MOSCOW, April 13 - PRIME, Natalya Karnova. The state will gradually reduce participation in the health insurance system, so it is likely that unemployed Russians who do not have benefits will still have to pay for compulsory health insurance policies (CHI) on their own. True, they will not be alone in this - to one degree or another, all over the world, both poor and rich, have to pay for medicine. Even in countries where health care is fully paid from the budget, citizens have to go abroad for treatment due to long waiting periods.

The mechanism of paid compulsory medical insurance will be implemented, only ambulance services will remain free

Opinions of experts and society on the idea of ​​obliging the unemployed to fully or partially pay for policies (CHI) differ diametrically. Some believe that the state and working citizens really should not bear the cost of treating the unemployed, others are sure that the innovation is "crude" and, in its declared form, looks antisocial, violating the rights of Russian citizens to medical care.

Currently in CHI system 146.5 million Russians are insured, of which, according to various estimates, about 8-12 million people do not pay contributions to social funds (including the Compulsory Health Insurance Fund). There are also self-employed, the situation with which is ambiguous. Lawyers in private practice, notaries, arbitration managers and entrepreneurs often pay fees themselves. Categories such as nannies, nurses and tutors do not always do this.

WHAT IS INCLUDED IN CHI

To understand why this topic causes such a stormy response, you need to know how the CHI system works. Now almost every citizen of the Russian Federation has the right to medical care, but not "free", as many people think, but only under the CHI policy. The policy is issued free of charge, and the money for the maintenance of the medical infrastructure and payment for the medical care provided goes through insurance companies. medical organizations from the Compulsory Medical Insurance Fund, where employers' contributions are transferred for their employees. Means for the treatment of the unemployed are directed from the regional budgets.

CHI provides almost the entire average statistically necessary volume of medical care, said Dmitry Kuznetsov, vice president of the All-Russian Union of Insurers (ARI), president of the Interregional Union of Medical Insurers. “Recently, many types of high-tech assistance have been loaded into the system, including “ ambulance”, the treatment of oncological diseases, which were previously paid from the budget. Thanks to this person, who was brought in an ambulance, they will perform an emergency operation, the necessary equipment is always available. The waiting time for medical assistance has also been significantly reduced," he said.

Undoubtedly, the system needs to be improved. This also applies to concretization of the program and changes in the role of participants in the system.

VOLUNTARY INSURANCE

In parallel, there is a system of voluntary medical insurance (VHI), when a person who wishes to buy a policy from an insurance company that is valid in selected medical institutions. Almost all major insurers work under VHI programs. The scope of services depends on the price of the policy and the amount of insurance coverage - some include dentistry using the most modern materials and technologies, prosthetics, long-term treatment of severe diseases, rehabilitation (including outside the Russian Federation). There are policies for certain types of diseases. Policy prices start from one and a half thousand rubles a year, but this is a minimum program. Also, a VHI policy can be obtained "free of charge" if your company purchases insurance as part of corporate medical insurance.

"VHI is less regulated compared to CHI, built on the basis of classical insurance market mechanisms and has fully proved its worth. It offers more services, freedom of choice, faster access to specialists. In terms of income, VHI is already comparable to OSAGO and at the same time leads in the smallest number complaints from clients of insurance companies," Kuznetsov said. This suggests that the insurer is interested in providing fast and high-quality medical care, otherwise he risks losing a client. Medical service providers are also interested in being chosen for insurance medicine, so they are forced to improve the quality, he added.

According to the expert, in the future Russia should move even more towards an insurance model with a system management similar to VMI. But emergency assistance should be free. It is also necessary to preserve the network of state institutions. To date, the share of private providers of medical services is about 30% and this is quite a sufficient figure.

FOREIGN EXPERIENCE

The Russian health insurance system can be safely called unique, just like any other system is unique. insurance system. Each country takes one of the schemes as a basis and, on its basis, develops its own model, taking into account the mentality, the level of economic development, the income of citizens and many other parameters.

At present, two main fundamentally different health care systems can be distinguished - state and insurance. Predominantly public insurance system in the UK. In many ways, it is built on the example of the model that was in the USSR. The main part of the funds comes from the state budget and is distributed from top to bottom along the management vertical. Centralized funding helps ensure quality and keep costs down. However, the choice of doctor or medical institution is limited, and the waiting time for the study can be endless.

“In England, they are justifiably proud of their “medicine of equal opportunity” created after the war. However, the long waiting times for many diagnostic and therapeutic procedures do not allow us to consider it ideal. As you know, citizens different countries choose Germany, the USA or Israel - countries with insurance models for financing healthcare," Kuznetsov said.

The insurance system with a different share of state regulation operates in such European countries as Germany, France, Holland, Austria, Belgium, Switzerland, some countries of Latin America and Japan. Financing is carried out through three channels: insurance premiums from the employer or payments from the income of entrepreneurs, earnings of workers - deductions from wages and state budget funds.

Each country has its own nuances. "France is satisfied with its CHI system, but at the same time, 90% of the country has a VHI policy, since their CHI system contains severe restrictions on the set of included services (specialists such as, for example, an ophthalmologist, are removed from the CHI) and is somewhat less perfect than ours - the insurers are several funds, divided according to professional criteria," the expert said.

A special subspecies of the insurance system - private - in the United States. There, medical insurance is a voluntary matter of citizens, often paid in full or in part by the employer. There is no state regulation in this area, and more than 80% of the population is covered by private medical insurance. State programs work for the poor, but it is difficult to get them, and they do not cover all the costs. The system was tried to improve by former US President Barack Obama. His Obamacare program made insurance mandatory. However, the new president - Donald Trump - canceled Obamacare, although there is no approved plan to replace it yet.

"It's all about the mentality: if our citizens need someone to take care of them, because "they are entitled to everything," then the Americans have the opposite. They opposed Obama's idea of ​​​​mandatory insurance - they say, when needed, then we will buy " Kuznetsov explained.

WHERE IS BETTER FOR THE POOR

The insurance system allows 80-90% of the population to receive qualified medical care. The pluses of experts include control over the quality of services provided by insurers, the minuses are the fact that low-income citizens do not always have equal opportunities for treatment.

Of course, it all depends on the specifics of each particular country. The largest volume of medical care at the expense of the state - in developed countries Europe, as well as in Japan. So, in Italy, for any operation in a private or public clinic, a person does not need to pay a single euro. However, there is practically no completely free medicine anywhere. In the same China, where alternative medicine is also included in the CHI system, there are mandatory payments. For example, a patient or his relatives pay 10% of hospital services.

In Israel, every insured person in the system participates in co-financing (working people pay a percentage of their salary, pensioners a percentage of old-age benefits, disabled people a percentage of disability benefits), but their compulsory medical insurance policy even involves the provision of foreign assistance if necessary, Kuznetsov said. In Switzerland, insurance medicine implies significant payments from the population, but if we compare it with our shadow payments, the amounts are comparable. In the US, even a "golden policy" purchased by a citizen covers only 90% of medical services. So, with some degree of probability, even the most wealthy will have to pay extra.

WHAT EXPECTS THE UNEMPLOYED

In this situation, sooner or later, Russians, for whom the employer does not pay contributions, will have to fully or partially pay for the CHI policy themselves, experts are sure. “I think that sooner or later, truly free medicine, as elsewhere abroad, will remain only at the level of emergency medical care. The state will pay for policies for privileged categories of the population, and the employer will pay for the rest, or the employee will have to buy the policy himself,” - says the director of the National Institute of Medical Law Yulia Pavlova.

David Melik-Guseinov, director of the Research Institute for Health Organization and Medical Management of the Moscow City Health Department, believes that discussion of the topic will raise acute questions that society may not be ready for. "Won't this lead to the fact that the unemployed and self-employed will be formally registered at 0.25 of the rate and will be registered as employed? The effect for collecting taxes in favor of the MHIF will be minimal," he wrote on his Facebook page.

The flat rate of taxation will also raise questions - everyone pays the same percentage, but in absolute terms, those who receive a higher salary may require special service conditions, the expert notes. Thus, the reform of the system of insurance medicine itself will continue, and the share of state participation in it will most likely decrease.

The government decided to change the formula for calculating regional contributions to compulsory health insurance unemployed citizens. This will lead to a significant increase in the costs of Moscow and St. Petersburg, RBC found out

Photo: Alexey Pavlishak / TASS

The government proposed to change the calculation of the tariff insurance premium for compulsory health insurance (CMI) for 80 million non-working Russians. The corresponding draft law was submitted to the State Duma on September 29 along with the draft budget of the Federal Compulsory Medical Insurance Fund for the next three years. Amendments to the methodology - the first in seven years - will lead to growth budget spending Moscow, St. Petersburg, Moscow and Leningrad regions by almost 70 billion rubles. compared to 2018. Contributions to the CHI system for the unemployed (children, students, pensioners, the unemployed) are made by the regional authorities.

Moscow and St. Petersburg will pay twice as much

The regional contribution for medical insurance of one unemployed person is determined by law as the product of the basic, common for all tariff of 18,865 rubles, the differentiation coefficient (individual for each region) and the appreciation coefficient medical services(uniform for the whole country, determined annually by the FFOMS budget). The government decided to revise the differentiation coefficient, which has not changed since 2012, and take into account the ratio of wages in the region and the average wage in the country when determining it. “The proposed approach will make it possible to take into account the peculiarities of the regions in which wage higher than the average for Russian Federation, <...>"- Leningrad region, Moscow region, Moscow, St. Petersburg, the explanatory note to the project says.

Now for these regions the coefficient of differentiation is the same - 0.3333. As a result of the amendments, for Moscow it will be increased to 0.8196 (almost 2.5 times), for St. Petersburg - up to 0.5965 (1.8 times), for the Moscow Region - up to 0.52 (1.6 times ) and for the Leningrad region - up to 0.4365 (1.3 times). In addition, the coefficient of appreciation of medical services for 2019 will be indexed to the forecast inflation rate (4.3%) and, accordingly, will increase from 1.073 to 1.119, follows from the FFOMS draft budget.

As a result, the rate of compulsory medical insurance contributions per non-working citizen will increase for Moscow from the current 6.75 thousand to 17.3 thousand rubles. (that is, more than 2.5 times), for St. Petersburg - from 6.75 thousand to 12.6 thousand rubles, for the Moscow region - from 6.75 thousand to 11 thousand rubles. and for the Leningrad region - from 6.75 thousand to 9.2 thousand rubles, follows from the calculations of RBC and is confirmed by the FFOMS document. RBC sent a request to the Ministry of Health.

The tariff is reduced for only one region

In addition to changing the methodology, the government updated the so-called regional wage coefficients, which will affect 33 more regions (Tyva, Tyumen region, Chelyabinsk region, Khanty-Mansi Autonomous Okrug, etc.). As a result, the differentiation coefficients decreased for 22 regions, most notably for the Tomsk region. And due to the increase in the cost of medical services, the tariff will increase for all regions, with the exception of the Tomsk region (minus 300 rubles).

Contributions to compulsory medical insurance for the non-working population are a constantly growing expense item of regional budgets. If in 2012 the contribution of all regions amounted to 299 billion rubles, then in 2018 it will reach 661 billion rubles. Regions are required to make monthly payments for unemployed persons to the territorial CHI fund. A significant amount of contributions “leads to a deficit in regional budgets for the financial support of programs of state guarantees for the provision of free medical care in terms of paying for medical care not included in compulsory medical insurance,” noted the Federation Council (*.pdf), and the Accounts Chamber pointed out problems with the methodology for determining the number of insured unemployed citizens, which is why the amount of contributions to compulsory medical insurance of the non-working population can be considered too high.

In 2019, the amount of regional contributions for the unemployed will increase to 719.3 billion rubles, and the entire increase will be provided by the budgets of Moscow, St. Petersburg, Moscow and Leningrad regions. Thus, Moscow's contribution will increase from 34 billion rubles. in 2018 to 68.9 billion rubles, in the Moscow region - from 24.5 billion to 44.6 billion rubles, in St. Petersburg - from 17.7 billion to 30.6 billion rubles, in the Leningrad region - from 5.4 billion up to 6.6 billion rubles.

Spending obligations could have grown even more if it were not for the changes in the method of personalized accounting for CHI, adopted last summer. Firstly, military personnel and persons equivalent to them were excluded from the register of the insured, and secondly, the number of non-working population is now determined on January 1, and not on April 1. As a result, the number of unemployed citizens, on the basis of which the amount of contributions is calculated, decreased by almost 5 million people: if on April 1, 2017 it was 85 million people (previous FFOMS budget), then on January 1, 2018 - about 80 million (the current draft budget). Including about 8 million unemployed (10% of the national figure) are registered in Moscow and the Moscow region.

Liberation of regions?

Deputy Prime Minister Tatyana Golikova earlier with a proposal to exempt the regions from paying insurance premiums for the non-working population and transfer these costs to federal budget. “The payment for the non-working population, the consolidated payment for Russia as a whole, has already begun to exceed the subsidy that the federal budget gives to equalize the level of budgetary security, that is, in fact, there is a flow through the regional budget to the budget of the Compulsory Medical Insurance Fund,” she said at the end of May 2018 . In the spring of 2017, she estimated the total volume of such payments at 7% of the expenditure side of regional budgets.

First Deputy Prime Minister and Finance Minister Anton Siluanov in June that the Ministry of Finance agreed to release regional budgets from the obligation to pay annual contributions to the Compulsory Health Insurance Fund for certain categories of non-working citizens (children, pensioners). “This is a significant amount of resources - about 500 billion rubles. In order to ensure a balance between the obligations transferred to the regions for the implementation of those national tasks that have been set for the upcoming period by the president, we are ready to take these powers to the federal level and free up the necessary resources for the constituent entities of the Russian Federation,” Siluanov said.

However, the FFOMS budget for 2019-2021 has been formed subject to the preservation of the obligation of the regions to pay contributions to compulsory medical insurance for the non-working population. Moreover, a “special procedure” is proposed for the changes to come into force, so that the regions can pay for the unemployed according to new methodology since 2019, follows from explanatory note. RBC sent a request to Golikova's secretariat and the Russian Ministry of Finance and received conflicting answers. The vice-premier's secretariat did not confirm plans to exempt the regions from contributions for the unemployed, answering: "Now another solution is being discussed." “This issue [of transferring powers to the federal level] is still being discussed,” the Ministry of Finance said.

With the participation of: Polina Zvezdina

The Ministry of Health denied the information that appeared in the media that it is planned to deprive the unemployed and self-employed of compulsory health insurance policies. If the idea were implemented, free treatment in public clinics and hospitals could lose, according to various estimates, 12-19 million people.

They either had to "go" into commercial medicine and pay for each visit to the doctor, or purchase a compulsory medical insurance policy for 20,000 rubles a year.

Regulatory authorities have not learned how to identify wealthy unemployed, but this is not a problem for the Ministry of Health. Photo: Reuters

The newspapers referred to a draft law prepared by the Ministry of Health with amendments to the system of personalized registration in the CHI system. The document pointed to the introduction of rules "terminating health insurance in respect of a certain category of insured persons and ensuring that the CHI policy is invalidated." The publications interpreted this as follows: able-bodied citizens who do not officially work anywhere and, therefore, do not transfer insurance premiums to the Compulsory Medical Insurance Fund, will lose the policy.

It is clear that the scandalous news, affecting the interests of millions of citizens, required immediate confirmation and clarification or refutation. And it followed in the morning.

"Ministry of Health of Russia and federal fund LMIs were surprised to find information circulated in the media that allegedly unemployed and self-employed Russians would be deprived of free compulsory health insurance policies. This information is not true and is a distortion of the position of the departments," the Ministry of Health said.

Why should the unemployed on the Bentley be treated at the general expense?

And the press secretary of the Minister of Health, Oleg Salagay, explained: “The right to free medical care is a social guarantee provided to all citizens within the framework of compulsory medical insurance. No reduction in its volume

not provided for in any of the draft regulations. The Constitution of the Russian Federation guarantees the right to free medical care to all citizens of our country, regardless of whether they work or not.

The MHIF "RG" explained how the mistake arose: the quoted fragment of the bill on "certain categories of insured citizens" did not apply to the unemployed and self-employed, but to the military. Medical assistance to military personnel is provided in our departmental medical institutions. But there are many cases when citizens, having switched to military service, retain their "civilian" compulsory medical insurance policy. As a result, they are treated departmental clinics and hospitals, but the "civilian" medical institutions to which they were attached before continue to receive funding for them. So the proposal that has made so much noise concerns putting things in order in the registration of citizens in the CHI system.

Background

It would seem that the incident is over, the journalists who misunderstood something are again to blame for everything ... But in fact, the topic is more than relevant. For years now, the government has been puzzling over how to force people who have incomes but are not officially employed anywhere to "come out of the shadows." According to estimates published last fall by Minister of Labor Maxim Topilin, there are about 15 million such people in the country. People work, earn a living, but contributions to the MHIF (as, by the way, in Pension Fund) do not pay. But when they get sick, they go to the clinic and get treated for free. That is, at our expense. There are also very successful businessmen who earn in real life for expensive cars, villas, trips, but on paper - only living wage(so that the tax authorities are not too picky). They pay symbolic contributions. They get sick and are treated, like everyone else, for real. Agree, when it comes to children and pensioners, it is logical that the state pays for their medical insurance (that is, in fact, we are with you). But why should the unemployed on the Bentley be treated at the "general" expense?

Therefore, in the Ministry of Labor, and in the State Duma, and in the Federation Council, various possibilities were discussed more than once to “stimulate” these citizens to legalize their income. From the point of view of pension legislation, this has already been done: receiving a "gray" salary, we now cannot earn a pension. But officials have not touched medical care so far. In various discussions, both Minister Maxim Topilin and the head of the Federation Council, Valentina Matviyenko, suggested considering various ways of influencing irresponsible citizens. For example, to introduce a "tax on parasitism" - in fact, to force the self-employed to make an annual payment for medical care. Or reduce the amount of free treatment for them under the CHI policy. Recently, a similar proposal was made by the head of the Accounts Chamber, Tatyana Golikova. According to the joint venture, the regions pay 618 billion rubles for the non-working population. There is no mention of children and the elderly, but the introduction of a payment for medical services for the self-employed could reduce the burden on regional budgets. However, while all such reasoning remains purely in the discussion channel. After all, according to the Constitution, the right to free medicine have all our citizens without exception. And to distinguish the "unemployed" on the "Bentley" from the person who is really unable to find a job, all our regulatory authorities have not yet learned.

Every citizen of the Russian Federation, in relation to which they have concluded an agreement on medical insurance, receives a mandatory medical insurance policy. The health insurance policy should only be in the hands of the insured citizen. This document has legal force throughout Russia, as well as on the territory of other states with which Russia has concluded an agreement on medical insurance for its citizens. For example, it is significantly lower in cost than .

For non-working citizens(unemployed, disabled, pensioners, students, children, housewives) the policy is issued at the place of permanent residence at the point of issue of policies of insurance companies. In case of any changes in the permanent place of residence, an unemployed citizen is obliged to return the policy he received to the insurer and receive another one at his new place of residence.

Issuing a policy, medical insurance organization should familiarize citizens with the rules of health insurance in the region of their residence, as well as territorial programs state guarantees providing them with medical free help, the condition for its fulfillment, and the list medical institutions, where you can get medical assistance on a mandatory basis health insurance. According to the law of the Russian Federation on medical insurance of Russian citizens, for non-working citizens, the insurers are the executive authorities at the place of permanent residence of the subject of the Russian Federation. Don't forget about.

For getting medical policy citizen of Russia must apply with a personal statement issued in the name of the executive head of the branch territorial fund on compulsory medical insurance of the subject of Russia in which he permanently resides. You can also send a written request to the republican or regional fund for compulsory health insurance.

The following must be attached to the application:

• a copy of the title passport pages;

• a copy of the certificate of registration at the place of stay in Moscow;

• a page with a note about the place of residence in the territory of the permanent place of residence, that is, the city where the citizen came from;

• a notarized copy of the work book, including a page with a record of dismissal at the last place of work. For example, this question concerns everyone and does not matter even if you have.