General tariff agreement for the provision of medical care. Tariff agreement for compulsory medical insurance
1.1. The subject of the agreement is the positions agreed upon by the parties on payment for medical care provided to citizens in the Moscow region within the framework of the current Moscow Regional Compulsory Health Insurance Program (hereinafter referred to as the Compulsory Medical Insurance Program).
1.2. Tariff regulation of payment for medical care in the compulsory medical insurance system of the Moscow region is carried out in accordance with current legislation, this agreement, the Regulations on tariff regulation of payment for medical care in the system of compulsory health insurance for citizens in the Moscow region, regulations of government authorities of the Moscow region, regulatory documents of the Fund, decisions Moscow Regional Conciliation Commission for determining tariffs for payment for medical care and municipal interdepartmental commissions for tariff regulation of payment for medical care in the compulsory medical insurance system.
1.3. Payment for medical care provided to citizens in the Moscow region under the Compulsory Medical Insurance Program by treatment and preventive institutions (HCI) is made by an insurance medical organization (IMO) on the basis of an agreement for the provision of treatment and preventive care (medical services) under compulsory health insurance at uniform rates within the limits of funds , transferred to medical insurance organizations by the Fund to finance the Compulsory Medical Insurance Program within the framework of the municipal order.
The municipal order is approved annually by the Ministry of Health of the Moscow Region, the Ministry of Compulsory Medical Insurance, and the executive authorities of municipalities.
Tariffs for payment for medical care provided in health care facilities of federal and departmental subordination, financed through an authorized medical insurance organization, are established in accordance with an agreement concluded between the Ministry of Health of the Moscow Region, the Fund and the relevant department.
1.4. Tariff for medical care - part of the cost of a unit of medical care reimbursed by health care facilities from compulsory health insurance funds. According to tariffs, compensation is made for the costs of medical institutions (departments) operating in the compulsory medical insurance system for the provision of medical care to citizens in the Moscow region for the following types of expenses (budget classification codes<*>):
1.4.1. "Payment of civil servants" - code 110100 (in accordance with the Decree of the Government of the Russian Federation "On differentiation in the levels of remuneration of public sector employees based on the Unified Tariff Schedule" dated 10.14.92 N 785, order of the Ministry of Health of the Russian Federation dated 10.15.99 N 377 " On approval of the Regulations on remuneration of healthcare workers" with subsequent amendments and additions, decrees, orders of the Government of the Russian Federation regulating the issues of remuneration of workers of healthcare institutions, including departmental subordination, laws and regulatory legal acts of the Moscow region). Exceeding the amount of remuneration for employees of healthcare institutions, which goes beyond the scope of the specified federal regulations and adopted by resolutions and orders of the Government of the Moscow Region, is subject to compensation from compulsory medical insurance funds, subject to the necessary amendments to the law of the Moscow Region on the regional budget in terms of increasing the cost item for the payment of contributions on compulsory medical insurance for the non-working population, as well as in the law of the Moscow region on the budget of the Moscow Regional Compulsory Health Insurance Fund in terms of increasing the income item (insurance premiums for compulsory medical insurance for the non-working population). Any other wage payments established by municipal administrations are not subject to payment from compulsory medical insurance funds.
Costs of establishing increased tariff rates, allowances, additional payments, raises and other payments established for employees of health care facilities of departmental subordination in accordance with regulatory legal acts and administrative documents of ministries and departments that go beyond the scope of resolutions, orders of the Government of the Russian Federation in the field of remuneration, compensation at the expense of funds are not subject to compulsory medical insurance.
1.4.2. “Accruals for wages (insurance contributions for state social insurance of citizens)” - code 110200.
1.4.3. "Medicines, dressings and other medical expenses" - code 110310 in part:
- costs of healthcare institutions (departments) operating in the compulsory medical insurance system of the Moscow region for the independent purchase of medicines (in accordance with the current List of vital and essential medicines and the formulary for the treatment of basic nosologies in inpatient conditions, approved in the prescribed manner), dressings and other medical expenses, with the exception of:
expenses for the purchase of implantable artificial organs and prostheses;
canned blood and blood substitutes, medicines for scientific work;
expenses for paying for blood donation to donors, including food;
expenses for the purchase of consumables for dental prosthetics in accordance with the legislation of the Russian Federation;
expenses for payment of the cost of medications dispensed free of charge during outpatient treatment in accordance with the established procedure.
1.4.4. “Soft equipment and uniforms” - code 110320 (excluding expenses for the purchase of special (protective) clothing and footwear, in the manner prescribed by the legislation of the Russian Federation).
1.4.5. "Food" - code 110330.
1.4.6. In the absence of debt under Articles 110100, 110200 ("Payment of civil servants", "Accruals for wages") and the level of costs has been reached<**>: for hospitals of groups 1, 2, 4 for medicines - no less than 18%, food - no less than 10%, soft equipment - no less than 1.4% of the amount of actual expenses of health care facilities for hospitals of groups 1, 2, 4, for hospitals 3 groups - for medicines - no less than 9%, food - no less than 10%, soft equipment - no less than 1% of the amount of actual expenses of health care facilities for a group 3 hospital - compulsory medical insurance funds are allowed to be spent on the following items:
- “Payment of utility services” - code 110700 (except for “Payment of rent and land” - code 110750, “Payment of benefits for utility services” - code 110760, “Other utilities” - code 110770);
- “Payment for current repairs of equipment and inventory” - code 111020;
- “Payment for current repairs of buildings and structures” - code 111030;
- “Payment for fuels and lubricants” - code 110340;
- “Other consumables and supplies” - code 110350 (in terms of expenses for paying for consumables and supplies, expenses for paying for materials, items for current business purposes, expenses for purchasing spare parts for vehicles, computer and organizational equipment, medical equipment, instruments, devices, devices, communications, purchase of furniture, inventory, etc., equipment and devices, including the costs of their installation and adjustment, costs of delivery and storage of low-value items, materials and spare parts, costs of stitching and binding of documents);
- "Transport services" - code 110500;
- “Payment for communication services” - code 110600;
- “Acquisition and modernization of non-production equipment and durable items for state and municipal institutions” - code 240120 - in terms of costs for the acquisition of medical equipment, computer and special equipment and in agreement with the municipal interdepartmental Commission on tariff regulation of payment for medical care in the compulsory medical insurance system Moscow region.
<*>The economic classification of budget expenditures of the Russian Federation is given in accordance with Appendix 7 to the Federal Law "On the Budget Classification of the Russian Federation" dated 08/15/1996 N 115-FZ and Order of the Ministry of Finance of the Russian Federation dated 05/25/99 N 38N "On approval of instructions on the procedure for applying the budget classification of the Russian Federation" Federation" subject to subsequent changes and additions. If changes and additions are made (during the current year) to Order No. 38N of the Ministry of Finance of the Russian Federation, the version adopted at the beginning of the year applies.
<**>In the first quarter 2003 - based on the results of the 2002 annual report, in the II quarter. 2003 - based on the results of the report for the first quarter. 2003, in the third quarter. 2003 - based on the results of the report for the first half of 2003, etc.
1.5. Financial resources allocated in accordance with Decree of the Government of the Moscow Region dated 03/05/2001 N 50/7 for the centralized purchase and supply of medicines and medical products are not taken into account as part of the tariffs for payment for medical care of healthcare institutions and are not included in the compulsory medical insurance funds, transferred to medical insurance organizations based on per capita financing standards.
1.6. The Fund informs the heads of municipal administrations no later than 5 days before the start of the next month:
- the size of the approved municipal differentiated per capita funding standard;
- the cost of the agreed volumes of medical care under the compulsory medical insurance program provided in municipalities (in points and rubles);
- the value of the main component of the full monetary equivalent of one point, according to which the Fund provides financing.
1.7. Funds from the unified social tax, the unified tax levied in connection with the application of the simplified taxation system, the unified tax on imputed income for certain types of activities, the unified agricultural tax, received by the Fund from the Federal Treasury Department for the Moscow Region, fines, penalties, subventions of the Federal Compulsory Medical Insurance Fund to equalize the conditions for the provision of medical care within the framework of territorial compulsory medical insurance programs, funds received from the regional budget as insurance premiums for compulsory medical insurance for the non-working population, and other revenues are transferred by the Fund to medical insurance organizations within the time limits specified in the contract on compulsory medical insurance financing.
Other revenues transferred to the Fund and included as an additional component of the full monetary equivalent of one point are not subject to consolidation and redistribution and are used to cover the costs of health care facilities of a given municipality.
1.8. Settlements between health care facilities and health care organizations are made within the framework of existing contracts for the provision of treatment and preventive care (medical services) under compulsory medical insurance in accordance with approved payment methods based on a scale of uniform tariffs for inpatient, hospital-replacement and outpatient medical care (in points, Appendix No. 1 -6 to this agreement) and the full monetary equivalent of one point, approved monthly by municipal interdepartmental commissions for tariff regulation of payment for medical care in the compulsory medical insurance system.
1.9. Payment for medical care provided by medical and preventive institutions is carried out by health care organizations in accordance with existing contracts for the provision of medical and preventive care (medical services) under compulsory health insurance within the terms and conditions stipulated by these contracts.
1.10. The CMO monitors the volume and quality of medical care provided to the insured in accordance with the current legislative and regulatory acts of the Russian Federation and the Moscow region, as well as the regulatory and administrative acts of the Fund.
1.11. If MOFOMS identifies facts of inappropriate use of compulsory medical insurance funds by health care facilities, the amounts of funds not spent for the intended purpose are withheld during the next financing of the health care facility by the insurance medical organization.
Tariff agreement in the compulsory health insurance system of the Kemerovo region for 2018
1. GENERAL PROVISIONS
1.1. Department of Public Health of the Kemerovo Region (hereinafter - DOZN), Territorial Compulsory Medical Insurance Fund of the Kemerovo Region (hereinafter - TFOMS), Insurance Medical Organizations (hereinafter - IMO), Kemerovo Regional Association of Doctors and Regional Organization of the Trade Union of Health Workers, hereinafter collectively referred to as the Parties, entered into a Tariff Agreement for the implementation of the Territorial Compulsory Health Insurance Program (hereinafter referred to as TPOMS).
1.2. Tariff regulation of payment for medical care in the compulsory medical insurance system is carried out in accordance with the legislation of the Russian Federation, regulatory documents of the Federal Compulsory Medical Insurance Fund, the Ministry of Health of the Russian Federation, legal acts of the Kemerovo region and this Tariff Agreement.
2. METHODS OF PAYMENT FOR MEDICAL CARE USED IN THE KEMEROVSK REGION
The list of medical organizations operating in the field of compulsory medical insurance, according to the conditions for the provision of medical care and methods of payment, is established in Appendix 1 to this Tariff Agreement.
Payment for medical care provided to insured persons in the Kemerovo region is made at the tariffs established by this Tariff Agreement, within the scope and cost of medical care established by the decision of the Commission for the Development of TPOMS (hereinafter referred to as the Commission). The volume limitation does not apply to medical care, payment for which is carried out according to a capitation standard, when carrying out mutual settlements between medical organizations - per unit of volume. The tariffs established by this Tariff Agreement are applied for inter-territorial settlements.
The distribution of planned indicators for the volume and cost of medical care between medical organizations and between medical insurance organizations is carried out within the framework of the volume and cost of medical care approved by the TPOMS, by decision of the Commission. Monitoring the compliance of the actual volumes of medical care with the planned volumes for the entire medical organization (taking into account data for all health care organizations) is carried out as part of a centralized calculation of the cost of medical care in accordance with established methods of payment for medical care.
Interaction between participants of compulsory health insurance is carried out in accordance with contracts in the field of compulsory health insurance, the Regulations for information interaction when maintaining personalized records of medical care provided to insured persons in the field of compulsory medical insurance and this Tariff Agreement.
Payment for medical care in outpatient settings
2.1. Payment for medical care provided on an outpatient basis is carried out:
- according to the per capita financing standard for attached insured persons, taking into account the performance indicators of the medical organization, including the inclusion of costs for medical care provided in other medical organizations (per unit of volume);
- per unit of volume of medical care - per medical service, per visit, per treatment (completed case), per conventional unit of labor intensity (UCU) (used when paying for medical care provided to insured persons outside the constituent entity of the Russian Federation, on the territory of which the compulsory medical insurance policy was issued, in certain medical organizations that do not have assigned persons, and when providing external services to unassigned insured persons).
2.2. The capitation standard provides for payment for the clinic’s own activities, external consultations and examinations provided on an outpatient basis to insured attached citizens, including the services of the admission and diagnostic department of hospitals without subsequent hospitalization. Payment for visits and services provided to insured citizens outside the attachment clinic is carried out according to approved tariffs. Visits and services provided to citizens not affiliated with any medical organization, including those insured outside the Kemerovo region, are paid according to tariffs. The visit rate includes the cost of visiting a specialist and the costs of auxiliary treatment and diagnostic units for conducting the necessary diagnostic studies and treatment procedures (except for CT, MRI and MSCT).
Payment and mutual settlements for MRI and MSCT performed are carried out subject to the availability of an electronic referral generated in the “Hospitalization Management” subsystem (the paragraph comes into effect after the implementation of changes in the format of information interaction adopted by the Compulsory Medical Insurance Order No. 54 dated March 23, 2018). In the absence of an electronic referral, mutual settlements for MRI and MSCT services provided are not carried out in the system of centralized calculation of the cost of medical care; payment for services is made within the framework of contractual relations between medical organizations.
Per capita financing is used in terms of payment for primary health care, including primary pre-hospital, primary medical and primary specialized, in emergency and planned forms, provided on an outpatient basis, by medical organizations with an assigned population (visits, appeals, services), for except as specified in clause 2.3.
2.3. When calculating the per capita standard, funds for payment are not taken into account:
- dental care;
- medical services in health centers;
- visits, medical services to the skin and venereal disease clinic;
- emergency visits;
- individual medical services (in accordance with Appendix 10 to the Tariff Agreement);
- completed cases of clinical examination and preventive medical examinations of certain categories of citizens;
- medical care provided to insured citizens of the Kemerovo region outside the region;
- early detection of cancer.
2.4. Medical organizations are financed according to differentiated per capita standards established for groups formed on the basis of an integrated differentiation coefficient.
2.5. Payment for medical care for types not included in the capitation standard (clause 2.3 of the Tariff Agreement) is made per unit of volume of medical care at the rates established by this Tariff Agreement within the planned cost.
2.6. To account for outpatient dental care, the classifier of basic medical services for the provision of primary health care specialized dental care, expressed in UET (Appendix 2 to the Tariff Agreement), is used. Payment for dental care is made per conventional unit of labor intensity (CUT) within the agreed cost.
Payment for medical care in inpatient settings
2.7. Payment for medical care in inpatient conditions is carried out:
- at the approved rates for a completed case of treatment of a disease included in the corresponding group of diseases (including clinical and statistical groups in accordance with the Instructions for grouping cases or VMP groups);
2.8. The cost of a completed treatment case based on clinical and statistical groups is determined taking into account the following parameters:
- base rate of financing of inpatient medical care;
- correction factors:
a) management coefficient;
b) coefficient of the level of provision of inpatient medical care;
c) coefficient of complexity of patient treatment.
2.9. Taking into account the uneven consumption of medical care throughout the year, a risk corridor for hospitalization cases is established - 103% - an acceptable deviation from the plan for the current month.
2.10. Payment for cases of medical care in the reception, reception and diagnostic department without subsequent hospitalization in a specialized department is carried out through mutual settlements for the service. CT, MRI, MSCT are paid additionally. Services provided to citizens not affiliated with any medical organization, including those insured outside the Kemerovo region, are paid according to tariffs.
2.11. Payment for dialysis procedures is carried out for the service and is paid in addition to payment for the DRG within the framework of one treatment case. If the treatment is lifelong, the treatment case is submitted for payment once a month, taking into account the number of dialysis services. If the patient is hospitalized for the main disease and dialysis is carried out in 2 different medical organizations, payment is made according to the DRG of the main disease for the medical organization in which the patient is hospitalized, and additionally for the services provided for the medical organization in which dialysis is carried out.
2.12. Payment for high-tech assistance is carried out within the established annual volumes and costs. When a medical organization fills out registers, the sign of VMP is indicated. Attribution of a case to VMP is carried out if the ICD-10 codes, patient model, type of treatment and method of treatment correspond to similar parameters established by TPOMS.
Payment for medical care in a day hospital
2.13. Payment for medical care in a day hospital is carried out:
- at the approved rates for a completed case of treatment of a disease included in the corresponding group of diseases (including clinical and statistical groups in accordance with the Instructions for grouping cases);
- for an interrupted case of medical care.
2.14. The cost of a completed case of treatment in a day hospital is determined on the basis of clinical and statistical groups, taking into account the following parameters:
- the basic rate of financing of medical care in a day hospital;
- coefficient of relative cost intensity of CSG;
- management coefficient.
2.15. Taking into account the uneven consumption of medical care throughout the year, a risk corridor for hospitalization cases is established - 103% - an acceptable deviation from the plan for the current month.
2.16. Payment for dialysis procedures is carried out for the service and is paid in addition to payment for the DRG within the framework of one treatment case. A treatment case is submitted for payment once a month, indicating the number of dialysis procedures. If the patient is hospitalized for the main disease and dialysis is carried out in 2 different medical organizations, payment is made according to the DRG of the main disease for the medical organization in which the patient is hospitalized, and additionally for the services provided for the medical organization in which dialysis is carried out.
2.17. In the event that several surgical interventions are performed on one day in the Central Archive, Central Aging, or a hospital on one day, the surgical intervention related to the DRG, which has the maximum cost-intensity coefficient, is presented for payment.
In the case of surgical intervention or medical rehabilitation services, the assignment of a treatment case to the DRG is carried out only by the Nomenclature code. Treatment case assignment by ICD-10 code is excluded.
Payment for emergency medical care
2.18. Payment for emergency medical care is carried out according to a per capita standard for the number of insured persons of the population served in combination with payment for calling an ambulance.
2.19. The population served is considered to be insured citizens assigned to primary care in the service area of the SSMP. When providing medical care to an insured person outside the service area, payment for medical care is made per call. The cost of calls provided to the population of a territory that does not belong to the service area of the Emergency Medical Service is deducted from the accrued per capita standard for emergency medical care, which territorially serves these insured persons.
2.20. When calculating the capitation standard, funds for payment for thrombolysis in patients with acute and repeated myocardial infarction, remote ECG and medical care provided to insured citizens of the Kemerovo region outside the region are not taken into account.
2.21. Payment for thrombolysis in patients with acute and repeated myocardial infarction by mobile emergency medical teams is carried out additionally per case (individual medical services) within the agreed volumes.
3. SIZE AND STRUCTURE OF TARIFFS FOR PAYMENT OF MEDICAL CARE
3.1. Tariffs for payment for medical care are formed in accordance with the methods of payment for medical care accepted in TPOMS, taking into account the requirements established by the methodology for calculating tariffs for payment for medical care, approved as part of the compulsory medical insurance rules, within the limits of funds approved in the TFOMS budget for the implementation of TPOMS, and determine level of reimbursement of costs of medical organizations for medical care provided under TPOMS.
3.2. Approved tariffs include expenses:
in a hospital - to the extent that provides a therapeutic and diagnostic process in the treatment of the underlying disease, as well as concomitant, background disease in the acute stage or requiring constant maintenance therapy, including:
- admission department expenses,
- specialized department,
- selected medical services, with the exception of dialysis,
- consultations with specialists, including from other medical organizations,
- consumables used for surgical interventions, including imported suture material,
- mesh implants for hernioplasty (all manufacturers, including titanium),
- metal structures (including imported ones: screws, including dynamic, cannulated, screws, plates, rods, submersible clamps, metal screw implants, porous, including Ti-Ni alloy, tightening staples with a “memory” effect forms", etc.),
- cages from all manufacturers used for stabilizing surgical interventions on the spine, incl. in the treatment of diseases of the spine (spondylodesis),
- plasmapheresis, hemosorption,
- surgical procedures, including those performed using minimally invasive methods, using laser technologies and endoscopic methods, incl. arthroscopic,
- all types of anesthesia, including anesthesia (with drugs included in the list of vital and essential drugs),
- medicines and medical products in accordance with current regulatory documents and the list of vital and essential medicines;
- laboratory tests (including PCR diagnostics), X-ray studies, other therapeutic and diagnostic studies, physiotherapeutic treatment and therapeutic massage, physical therapy, hardware treatment, blockades with medications included in the list of vital and essential drugs, densitometry, etc. ;
in a day hospital - to the extent that provides a therapeutic and diagnostic process in the treatment of the underlying disease and concomitant disease, background in the acute stage or requiring constant maintenance therapy, including: costs of a specialized day hospital, specialist consultations, laboratory, X-ray studies, other therapeutic and diagnostic research, physiotherapeutic treatment and therapeutic massage, physical therapy, hardware treatment, as well as costs for medical manipulations and procedures according to indications, drug therapy, including using parenteral routes of administration, and the provision of medical products, for drugs and medical devices in accordance with current regulatory documents and the list of vital and essential medicines, medical products and consumables used in the provision of medical care;
in an outpatient setting - a visit rate in the amount that provides the diagnostic and treatment process in the treatment of the main and/or concomitant disease, including: costs of operations (manipulations), physiotherapeutic treatment, therapeutic massage, physical therapy, treatment room services, X-ray examinations , ultrasound, endoscopic and other diagnostic studies.
Tariff for a completed case of medical examination, preventive medical examinations - carrying out the entire scope of examinations, studies and other activities provided for by the relevant regulatory documents (with the exception of the costs of an examination by a psychiatrist);
In dentistry (the cost of UET) - to the extent that ensures the diagnostic and treatment process in the treatment of the underlying disease, including: the costs of the relevant office, surgical benefits, all types of anesthesia, including anesthesia, diagnostic and treatment studies, visiography, drug provision for emergency care help; medicines and medical products, fillings and other consumables, incl. imported production necessary for the provision of dental care, etc.;
when providing emergency medical care - to the extent that ensures the provision of ambulance and emergency medical care, drug supply for the provision of ambulance and emergency care.
3.3. To calculate the cost of agreed volumes of medical care for medical organizations, average tariffs and standards are used (Appendix 3).
3.4. The cost of the agreed volumes for medical organizations and medical insurance organizations is balanced with the cost of TPOMS for the current financial year, minus the costs of medical care provided to the insured of the Kemerovo region outside the region, and the costs of administrative and managerial personnel in the compulsory medical insurance system.
Tariffs for medical care provided on an outpatient basis
3.5. The average standard of financial support for primary health care in an outpatient setting per one insured person, determined on the basis of the standards for the volume of medical care and financial costs per unit of volume established by TPOMS, is 4,568.9 rubles.
3.6. The per capita standard for financing primary health care in an outpatient setting per attached insured person is 276.74 rubles. per month, including the base part of 262.90 rubles.
3.6.1. From 04/01/2018, the per capita standard for financing primary health care in an outpatient setting per registered insured person is RUB 269.89. per month, including the base part of 256.40 rubles.
3.6.2. From May 1, 2018, the per capita standard for financing primary health care in outpatient settings per registered insured person is RUB 274.34. per month, including the base part of 260.62 rubles.
3.7. The basic (average) per capita standard is differentiated in the context of groups of medical organizations that have an attached population, based on factors that objectively characterize the differences in the needs of the attached population for medical care and the characteristics of the organization of medical care. For this purpose, the integrated differentiation coefficient of the per capita standard is used (Appendix 4).
3.8. The integrated differentiation coefficient is defined as the product:
- Age-sex coefficient, calculated taking into account the coefficients of medical care consumption by age and sex groups (Appendix 5);
- Differentiation coefficient based on the level of costs for maintaining individual structural units (medical and midwifery stations).
3.9. In order to increase the efficiency of the activities of medical organizations in providing outpatient medical care to the attached population, and to compensate for the risks arising from capitation payment, part of the funds - 10% of the capitation standard (the incentive part of the capitation standard) - is transferred on the basis of a monthly assessment of performance indicators (Appendices 6, 7 ).
3.10. Tariffs for payment for medical care provided on an outpatient basis are established:
- to visit, contact a doctor by specialty, by type of appointment (Appendix 8);
- for medical services, including services of admission, reception and diagnostic departments of hospitals (Appendix 9);
- for certain medical services (Appendix 10);
- for a completed case of clinical examination of orphans and children in difficult life situations staying in inpatient institutions, orphans and children left without parental care, including adopted children, taken into guardianship (trusteeship), into foster care or foster care family, individual groups of the adult population; preventive medical examination (Appendix 11).
3.11. For payments between institutions within the framework of the centralized calculation of the cost of medical care, the tariffs established by the Tariff Agreement are applied. When creating billing registers, all services provided to unassigned patients at approved rates are taken into account. Mutual settlements for medical care provided between medical organizations are taken into account as part of the centralized calculation carried out by the Federal Compulsory Compulsory Medical Insurance Fund. The register of accounts for a medical organization includes all volumes of medical care performed. The consolidated account is reduced by the amount of funds to be transferred to other medical organizations for medical services.
Tariffs for medical care provided in inpatient settings
3.12. The average standard for financial provision of medical care per one insured person, determined on the basis of the standards for the volume of medical care and financial costs per unit of volume established by the Compulsory Medical Insurance TP - 5,887.4 rubles.
3.13. The base rate for an inpatient treatment case is 17,339 rubles, taking into account the differentiation coefficient of 20,460 rubles. The base rate may be revised quarterly, taking into account the actual implementation of the approved volumes and cost of inpatient care.
3.14. The list of clinical and statistical groups of diseases, coefficients of relative cost intensity and management coefficients by group, cost of a case by level, amount of payment for interrupted cases are given in Appendix 12.
3.15. The coefficients for the level of provision of inpatient medical care are set in the amount
|
1st level |
|
|
Level 2 (weighted average) |
|
|
Level 3 (weighted average) |
|
The coefficient of the level of provision of inpatient medical care reflects the difference in the costs of providing medical care, taking into account the severity of the patient’s condition, the presence of complications, and the conduct of in-depth studies at various levels of medical care.
The list of DRGs to which the level coefficient does not apply is given in Appendix 12.
3.16. Patient treatment complexity coefficients:
* valid from 01.09.2018.
The complexity coefficient of patient treatment when performing similar operations on paired organs and combined surgical interventions does not apply to DRG 233 “Severe multiple and combined trauma (polytrauma).”
The value of the complexity coefficient of treating a patient in the presence of several criteria cannot exceed 1.8, with the exception of cases of extremely long hospitalization. In the case of a combination of the fact of an extremely long hospitalization with other criteria, the calculated value of the patient’s treatment complexity coefficient based on the duration of hospitalization is taken into account without limiting the final value.
Treatment complexity coefficients are not applied when paying for high-tech medical care.
3.17. The assignment of a case of treatment to a specific DRG is carried out by the TFOMS in accordance with the methodological recommendations of the FFOMS, with the exception of 2.003 “Complications associated with pregnancy, treatment of multiple organ failure syndrome in pregnant women and postpartum women” and 233 “Severe multiple and combined trauma (polytrauma)”. For these groups, the assignment of a case to a specific group is carried out by the medical organization independently when creating registers.
In accordance with the Instructions for grouping cases, the assignment of a case to a DRG is carried out taking into account the diagnosis code according to ICD-10 and the service code according to the Nomenclature. The list of DRGs that do not provide the opportunity to choose between diagnosis and service criteria is given in Appendix 17.
3.18. Tariffs for payment for cases of treatment using high-tech medical care methods are given in Appendix 18.
3.19. Payment procedure for interrupted treatment cases.
For payment purposes, interrupted cases include cases when a patient is transferred from one structural unit to another within one medical organization, when a patient is transferred to another medical organization, the patient refuses further treatment, unauthorized care, death, as well as cases in which the duration of hospitalization is less than 3 days inclusive. The amount of payment for interrupted cases is established for each group (Appendix 12).
3.19.1. For intrahospital transfers, if this is due to the occurrence of a new disease or condition included in another ICD-10 class, all cases are subject to payment according to the appropriate DRG.
3.19.2. For intrahospital transfers, if the disease is classified in one ICD-10 class, payment is made within the single case with the highest payment amount. In this case, the duration of a treatment case is estimated in total based on the stay in several departments.
3.19.3. The exception is class XV - pregnancy, childbirth and the postpartum period (ICD codes X O00 - O99). Payment for two DRGs: 2 “Complications associated with pregnancy” and 4 “Delivery” or 5 “Caesarean section” is possible:
in case of stay in the pregnancy pathology department for 6 days or more.
in case of stay in the pregnancy pathology department for at least 2 days when providing medical care according to ICD-10 O14.1, O34.2, O36.3, O36.4, O42.2.
3.19.4. Lethal cases lasting more than 3 days are paid at the rate per case of treatment.
3.20. Payment for two DRGs within one treated case is carried out in the following cases of treatment for diseases belonging to the same ICD class during medical rehabilitation after completion of treatment for the disease for which treatment was carried out;
3.21. Payment for cases of justified extra-long hospitalization is carried out using the patient’s treatment complexity coefficient. In this case, the criterion for classifying a case as extra-long is hospitalization for a period of more than 30 days, except for DRGs, which are considered extra-long for a stay of more than 45 days, the list is given in Appendix 16. The value of the complexity coefficient of patient treatment is determined depending on the actual number of bed days spent. The procedure for calculating the coefficient is given in the Algorithm for calculating the cost of medical care (Appendix 26).
3.22. If several surgical interventions are performed in a hospital, all surgical interventions are submitted for payment. Payment is made for one surgical intervention related to the DRG, which has the maximum cost ratio. At the same time, for cases of treatment in which the same type of operations on paired organs and combined surgical interventions is provided, the complexity coefficient of patient treatment is applied. The list of combined surgical interventions and the List of similar operations on paired organs and symmetrical areas of the body are given in Appendices 13, 14.
Tariffs for medical care provided in a day hospital
3.23. The average standard for financial provision of medical care per one insured person, determined on the basis of the standards for the volume of medical care and financial costs per unit of volume established by TPOMS - 1,027.7 rubles.
3.24. The base rate for a case of treatment in a day hospital is 10,746 rubles, taking into account the differentiation coefficient of 12,680 rubles. The base rate may be revised quarterly, taking into account the actual implementation of the approved volumes and cost of medical care provided in a day hospital.
3.24.1. The base rate for a case of treatment in a day hospital from 08/01/2018 is 10,678 rubles, taking into account the differentiation coefficient of 12,600 rubles.
3.25. The list of clinical and statistical groups of diseases, coefficients of relative cost intensity and management coefficients by group, cost of a case, amount of payment for interrupted cases are given in Appendix 19.
3.26. Payment procedure for interrupted treatment cases. For payment purposes, interrupted cases include cases when a patient is transferred from one structural unit to another within one medical organization, when a patient is transferred to another medical organization, the patient is prematurely discharged from a medical organization, the patient refuses further treatment, death, as well as cases in which the duration of hospitalization is less than 3 days inclusive. The amount of payment for interrupted cases is established for each group (Appendix 19), with the exception of DRG 5001 “In Vitro Fertilization”, DRG 5002 “In Vitro Fertilization (confirmed pregnancy).
3.26.1. Payment for two DRGs for diseases belonging to the same ICD class is carried out during medical rehabilitation of the patient after completion of treatment in the same medical organization for the disease for which treatment was provided.
Tariffs for emergency medical care
3.27. The average standard for financial provision of medical care per one insured person, determined on the basis of the standards for the volume of medical care and financial costs per unit of volume established by TPOMS - 777.2 rubles.
3.28. The size of the average regional per capita standard for calculating differentiated per capita standards for financing emergency medical care is 64.20 rubles. per 1 insured person per month.
3.29. When calculating the per capita standard (Appendix 20), the integrated differentiation coefficient is used. The integrated differentiation coefficient takes into account the sex and age coefficient, calculated taking into account the coefficients of medical care consumption by sex and age groups (Appendix 21), and the differentiation coefficient, taking into account the average radius of the service territory.
3.30. The cost of calling an ambulance for mutual settlements by type of team and the cost of individual medical services are given in Appendix 22.
3.31. When creating billing registers, all calls provided to unassigned patients at approved rates are taken into account. Mutual settlements for medical care provided between medical organizations are taken into account as part of the centralized calculation carried out by the Federal Compulsory Compulsory Medical Insurance Fund. The register of accounts for a medical organization includes all volumes of medical care performed. The consolidated account is reduced by the amount of funds to be transferred to other medical organizations for medical services.
Tariff structure
3.32. The structure of tariffs for payment of medical care is established in accordance with the territorial program of compulsory health insurance of the Kemerovo region and includes costs for wages, accruals for wages, other payments, purchase of medicines, consumables, food, soft equipment, medical instruments, reagents and chemicals, other material supplies, expenses for paying for the cost of laboratory and instrumental studies conducted in other institutions (if there is no laboratory and diagnostic equipment in the medical organization), catering (if there is no organized food in the medical organization), expenses for payment for communication services , transport services, utilities, works and services for property maintenance, expenses for rent for the use of property, payment for software and other services, social security for employees of medical organizations established by the legislation of the Russian Federation, other expenses, expenses for the acquisition of fixed assets (equipment , industrial and household equipment) worth up to one hundred thousand rubles per unit.
Detailed information with a list of expenses included in the tariffs is given in Appendix 23.
3.33. The following expenses of medical organizations are not included in the tariff structure and are not subject to payment from compulsory health insurance funds:
- not related to activities under TPOMS, including costs of maintaining property leased and (or) used in commercial activities;
- for major repairs of non-financial assets (including buildings and structures, acquisition of materials for major repairs and payment of labor for workers involved in major repairs, preparation and examination of design estimates, major repairs of equipment, vehicles, etc.) ;
- for the purchase of immunobiological preparations for vaccination of the population in accordance with the National calendar of preventive vaccinations and the calendar of preventive vaccinations for epidemic indications;
- for the purchase of fixed assets worth over 100,000 rubles per unit;
- expenses for higher and/or secondary specialized education, residency training, internship;
- other expenses financed according to the TPGG from budgets of all levels.
3.34. If there are several sources of financing, reimbursement of general hospital expenses solely from compulsory medical insurance funds is not allowed. When assigning expenses to sources of financing, it is necessary to determine appropriate criteria for allocating expenses to sources for expense items and approve them in the accounting policies of the organization.
3.35. The distribution of general hospital costs, costs of auxiliary units by funding sources, as well as by conditions of medical care (outpatient, day hospital, 24-hour hospital and emergency medical care) is carried out in one of the following ways:
- in proportion to the wage fund of key personnel directly involved in the provision of medical care (medical services);
- proportional to the volume of medical services provided;
- in proportion to the share of income in the total income of the medical organization;
- proportional to the other selected classification criterion.
3.36. The share of costs for the current maintenance of medical organizations is taken into account when calculating tariffs based on the average share of costs of this group in the total costs incurred in the compulsory medical insurance system for the previous financial period by type of medical care.
4. AMOUNT OF NON-PAYMENT OR INFULL PAYMENT OF COSTS FOR PROVIDING MEDICAL CARE
4.1. Payment for medical care is made taking into account the results of monitoring the volumes, timing, quality and conditions of providing medical care under compulsory medical insurance, carried out in accordance with the Procedure for organizing and monitoring the volumes, timing, quality and conditions of providing medical care under compulsory medical insurance, approved by order of the Federal Compulsory Medical Insurance Fund. dated 01.12.2010 No. 230.
4.2. For violations identified during monitoring of the volume, timing, quality and conditions of providing medical care under compulsory medical insurance, medical organizations are liable in accordance with Article 40 of Federal Law No. 326-FZ “On Compulsory Medical Insurance in the Russian Federation” with application to them measures provided for in Article 41 of the Federal Law, the terms of contracts for the provision and payment of medical care under compulsory health insurance.
4.3. The basis for partial or complete non-payment of medical care is the results of monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance, carried out in the manner approved by the regulatory documents of the Ministry of Health of Russia, the Federal Compulsory Medical Insurance Fund, DOZN KO and TFOMS KO.
4.4. Tariffs for medical care approved by this Tariff Agreement are used to calculate the amount not subject to payment (payment reduction) based on the results of monitoring the volume, timing and quality of medical care (with the exception of medical and economic control, calculation of the amount not subject to payment based on the results of which carried out according to the estimated cost of the case in the registry). The list of grounds for refusal to pay for medical care (reduction of payment for medical care) and the amount of sanctions applied are given in Appendix 24.
5. FINAL PROVISIONS
5.1. Certain features of calculating and paying for the cost of medical care are established by the Algorithm for calculating the cost of medical care (Appendix 26).
5.2. If a citizen’s affiliation with a health care organization changes during the treatment period, visits are distributed among health care organizations taking into account the actual insurance during the period of medical care, payment for the treatment case is made by the health care organization in which the patient was insured at the beginning of treatment. If the patient was not insured at the beginning of treatment, payment is made by the health insurance company that insured the citizen at the end of treatment.
5.3. The cost of treatment for the insured is determined according to the tariffs in effect on the first day of the billing month. Changes made to the Tariff Agreement come into force from the billing period following the month the decision was made, unless a different procedure for entry into force is established.
5.4. Tariffs for medical services are indexed based on the actual receipt of funds for compulsory medical insurance.
5.5. This Tariff Agreement applies to the relationship between the parties regarding payments for medical care from 01.2018 to 12.31.2018. This agreement may be amended or supplemented by agreement of all parties. Changes and additions are an integral part of this agreement from the moment they are signed by the parties.
5.6. The following Appendices are an integral part of this Tariff Agreement:
- List of medical organizations providing medical care in the compulsory medical insurance system and payment methods;
- Classifier of basic medical services for the provision of primary health care specialized dental care provided on an outpatient basis, expressed in conventional units of labor intensity (CUT);
- Average tariffs and standards for calculating the cost of agreed volumes of medical care;
- Per capita standards for financing outpatient medical care;
- Age-sex cost coefficient for payment of medical care provided in outpatient settings;
- List of performance indicators of medical organizations;
- Target performance indicators for medical organizations;
- Tariffs for visits and requests from medical specialists;
- Tariffs for medical services for inter-institutional and inter-territorial payments;
- Tariffs for individual medical services (without mutual settlements);
- Tariffs for a completed case of medical examination and preventive medical examinations;
- List of clinical and statistical groups of diseases, relative cost intensity coefficients and management impact coefficients for payment for medical care provided in inpatient settings, cost of a treatment case, amount of payment for interrupted cases;
- List of combined surgical interventions;
- List of similar operations on paired organs and symmetrical areas of the body;
- List of combinations of different types of antitumor treatment within 1 hospitalization;
- List of DRGs that are considered extra-long for a stay of more than 45 days;
- List of DRGs that do not provide the opportunity to choose between diagnosis and service criteria;
- Tariffs for high-tech medical care;
- List of clinical and statistical groups of diseases, coefficients of relative cost intensity and coefficients of management impact for payment for medical care provided in a day hospital, the cost of a case of treatment, the amount of payment for interrupted cases;
- Per capita standards for financing emergency medical care;
- Age-sex cost ratio for emergency medical care;
- The cost of calling an ambulance for mutual settlements by type of team;
- List of expenses included in the structure of the tariff for payment of medical care;
- List of grounds for refusal to pay for medical care (reduction of payment for medical care) and payment of fines by a medical organization based on the results of monitoring the volume, timing, quality and conditions of medical care, as well as ensuring the rights of insured citizens, and the amount of sanctions;
- Duration of treatment;
- Algorithm for calculating the cost of medical care.
- Appendix 1. Application for choosing a medical organization for receiving primary health care Appendix 2. Application for choosing a medical organization for receiving primary health care Appendix 3. Application for choosing a medical organization for receiving primary health care in the specialty "dentistry" Appendix 4. Application for choosing a medical organization to receive primary health care in the specialty "dentistry" Appendix 5. Informed consent to the conditions for the provision of primary health care when choosing a medical organization Appendix 6. Informed consent to the conditions for the provision of primary health care according to the profile "dentistry" when choosing a medical organization
Tariff agreement
to pay for medical care provided under the territorial program of compulsory medical insurance of the city of Moscow for 2017
(Moscow, December 29, 2016)
With changes and additions from:
hereinafter referred to as the Parties, in accordance with Part 2 of Article 30 of the Federal Law of November 29, 2010 N 326-FZ “On Compulsory Medical Insurance in the Russian Federation”, entered into this Tariff Agreement for the payment of medical care provided under the Territorial Compulsory Medical Insurance Program of the city of Moscow for 2017 (hereinafter referred to as the Tariff Agreement), as follows:
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The tariff agreement on compulsory medical insurance for the next year was approved at the end of the year. The commission for the development of the territorial TFOMS program is responsible for developing tariffs for medical institutions.
The situation was considered when the commission decided to reduce the tariff without warning, as a result of which the medical institution suffered serious losses.
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Tariff agreement for compulsory medical insurance
Let's consider a practical situation and analyze it in detail from a legal point of view. The medical institution operates in the compulsory medical insurance system, has a permit to carry out medical activities, and is included in the registers of medical institutions.
The commission for the development of the territorial part of the compulsory medical insurance program annually develops and approves a regional tariff agreement, which is valid within the relevant constituent entity of the Russian Federation.
At the end of 2016, the tariff agreement for 2017 was approved. For one of the medical services provided in a medical institution, a payment tariff was set at 7,000 rubles. This tariff was used in settlements between TFOMS and insurance companies from the beginning of the year to May 15, 2017.
At the beginning of May, the Commission sent a tariff agreement to the medical institution, from which it follows that the previously established tariff for this medical service was reduced to 5,000 rubles. Moreover, the start of this agreement is determined from 01/01/2016, that is, for the past months.
The introduction of compulsory health insurance (CHI) provided the population with the opportunity to receive medical care in the country regardless of their place of permanent residence or registration. The volume, as well as the procedure for free medical care, is determined by the relevant administrative documents of the Government and the Ministry of Health of Russia. The source of financing is insurance fees from production and business entities. The expenditure of funds is of a planned nature and provides for the annual determination of the cost of services and tariffs, with them fixed in the agreement. The tariff agreement for compulsory medical insurance for 2020 is presented below.
What is a tariff agreement
Tariff agreement (TA) is a document regulating all issues related to the provision of insurance coverage, receipt of fees, tariffing of services, distribution of fund funds. The parties to the agreement are represented by the compulsory medical insurance fund, the health department, representatives of medical institutions, insurance companies and medical trade unions of the constituent entity of the federation. Calculations of the full tariff are carried out based on an analysis of the state of affairs of the past year and prospects for the next period. Since the base represents the result of financial calculations, it should be recalled what the full tariff in the compulsory medical insurance system is.
Full insurance tariff - all expense items for the maintenance of compulsory medical insurance (wages, utility costs, medications, purchase of related funds for the provision of medical care, etc.), with the exception of capital investments (purchase of expensive medical equipment, capital construction, repairs).
The main sections of the CU include the following provisions:
- an updated list of services provided by insurance coverage;
- volume, methodology and procedure for calculating insurance rates;
- methods of making payments to the compulsory insurance fund;
- a list of insurance companies that have received a license and are admitted to insurance under compulsory medical insurance;
- a list of medical institutions with concluded agreements on the provision of compulsory medical insurance assistance;
- instructions, recommendations for keeping records of medical care provided and spending the Fund’s funds on this work;
- direct reports on the write-off of funds aimed at providing free medical care to the population and so on.
Over the course of the calendar year, the tariff agreement can be supplemented with annexes with changes in the tariffication of services, justification for decisions made on this matter, additional instructional and information materials, as well as other documents necessary for organizing the provision of high-quality medical care in a separate subject of the federation.
Where can I see the list of tariffs?
In pursuance of Order No. 108-FFOMS, organizational and practical measures were carried out that, from the beginning of 2015, allowed residents of the country to view the compulsory medical insurance tariff for any type of service provided free of charge, and for insured persons to become familiar with the amount of money spent on restoring their health. To obtain information, just go online to the medical tariff directory posted on the official website of the local Compulsory Medical Insurance Fund.
The information system was created to achieve the following goals:
- Implementation of control functions by the population. If a discrepancy is detected in the quality or volume of medical care actually provided and stated in the tariff agreement, the insured person has the opportunity to demand that the deficiency be eliminated by informing the insurers or the Compulsory Medical Insurance Fund.
- The information provided on tariff rules allows the insured person to compare prices within the framework of compulsory medical insurance and private clinics, which suggests an increase in requests for treatment to public medical institutions.
- Prevention of corruption in healthcare. The certificates contain information about the portion of the cost of the service allocated to pay the doctor. Awareness of the approximate amount will prevent “gratitude” from the patient to the doctor.
- Openness of information about tariffs and fees will force the heads of medical institutions to a balanced redistribution of funds received.
- It will make it possible for the population to take responsibility for their health. Knowing the cost of a particular service, many will take preventive measures to preserve their health so as not to “donate” significant amounts of their own funds to medical institutions.
If it is not possible to obtain the information you are interested in about compulsory insurance or tariffs via the Internet, you can check it with the treating doctor, the administration of the medical institution or the insurer.
Tariff agreement on compulsory medical insurance for 2020 in Moscow and Moscow Region
The Moscow Government, by resolution No. 1011-PP, together with other participants of the Customs Union, for the period 2020 tariff agreement, among other things, established the following provisions:
- the number of medical institutions allowed to provide free medical care under the territorial program was 250;
- the list of high-tech medical care has been expanded with funds from the territorial Compulsory Medical Insurance Fund (in the areas of gynecology, hematology, pediatric surgery and others);
- in addition to the main program, at the expense of the local fund, free provision of medical care for abdominal surgery, combustiology, and neurosurgery is provided;
- tariffs for the provision of services, taking into account all types of expenses per unit of volume of care - for abdominal surgery interventions alone, more than 250.0 thousand rubles are provided.
The total amount of funds allocated for the provision of free medical care in Moscow has increased. Consequently, the opportunity to receive high-quality medical services for both people in the capital and those living in the country has increased, and the waiting time for quotas has decreased significantly.
In the Moscow region, a tariff agreement was concluded in December last year. Based on the analysis of the results of providing medical care to the population and the planned level of occupancy of the territorial fund, it determined:
- The basic “capitation” standard for payment of services per patient, which amounted to 200.0 rubles.
- Depending on the type of care, gender, and age of the patient, correction factors have been approved. They have not undergone any significant changes compared to last year.
- Expanding the list of medical institutions participating in the compulsory insurance system for the region's population.
- Algorithms for assessing the effectiveness of the activities of medical institutions in the region serving the population with the volume of free insurance medicine.
The tariff agreement on compulsory medical insurance, adopted by the constituent entities of the country, taking into account the characteristics of the regions, sufficiently ensures the fulfillment of the tasks of providing free medical care to the population. The upward trend in funding for certain types of services provides an opportunity to receive better quality care in medical institutions, increase the number of specialized procedures (surgeries, IVF, etc.), and treat more people over the next calendar year.
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