as subjects health insurance act: citizen, policyholder, insurance medical organization, medical institution.

The insurers for compulsory health insurance are the executive authorities of the subjects Russian Federation and local governments - for the non-working population; organizations, individuals registered as individual entrepreneurs, notaries engaged in private practice, lawyers, individuals who have concluded employment contracts with employees, as well as paying remuneration under civil law contracts, on which taxes are charged in accordance with the legislation of the Russian Federation in the part that is subject to enrollment in compulsory medical insurance funds - for the working population.

The insurers in case of voluntary medical insurance are individual citizens with legal capacity and/or enterprises representing the interests of citizens.

Insurance medical organizations are legal entities that provide medical insurance and have a state permit (license) for the right to engage in medical insurance.

Medical institutions in the health insurance system are licensed medical and preventive institutions, research and medical institutes, other institutions providing medical care, as well as persons engaged in medical activities, both individually and collectively.

20. Financial and legal basis for compulsory health insurance

The financial resources of the state system of compulsory medical insurance are formed at the expense of deductions from insurers for compulsory medical insurance.

For implementation public policy in the field of compulsory medical insurance, the Federal and territorial funds of compulsory medical insurance are being created as independent non-profit financial and credit institutions.

The Federal Compulsory Medical Insurance Fund is created by the Supreme Council of the Russian Federation and the Government of the Russian Federation and operates in accordance with the legislation of the Russian Federation.

Territorial compulsory medical insurance funds are created by the Supreme Councils of the republics within the Russian Federation and the governments of the republics within the Russian Federation, the Councils of People's Deputies of the autonomous region, autonomous districts, territories, regions, cities of Moscow and St. Petersburg and the relevant executive authorities and carry out their activities in in accordance with the legislation of the Russian Federation, the republics within the Russian Federation, the regulatory legal acts of the autonomous region, autonomous districts, territories, regions, cities of Moscow and St. Petersburg.

Compulsory health insurance funds are designed to accumulate financial resources for compulsory medical insurance, ensuring the financial stability of the state system of compulsory medical insurance and equalizing financial resources for its implementation.

The financial resources of the mandatory medical insurance funds are in the state ownership of the Russian Federation, are not included in the budgets, other funds and are not subject to withdrawal.

The procedure for collecting insurance premiums for compulsory health insurance is developed by the Government of the Russian Federation and approved by the Supreme Council of the Russian Federation.

Mandatory health insurance funds maintain databases and other information resources in the field of compulsory health insurance of citizens.

The federal executive body responsible for the development of state policy and legal regulation in the field of healthcare determines the procedure for the formation of a system of accounting and reporting, as well as the procedure and conditions for maintaining databases and other information resources in the system of compulsory medical insurance.

Article 9 federal law dated November 29, 2010 N 326-FZ “On Compulsory Medical Insurance in the Russian Federation”

The subjects of compulsory medical insurance are: 1) insured persons; 2) insurers; 3) the Federal Fund.

Participants of compulsory medical insurance are: 1) territorial funds; 2) insurance medical organizations; 3) medical organizations.

The object of compulsory medical insurance is the insured risk associated with the occurrence insured event.

The insured persons are citizens of the Russian Federation, foreign citizens permanently or temporarily residing in the Russian Federation, stateless persons (with the exception of highly qualified specialists and members of their families in accordance with the Federal Law of July 25, 2002 N 115-FZ "On the legal status foreign citizens in the Russian Federation"), as well as persons entitled to medical care in accordance with the Federal Law "On Refugees".

Insurers for working citizens are: persons making payments and other remuneration to individuals: organizations; individual entrepreneurs; individuals who are not recognized as individual entrepreneurs; individual entrepreneurs engaged in private practice notaries, lawyers.

Insurers for non-working citizens are the executive authorities of the constituent entities of the Russian Federation, authorized by the highest executive authorities of the constituent entities of the Russian Federation. These insurers are payers of insurance premiums for compulsory medical insurance of the non-working population.

The insurer for compulsory health insurance is the Federal Fund as part of the implementation of the basic program of compulsory health insurance.

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

Territorial funds - non-profit organizations established by the constituent entities of the Russian Federation in accordance with this Federal Law for the implementation of state policy in the field of compulsory medical insurance in the territories of the constituent entities of the Russian Federation.

An insurance medical organization operating in the field of compulsory medical insurance is an insurance organization that has a license issued by federal agency executive power, carrying out the functions of control and supervision in the field of insurance activities. Features of licensing the activities of insurance medical organizations are determined by the Government of the Russian Federation. The insurance medical organization exercises certain powers of the insurer in accordance with this Federal Law and the agreement on financial support for compulsory medical insurance concluded between the territorial fund and the insurance medical organization.

Medical organizations in the field of compulsory health insurance include those that have the right to carry out medical activities and are included in the register of medical organizations operating in the field of compulsory health insurance.

In health insurance, there are four subjects, the relationship between which is carried out through contracts: the insurer, the policyholder, the insured, the provider of medical services.

INSURER - an insurance institution that collects insurance premiums, forming insurance funds providing from these funds payment for medical services and other types of monetary and material compensation provided for by the contracts.

INSURANT individual or legal entity
(institution or enterprise) a person contributing under contracts
contributions to insurance funds with the insurer, ensuring
providing health insurance. Non-working policyholder
the dwindling population is the local administration, the environment
funds are allocated from the state budget according to
current level.

INSURED - persons who are provided with medical service and other types of material and monetary compensation provided for by medical insurance contracts.

PROVIDER OF MEDICAL SERVICES - a medical institution (enterprise), independently practicing doctors, providing medical care to the insured in accordance with contracts and receiving payment for their services by insurers from health insurance funds.

The organizer of health insurance is an insurance company.

Insurance organization:

1) enters into an agreement with the policyholder and receives from him
insurance premiums;

2) issues insurance policies insured persons for which they receive medical assistance;

3) enters into contracts with medical institutions and self-practicing doctors and pays for the services provided by them;

4) participates in the formation of prices for medical services and control over their quality;

5) establish insurance rates.

Insurance rates should provide payment for medical services to the insured and the direct income of the insurance organization.

Depending on the use of income, insurance organizations are divided into commercial and non-commercial.

Non-commercial - use income to finance the activities of the organization and developed health care, but cannot risk their capital and have the right to invest only in highly reliable securities, enterprises and banks that allow the immediate return of all funds to the insurance organization if necessary.

Commercial ones are more free in their operations, they can carry out direct capitalization of their income in all legal ways, while guaranteeing the fulfillment of their obligations under medical insurance contracts. Therefore, such insurance companies widely use underwriting and reinsurance in their activities.

UNDERWRITING (eng. undrwriting, literally - subscription) - a system that allows you to study the partners with whom the contract is concluded in order to establish an insurance rate corresponding to the insurance risk. health study,

conditions and lifestyle of the insured is carried out according to the medical record, testing and conversation with him. At the same time, the need and cost of his medical care is predicted, taking into account his individual characteristics.

REINSURANCE of the capital of an insurance company in a larger company, which assumes responsibility for a corresponding part of the income of a smaller company.

The main types of health insurance include:

- Compulsory health insurance - CHI;

Voluntary medical insurance - VHI.

CHI is a part of social insurance that guarantees the country's population social protection in the form of a certain set of medical services paid from health insurance funds. This type of insurance is

It is operated by state (for example, the Territorial CHI Fund) and non-state non-profit organizations and is controlled by the state.

CHI is characterized by: 1) mass character; 2) a guaranteed minimum of medical services; 3) a state or state-controlled organization; 4) subordination to the main goals of the health care system.

Medical assistance is provided to the insured in accordance with the basic CHI program. The basic program determines the volume and conditions for the provision of medical and drug assistance to citizens of the Russian Federation. On the basis of the basic program of the Russian Federation in the regions, a territorial program of compulsory medical insurance is developed and approved, the volume of medical services provided, which cannot be less than the volume established by the basic program. Control over the quality, volumes and terms of delivery medical care carried out by an insurance medical organization, as well as by a health management authority.

In accordance with the program, citizens are guaranteed: 1) provision of primary health care, including emergency medical care, diagnosis and treatment on an outpatient basis (including emergency and first aid), the implementation of disease prevention measures; 2) inpatient care.

The volume and conditions of drug assistance are determined by the territorial CHI programs. Payment for the necessary medicines and medical products in a hospital and in the provision of emergency and emergency medical care is carried out at the expense of insurance premiums for CHI. and in outpatient clinics - at the expense of personal funds of citizens.

VHI- can be independent and additional, being additional to the obligatory one. It can be individual and group, it is carried out by various, often commercial insurance companies, on the basis of various packages of insurance programs, at differentiated rates, using age-related insurance (as a rule, at higher rates;

Insurance medical organizations offered a choice medical institutions and doctors, various types of medical insurance policies (diagnostics, outpatient, inpatient, dental care). Voluntary insurance funds may be used by the insurer for commercial purposes.

In general, VHI, removing part of the financial burden from the public health system, provides high-quality medical care for certain groups of the population, more service than within the framework of compulsory medical insurance. At the same time, medical services become less expensive for the population than their full private payment. Part of the funds in accordance with the terms of the contract can be returned to the country

as a premium for a healthy lifestyle and well-preserved health, stimulating concern for the preservation and promotion of health in the interests of society. Comprehensive (complete) health insurance involves: 1) hospital insurance (inpatient and outpatient, including payment for surgical interventions); 2) drug insurance (provision of drugs at the expense of insurance funds); 3) dental insurance; 4) preventive insurance; 5) rehabilitation insurance; 6) insurance against accidents with.> guchaev and injuries; 7) insurance in case of temporary disability; 8) permanent disability insurance: 9) women's reproductive insurance, 10) life insurance.

The listed types of insurance can be used most widely by private insurance companies. In the future, comprehensive health insurance can be used in CHI system.

The health insurance system provides citizens with the right to:

1. OMS and DMS.

2. Free choice of medical insurance organization.

3. Free choice of a medical institution and a doctor in accordance with the MHI and VHI agreements.

4. Obtaining medical care throughout Russia, including outside the permanent place of residence.

5. Receipt of medical services corresponding in volume and quality to the terms of the contract, regardless of the amount of the paid insurance premium.

6. Filing a claim against an insured, an insurance medical organization, a medical institution, including for material compensation for what was caused through their fault

damage, regardless of whether it is foreseen or not in the health insurance contract.

7. Refund of a part of insurance premiums for VHI, if it is provided for by the terms of the contract.

Table 1

Features of CHI and VHI

	ome	VHI
	non-commercial	Commercial
Is kind	Social Security	Personal insurance
Nature of insurance	General or mass	Individual or group
Regulated by Law	"On medical insurance of citizens in the Russian Federation"	"On insurance", "On medical insurance of citizens in the Russian Federation"
Who is carried out	Government and government-controlled entities	Insurance organizations of various forms of ownership
Who determines the rules of insurance	State	insurance organization
Who is the insured	State (local executive authorities), employers	Legal entities and individuals
Sources of funds	- contributions from employers; - the state budget	- personal income of citizens; - employers' profit
Health insurance program	(guaranteed minimum service) is approved by the authorities	Determined by the agreement between the insurer and the insured:
Tariffs are set	According to a single approved methodology	Agreement between the insurer and the policyholder
Quality control system	Determined by government agencies	Established by the agreement of subjects of insurance
Proceeds can be used	Only for the main activity - health insurance	For any commercial and non-commercial activity.

LEGAL FRAMEWORK

For a number of years, federal regulations and bills have formulated a clear structure of the medical sphere of social insurance. These provisions designate the rights of each of the parties, regulate the legal and financial relations of all participants in the insurance medical system.

How are the rights and obligations of subjects of compulsory health insurance determined? What functions belong to each of the parties, and how does this affect the observance of social guarantees for Russian citizens?

Definition of Social Health Insurance Participants

According to the norms adopted at the legislative level, the subjects of compulsory health insurance are such participants in this social system:

• Subjects for whose benefit insurance payments— insured persons;
• Payers of insurance premiums - this function is performed by insurers, they are also employers of insured persons;
• Participants in the financial sector in this area are the Federal Fund, insurance honey. institutions, insurance funds of the territorial format;
• Organizations of a medical profile of activity - outpatient departments, medical hospitals, dispensaries, dispensaries, dental clinics, specialized medical institutions.

In this structure of subjects of health insurance, the main and only guarantor is the Federal Social Insurance Fund. His powers and rights are confirmed by government guarantees.

All of the listed subjects of compulsory health insurance have obligations to other participants, as well as to federal structures vested with the right to exercise control over the implementation of established standards and bills.

The uninterrupted and efficient operation of all entities becomes possible with the close and conscientious fulfillment of these obligations.

All actions of each of the participants must be confirmed in a documentary format. For example, - the right to receive payments by the insured person must be confirmed by the fact of regular payment of insurance medical contributions the employer of the applicant for cash assistance. At the same time, in order to receive this amount, it is necessary to confirm the fact of the insured event from the medical institution that examined or treated the insured person. At the same time, the medical institution itself, participating in the insurance system medical support has no right to refuse assistance to the insured person. The doctors of this organization are obliged to provide assistance even in cases where the amount of insurance exceeds real costs for the treatment of the applied citizen.

Since the subjects of health insurance are mainly legal entities, then the fulfillment of their obligations is controlled by the social insurance commissioners. Their responsibilities include monitoring the fulfillment of financial obligations, compliance with the regime of financial transactions, and the provision of quality medical services.

Policyholders

One of the key subjects of compulsory health insurance is the employer of the insured person. This category also includes individual entrepreneurs and individuals who hire employees for temporary or seasonal work under employment contracts. This also includes employees of the notarial structure and the bar.

The main requirement for policyholders is the timely and full payment of insurance premiums for their employees.

The functional obligations of this category are reduced to the following actions:

• Conclusion of contracts for the services of territorial funds of compulsory medical insurance;
• Making contributions in accordance with the established schedule and in full;
• Provide measures to minimize the impact of harmful factors on the health of their employees.

All categories of insurers undertake to provide the insurer with all information about the health of their employees, as well as about their working conditions. At the same time, employers are obliged to comply with the recommendations, the purpose of which is to improve working conditions in the interests of the health of employees and employees.

Another category of insurers is formed for certain groups of citizens who do not have permanent employment, or who enjoy state social benefits and financial support at the federal level. For such people, the insurer can be federal services social security, executive federal or municipal authorities, local government structures.

In this group of participants, the subjects of health insurance are individuals in whose favor insurance premiums are made from insurers. In fact, the insured persons are the direct beneficiaries in the event of an insured event.

The insured persons, as follows from the description of the powers and duties of the insurers, can be both employed citizens and those who, for various reasons, are unable to work - mothers in maternity leave, disabled people, persons who are in the employment service on a temporary basis.

Insurers

This most extended structure of participants in the medical insurance system ensures the movement of funds, their calculation and distribution. Also, the powers of these subjects of compulsory health insurance include drawing up insurance contracts, the function of monitoring the fulfillment of requirements by the insured, as well as verifying the authenticity of the fact of an insured event.

The main actor of this structure is the Federal Compulsory Medical Insurance Fund.

Its extensive network operates in various regions - territorial social insurance bodies for medical insurance risks.

The link between the fund, its subdivisions, policyholders and insured entities is medical insurance institutions. They are empowered to draw up and sign contracts for medical insurance. They are also entrusted with the preparation of tariffication for payments in specific insurance cases, the determination of the amount of insurance premiums, as well as the right to accredit medical institutions.

This group of insurers must be accredited at the federal level, and the degree of its competence must be confirmed by the presence of a license from the Ministry of Finance. As part of the service of insured persons, these subjects of medical compulsory insurance accounting for funds, their distribution, ensure investment and safety.

Along with financial structures, medical institutions are also participants in compulsory health insurance. A mandatory requirement for these participants in the insurance system is their presence in the federal register of medical organizations. Such a right is also accompanied by appropriate accreditation, the availability of a license and the confirmed competence of medical personnel.

Private medical entrepreneurs conducting their own medical practice can also act as this subject.

As you can see, all of the listed entities that are participants in compulsory health insurance could not act separately, and their relations are aimed at achieving a common goal - ensuring social protection insured persons, as well as maintaining financial interests within the federal programs welfare.

The structure of the compulsory health insurance system consists of several interconnected links. Each structural unit is endowed with specific functions and responsibilities.

In Art. 9 of the Federal Law No. 326 singles out the subjects of compulsory medical insurance and its participants.

Insured, policyholders and Federal Foundation are subjects of compulsory medical insurance (Article 9, Clause 1 of the Federal Law No. 326).

According to paragraph 2 of Article 9 of the Federal Law No. 326, territorial funds, insurance organizations, institutions engaged in medical activities, are participants in compulsory medical insurance.

To begin with, let's define the object of compulsory medical insurance, the object of insurance in a broad sense should be understood as all those events that can occur regardless of our will or actions and have a negative impact on health, in which there will be a need to receive medical care. In a narrow sense, with compulsory health insurance, an insured risk is insured, that is, an event that has not yet taken place. The system of compulsory health insurance operates the so-called principle of solidarity of insurance participants, which consists in the fact that insurance payments, contributed for a particular person to the compulsory medical insurance funds are not returned back, even if the insured event did not happen, but go to provide medical care to other people.

An individual who is covered by the compulsory health insurance program is an insured person.

The insured is any citizen of Russia, regardless of gender, age, race, as well as foreigners permanently or temporarily residing in the territory of the Russian Federation, stateless persons, refugees in accordance with Federal Law No. 390 of December 28, 2013 "On Refugees".

According to Article 10 of the Federal Law No. 326, the insured are: employment contract, self-employed, non-working citizens, children from birth to adulthood, non-working pensioners, full-time students, members of farms and family communities.

The presence of a compulsory medical insurance policy gives the insured the main right - the right to receive free medical care throughout the Russian Federation, to the extent that is fixed by the basic program of compulsory medical insurance. The policy is a kind of contract between the insured, the insurance medical company and medical institution.

The number of insured persons in the Russian Federation, according to the Federal Compulsory Medical Insurance Fund, at the beginning of 2016 is 146,548,831 people, while 5,416,817 citizens are insured in St. Petersburg. Information portal Federal Fund OMS of the Russian Federation [Electronic resource] URL: http://www.ffoms.ru// (accessed 08.02.2016).

Insurers are entities that pay insurance premiums to the CHI system to provide insured citizens with medical care in the event of an insured event.

In accordance with Art. 17 of the Federal Law No. 326, policyholders have certain rights and obligations. For example, the policyholder has the right to receive information about changes, adjustments to the conditions and amount of payment of insurance premiums, freely choose insurance organization. The insured must fulfill the following obligations: register and de-register for the purposes of compulsory health insurance, pay insurance premiums in a timely manner and in full. Clause 2 of Art. 17 of the Federal Law "On Compulsory Medical Insurance in the Russian Federation" dated November 29, 2010 No. 326-FZ. In red. dated 2015 N 432-FZ // SZ RF. 2010, No. 49, art. 6422; 2016, N1 (part I), art.52. - [Electronic resource] URL: http://www.base.consultant.ru (accessed 05.02.2016)

For the working population, insurers are employers, for the non-working population, they are executive authorities (Councils of Ministers of the republics within the Russian Federation, government controlled cities of Moscow, St. Petersburg, autonomous regions, territories, and so on). In addition, the insurers are individual entrepreneurs who use hired workers, notaries and lawyers in private practice.

The rate for insurance payments is set as a percentage of the accrued wages. As mentioned above, in 2016 this tariff is 5.1%.

The main structural units of compulsory health insurance are the Federal and Territorial Funds compulsory insurance. They are formed as autonomous non-commercial financial and credit organizations for the implementation of state support in the field of compulsory medical insurance.

The Federal Fund (hereinafter FFOMS) acts as an insurer for compulsory health insurance. We can say that this is a body of public health protection. The Fund carries out its activities in accordance with the legislation of the Russian Federation, is formed by the Federation Council and the Government of the Russian Federation.

For the most part, the Federal Fund performs the regulatory and coordinating management of the CHI system.

The Territorial Compulsory Medical Insurance Fund (hereinafter TFOMS) refers to the participants in the insurance system. This fund acts as an insurer, implementing territorial insurance programs in the territory of the country's constituent entities.

Territorial funds occupy a central place in the structure of CHI, since it is they who own the distribution and accumulation Money. They are formed in each of the subjects of the Russian Federation by the bodies of representative and executive power of the subjects and have their branches in cities and regions.

The next link in the structure of the compulsory health insurance system is medical insurance organizations, they also belong to the subjects of insurance.

An insurance medical organization (hereinafter referred to as CMO) is an organization that operates as a direct insurer. It must have a license for its activities, have a certain authorized capital for 2016 in the amount of not less than sixty million rubles, must be included in the register of medical insurance organizations. Compulsory health insurance of citizens may be covered by insurance medical organizations with any form of ownership that have a state permit (license) for the right to engage in health insurance. The main task of the insurance medical organization is the implementation of compulsory medical insurance by paying for medical care provided to citizens in accordance with the territorial program of compulsory medical insurance. HIOs control the volume and quality of medical services, as well as ensure the protection of the rights of the insured, up to the presentation of legal claims against a medical institution or health worker for material compensation for material or moral damage caused to the insured through their fault.

The role of medical healthcare institutions - polyclinics, hospitals - is to provide medical services to insured citizens in accordance with the basic and territorial programs medical insurance.

Under medical service should be understood as an event, or a set of events aimed at preventing diseases, diagnosing and curing them, having a complete meaning and a specific price.

Medical institutions, both private and public, must have a license to carry out medical activities and be included in the register of medical organizations. They can carry out their activities not only in the compulsory medical insurance system, but also in the system voluntary insurance, as well as in the system of paid services.

Medical institutions are financed by insurance medical organizations on the basis of presented invoices. Payment of bills is carried out according to tariffs in accordance with the volume of medical care provided by the institution. For outpatient clinics, such a unit of care is a medical visit, for inpatients, a completed case of hospitalization.