

• Officials of regional authorities;
• Representatives of TFOMS;
• Officials of medical institutions;
• Insurance companies.

The preparation of the regional program is carried out on the basis of information from the annual monitoring of the volume and quality of medical care, which is carried out by the authorities of the constituent entities of the Russian Federation to ensure the protection of public health. The authority to approve the territorial compulsory medical insurance program falls within the competence of the regional executive bodies, and its changes are allowed in cases where it is necessary to amend one or more criteria.

The territorial compulsory medical insurance program operates within one region of the Russian Federation, and in its preparation all provisions included in the federal state guarantee program are observed.

We will tell you how territorial compulsory health insurance programs are formed, how this is regulated and what features need to be taken into account when drawing them up.

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The main thing in the article

Territorial program

The territorial compulsory medical insurance program is formed by each region of the Russian Federation based on the procedure that is determined by this region independently and enshrined in the relevant law.

Regional state guarantee programs must be published on the Internet within 14 days from the date of signing.

Funds within the framework of the territorial program

The territorial compulsory health insurance program, which determines the standards and cost of providing medical care, is provided for by the current compulsory medical insurance system.

In accordance with this system, medical institutions receive funds spent on medical care from insurance companies. At the same time, the territorial program specifies the criteria that medical care must meet and which must be observed.

The basis for interaction with the insurance company is an agreement for payment and provision of medical services. The standard form of such an agreement was approved by order of the Ministry of Health of the Russian Federation No. 1355n dated December 24, 2012.

The volume of medical care that guides medical institutions is approved for the year. These volumes are broken down quarterly and may be subsequently adjusted.

If the approved procedure is followed, can the training of health workers be paid for at the expense of the Compulsory Medical Insurance Fund? What is the procedure and what needs to be done - we will tell you in the video note.

Types of financing

The program is based on the principle of per capita financing of medical care. When insurance companies pay for medical care already provided, they take into account how many insured persons are attached to each medical institution.

In addition, it takes into account how much money was spent on various types of medical services, based on the lists of expenses that are included in the territorial compulsory medical insurance program.

How to make calculations of financial support is described in detail in the methodological recommendations - letter of the Ministry of Health of the Russian Federation No. 11-8/10/2-8266 and FFOMS No. 12578/26/i dated December 22, 2016.

The rules approved by order of the Ministry of Health and Social Development of the Russian Federation No. 158n dated 00.28.2011 describe what indicators are taken into account by insurance companies when determining the amount of provision for outpatient medical institutions:

1. The number of people who are attached to a medical institution.
2. Indicators of tariffs that are applied when paying for medical care.



Information for territorial compulsory medical insurance funds

Medical institutions must comply with the territorial program. Organizations must also send the following information to insurance companies:

• data on the number of insured patients who chose a medical institution to receive outpatient medical services;
• list of patients assigned to an outpatient medical facility. This is necessary for the further conclusion of an agreement on the provision of payment for medical care in the compulsory medical insurance system. In addition, these lists are subsequently changed based on reconciliation reports.

Also, these data are provided to the territorial fund within the time limits established by the commission for the formation of the territorial program. This is stated in more detail in the letter of the Ministry of Health of the Russian Federation No. 11-9/10/2-5718 dated December 25, 2012.

In order to receive the necessary funds, the medical institution must submit an application for an advance payment to the insurance company every month, before the 10th, indicating the amount of the advance and the period for which it is provided.

The form of such an application is approved by the Methodological Recommendations of the Federal Compulsory Medical Insurance Fund letter No. 9161/30-1/i dated December 30, 2011.

The amount of the advance is limited - no more than 50% of the amount of funds that are provided monthly to medical institutions as payment for medical care provided.

There are two exceptions to this rule:

1. You can increase the advance by 20% from the initial one in the 2nd and 3rd quarter.
2. You can increase the advance to 95% of the monthly amount of funds in December.

The program provides for sending the following documents to the insurance company to pay for medical care:

• bills for medical care;
• registers of accounts in the approved form.

If these documents are not provided, or are provided but do not correspond to reality, various sanctions will be applied to the medical institution. Therefore, without this documentation, medical care cannot be paid for.

Invoices and invoice registers

As mentioned above, registers of accounts and invoices for payment are the most important documents that allow medical institutions to receive funds as payment for medical care provided.

They indicate the total volume of medical services provided by type, as well as approved tariffs for these units.

The provided registers of accounts are the main reason for inspections of medical insurance organizations in relation to medical institutions.

Control is carried out by insurance organizations in accordance with the Federal Law “On Compulsory Medical Insurance”. If errors are identified in these documents during control, financial sanctions may be applied to the medical institution.

So, if any services should not have been paid for by the medical institution, or were provided in excess of the norm, the amount for their provision will be deducted from the total amount of funds.

The amount of sanctions is calculated according to uniform methods and formulas approved by the Ministry of Health and Social Development and the Federal Compulsory Medical Insurance Fund.

However, the compulsory medical insurance program allows medical institutions to also finalize rejected bills and resubmit them to the insurance organization. A period of 25 working days is given for this from the date of receipt of the certificate from the medical institution.

If the actual volume of medical care turns out to be more than indicated in the invoices, next month the advance payment for the medical institution from the insurance company will be reduced by the amount of the excess.

There are exceptions to this situation:

• high level of patient morbidity;
• increase in tariffs for medical care;
• change in the number of insured persons;
• changes in the gender, age and structural composition of insured persons.

The territorial compulsory medical insurance program allows medical institutions to spend funds received from insurance organizations only on those items that are directly related to the process of providing medical care. This follows from numerous explanations from the Federal Compulsory Medical Insurance Fund and the federal state guarantee program.

Are all consumables included in territorial programs?

Does the territorial compulsory health insurance program include all the consumables that are specified in the basic part of the program? For example, composite for fillings - will it be included in the regional program?

The current state guarantee program, approved for the period until 2019, determines the list of medical services that patients can receive free of charge.

The program is compiled taking into account current medical standards and procedures; morbidity and mortality rates are also taken into account, as well as characteristics of the gender and age of patients, etc.

The basic program includes:

1. Volumes of medical care calculated per patient.
2. Expenses for the provision of one medical service.
3. Standards for medical coverage per insured person.
4. Criteria for the quality and availability of medical care at the expense of compulsory medical insurance funds.
5. Requirements that regional programs must meet.

Based on this, the basic part of the compulsory medical insurance program does not contain restrictions on the use of consumables that are used in the provision of various medical services free of charge to patients.

A compulsory health insurance policy provides access to free healthcare services. But does everyone know what opportunities the compulsory medical insurance policy provides, what is included in the free service, what types of examinations and operations can be performed?

Legislative acts regulating the compulsory medical insurance system

Free healthcare services are provided as part of compulsory health insurance. The compulsory medical insurance system guarantees citizens equal rights to receive medical services. It is regulated by a number of legal acts:

• Law No. 326-FZ “On Compulsory Health Insurance in the Russian Federation”;
• Government Decree No. 1403 “On the program of state guarantees of free medical care to citizens for 2017 and for the planning period of 2018 and 2019,” which contains the basic compulsory medical insurance program. This document, in particular, explains what is included in compulsory medical insurance in 2017;
• a number of other acts allowing citizens to receive a minimum guaranteed volume of services.

Who is entitled to free health care?

Both Russians (for an indefinite period) and persons without Russian citizenship (with a limited validity period) can receive a compulsory medical insurance policy. The presence of this document means that the patient is under the protection of the insurance company with which he has entered into an agreement.

Medical care is provided by the health care organization (both public and private institutions participate in the compulsory medical insurance system) to which the patient is attached. At the same time, he has the right to change the clinic and attending physician once a year and an unlimited number of times when moving to another place of residence. Once a year, you are allowed to change your insurer; this must be done no later than November 1.

List of services under the compulsory medical insurance policy

What types of medical care are available under the policy, are high-tech diagnostic methods included in it, is MRI included in the list of free services under compulsory medical insurance?
The legislation provides for the following forms of medical care:

• emergency (ambulance);
• outpatient, including examinations (the basic list includes MRI, ultrasound and endoscopic methods (gastroscopy, colonoscopy, etc.);
• stationary:

- in cases of exacerbation of diseases;
— referral for treatment and operations (available services include chemotherapy, removal of prostate adenoma, treatment of gynecological diseases, etc.);
— medical services for pregnant women, as well as childbirth, recovery after it, abortions;
- when intensive care is required (in case of poisoning, severe injuries);

• high-tech;
• palliative.

The last point regarding serious illnesses was added in 2017. In total, the basic list includes about 20 cases for which free medical care is available.

Is it allowed to carry out therapeutic massage, remove papillomas, warts - are such procedures provided by the compulsory medical insurance policy, which is included in the program? Having indications for the procedure will allow you to take a massage course free of charge. As for skin defects, the operation will be performed free of charge if the growth is bleeding or damaged, that is, there is a danger to the life and health of the patient.

Within the framework of the compulsory medical insurance system, there are basic and territorial programs: the first is applied throughout the country, the rest - within a specific subject of the Russian Federation. The list of services under regional programs is wider. Some of them provide free tests for chlamydia and spermogram, some allergy tests (such types of examinations, for example, are carried out under the compulsory medical insurance policy in Moscow, the Moscow region and St. Petersburg).

From time to time, the media report on public initiatives to add or remove this or that service from the list. Thus, proposals to exclude abortion from the compulsory medical insurance system and include the work of a nutritionist in it were previously discussed, but they were not reflected in legislative acts.

Dental services under compulsory medical insurance policy

Is free dentistry available under the compulsory medical insurance policy? This question interests many, since dental services, as you know, are not cheap. So, what opportunities does dentistry provide under the compulsory medical insurance policy, and what is included in the free service?
A visitor to a clinic participating in the compulsory medical insurance system can count on:

• for reception, examination and consultation;
• for the prevention and treatment of inflammation of the oral cavity;
• for dental fillings;
• for surgical intervention (tooth extraction, opening of an abscess, etc.);
• for an x-ray examination.

Please remember that dental services are also subject to restrictions. For example, filling will not require payment if cement material is used during the treatment. But they won’t install a light seal for free.

Certain services are possible with a referral, for example, the surgeon will perform trimming of the tongue frenulum upon presentation of a certificate from the orthodontist.

How to find out if a service is included in the compulsory medical insurance program?

Information on services provided free of charge is contained in the regulatory documents adopted in a particular subject. A detailed list is also provided by healthcare institutions and insurance companies operating in the compulsory medical insurance system.
There is no list of compulsory medical insurance services on the official healthcare website in 2018, but from the Ministry of Health resource you can go to the Compulsory Medical Insurance website, where all the regulations relating to the compulsory health insurance system are posted.

1. The territorial program of compulsory health insurance is an integral part of the territorial program of state guarantees of free medical care to citizens, approved in the manner established by the legislation of the constituent entity of the Russian Federation. The territorial compulsory health insurance program is formed in accordance with the requirements established by the basic compulsory health insurance program.

2. The territorial compulsory health insurance program includes the types and conditions of medical care (including a list of types of high-tech medical care, which includes treatment methods), a list of insured events established by the basic compulsory health insurance program, and determines taking into account the morbidity structure in the constituent entity of the Russian Federation, the values ​​of standards for the volume of medical care provided per one insured person, standards for financial costs per unit of volume of medical care per one insured person and standards for financial support of the territorial compulsory health insurance program per one insured person. The values ​​of the standards of financial costs per unit of volume of medical care per insured person specified in this part are also established according to the list of types of high-tech medical care, which also contains treatment methods.

3. The standard for financial support of the territorial compulsory health insurance program may exceed the standard for financial support of the basic compulsory health insurance program established by the basic compulsory health insurance program in the event of establishing an additional volume of insurance coverage for insured events established by the basic compulsory medical insurance program, as well as in the case of establishing a list insurance cases, types and conditions of medical care in addition to those established by the basic compulsory health insurance program.

4. Financial support for the territorial compulsory health insurance program in the cases specified in part 3 of this article is carried out through payments from constituent entities of the Russian Federation paid to the budget of the territorial fund, in the amount of the difference between the financial support standard for the territorial compulsory health insurance program and the financial support standard for the basic compulsory health insurance programs taking into account the number of insured persons on the territory of a constituent entity of the Russian Federation.

5. If an additional volume of insurance coverage is established for insured events established by the basic compulsory health insurance program, the territorial compulsory health insurance program must provide a list of areas for using compulsory health insurance funds.

6. The territorial compulsory medical insurance program, as part of the implementation of the basic compulsory medical insurance program, determines on the territory of a constituent entity of the Russian Federation methods of payment for medical care provided to insured persons under compulsory medical insurance, the structure of the tariff for payment of medical care, contains a register of medical organizations participating in the implementation of the territorial compulsory health insurance programs, determines the conditions for the provision of medical care in them, as well as target values ​​for the criteria for the availability and quality of medical care.

7. The territorial compulsory health insurance program may include a list of insurance cases, types and conditions for the provision of medical care in addition to those established by the basic compulsory health insurance program, subject to the requirements established by the basic compulsory health insurance program.

8. When the territorial compulsory health insurance program establishes a list of insured events, types and conditions for the provision of medical care, in addition to those established by the basic compulsory health insurance program, the territorial compulsory health insurance program must also include the values ​​of the standards for the volume of medical care provided per one insured person , standards of financial costs per unit of volume of provision of medical care per one insured person, the value of the standard of financial support per one insured person, methods of payment for medical care provided under compulsory health insurance to insured persons, tariff structure for payment of medical care, register of medical organizations participating in the implementation of the territorial compulsory health insurance program, conditions for the provision of medical care in such medical organizations.

9. To develop a draft territorial compulsory health insurance program in a constituent entity of the Russian Federation, a commission is created to develop a territorial compulsory medical insurance program, which includes representatives of the executive body of the constituent entity of the Russian Federation, authorized by the highest executive body of state power of the constituent entity of the Russian Federation, the territorial fund, insurance medical organizations and medical organizations, representatives of medical professional non-profit organizations or their associations (unions) and trade unions of medical workers or their associations (associations) operating in the territory of a constituent entity of the Russian Federation, on a parity basis. The commission for the development of a territorial compulsory health insurance program is formed and carries out its activities in accordance with the regulations, which are an annex to the rules of compulsory health insurance.

(see text in the previous edition)

10. The volumes of medical care established by the territorial compulsory health insurance program are distributed by decision of the commission specified in part 9 of this article between medical insurance organizations and between medical organizations based on the number, gender and age of insured persons, the number of insured persons attached to medical organizations providing outpatient care, as well as the medical care needs of insured persons. The volumes of medical care provided by the territorial compulsory health insurance program of the constituent entity of the Russian Federation, in which the insured persons were issued a compulsory medical insurance policy, include the volumes of medical care provided to these insured persons outside the territory of this constituent entity of the Russian Federation.

Updated 01/13/2020

The types of quality and conditions for the provision of medical care are determined by the Territorial program of state guarantees of free provision of medical care to citizens in the city of Moscow for 2020 and for the planning period of 2021 and 2022

Territorial compulsory medical program

Moscow city insurance

(Extract from Moscow Government Decree No. 1822-PP dated December 24, 2019)

4.1. The development of the compulsory health insurance system in the city of Moscow is carried out by the Moscow City Compulsory Health Insurance Fund as part of the implementation of the legislation of the Russian Federation on compulsory health insurance, which provides for the implementation of a set of measures aimed at increasing the socio-economic efficiency of the compulsory health insurance system, ensuring the targeted and rational use of compulsory health insurance funds. medical insurance, modernization, development and ensuring the uninterrupted functioning of the compulsory health insurance information system through the use of modern information technologies, hardware, software and telecommunications by ensuring personalized recording of information about the medical care provided and the protection of personal data.

4.2. In order to create organizational measures aimed at ensuring, in the event of an insured event, guarantees of free provision of medical care to citizens at the expense of compulsory health insurance, including the timeliness of the provision of said medical care, in the city of Moscow:

4.2.1. Acceptance of relevant applications on paper and the issuance of compulsory medical insurance policies based on such applications, in addition to medical insurance organizations operating in the field of compulsory medical insurance in the city of Moscow, is also carried out by the State Budgetary Institution of the city of Moscow "Multifunctional centers for the provision of public services of the city of Moscow" on the basis relevant agreement between the specified
institution and the Moscow City Compulsory Medical Insurance Fund and taking into account the agreements concluded by this institution with medical insurance organizations operating in the field of compulsory medical insurance in the city of Moscow.

4.2.2. Submission of relevant applications in electronic form is possible using the “personal account” subsystem of the state information system “Portal of state and municipal services (functions) of the city
Moscow" or through the personal account of a person insured under compulsory health insurance on the official website of the Moscow City Compulsory Health Insurance Fund with the subsequent issuance of compulsory health insurance policies upon such applications by the State Budgetary Institution of the City of Moscow "Multifunctional Centers
provision of public services of the city of Moscow" on the basis of the agreement specified in clause 4.2.1 of the Territorial Program, or by an insurance medical organization, depending on the place of receipt of the compulsory health insurance policy, chosen by the person insured under compulsory health insurance when submitting the corresponding application.

4.3. The territorial compulsory health insurance program, as an integral part of the territorial program, creates a unified mechanism for citizens from among those insured under compulsory health insurance (hereinafter also referred to as compulsory health insurance insured persons) to exercise their rights to receive free medical care at the expense of compulsory health insurance funds.

4.4. The goal of implementing the Territorial Compulsory Medical Insurance Program is to provide, within the framework of the basic compulsory medical insurance program, free medical care of guaranteed volume and appropriate quality to insured persons under compulsory medical insurance in medical organizations included in the Register of medical organizations operating in the field of compulsory medical insurance.

4.5. Within the framework of the Territorial Compulsory Medical Insurance Program, insured persons under Compulsory Medical Insurance:

4.5.1. Provided in medical organizations participating in the implementation of the Territorial Compulsory Medical Insurance Program, primary health care, including preventive care, ambulance, including specialized ambulance, medical care and medical evacuation (with the exception of sanitary aviation evacuation), specialized, including high-tech medical care , the types of which are included in Section I of Appendix 12 to the Territorial Program, for diseases and conditions specified in Section 3 of the Territorial Program (with the exception of sexually transmitted diseases caused by the human immunodeficiency virus, acquired immunodeficiency syndrome, tuberculosis, mental disorders and behavioral disorders) .

4.5.2. Preventive measures are carried out, including clinical examination, clinical observation for diseases and conditions specified in section 3 of the Territorial Program (with the exception of sexually transmitted diseases caused by the human immunodeficiency virus, acquired immunodeficiency syndrome, tuberculosis, mental disorders and behavioral disorders), and preventive medical examinations of certain categories of citizens specified in section 3 of the Territorial Program, as well as measures for medical rehabilitation carried out in medical organizations on an outpatient and inpatient basis and in a day hospital, measures for carrying out renal replacement therapy, measures for the use of assisted reproductive technologies (including including in vitro fertilization), including the provision of medications in accordance with the legislation of the Russian Federation.

4.5.3. Preventive medical examinations (examinations) of minors are carried out in order to obtain permission to engage in physical education and sports, including recreational activities, issued in the form of certificates of the absence (presence) of medical contraindications for such activities.

4.5.4. The registration and issuance of certificates confirming the absence (presence) of medical contraindications for physical education, including recreational activities, is carried out for certain categories of citizens specified in Section 3 of the Territorial Program, based on the results of medical examinations and preventive medical examinations.

4.5.5. Audiological screening is carried out for newborns and children in the first year of life.

4.6. Within the framework of the Territorial Compulsory Medical Insurance program, infertility treatment is provided for medical reasons using assisted reproductive technologies, including in vitro fertilization, as well as renal replacement therapy:

4.6.1. Persons insured under compulsory health insurance in the city of Moscow, in accordance with the directions of the relevant patient selection commissions created by the Moscow Department of Health, within the scope of medical care established by the Commission for the development of the territorial program of compulsory health insurance of the city of Moscow.

4.6.2. Persons insured under compulsory health insurance in other constituent entities of the Russian Federation, in accordance with the directions of the relevant commissions created by executive authorities in the field of healthcare of the constituent entities of the Russian Federation, or appeals (petitions) of executive authorities or territorial funds of compulsory medical insurance of the constituent entities of the Russian Federation with subsequent settlements between The Moscow City Compulsory Medical Insurance Fund and the territorial compulsory medical insurance funds of the constituent entities of the Russian Federation, in which compulsory medical insurance policies were issued to the specified persons.

4.7. Within the framework of the Territorial Compulsory Medical Insurance Program, persons insured under compulsory health insurance in the city of Moscow:

4.7.1. High-tech medical care is provided for malignant neoplasms in addition to the basic compulsory health insurance program (Appendix 13 to the Territorial Program) in the medical organizations specified in Section 1 of Appendix 14 to the Territorial Program.

4.7.2. Prenatal (antenatal) diagnosis of child development disorders not established by the basic compulsory health insurance program is carried out for pregnant women in medical organizations specified in section 2 of Appendix 14 to the Territorial Program, according to the list of such diagnostic services approved by the Tariff Agreement for payment of medical care provided under Territorial compulsory medical insurance program.

4.7.3. Treatment of oncological diseases that predominate in the structure of morbidity in the city of Moscow is carried out in a day hospital and inpatient conditions, with the provision of medications provided for by a treatment regimen determined in accordance with the clinical recommendation (medical methodology) for the treatment of oncological disease.

4.7.4. With the involvement of medical organizations of the state health care system of the city of Moscow, providing primary health care, clinical examination of persons staying in inpatient social service organizations is carried out within the framework of the basic compulsory health insurance program, and in the presence of chronic diseases, dispensary observation of these persons is carried out.

4.7.5. Hospitalization of persons located in inpatient social service organizations is carried out in medical organizations of the state health care system of the city of Moscow, providing specialized medical care in inpatient conditions, in order to provide specialized, including high-tech, medical care if such persons are identified as part of a medical examination. or when carrying out dispensary observation of diseases and conditions that are indications for the provision of specialized, including high-tech, medical care in a hospital setting.