Compulsory health insurance in the Russian Federation is a system that is aimed at protecting the health of the population. An essential task is to ensure the guaranteed receipt of free medical services by citizens in situations where an insured event occurs.

The objects here are the risks included in the insurance, which entail costs as a result of a person applying for the necessary services.

Members of the system include:

• . insurers;
• . individuals who have entered into an agreement and have a special policy;
• . medical institutions that have the appropriate license, which gives the right to carry out a certain type of activity;
• various CHI funds.

There are two programs that determine the amount and conditions for the provision of medical care within the free service.

• Basic program . Forms a list of cases, determines the ways in which payment can be made through the use of Money compulsory insurance. In addition, this includes the formation of criteria that determine the level of quality and accessibility of the services provided.
• Territorial . It is a component that provides guarantees for receiving free medical care exclusively within the territory of the subject of the Russian Federation in the amount established by the program.

CHI funds

Special funds play a significant role in compulsory medical insurance. They regulate and fund the costs associated with the provision of medical care insured population.
The main tasks are:

• control over the proper and correct use of CHI funds;
• formation targeted programs included in the MHIF.

Mandatory funds budget health insurance formed due to:

• appropriations from state budget;
• payments made by enterprises;
• voluntary contributions;
• income from the turnover of temporarily free funds of the MHIF.

Compulsory health insurance contributions for the working population are paid directly by employers on a monthly basis according to the established interest rate.

For compulsory medical insurance of the population, which is temporarily and permanently disabled, payments to the funds are made at the place of residence by the bodies that are part of the executive branch.

Commercial Insurance companies are direct participants in compulsory insurance. They have the right to carry out insurance activities only if they have the appropriate license. Their responsibilities include concluding agreements with medical institutions to provide free assistance to their clients, issuing compulsory health insurance policies, monitoring the quality and terms of service.

Insured citizens seek help directly from a medical institution. In this case, it is imperative to have a policy of the established sample with you.

An insurance policy of compulsory medical insurance is a document that confirms the right of an insured citizen to receive free services on the territory of the Russian Federation to the extent that the basic CHI program provides.

It must contain the personal data of the owner, the validity period and number of the insurance contract, a note on which clinic the insured person is attached to, and the contact details of the insurer. The policy entitles the holder to receive free help in all medical institutions included in the CHI register.

According to federal law No. 326, every citizen has the right to choose the insurance company where he can receive medical policy compulsory health insurance.

Re-issuance of the policy is provided in cases where:

• the full name of the insured person, his place of residence, in passport data, date or place of birth changes;
• errors have been identified in the information provided.

In this case, within a month from the moment of the changes that have occurred, the citizen must inform the relevant company about this fact and provide documents confirming it.

When changing the place of residence, if there is no insurance company to which the citizen belonged, an application is submitted to change the organization to any office operating in the region.

A duplicate of the policy is issued only if there is an application from the insured under the following circumstances:

• the policy has become unusable (some of its parts are lost, faded text, tears and other damage);
• the document has been lost.

There are currently three varieties insurance policy CHI:

• a plastic card;
• A5 sheet;
• an electronic application with a number that is applied to a universal electronic card.

Law of the Russian Federation No. 326

To date, the activities of CHI are regulated by No. 326-FZ “On Compulsory Medical Insurance in the Russian Federation”. Its main function is to control all persons acting in the CHI system. In addition, his duties include the determination of the legal provisions of objects and subjects included in the system of compulsory health insurance.

Other provisions and acts of the regions also control the relationship of all participants in the system. For every emerging insured event use its own individual procedure for its consideration.

Each institution has its own legal department, which monitors compliance with the provisions of this law.

Voluntary health insurance (VHI) provides an opportunity to receive additional medical services and emergency assistance in those areas of health protection that are not provided by the MHI. There is no law on voluntary health insurance yet, but there are related legal acts regulating this area of ​​insurance. In the event of contradictions in the process of implementing a particular VMI program, as well as in resolving disputes between the insurer and the insured persons, lawyers use several legislative acts, federal laws and articles at once Civil Code RF.

Legislative regulation

Paragraph 1 of Article 41 of the Constitution Russian Federation establishes that “everyone has the right to health protection and medical care”. MHI (compulsory health insurance), financed from the state budget or the budgets of the constituent entities of the Russian Federation and other sources, guarantees the receipt of assistance in emergency situations that threaten a person’s life, and should be provided even in the absence of a policy, free of charge.

Until January 2011 insurance activity in the country was regulated by the Law of the Russian Federation No. 1499-I dated June 28, 1991 "On the health insurance of citizens in the Russian Federation" (last edition of July 24, 2009). It defined the basic concepts, rules, participants and their interaction, regulated the work of insurance companies and medical institutions. The law considered VHI as an additional type of insurance to compulsory medical insurance. With the termination of this document, voluntary medical insurance has become an independent activity. And from January 1, 2011, Federal Law No. 326-FZ of November 29, 2010 “On Compulsory Medical Insurance in the Russian Federation” came into force, affecting the following issues:

• Definition and principles of the CHI system;
• The role of the state and subjects of the Russian Federation in insurance;
• Interaction between the parties to the medical insurance contract;
• Sources of CHI financing;
• CHI programs and their services;
• Contractual relations between insurers, policyholders and healthcare facilities;
• Implementation of control and supervision.

However, this Federal Law does not consider voluntary health insurance, therefore, most litigation and other legal practice in the field of VHI are based on separate legislative acts, as well as on the Insurance Rules, which are developed by the insurer itself, the association of insurers or the state. Usually, such rules stipulate the main provisions of the medical insurance contract.

How is DMS regulated?

To date, the rules governing voluntary medical insurance, or rather their individual parts, terms, concepts and some legal situations can be found on the pages of two main acts - in the Civil Code of the Russian Federation and the Law of the Russian Federation No. 4015-1 dated November 27, 1992 "On the organization of insurance business in the Russian Federation". Thus, the main issues of insurance are considered in the second part of the Civil Code of the Russian Federation (Chapter 48). In accordance with paragraph 1 of Article 927 of the Civil Code of the Russian Federation, insurance is carried out on the basis of contracts “concluded by a citizen or legal entity(insured) with an insurance organization (insurer). Articles 934 and 940 introduce the concept of a “personal insurance contract”.

In accordance with it, the insurer must pay for medical services provided to the insured person upon the occurrence of an insured event, in an amount not exceeding sum insured and the insurer must pay insurance premiums. The contract is concluded in writing. Article 942 provides essential conditions of the contract: the insured person (the policyholder or another person can become it), insured events, the amount of insurance, the term of the contract. According to Article 943, the terms of the contract are determined by the rules in force in the insurance company (or association of the IC), and the insured and the insurer can "agree to change or exclude certain provisions of the insurance rules and to supplement the rules."

Law of the Russian Federation No. 4015-1 covers such issues as the goals of insurance, participants in insurance activities, and offers basic definitions: insurance risk, amount, premium, tariff, case, financial support of insurance companies, supervision in the insurance industry. According to Law No. 4015-1, insurance rules have the force of an internal regulatory document of the insurance company and must be observed by both parties entering into the contract. In addition, the documents signed by the parties to the transaction for the implementation of voluntary medical insurance also have legal force.

Medical insurance rules and contract features

The relationship between the insurance company and the insured is determined by the contract and insurance rules. These documents are of great importance in resolving disputes. At the time of execution of the contract, the insured should carefully read the terms and conditions of the insurer, check that the agreement contains all the necessary points. The insurance rules and the composition of the VHI agreement are largely similar for most insurers, and they contain:

• Basic terms;
• Participants and objects of medical insurance;
• Definition of insured risk and event;
• Sum insured and insurance premiums;
• Conditions for concluding and terminating the contract, period of validity;
• Rights and obligations of participants;
• Insurance payment;
• Personal information;
• Resolution of disputes;
• Other conditions.

In accordance with the Rules, a VHI agreement is drawn up, which determines the procedure and conditions for the insured person to receive medical services. It is agreed and signed by both parties. The main sections of the document include information about the policyholder, insured persons and the insurance company; insurance program; scope of services, procedure and time of their receipt; medical organizations; the procedure for paying insurance premiums; sum insured; responsibility and rights of participants. In addition to these sections, the contract must also have sheets with applications. They include all the necessary additions, as well as non-standard solutions or services for a particular policy. In addition, the annexes detail the VMI programs, the insurer's tariffs, and the appearance of the policy. A medical questionnaire is attached to the document, if necessary.

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

Legislative acts regulating the CHI system

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

• Law No. 326-FZ "On Compulsory Medical Insurance in the Russian Federation";
• government decree No. 1403 “On the program state guarantees free provision of medical care to citizens for 2017 and for the planning period of 2018 and 2019”, which contains the basic CHI program. This document, in particular, explains what is included in the CHI in 2017;
• a number of other acts that allow citizens to receive a minimum guaranteed volume of services.

Who is eligible for free medical care?

Both Russians (indefinitely) and stateless persons of the Russian Federation (with a limited validity period) can receive a compulsory medical insurance policy. The presence of this document means that the patient is under the protection of the insurance company with which he entered into an agreement.

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

List of services under the CHI policy

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

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

- in cases of exacerbation of diseases;
– in the direction of treatment and operations (among the available services are chemotherapy, removal of prostate adenoma, treatment of diseases in gynecology, etc.);
– medical services for pregnant women, as well as childbirth, recovery after them, abortions;
- when intensive care is required (for poisoning, severe injuries);

• high-tech;
• palliative.

The last item on severe illness was added in 2017. In total, the basic list includes about 20 cases for which free medical care is available.

Is it allowed to carry out therapeutic massage, remove papillomas, warts - does the CHI policy provide such procedures, what is included in the program? To take a massage course free of charge will allow the presence of indications for the procedure. As for skin defects, the operation will be performed free of charge if the growth bleeds or is damaged, that is, there is a danger to the life and health of the patient.

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

From time to time, the media report on public initiatives to add or remove this or that service from the list. For example, earlier proposals were discussed to exclude abortions from the mandatory health insurance system and include the work of a nutritionist in it, but they were not reflected in legislative acts.

Dental services under the MHI policy

Is free dentistry available under the CHI policy? This question is of interest to many, since the services of dentists, as you know, are not cheap. So, what opportunities does dentistry provide under the CHI policy, what is included in the free service?
A visitor to a clinic participating in the CHI system can expect:

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

It should be remembered that there are also restrictions on the services of dentists. For example, filling will not require payment of a fee if a cement material is used during the treatment. But a light seal will not be installed for free.

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

How can I find out if a service is included in the CHI program?

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

The level of physical, mental and social well-being is defined as a person's health. The right to protection and protection of health is enshrined in paragraph 1 of Article 41 of the Constitution of the Russian Federation.

Health is the highest blessing given to a person, without which everything else loses its meaning. Each person should take care of their own health, but society is also obliged to create conditions for maintaining and improving the health of its members. This set of measures is called medical care.

The Constitution of the Russian Federation declares human life and health as the highest value. Guided by this principle, emergency medical care in the event of a threat to human life is provided in the absence of a medical policy or other form of payment for this service.

Insurance plays an important role in the complex of measures to protect the right to health.

Types of life and health insurance coverage. All citizens of the Russian Federation are participants in the system of compulsory medical insurance (OMI). Regulates relations in the system Federal Law No. 326-FZ of November 29, 2010. "On Compulsory Medical Insurance in the Russian Federation".

The insurers are: for non-working citizens - the executive committees of the constituent entities of the Russian Federation and self-government bodies. For the working population - organizations, enterprises, individual entrepreneurs and other individuals who have entered into labor and civil law contracts involving remuneration.

Insurers are medical organizations licensed to provide medical insurance.

Under the MHI program, citizens are provided free of charge:

emergency care in conditions threatening life and health caused by sudden illnesses, accidents, exacerbations of chronic diseases, difficult childbirth or pregnancy complications;

outpatient care, including prevention, diagnosis, including in specialized diagnostic centers, home treatment and day hospitals;

· inpatient care;

Placement in isolation rooms according to epidemiological indicators;

planned hospitalization for diagnosis, treatment and rehabilitation;

assistance in case of pathology of pregnancy, childbirth and abortion;

Assistance during the neonatal period.

The financial base of compulsory medical insurance is formed at the expense of deductions of insurers in federal fund compulsory medical insurance, as well as at the expense of receipts from economic entities to the territorial funds of compulsory medical insurance. Evasion of policyholders - enterprises or organizations, from paying insurance premiums or understating the base from which the premium is paid, entail penalties.

Insurers interact with medical institutions and bear legal and financial responsibility for the volume and quality of the medical services they provide. In case of violation of the conditions for the provision of medical services, the insurer has the right to refuse to pay for the services to the medical institution, or to make it in full.

CHI standards regulate the financing of medical institutions of the compulsory health insurance system. According to the existing International Classification of Diseases ICD-10, for example, with influenza of any form, it is necessary to take tests and measure temperature. Nothing else is included in the flu treatment program.

Previously, until 2011, voluntary medical insurance (VHI) was regulated by the Law of the Russian Federation of 06/28/1991. No. 1499-1 "On medical insurance of citizens of the Russian Federation". Adopted in 2010 new law Russian Federation on compulsory medical insurance. In it, the issue of voluntary health insurance was not considered.

Currently, VHI is regulated by the provisions of the Civil Code of the Russian Federation on insurance and the Law of the Russian Federation of November 27, 1992 No. No. 4015-1 "On the organization of insurance business in the Russian Federation".

Voluntary health insurance, where the insured is individual, which, as a rule, is also insured, for a number of reasons has not yet become widespread. Low insurance culture, insufficient awareness of the population about the essence of the services offered, the ongoing incompetence and lack of professionalism of some insurers are the main reasons for the “underdevelopment” of this segment of the insurance market.

The situation is much better with regard to VHI, where the insured is a legal entity. In this case, the owner or administration of the enterprise receive a number of undeniable advantages. So, according to the Federal Law of the Russian Federation of 24.07.2007 No. "On amendments to part two tax code RF” the amounts spent by the employer on the insurance of employees are charged to the payroll fund and are deducted from the taxable base.

Insured employees who have the opportunity to receive medical care in medical institutions of the VHI system are more motivated to perform their duties in a quality manner and are loyal to the organization that provided them with this type of social package.

Some of the benefits of the VHI program:

Possibility to choose any medical institution within the given price category;

round-the-clock opportunity to receive qualified advice by phone;

The program may include a number of expensive diagnostic methods, such as computed tomography or magnetic resonance imaging;

dental care.

A clinic with a narrow specialization often has more modern and expensive equipment, unlike budget polyclinics. There are many options for the cost and volume of services provided in the VHI system.

Another type of protection of life and health. This is long-term life insurance (LTLI).

The essence of the proposal is that a citizen enters into a long-term contract (5, 10, 15, 20, 25 years, etc.) with an insurance company for the financial protection of life and health in the event of an accident that resulted in injury, disability or death of the insured person. There are programs to provide financial assistance for treatment in case of diagnosing a number of deadly diseases such as cancer, heart attack, stroke, paralysis, coronary artery bypass grafting, organ transplantation, terminal renal failure in the insured.

If the end of the insurance period is successfully reached, the client receives back the insurance premiums he has paid.

The concept of compulsory health insurance

Compulsory health insurance (CHI) is at the heart of the functioning Russian system healthcare. In accordance with the law, all citizens included in the insurance system are entitled to receive free medical care throughout the Russian Federation. Federal Law No. 326-FZ of November 29, 2010 (as amended on February 6, 2019) "On Compulsory Medical Insurance in the Russian Federation" gives the following definition of CHI:

Compulsory health insurance- a type of compulsory social insurance, which is a system of legal, economic and organizational measures created by the state aimed at ensuring, in the event of an insured event, guarantees of free provision of medical care to the insured person at the expense of compulsory medical insurance within the limits of the territorial program of compulsory medical insurance and in cases established by this Federal Law within the framework of the basic program of compulsory medical insurance.

The priority of the development of insurance in the social sphere is also perceived in the provisions of the Constitution of the Russian Federation, which proclaims the promotion of voluntary social insurance, and guarantees of free medical care are provided at the expense of the relevant budget, insurance premiums, and other revenues (clause 3, article 39, clause 1, article 41).

Principles of compulsory health insurance

Compulsory health insurance as an object of legal regulation is endowed with a system of principles. They are reflected in the Federal Law "On Compulsory Medical Insurance in the Russian Federation".

Each of the above principles of compulsory health insurance needs to be considered separately. You should start with the principle of providing free medical care to the insured person in the event of an insured event. This principle is built on the basis of Article 41 of the Constitution of the Russian Federation. Compliance with this principle guarantees that every person in need will receive certain types of medical care free of charge. Medical assistance is provided free of charge within the framework of the territorial program of compulsory medical insurance and the basic program of compulsory medical insurance.

Of no less interest is the principle of sustainability of the financial system of compulsory health insurance. It means that the presence of effective economic levers with the help of which the state provides continuous and timely financing of obligations within the framework of compulsory health insurance relations, in particular, the timely transfer of funds from the budget to medical and medical organizations. In fact, financial system compulsory health insurance proclaimed autonomous.

Then the principle of obligatory payment by insurers of insurance premiums for compulsory health insurance is considered. Like any insurance, compulsory health insurance is provided mainly at the expense of the funds that the insurer receives from the insured.

An equally important principle of CHI is the state guarantee of protection of insured persons from social risks. The state ensures the observance of the rights of the insured persons to the fulfillment of obligations for the obligatory occurrence of expenses by the Insurer, and the claim for damages was rightfully dismissed.

The principle of creating conditions for ensuring the availability and quality of medical care provided under compulsory health insurance programs allows citizens to have full access to medical services and gives the right to demand high quality medical care.

Normative legal acts regulating compulsory medical insurance in the Russian Federation

Legislation in the field of regulation of legal relations in CHI is constantly evolving. The legal foundations of compulsory health insurance are laid down in the Federal Law of November 21, 2011 N 323-FZ "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation". This legal act defines:

• legal, organizational and economic fundamentals protection of the health of citizens;
• the rights and obligations of a person and a citizen, certain groups of the population in the field of protecting the health of citizens, guarantees for the implementation of these rights;
• the powers of state authorities of the Russian Federation, state authorities of the constituent entities of the Russian Federation and local governments in the field of protecting the health of citizens;
• rights and obligations of organizations, individual entrepreneurs when carrying out activities in the field of protecting the health of citizens;
• rights and obligations medical workers and pharmaceutical workers.

The principle of observance of the rights and freedoms of citizens of the Russian Federation is put in the first place in this Law.

The next most important regulatory legal act in terms of establishing the legal framework in the field of compulsory medical insurance is the Federal Law of July 16, 1999 N 165-FZ FZ "On the Fundamentals of Compulsory Social Insurance". This Law, in accordance with the generally recognized principles and norms of international law, regulates relations in the system of compulsory social insurance, determines the legal status of subjects of compulsory social insurance, the grounds for the emergence and procedure for exercising their rights and obligations, the responsibility of subjects of compulsory social insurance, and also establishes the foundations for state regulation of compulsory social insurance.

Law of the Russian Federation of November 27, 1992 N 4015-1 (as amended on November 28, 2018) "On the Organization of the Insurance Business in the Russian Federation" (as amended and supplemented, entered into force on January 1, 2019) regulates relations between persons engaged in activities in the field of insurance business, or with their participation, relations for the implementation of state supervision over the activities of insurance business entities, as well as other relations related with the organization of the insurance business.

Federal Law No. 212-FZ of July 24, 2009 "On Insurance Contributions to Pension Fund of the Russian Federation, the Social Insurance Fund of the Russian Federation, the Federal Compulsory Medical Insurance Fund" regulates relations related to the calculation and payment (transfer) of insurance premiums to various funds.

The Tax Code of the Russian Federation determines the procedure for paying taxes and fees for any organization. The special composition has the norm of Art. 294.1 of the Tax Code of the Russian Federation, which contains the specifics of determining the income and expenses of insurance companies providing compulsory health insurance. According to Article 294.1 of the Tax Code of the Russian Federation, the income of insurance organizations providing compulsory medical insurance, in addition to the income provided for in Articles 249 and 250 of the Tax Code of the Russian Federation, includes funds transferred territorial funds compulsory health insurance (TFOMS).

The main parameters for the implementation of compulsory medical insurance are enshrined in the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Medical Insurance in the Russian Federation". In its provisions, the Law on Compulsory Health Insurance contains key tools for achieving long-term goals and objectives.

The laws of the constituent entities of the Russian Federation, in contrast to federal laws and the laws of the Russian Federation have a limited scope - only within the limits of the subject by which this regulatory legal act was adopted. Federal authorities The executive branch adopts normative acts based on the provisions of laws and not contradicting them.

An important place is occupied by the Rules of Compulsory Medical Insurance, which are approved by the Order of the Ministry of Health and Social Development of Russia of February 28, 2011 N 158n (as amended on January 11, 2017) "On Approval of the Rules of Compulsory Medical Insurance" (Registered in the Ministry of Justice of Russia on March 3, 2011 N 19998). These rules regulate the basics of the functioning of the CHI. This is reflected in the figure below.

The procedure for concluding compulsory medical insurance agreements is regulated by Chapter 28 of the Civil Code of the Russian Federation. International Treaties The Russian Federation, along with the generally recognized principles and norms of international law, are an integral part of legal system RF.

Currently, there are a number of agreements on health insurance for citizens of the Commonwealth of Independent States, who are temporarily in Russia. Regional rule-making is designed to reflect the territorial features in the field of compulsory health insurance. However, this process is often plagued by general problems in the formation of legal acts that do not always take into account the system of legislation.

Important elements of the legal regulation of CHI are territorial programs of compulsory medical insurance. According to paragraph 9 of Art. 3 of Law N 326-FZ, the territorial program of compulsory medical insurance is an integral part of the Territorial program of state guarantees for the provision of free medical care to citizens, developed and approved in the subject of the Federation in the manner established by the Government of the Russian Federation.

Territorial CHI program defines the rights of insured persons to free medical care on the territory of a constituent entity of the Federation and meets the uniform requirements of the basic program of compulsory medical insurance.

The CHI Law requires a significant amount of by-laws regulatory framework, allowing to provide in practice the mechanism of obligatory medical insurance.