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

INSURER - an insurance institution that collects insurance premiums, forms 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 care 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 funds health insurance.

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 to the insured, under which they receive medical care;

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 offer a choice of 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 in within the CHI. 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 also be used in the compulsory medical insurance 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. Obtaining medical services corresponding in volume and quality to the terms of the contract, regardless of the amount 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 government bodies	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

Article 9. Subjects of compulsory medical insurance and participants in compulsory medical insurance

Federal Law No. 326-FZ in accordance with Art. 1 and Art. 9 defines the legal status and regulates the activities of the following persons:

- CHI subjects:

1) insured persons;

2) policyholders;

3) the Federal Compulsory Medical Insurance Fund (hereinafter - FOMS);

- OMC participants:

1) territorial funds of compulsory medical insurance (hereinafter - territorial funds);

2) insurance medical organizations;

3) medical organizations.

Direct insurance relations are formed between the subjects of CHI. There is no compulsory medical insurance agreement between these persons; legal relations arise by virtue of law. CHI participants carry out insurance coverage in the event of insured event.

Article 10 of Federal Law No. 326-FZ contains an exhaustive list of persons insured in the CHI system. These include citizens of the Russian Federation permanently or temporarily residing in the Russian Federation Foreign citizens, stateless persons:

1) working under an employment contract or a civil law contract, the subject of which is the performance of work, the provision of services, as well as under an author's order agreement or a license agreement;

2) self-employed (individual entrepreneurs engaged in private practice notaries, lawyers);

3) who are members of peasant (farm) holdings;

4) who are members of family (tribal) communities of indigenous peoples of the North, Siberia and Far East Russian Federation, living in the regions of the North, Siberia and the Far East of the Russian Federation, engaged in traditional economic sectors;

5) non-working citizens:

a) children from the date of birth until they reach the age of 18;

b) non-working pensioners, regardless of the basis for assigning a pension;

c) citizens studying full-time in educational institutions primary vocational, secondary vocational and higher vocational education;

d) unemployed citizens registered in accordance with the employment legislation;

e) one of the parents or guardian who takes care of the child until the child reaches the age of three years;

f) able-bodied citizens engaged in caring for disabled children, disabled people of group I, persons who have reached the age of 80 years;

g) other citizens not working under an employment contract, with the exception of military personnel and persons equated to them in the organization of medical care.

Highly qualified specialists and members of their families are not considered insured persons in accordance with the Federal Law of July 25, 2002 No. 115-FZ “On the legal status of foreign citizens in Russian Federation”, as well as persons entitled to medical care in accordance with the Federal Law of February 19, 1993 No. 4528-1 “On Refugees”. These include: 1) refugees are persons who are not citizens of the Russian Federation and who, due to a well-founded fear of being persecuted on grounds of race, religion, citizenship, nationality, membership of a particular social group or political opinion, are outside the country of their civil belonging and are unable to enjoy the protection of that country or are unwilling to enjoy such protection due to such fear; or, having no particular nationality and being outside the country of his former habitual residence as a result of such events, are unable or unwilling to return to it owing to such fear; 2) family members of a refugee - recognition as refugees of persons who are members of the same family is carried out in respect of each family member who has reached the age of eighteen.

Article 11. Policyholders

1. Insurers for working citizens are:

1) persons making payments and other remuneration to individuals (including legal entities and individuals, regardless of whether they are recognized as individual entrepreneurs):

a) organizations;

b) individual entrepreneurs;

c) individuals who are not recognized as individual entrepreneurs;

2) individual entrepreneurs engaged in private practice, notaries, lawyers.

2. Insurers for non-working citizens are the executive authorities of the subjects of the Russian Federation, authorized by the highest executive bodies of state power of the subjects of the Russian Federation.

In accordance with the Federal Law of July 16, 1999 No. 165-FZ “On the Basics of Compulsory Social Insurance”, insurers are organizations of any legal form, as well as citizens who are obliged, in accordance with federal laws on specific types of compulsory social insurance, to pay insurance premiums, and in certain cases established by federal laws, pay certain types of insurance coverage. The insurers are also executive authorities and local governments, which are obliged, in accordance with federal laws on specific types of compulsory social insurance, to pay insurance premiums for compulsory medical insurance of non-working citizens.

In accordance with Article.Article. 12, 13 of Federal Law No. 326-FZ, the MHIF insurer is the MHIF within the framework of the implementation of the basic MHI program and territorial funds in terms of the implementation of territorial MHI programs within the framework of the basic MHI program.

The Federal Fund is a non-profit organization established by the Russian Federation in accordance with this Federal Law for the implementation public policy in the field of compulsory health insurance.

In the new system of compulsory medical insurance, as part of the implementation of the basic program of compulsory medical insurance in The only organization acting as an insurer is the Federal Fund. In accordance with the new legal regulation, the Federal Fund becomes the key entity that accumulates and distributes the funds of compulsory health insurance. Legal basis of activity Federal Fund constitute the Constitution of the Russian Federation, the Budget Code of the Russian Federation, the Federal Law "On Compulsory Medical Insurance in the Russian Federation", the federal law on the budget of the Federal Fund for the next financial year, regulatory acts of the Government of the Russian Federation and the authorized federal executive body.

Article 13. Territorial funds

1. Territorial funds - non-profit organizations created 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.

2. Territorial funds exercise certain powers of the insurer in terms of the implementation of territorial programs of compulsory medical insurance within the framework of the basic program of compulsory medical insurance in accordance with this Federal Law.

3. Territorial funds exercise the powers of the insurer in terms of the additional volumes of insurance coverage established by the territorial programs of compulsory medical insurance for insured events established by the basic program of compulsory medical insurance, as well as additional grounds, lists of insured events, types and conditions for the provision of medical care in addition to the established basic compulsory health insurance program.

4. To exercise the powers established by this Federal Law, territorial funds may create branches and representative offices.

Thus, territorial funds can be created only by subjects of the Russian Federation. The federal legislator has established a special goal of their activities - the implementation of state policy in the field of compulsory medical insurance in the territories of the constituent entities of the Russian Federation. Territorial funds can use the property of the constituent entities of the Russian Federation transferred to them and the property acquired at the expense of compulsory medical insurance funds on the basis of the right of operational management (subparagraph 3 of article 34, subparagraph 9 of article 51 of the commented Law). The owner of the property of the territorial fund is the subject of the Russian Federation.

Territorial funds are not structural subdivisions of the Federal Fund.

Article 14. Insurance medical organization operating in the field of compulsory health insurance

1. An insurance medical organization carrying out activities in the field of compulsory medical insurance (hereinafter referred to as an insurance medical organization), - insurance organization licensed by federal body 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. An insurance medical organization shall exercise certain powers of an insurer in accordance with this Federal Law and an agreement on the financial support of compulsory medical

medical insurance concluded between the territorial fund and the insurance medical organization (hereinafter referred to as the agreement on the financial provision of compulsory medical insurance).

2. The founders (participants, shareholders) and management bodies of an insurance medical organization are not entitled to include employees of federal executive authorities in the field of healthcare, executive authorities of the constituent entities of the Russian Federation in the field of healthcare, local governments authorized to manage the healthcare sector, Federal Fund and territorial funds, medical organizations providing medical care under compulsory medical insurance.

3. Insurance medical organizations are not entitled to carry out other activities, except for the activities of compulsory and voluntary medical insurance, activities.

4. Medical insurance organizations keep separate records of operations with compulsory medical insurance funds and voluntary medical insurance funds, taking into account the specifics established by the regulatory legal acts of the federal executive body that performs the functions of legal regulation in the field of insurance activities, and the Federal Fund.

5. Insurance medical organizations keep separate records own funds and means of compulsory health insurance intended to pay for medical care.

6. Funds intended to pay for medical care and received by an insurance medical organization are funds for targeted financing (hereinafter referred to as targeted funds).

7. Insurance medical organizations carry out their activities in the field of compulsory medical insurance on the basis of an agreement on the financial support of compulsory medical insurance, an agreement for the provision and payment of medical care under compulsory medical insurance concluded between an insurance medical organization and a medical organization (hereinafter referred to as the agreement for the provision and payment for medical care under compulsory health insurance).

8. Insurance medical organizations are liable for obligations arising from contracts concluded in the field of compulsory medical insurance in accordance with the legislation of the Russian Federation and the terms of these contracts.

9. Medical insurance organizations, in accordance with the requirements established by the rules of compulsory medical insurance, post on their official websites on the Internet, publish in the media or bring to the attention of the insured persons in other ways provided for by the legislation of the Russian Federation, information about their activities, composition founders (participants, shareholders), financial results activities, about work experience, on the number of insured persons, on medical organizations operating in the field of compulsory medical insurance on the territory of a constituent entity of the Russian Federation, on the types, quality and conditions for the provision of medical care, on violations in the provision of medical care identified at the request of insured persons, on the rights of citizens in the field of compulsory medical insurance, including the right to choose or replace an insurance medical organization, a medical organization, the procedure for obtaining a compulsory medical insurance policy, as well as the obligations of insured persons in accordance with this Federal Law.

10. An insurance medical organization is included in the register of insurance medical organizations operating in the field of compulsory medical insurance (hereinafter also referred to as the register of insurance medical organizations), on the basis of a notification sent by it to the territorial fund before September 1 of the year preceding the year in which the insurance medical the organization intends to carry out activities in the field of compulsory health insurance. The procedure for maintaining, the form and list of information in the register of medical insurance organizations are established by the rules of compulsory medical insurance.

11. If there are no insurance medical organizations included in the register of insurance medical organizations in the territories of the constituent entities of the Russian Federation, their powers are exercised by the territorial fund until the day the activities of insurance medical organizations included in the register of insurance medical organizations begin.

In the system of compulsory health insurance main feature new legal status of medical insurance organizations is that from January 1, 2011 they have lost the status of an insurer. However, they continue to be insurance companies.

The basic concept of an insurance medical organization operating in the field of compulsory medical insurance. Firstly, only an insurance organization has the right to engage in this type of activity. Secondly, it must have special legal capacity - to have a license issued by the federal executive body that exercises the functions of control and supervision in the field of insurance activities.

The insurance medical organization may exercise certain powers of the insurer (Federal Fund) in accordance with the commented law and the agreement on the financial support of compulsory medical insurance concluded between the territorial fund and the insurance medical organization. So, according to paragraph 2 of Art. 38 the agreement on financial security should contain provisions providing for the obligations of the medical insurance organization for registration, re-issuance, issuance of the policy compulsory insurance, conducting examinations of the quality of medical care provided, carrying out activities to protect the rights and legitimate interests of insured persons, etc. According to paragraph 2 of Art. 940 of the Civil Code of the Russian Federation, an insurance contract can be concluded by drawing up one document or by delivery by the insurer to the insured on the basis of his written or oral application insurance policy signed by the insurer.

According to part 2 of Art. 4 of the current Law, an insurer is a medical insurance organization that concludes compulsory medical insurance contracts with policyholders. Thus, after the entry into force of the Law under consideration, the MHIF and territorial funds are directly involved in insurance legal relations under compulsory medical insurance.

As mentioned above, insurance medical organizations from 01.01.2011 lose the status of an insurer for CHI. However, in accordance with the provisions of h. 1 Article. 14 of Federal Law No. 326-FZ, they will be able to exercise certain powers of an insurer for CHI when exercising their rights and obligations in accordance with an agreement on financial support for compulsory medical insurance (in particular, they will issue CHI policies).

According to part 9 of Art. 14 of Federal Law No. 326-FZ, medical insurance organizations must publish on their official websites on the Internet, in the media or in other ways the following information:

about their activities,

On the composition of the founders (participants, shareholders),

On the financial performance,

About work experience

About the number of insured persons,

On the number of medical organizations operating in the field of CHI in the territory subject of the Russian Federation,

On the types, quality and conditions for the provision of medical care,

About the violations revealed at the request of the insured persons in the provision of medical care,

On the rights of citizens in the field of compulsory medical insurance, including the right to choose or replace an insurance medical organization, a medical organization,

About the procedure for obtaining a compulsory medical insurance policy,

On the obligations of insured persons in accordance with Federal Law No. 326-FZ.

Part 10 of Art. 14 of Federal Law No. 326-FZ, a medical insurance organization is included in the register of medical insurance organizations operating in the field of compulsory medical insurance, on the basis of a notification sent by it to the territorial fund before September 1 of the year preceding the year in which it intends to carry out activities in the field of compulsory medical insurance. Such an organization must have a license issued by Rosstrakhnadzor (Part 1, Article 14 of Federal Law No. 326-FZ).

In accordance with Part 11 of Art. 14 of Federal Law No. 326-FZ, if there are no organizations included in the register of medical insurance organizations in the territories of the constituent entities of the Russian Federation, their powers are exercised by the territorial fund until the day the organizations included in the specified register begin their activities.

Article 15. Medical organizations

1. For the purposes of this Federal Law, medical organizations in the field of compulsory health insurance (hereinafter referred to as medical organizations) include those having the right to carry out medical activities and included in the register of medical organizations operating in the field of compulsory medical insurance (hereinafter also referred to as the register of medical organizations) , in accordance with this Federal Law:

1) organization of any organizational and legal form provided for by the legislation of the Russian Federation;

2. A medical organization is included in the register of medical organizations on the basis of a notification sent by it to the territorial fund before September 1 of the year preceding the year in which the medical organization intends to operate in the field of compulsory medical insurance. The territorial fund does not have the right to refuse to include a medical organization in the register of medical organizations. Commission on

development of a territorial program of compulsory medical insurance in a constituent entity of the Russian Federation, other deadlines for submitting notifications by newly created medical organizations may be established.

3. The register of medical organizations contains the names, addresses of medical organizations and a list of services provided by these medical organizations within the framework of the territorial program of compulsory medical insurance. The procedure for maintaining, the form and list of information in the register of medical organizations are established by the rules of compulsory medical insurance. The register of medical organizations is maintained by the territorial fund, posted on a mandatory basis on its official website on the Internet and may be additionally published in other ways.

4. Medical organizations included in the register of medical organizations do not have the right, during the year in which they operate in the field of compulsory medical insurance, to withdraw from the number of medical organizations operating in the field of compulsory medical insurance, except in cases of liquidation of a medical organization, loss of the right to carry out medical activities, bankruptcy or other cases provided for by the legislation of the Russian Federation.

5. A medical organization carries out its activities in the field of compulsory medical insurance on the basis of an agreement for the provision and payment of medical care under compulsory medical insurance and is not entitled to refuse to provide medical assistance to insured persons in accordance with the territorial program of compulsory medical insurance.

6. Medical organizations keep separate records of operations with compulsory medical insurance funds.

7. Medical organizations established in accordance with the legislation of the Russian Federation and located outside the territory of the Russian Federation are entitled to provide types of medical care to insured persons established by the basic program of compulsory medical insurance at the expense of compulsory medical insurance in the manner established by the rules of compulsory medical insurance.

Thus, the legal regulation of the activities of medical organizations participating in the CHI program has changed.

Based on Part 1 of Art. 15 of Federal Law No. 326-FZ, medical organizations in the field of CHI include:

1) organizations of any organizational and legal form provided for by the legislation of the Russian Federation;

2) individual entrepreneurs engaged in private medical practice.

Such organizations must have the right to carry out medical activities and be included in the register of organizations operating in the field of CHI (Part 1, Article 15 of Federal Law No. 326-FZ).

The most important change concerns the procedure for including medical organizations in the relevant register.

According to part 2 of Art. 15 of Federal Law No. 326-FZ, a medical organization is included in the register on the basis of a notification sent by it to the territorial fund before September 1 of the year preceding the year in which it intends to operate in the field of CHI. The Territorial Fund has no right to refuse to be included in the register. Thus, Federal Law No. 326-FZ establishes a notification procedure for the inclusion of medical organizations in the CHI program.

In accordance with Part 3 of Art. 15 of Federal Law No. 326-FZ, the register of medical organizations will be maintained by the Territorial Fund, posted on its official website on the Internet and may be additionally published in other ways.

A medical organization included in the register, during the year in which it operates in the field of CHI, the provisions of Part 4 of Art. 15 of Federal Law No. 326-FZ it is forbidden to withdraw from the number of organizations operating in the field of CHI. Exceptions are cases:

Liquidation of the organization

Loss of the right to carry out medical activities,

Bankruptcy or other cases provided for by the legislation of the Russian Federation.

According to Part 5 of Art. 15 of Federal Law No. 326-FZ, a medical organization operates on the basis of an agreement for the provision and payment of medical care under compulsory medical insurance and is not entitled to refuse to provide medical assistance to insured persons in accordance with the territorial compulsory medical insurance program.

Accumulation and distribution of funds of the system of compulsory medical insurance is carried out Federal Compulsory Medical Insurance Fund And territorial funds of obligatory medical insurance, operating at the regional level. The Federal CHI Fund is the recipient of CHI contributions, which are then redistributed in the form of subventions between the territorial CHI funds. The Federal CHI Fund also coordinates actions in the system, collects and analyzes information, and works to improve activities.

Figure 17.1.

Territorial CHI funds distribute funds among medical insurance organizations operating in the field of CHI. These are independent commercial insurers that have received a license to conduct compulsory medical insurance and are included in the register of insurance medical organizations. In the absence of such in the territory of the subject of the Russian Federation, their powers are exercised by the territorial CHI fund or its branch (structural subdivision of the state organization). At the moment, insurance medical organizations do not work only in the Chukotka Autonomous Okrug.

Territorial CHI funds transfer funds in accordance with territorial CHI programs.

Basic program of compulsory health insurance- This is a document that determines the rights of insured persons to provide them with free medical care throughout the Russian Federation and establishes uniform requirements for territorial programs of compulsory medical insurance.

The basic program determines the types of medical care, the list of insured events, the structure of the tariff for paying for medical care, methods of payment, as well as the criteria for the availability and quality of medical care, and the standards for financial support of the program.

Note!

Free medical care under the basic program is available throughout the Russian Federation.

Territorial program of compulsory medical insurance- This is a document that defines the rights of insured persons to the free provision of medical care to them on the territory of a constituent entity of the Russian Federation.

Each territorial program includes the types and conditions for the provision of medical care, a list of insured events, determines the values ​​​​of the standards for the volume of medical care, as well as financial costs per insured person. The standard for financial support of the territorial program cannot be less than the similar standard established by the basic CHI program.

Note!

Area programs may provide additional service guarantees over the base program.

The document certifying the right of the insured person to free medical care is compulsory health insurance policy. To obtain it, a citizen will submit an application to the medical insurance organization of his choice. When applying for medical assistance, the insured person must present compulsory medical insurance policy except in cases of emergency medical care.

The right of the insured person to receive free medical care is realized on the basis of agreements concluded between CHI participants contracts:

• on the financial support of compulsory medical insurance;
• for the provision and payment of medical care under compulsory medical insurance.

Financial security agreement, concluded between the insurance medical organization and the territorial CHI fund, is a document according to which the insurance medical organization undertakes to pay for medical care provided to insured persons in accordance with the conditions established by the territorial CHI program, at the expense of targeted funds.

This contract is concluded with an insurance medical organization if it has a list of insured persons. Upon termination or suspension of a license, liquidation of an insurance medical organization, the agreement on financial support for CHI is considered terminated.

Contract for the provision and payment of medical care, concluded between the insurance medical and medical organizations - a document according to which the medical organization undertakes to provide medical care to the insured person, and the insurance medical organization undertakes to pay for it. It reflects the main function of insurance medical organizations related to the control of the volume, timing and quality of medical services provided to citizens when paying bills.

It should be noted that the insurance medical organization does not have the right to refuse the medical organization selected by the insured person and included in the register to conclude a contract for the provision and payment of medical care under compulsory medical insurance.

An insurance medical organization pays for the services of medical organizations in accordance with the adopted territorial program. In case of suspension or termination of the license, as well as liquidation of the medical insurance organization, the contract for the provision and payment of medical care is considered terminated. Similar consequences occur when a medical organization loses the right to carry out medical activities.

Insurance medical organizations have special expert commissions that conduct periodic checks in medical institutions for the correctness of the diagnosis, treatment, recommended medical procedures and medicines. If any violations are found, fines may be imposed, the relevant bills may not be paid, and other sanctions may be applied. If the insured citizen was dissatisfied with the treatment provided to him or doubts the correctness of the established diagnosis, he has the right to contact the insurance medical organization, the policy of which he has. She can conduct an inspection in this medical organization, appoint an examination, make an appropriate presentation to the health authorities that control the activities of medical institutions. Quality control is carried out both by medical experts of the insurance medical organization and by an expert commission at the territorial CHI fund. For this purpose, an analysis of the insured event, the compliance of the quality of the service provided with the standards (the correctness of the established diagnosis and treatment, the validity of hospitalization, etc.) is carried out.

As part of CHI systems all insured persons are provided with the same, standard services, therefore, it is practically indifferent to the insured, with which of the insurance medical organizations operating in a given territory, to conclude an insurance contract. To date, the differences between insurers are only in the quality of service. Its level is determined by the presence of a sufficient number of qualified personnel loyal to the insured persons, the organization and mode of operation of the dispatch service, the quality of the services of expert doctors, etc.

The procedure for paying for medical services in the CHI system is determined by the regulation adopted in the given territory - territorial tariff agreement. In it, prices for medical services are set by the territorial CHI fund, the association of insurance medical organizations, the territory administration, and the association of medical organizations.

The subjects of health insurance are a citizen, an insured, a MHIF, a medical insurance organization, a medical institution.

Policyholder

The insured is the party that insures its own health or the health of its employees. As insurers in compulsory health insurance are:
executive authorities of the constituent entities of the Russian Federation and local governments - for the non-working population;
organizations, individuals registered as individual entrepreneurs, private notaries, lawyers, individuals who have concluded employment contracts with employees, as well as paying remuneration under civil law contracts, on which taxes are charged in full accordance with the legislation of the Russian Federation in the part subject to enrollment in the compulsory health insurance funds - for the working population.
Decree of the Government of the Russian Federation of September 15, 2005 N 570 "On approval of the Rules for the registration of policyholders in the TFOMS under compulsory medical insurance and the form of the certificate of registration of the insurant in the TFOMS under compulsory medical insurance" approved the relevant Rules for the registration of insurers in the TFOMS under compulsory medical insurance.
Organizations, individuals registered as individual entrepreneurs, private notaries, lawyers, individuals who have entered into employment contracts with employees, as well as paying remuneration under civil law contracts, on which, in full accordance with the legislation of the Russian Federation, taxes are charged in part, subject to enrollment in the compulsory health insurance funds are subject to registration in the territorial compulsory health insurance fund as insurers for the working population.
The executive authorities of the constituent entities of the Russian Federation act as insurers for the non-working population.
Organizations are subject to registration as insurers in the territorial fund at their location, and registration of organizations as insurers is carried out by the territorial fund within 5 days from the date of submission in the manner established by Decree of the Government of the Russian Federation of June 19, 2002 N 438 "On the Unified State Register of Legal Entities", the federal executive body responsible for state registration legal entities and individual entrepreneurs, to the territorial fund of information contained in the Unified State Register of Legal Entities.
The said Resolution provides that information on the date of registration of a legal entity as an insured, its registration number, the name of the body that carried out the said registration, or the date of deregistration of a legal entity as an insurer, shall be submitted by the relevant bodies of state non-budgetary funds no later than 5 days from the date of registration legal entity as an insured or deregistration as an insured.
The specified information is submitted in electronic form using the means of electronic digital signature through communication channels on the terms established by agreement of the parties. The format of the transmitted information is established by the Federal tax service, and if it is impossible to transfer information in the specified form, the bodies of state off-budget funds send them by post with a return receipt.
The rules for the registration of insurers in the TFOMS under compulsory medical insurance determine that an organization that has separate subdivisions is obliged to register as an insurer with the territorial fund at the location of each separate subdivision with compulsory health insurance based on an application in the established form.
The application is submitted to the territorial fund no later than 30 days from the date of the creation of a separate subdivision with the submission of copies of documents confirming the creation of a separate subdivision (constituent documents containing information on the creation of a separate subdivision, or an order (order) on the creation of a separate subdivision and a regulation on separate subdivision); documents confirming the fulfillment by the organization of the obligation to pay tax credited to the compulsory medical insurance funds; certificates of registration of the organization as an insurer in the territorial fund at its location. These copies of documents must be notarized.
The rules for registering policyholders in the TFOMS under compulsory medical insurance provide that individual entrepreneurs, private notaries, lawyers and individuals are subject to registration as policyholders in the territorial fund at their place of residence.
In the event that private notaries carry out their activities in another place, they are subject to registration as insurers in the territorial fund at the place where this activity is carried out.
TFOMS registers individual entrepreneur as an insured within 5 days from the date of submission by the federal executive body that carries out state registration of legal entities and individual entrepreneurs to the territorial fund of the information contained in the Unified State Register of Individual Entrepreneurs, in the manner established by the Decree of the Government of the Russian Federation of October 16, 2003 No. 630.
Information on the date of registration of an individual entrepreneur as an insurer, his registration number, the name of the body that carried out the specified registration, or information on the date of deregistration of an individual entrepreneur as an insurer, shall be submitted by the bodies of state non-budgetary funds no later than 5 days from the date of registration of an individual entrepreneur as insured or deregistration as an insured.
Registration of a private notary as an insured, in accordance with the Rules for the registration of insurers in the TFOMS under compulsory medical insurance, is carried out on the basis of an application in the established form.
The application is submitted no later than 30 days from the date of issuance of the order on the appointment of a person to the position of a notary. The application shall be accompanied by notarized copies of the certificate of registration of an individual in tax authority and (or) notification of registration of an individual with the tax authority at the place of residence (at the place of business); licenses for the right of notarial activity; order on appointment to the position of a notary; documents proving the identity of the insured and confirming his registration at the place of residence.
The rules for registering policyholders in the TFOMS under compulsory medical insurance also provide for the registration of a lawyer as an insurer on the basis of an application in the established form. The application is submitted no later than 30 days from the date of issuance of the lawyer's certificate with the attachment of notarized copies of the lawyer's certificate; documents proving the identity of the insured and confirming his registration at the place of residence.
Registration of an individual as an insured is carried out on the basis of an application in the established form.
The application is submitted no later than 30 days from the date of conclusion of employment contracts with employees, as well as civil law contracts, on remuneration for which, in full accordance with the legislation of the Russian Federation, taxes are charged in the part to be credited to the compulsory medical insurance funds. Notarized copies are attached to the application. employment contract with an employee or a contract of a civil law nature, on remuneration for which, in full accordance with the legislation of the Russian Federation, taxes are charged in the part that is subject to enrollment in the compulsory medical insurance funds; documents proving the identity of the insured and confirming his registration at the place of residence.
The executive authorities of the constituent entities of the Russian Federation act as insurers for the non-working population. Their registration as an insurer is carried out in the territorial fund with compulsory medical insurance.
These bodies are registered on the basis of an application in the prescribed form, which is submitted no later than 30 days from the date of their establishment.
TFOMS maintains a register of policyholders who are registered with the territorial fund. The form of the journal is established by the Federal Compulsory Medical Insurance Fund. Among other things, for each registered insured, the territorial fund starts an insured file, in which documents related to the registration of the insured are stored.
When registering with a territorial fund, each insurer is assigned a registration number, the structure of which is approved by the Federal Compulsory Medical Insurance Fund. This registration number cannot be re-assigned to another policyholder, including after the policyholder is deregistered from the territorial fund, as well as in the event of the death of an individual.
The certificate of registration of the insured in the territorial fund in case of compulsory medical insurance, the territorial fund, within 5 days from the date of entering the account in the register of the insurers, hands over (sends by registered mail with acknowledgment of receipt) to the insurant.
When transferring funds to be credited to the income of compulsory medical insurance funds, in payment orders, as well as in other cases provided for by regulatory legal acts of the Russian Federation, the insured indicates his registration number of the insured in the territorial fund.
Amendments to the affairs of policyholders - organizations registered with the territorial fund, and their deregistration during their reorganization, liquidation, as well as when changing the location or exclusion of a legal entity that has ceased its activities from the Unified State Register of Legal Entities by decision of the registering body is carried out by the territorial fund on the basis of information provided by the federal executive body that carries out state registration of legal entities and individual entrepreneurs.
Insurers - private notaries, lawyers and individuals notify the territorial fund in writing of a change in the place of residence and other information specified during registration in the territorial fund within 10 days from the date such changes are made to the Unified State Register taxpayers.
Deregistration in the territorial fund of insurers - private notaries and lawyers is carried out in case of termination of their activities in this capacity or change of place of residence to a place of residence in another subject of the Russian Federation.
Deregistration in the territorial fund of insurers - individuals is carried out in the event of the expiration (termination) of employment contracts concluded with employees, as well as civil law contracts or a change of residence to a place of residence in another subject of the Russian Federation.
Territorial funds ensure the safety of documents and information submitted for registration of policyholders in territorial funds, in full compliance with the legislation of the Russian Federation.

MHIF

Payments for the working and non-working population are transferred to specialized financial and credit institutions - the Federal and Territorial Compulsory Medical Insurance Funds. These institutions were created on the basis of Resolution of the Supreme Council of the Russian Federation N 4543-1 dated February 24, 1993, which approved the Regulations on the Federal Compulsory Medical Insurance Fund (FFOMS) and the Model Regulations on the Territorial Compulsory Medical Insurance Fund (TFOMS).
Compulsory medical insurance funds are independent state non-profit financial and credit institutions that implement the Law of the Russian Federation "On Medical Insurance" and implement the state policy in the field of compulsory medical insurance of citizens.
To implement the state 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. Compulsory health insurance funds are designed to accumulate financial resources for compulsory health insurance, ensuring financial stability state system compulsory health insurance and equalization financial resources for its implementation (Law of the Russian Federation of June 28, 1991 N 1499-1 "On medical insurance of citizens in the Russian Federation").
The main tasks of the Federal Fund are:
security financial stability systems of compulsory medical insurance and creation of conditions for leveling the volume and quality of medical care provided to citizens throughout the Russian Federation within the framework of the basic program of compulsory medical insurance;
accumulation of financial resources from the budget of the Federal Compulsory Medical Insurance Fund to ensure the financial stability of the compulsory medical insurance system.
FFOMS performs the following main functions:
carries out alignment financial terms activities of territorial funds of compulsory medical insurance within the framework of the basic program of compulsory medical insurance;
develops and in due course makes proposals on the amount of contributions for compulsory health insurance;
carries out, in full accordance with the established procedure, the accumulation of financial resources from the budget of the Federal Compulsory Medical Insurance Fund;
allocates, in accordance with the established procedure, funds to the territorial funds of compulsory medical insurance, including on a non-refundable and repayable basis, for the implementation of territorial programs of compulsory medical insurance;
carries out, together with the territorial funds of compulsory medical insurance, control over the rational use of financial resources in the system of compulsory medical insurance, including by conducting appropriate audits and targeted inspections;
carries out, within its competence, organizational and methodological activities to ensure the functioning of the system of compulsory medical insurance;
makes, in accordance with the established procedure, proposals for improving legislative and other regulatory legal acts on issues of compulsory medical insurance;
participates in the development of the basic program of compulsory medical insurance of citizens;
collects and analyzes information, including on the financial resources of the compulsory medical insurance system, and submits relevant materials to the Ministry of Health and Social Development of the Russian Federation;
organizes, in accordance with the established procedure, the training of specialists for the system of compulsory medical insurance;
studies and generalizes the practice of applying normative legal acts on the issues of compulsory medical insurance;
ensures, in accordance with the established procedure, the organization of research work in the field of compulsory medical insurance;
participates in accordance with the established procedure in international cooperation on the issues of compulsory medical insurance;
annually submits projects to the Ministry of Health and Social Development of the Russian Federation federal laws on the budget of the Federal Compulsory Medical Insurance Fund for the next financial year and planning period and on its execution for the reporting financial year.
The formation and execution of the budget of the Federal Compulsory Medical Insurance Fund is carried out in full accordance with the budgetary legislation of the Russian Federation. The procedure for spending funds when conducting CHI, the principles of financial interaction between executive authorities, the Federal and territorial CHI funds, and other subjects of health insurance are determined by the Temporary Procedure for Financial Interaction and Spending of Funds in the System of Compulsory Medical Insurance of Citizens (approved by FFOMS on April 5, 2001 N 1518 / 21-1).
In accordance with it, from the funds received on the main accounts of the territorial fund of the part of the unified social tax, part of the unified tax on imputed income to be credited to the territorial fund, insurance premiums for compulsory medical insurance of the non-working population, as well as other revenues provided for by the legislation of the Russian Federation, the territorial fund shall carry out:
financing of insurance medical organizations according to differentiated average per capita standards for paying for medical care within the framework of the territorial CHI program;
payment for medical services provided to citizens insured by the territorial fund (in the case of compulsory medical insurance by the territorial fund);
financing of health care activities within the framework of regional targeted programs, approved in the prescribed manner, for medical institutions operating in the compulsory health insurance system;
formation of a normalized safety stock designed to ensure the financial stability of the system of compulsory medical insurance in the territory of the subject of the Russian Federation;
the formation of funds intended to provide them with managerial functions according to the standard established by the executive director in agreement with the board of the territorial fund as a percentage of the amount of all funds received, excluding the balance of financial resources at the beginning of the year.
The size of the normalized insurance stock of the MHIF is determined in the amount of at least 15 percent of the total amount of subsidies directed to the territorial funds of compulsory medical insurance for the implementation of territorial programs of compulsory medical insurance within the framework of the basic program of compulsory medical insurance.
Funds reserved in case of critical situations with the financing of compulsory medical insurance as a result of natural disasters, catastrophes, terrorist acts and other emergencies, in case of their non-use during the year, are directed at the end of the year to equalize the financial conditions for the activities of territorial funds for financing territorial programs of compulsory medical insurance of the constituent entities of the Russian Federation (decision of the board of the Federal Compulsory Medical Insurance Fund dated September 19, 2007 N 13A / 01).
The funds of the normalized insurance reserve of the MHIF are sent to the territorial fund to equalize the financial conditions for the activities of territorial funds to finance the territorial programs of compulsory medical insurance of a constituent entity of the Russian Federation for the implementation of the territorial program of compulsory medical insurance based on the application of the territorial fund.
Funds reserved in case of critical situations with the financing of compulsory medical insurance as a result of natural disasters, catastrophes, terrorist acts and other emergencies, in case of their non-use during the year, are directed at the end of the year to equalize the financial conditions for the activities of territorial funds for financing territorial programs of compulsory medical insurance of subjects of the Russian Federation.
In order to ensure the financial stability of the compulsory medical insurance system, the normalized insurance reserve in the amount of up to 10% of the funds provided for under this article is reserved in case of critical situations with the financing of compulsory medical insurance as a result of natural disasters, catastrophes, terrorist acts and other emergencies during of the year.
These funds, if they are not used during the year, are directed at the end of the year to equalize the financial conditions for the activities of territorial funds to finance the territorial programs of compulsory medical insurance of the constituent entities of the Russian Federation.
The composition of the tariff for medical and other services provided under the territorial CHI program is determined in full accordance with the current normative documents decision of the conciliation commission, which on an equal footing includes interested parties, namely: representatives of the territorial fund of compulsory medical insurance and its branches, bodies government controlled, insurance medical organizations, professional medical associations (in the absence of the latter, the interests of medical institutions can be represented by trade unions of medical workers). At the same time, a territorial tariff agreement (general agreement on prices and tariffs) is concluded.
Payment for the medical care provided is carried out by the insurer on the basis of invoices presented by medical institutions. The procedure for paying for medical care is regulated by the Regulations on the procedure for paying for medical services in the CHI system, which determines the types and methods of payment for medical services in the territory.
Medical institutions of any form of ownership, licensed to provide certain types of medical care, use the funds received in full accordance with the concluded contracts for payment for medical care (medical services) under compulsory medical insurance, for payment for medical care under the territorial CHI program, at tariffs adopted under tariff agreement on compulsory health insurance in the territory of the subject of the Russian Federation.
The funds received from the territorial fund for certain health care activities are used by medical institutions operating in the CHI system within the framework of approved targeted health care programs.
Payment for medical care is made on the basis of an agreement for the provision of medical and preventive care (medical services) under compulsory medical insurance, concluded medical institution and the insurer, and can be carried out in two ways:
1. Direct payment by the territorial fund CHI medical services provided by medical institutions (in this case, the fund or its branch acts as an insurer - performs the functions of a medical insurance organization).
2. TFOMS transfers the funds of compulsory medical insurance based on information about the concluded insurance contracts and in full compliance with the differentiated average per capita funding standard CHI insurance medical organizations that carry out settlements with medical institutions. The interaction between the compulsory medical insurance fund and the medical insurance organization, as well as their mutual responsibility, is regulated by the agreement on the financing of compulsory medical insurance and the regulation on the conduct of compulsory medical insurance by branches of the territorial compulsory medical insurance fund.
The document certifying the right of the insured to receive medical services included in the territorial program of compulsory medical insurance is an insurance policy of a single form for the entire territory of the region. In the event of an insured event with an insured person under compulsory health insurance outside the territory of insurance, medical services provided in the scope of the basic program of compulsory health insurance are paid for by the territorial CHI funds at the place of medical care.
So, thanks to the inclusion of compulsory (social) health insurance in various organizational and economic models of health care, high degree social protection of the population in terms of providing a guaranteed volume of free medical care (compulsory medical insurance program). An effective system of financing medical institutions and remuneration of doctors is being formed.
Under the compulsory medical insurance agreement, the maximum amount of obligations of the insurer for individual risk (the cost of medical care provided to a specific person during the term of the compulsory medical insurance agreement for non-working citizens and the insurance period for working citizens) is not determined.
This provision means that the duration of treatment, the number of requests for medical assistance, the provision of medicines during the provision of medical assistance to a specific person who applied for it, are not legally limited within the CHI system.
In accordance with Article 6 of the Law "On Health Insurance of Citizens in the Russian Federation", relations on compulsory health insurance of working citizens arise from the moment a citizen concludes an employment contract with an employer duly registered as a taxpayer with a territorial tax authority and paying a single social tax (contribution ) or other tax in the part calculated and paid to the compulsory medical insurance funds in full accordance with the legislation of the Russian Federation on taxes and fees.
So, the employment of a citizen automatically means that he entered into a CHI relationship, provided that the organization where he got a job is registered in the prescribed manner as a taxpayer in the territorial tax authority.
In case of voluntary medical insurance, the insurers are individual citizens with legal capacity and/or enterprises representing the interests of citizens.

Insurance medical organizations

(SMO, insurers)

Insurance medical organizations are legal entities that carry out health insurance and have a state permit (license) for the right to engage in health insurance. In accordance with Article 14 of the Law of the Russian Federation "On the health insurance of citizens in the Russian Federation", the Regulations on insurance medical organizations providing compulsory medical insurance, approved by the Decree of the Council of Ministers - the Government of the Russian Federation of October 11, 1993 N 1018, insurance medical organizations that carry out compulsory medical insurance, legal entities that are independent economic entities with all forms of ownership provided for by the legislation of the Russian Federation, possessing the necessary medical insurance authorized capital, provided for by the Law of the Russian Federation of November 27, 1992 N 4015-1 "On the organization of insurance business in the Russian Federation", and carrying out their activities on compulsory medical insurance on non-profit basis in full compliance with the legislation of the Russian Federation.
Insurance medical organizations carry out their activities on the basis of a license obtained in accordance with the procedure established by the legislation of the Russian Federation, which regulates relations on compulsory medical insurance.
So, those organizations that insure the health of citizens act as insurers or insurance medical organizations.
The relationship between the insured and the insurance medical organization in the case of compulsory and voluntary medical insurance is carried out on the basis of an insurance contract of a standard form (Appendices 1, 2, 3).
The functions of an insurance medical organization are not limited to concluding an agreement with a medical institution for the provision of medical and preventive care to the insured. The insurer is also obliged to control the volume, timing and quality of medical services in full compliance with the terms of the contract. In turn, the contract for the provision of medical and preventive care should provide for the procedure for such control.
According to D.P. Savinova, the structure of insurance medical relations is fundamentally different from insurance relations of another type by the existence of an agreement with a medical institution. While the insurer does not have such an agreement, he is not entitled to enter into insurance medical relations.
One of essential conditions said agreement- "the procedure for monitoring the quality of medical care and the use of insurance funds." Since the ϶ҭᴏ condition is declared by law as essential, failure to reach an agreement on it may lead to the fact that the contract will not be recognized as concluded. Reaching an agreement here is extremely difficult. Medical institutions categorically do not want to be controlled, and, taking advantage of their monopoly position, they simply refuse to conclude contracts that contain such a condition.
As a result, the insurer is forced to conclude a contract with a medical institution even when there are no control conditions or the control procedure is not specified, which is equivalent to the absence of such conditions. Because of this, the right of the insurer to provide medical insurance becomes doubtful, and therefore, there is a threat of sanctions (Savinov D.P., 2000).
The insurance medical organization bears material (property) liability to the insured party or the insured for failure to comply with the terms of the medical insurance contract, including for improper control of the quality of medical care provided in a particular medical institution.

Medical institutions

Medical care in the compulsory health insurance system can be provided by medical institutions of any form of ownership that have the appropriate licenses.
Treatment and prophylactic institutions, research and medical institutes, other institutions providing medical care, as well as persons providing medical activity both individually and collectively and licensed for this type of activity, are medical institutions in the health insurance system.
Relations between a medical institution and an insurance medical organization are built on the basis of a contract for the provision of medical and preventive care (medical services).
Medical institutions, together with insurers, are responsible for the volume and quality of medical services provided, for the refusal to provide medical assistance to the insured party. In case of violation by the medical institution of the terms of the contract, the insurance medical organization has the right to partially or completely not reimburse the costs of providing medical services.
The health insurance contract, which is concluded between the insured and the insurer, must necessarily indicate:
names of the parties;
the duration of the contract;
number of insured persons;
the amount, terms and procedure for making insurance premiums;
a list of medical services corresponding to programs of compulsory or voluntary medical insurance;
rights, obligations, liability of the parties and other conditions that do not contradict the legislation of the Russian Federation.
Form standard contracts compulsory and voluntary medical insurance, the procedure and conditions for their conclusion are established by the Council of Ministers of the Russian Federation.
The health insurance contract is considered concluded from the moment of payment of the first insurance premium, unless otherwise provided by the terms of the contract.

Lecture, abstract. 4.3. Subjects of health insurance - concept and types. Classification, essence and features. 2018-2019.

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About authors
LIST OF ABBREVIATIONS AND ABBREVIATIONS
INTRODUCTION
Chapter 1. CONCEPT AND ESSENCE OF LAW
1.1. The concept of law
1.2. The structure of the legal relationship
1.3. Tort and legal liability
1.4. Types of offenses
Chapter 2. MEDICAL LAW. LEGAL REGULATION OF HEALTH IN THE RUSSIAN FEDERATION
2.1. The concept of medical law
2.2. Legal support for the protection of the health of citizens in Russia
Chapter 3. PRINCIPLES OF ORGANIZATION AND FUNCTIONING OF THE HEALTH CARE SYSTEM
3.1. World Health Practices
3.2. The modern healthcare system is a system of regulated health insurance for citizens
3.3. Global concepts of health development
Chapter 4. MEDICAL INSURANCE IN RUSSIA
4.1. Stages of development of medical insurance in the Russian Federation
4.2. The concept of insurance. Features of health insurance
4.3. Subjects of health insurance
Chapter 5. RIGHTS OF CITIZENS IN THE SPHERE OF HEALTH PROTECTION
5.1. The concept and types of patient rights
5.2. Social rights and guarantees
5.3. The rights of various categories of citizens
5.4. The rights of citizens in the provision of medical care to them
5.5. Rights of stateless persons, foreigners, refugees, citizens of the Russian Federation abroad
5.6. Health Benefits
5.7. Social tax deductions
5.8. Types of violations of patient rights
Chapter 6. RIGHTS OF MEDICAL WORKERS, WAYS AND MEANS OF THEIR PROTECTION
6.1. Rights of medical workers
4. The right to insurance of a professional mistake, as a result of which harm or damage to the health of a citizen was caused, not related to the negligent or negligent performance by a medical worker of his professional duties.

Subjects of compulsory health insurance are:

insured persons;

Insurers;

Federal fund.

Participants of compulsory health insurance are:

Territorial funds;

Insurance medical organizations;

Medical organizations.

According to Article 9 of the Federal Law "On Compulsory Medical Insurance in the Russian Federation", insured persons are citizens of the Russian Federation permanently or temporarily residing in the territory of the Russian Federation, foreign citizens, stateless persons (with the exception of highly qualified specialists and members of their families), as well as persons entitled to for medical care in accordance with the Federal Law “On Refugees” (working under an employment contract, self-employed, members of farms, non-working citizens).

The insurers for working citizens are:

Persons making payments and other remuneration to individuals;

1. Organizations;

   Individual entrepreneurs;

   Individuals who do not recognize themselves as individual entrepreneurs;

Individual entrepreneurs engaged in private practice (lawyers, notaries)

The insured for non-working citizens are the executive authorities of the subjects of the Russian Federation, authorized by the highest executive body of state power of the subjects of the Russian Federation. These insurers are payers of insurance premiums for compulsory medical insurance of the non-working population.

The Federal Compulsory Medical Insurance Fund (FFOMS) is an independent non-profit institution that operates in accordance with the provisions of the Constitution of the Russian Federation, federal laws, decrees and orders of the President of the Russian Federation, decrees and orders of the Government of the Russian Federation, as well as the Charter of the Fund 10 .

The main tasks of the FFOMS are:

financial support of the rights of citizens to medical care established by Russian legislation at the expense of compulsory medical insurance;

ensuring the financial sustainability of the compulsory medical insurance system and creating conditions for equalizing the volume and improving the quality of medical care provided to citizens throughout the country under the basic program of compulsory medical insurance;

accumulation of financial resources of the FFOMS to ensure the financial stability of the compulsory health insurance system.

The financial resources of the FFOMS are formed from the following receipts:

unified social tax of business entities and other organizations on CHI in the amount in accordance with part two of the Tax Code of the Russian Federation,

appropriations from federal budget for the implementation of federal target programs within the framework of compulsory medical insurance:

voluntary contributions of legal entities and individuals

income from the use of temporarily free financial resources

income from other sources not prohibited by law,

normalized insurance stock FFOMS.

Territorial funds are non-profit organizations created by the constituent entities of the Russian Federation to implement state policy in the field of compulsory medical insurance in the territory of the constituent entities of the Russian Federation.

Currently, the implementation of state policy in the field of compulsory medical insurance, in addition to the Federal Fund for Compulsory Medical Insurance, is carried out by 86 territorial compulsory medical insurance funds, of which 2 are established in the Crimean Federal District.

An insurance medical organization is an insurance organization that has a license issued by the federal executive body that exercises the function of control and supervision in the field of insurance activities.

Medical organizations in the field of compulsory health insurance include those having the right to carry out medical activities and included in the register of medical organizations operating in the field of compulsory health insurance:

Organizations of any organizational and legal form provided for by the legislation of the Russian Federation;

Individual entrepreneurs engaged in private medical care.

The number of persons insured under compulsory health insurance as of April 1, 2015 amounted to 143.8 million people; including 60 million employed and 83.8 million non-working citizens. eleven

The object of compulsory health insurance is the insured risk, which is associated with the occurrence of an insured event.

An insured risk is an anticipated event, upon the occurrence of which it becomes necessary to incur the costs of paying for the medical care provided to the insured person 12 .

An event considered as an insured risk must have a sign of probability and randomness of its occurrence. The likelihood of illness or injury in a person is due to the fact that all living beings are subject to physical damage or disease.

The accidental occurrence of an event, upon the occurrence of which it becomes necessary for the insured person to pay for the medical care provided to the insured person, is due to the fact that such events arise all depending on the will, consciousness and actions of people.

An insured event is an event that has occurred, upon the occurrence of which the insured person is provided with insurance coverage for compulsory health insurance 13 .

In an insured event, risk events are the “starting point” for the emergence of legal relations for compulsory health insurance, and ultimately for the provision of insurance coverage to the insured person. The events that have occurred are subject to consideration as legal facts.

Insurance coverage for compulsory medical insurance is carried out upon the occurrence of an insured event. The provision, in itself, consists in the use of a number of obligations to provide the insured person in need with the necessary medical care.

1 Fundamentals of insurance activities: Textbook / Ed. ed. prof. T.A. Fedorov. - M .: Publishing house BEK, 2002.

2 of the Federal Law of November 29, 2010 No. 326-FZ “On Compulsory Medical Insurance in the Russian Federation” (as amended on January 1, 2015) URL: http://base.consultant.ru/cons/cgi/online.cgi?req=doc; base=LAW;n=171752

3 "Compulsory health insurance in the Russian Federation" // Scientific and practical journal. - 2013 - No. 6. - 22 p.

4 The Constitution of the Russian Federation // Collection of Legislation of the Russian Federation, 04.08.2014, N 31, Art. 4398.

5 Order of the Ministry of Health of Russia N 158n “On Approval of the Rules for Compulsory Medical Insurance” dated February 28, 2011 (as amended on August 6, 2015) URL: http://base.consultant.ru/cons/cgi/online.cgi?SEARCHPLUS=Ob %approval%20legal%20compulsory%20medical%20insurance&SRD=true&red=home#doc/LAW/187123/4294967296/0

6 of the Federal Law of November 29, 2010 No. 326-FZ “On Compulsory Medical Insurance in the Russian Federation” (as amended on January 1, 2015) URL: http://base.consultant.ru/cons/cgi/online.cgi?req=doc; base=LAW;n=171752

7 Decree of the Supreme Council of the RSFSR N 1920-1 "On the Declaration of the Rights and Freedoms of Man and Citizen" art. 25 // "Vedomosti SND of the RSFSR and the Supreme Council of the RSFSR" - 12/26/1991

8 MFOMS website URL: http://www.mgfoms.ru/sistema-oms/polis/

9 Andreeva E.N. "Features of the implementation and development of CHI" / V.A. Lind, V.V. Petukhova. - Medical insurance No. 2, - M .: 2005 - 89s.

10 FFOMS website URL: http://ora.ffoms.ru/portal/page/portal/top/about/general/

11 FFOMS website URL: http://ora.ffoms.ru/portal/page/portal/top/about/