The Russian system of compulsory health insurance (CHI) has recently undergone major changes.

Through the joint efforts of the Ministry of Health of the Russian Federation and the Federal Compulsory Medical Insurance Fund, a number of significant innovations and reforms were implemented. The modernization of the compulsory medical insurance system and the underlying compulsory medical insurance law, adopted in 2010, were warmly welcomed by many experts and government officials. According to T.A. Golikova: “The adoption of the law on compulsory health insurance is an important stage in the modernization of healthcare. We are moving to a competitive model that puts the patient and the quality of care at the forefront.” Unfortunately, over time, some experts and officials began to publicly criticize those basic principles of the modern compulsory medical insurance system, in the development and implementation of which they themselves were directly involved.

So what did the modernization of the compulsory medical insurance system bring to Russians? How do medical insurance organizations (HIOs) and territorial compulsory medical insurance funds interact today? MK understood this.

The compulsory health insurance system was introduced in the 90s with the main goal of saving healthcare in the face of shrinking budgets and guaranteeing Russians free medical care. Compulsory medical insurance has coped with these tasks, but they have been replaced by new ones: modernization of the medical industry, introduction and wide availability of new treatment technologies, transition from medical care mainly in emergency situations to maintaining health, preventing diseases and preventing the development of severe forms of dangerous diseases. Recently, the Ministry of Health and the Compulsory Medical Insurance Fund have done a lot to develop the compulsory medical insurance system in these areas. Today, at the expense of compulsory medical insurance, a program of medical examination of the population is carried out and high-tech medical care is provided in the treatment of complex diseases.

In addition, the operating procedure of the compulsory medical insurance system is also being improved: more effective methods of payment for medical services are being introduced, new mechanisms are being created to control the quality of medical care and protect the rights of insured citizens. Thus, a uniform compulsory medical insurance policy has been introduced, according to which every citizen can receive medical care in any corner of the country. Russians received the right to independently choose clinics and medical insurance organizations.

There is huge competition in the CMO market today. There is a real struggle for patients, which means there are more and more incentives to expand the range of services and improve their quality.

Registration of the insured and issuance of the policy

By law, a patient can change their medical treatment at least every year. What to do if you decide to change your insurer or change your old-style policy to a new one? You should contact one of the regional branches of insurance companies. Regardless of which company you prefer, the insurer will tell you about the procedure for obtaining a compulsory medical insurance policy, your rights in the compulsory medical insurance system, answer all your questions, accept your application and inform you about the timing and procedure for obtaining the policy.

What happens? If you change your old policy to a new one, the insurer will check your data with the database, immediately print and issue you a temporary certificate (acts as a compulsory medical insurance policy until the latter is received), update its register of insured persons, and send the data to the territorial compulsory medical insurance fund on the same day. In turn, the territorial fund collects all applications received during the day from all insurers in the region and checks whether the information is duplicated at the level of the region's insurance carrier. Then the fund sends the received data to the general database of the Federal Compulsory Medical Insurance Fund with an application for the production of a new policy. The FFOMS is already checking the received data for duplication throughout the country and orders the production of a personalized compulsory medical insurance policy on a secure form in Goznak. As soon as it is ready, the FFOMS will send the policy to the territorial fund, where it will be transferred to the insurer. The latter will inform the citizen about the readiness of the policy and, accordingly, will issue it. In general, the production and delivery of the policy takes no more than 30 working days.

This procedure not only makes it possible for every insured person to receive medical care in any locality of the country and prevents duplication of costs, but also ensures reliable accounting and proportional financing of federal programs by region.

Professional patient support

As already mentioned, today medical insurance organizations are interested in providing the highest quality services to their insured. The patient can contact his or her health care provider regarding almost any issue related to the provision of medical care. For example, if you are asked to wait a long time to see a doctor or are delayed in getting a test done, if you feel that the medical care you received was of poor quality or if they suddenly demanded money for something you were entitled to for free, do not hesitate to contact your insurer. In any of these situations, the CMO is not only obligated, but also interested in helping you. The insurer will explain to you what needs to be done to resolve the issue, get involved in solving the problem, and call the chief doctor of your clinic or hospital where you are being treated.

If the insurer deems it necessary or at your request, the quality of care provided to you will be assessed. If violations are revealed during this inspection, the medical organization may be fined. The CMO will provide you with consulting and legal support. Now these types of controls have become a regular practice: for example, in the period 2014-2015, insurance organizations reviewed more than 60 million requests from patients. However, if it seems to you that insurers are shirking their duties, you can contact the territorial compulsory medical insurance fund with a complaint - and then the insurers themselves will be subject to inspection.

It is worthwhile to dwell in more detail on the medical-economic examination and examination of the quality of medical care provided. Today this is not only the main function of the insurer, but also the only mechanism for non-departmental control of medical organizations. By law, insurers have the right to impose sanctions on clinics or hospitals if they provide poor-quality medical care. In some cases, this turns out to be a serious incentive to improve the quality of medical services. Such examinations today are carried out by medical experts, both full-time and freelance. To prevent such examinations from being carried out for show, there is selective control by the TFOMS, which can conduct a re-examination. And if it turns out that the initial examination of the insurance company was carried out poorly, the territorial compulsory medical insurance fund will fine the insurer itself. To avoid conflicts of interest, doctors who work in organizations other than those being audited are required to conduct the examination. And in particularly difficult cases, insurers (usually federal) conduct examinations using experts from other entities and with higher qualifications from the country's leading medical organizations. In 2014-2015, based on the results of medical and economic control, 42.6 million invoices were identified, containing 52.6 million violations.

Payment for medical services

And a few more words about how medical care provided to Russians is paid for today. All money is accumulated in the FFOMS, from where it is transferred to the TFOMS, which distribute it to their “wards” HMOs depending on the number of insured and a number of other indicators. All medical organizations in each Russian region collect monthly invoices for all services and send them to insurers. For example, in the Tula region, where there are more than 60 medical organizations that are part of the compulsory medical insurance system, they all create registers of invoices for payment for medical care provided, depending on the insurance affiliation of patients and send the registers to the branches of the medical insurance company present in the local market. Insurance companies, before paying bills, conduct medical and economic control to establish the legality of payment (for example, whether the insured company is the same, whether the service is included in compulsory medical insurance, etc.). This is done to ensure that public money is used for its intended purpose.

Upon completion of the inspection, medical organizations receive payment from insurers. However, if the invoice was rejected due to a technical error, the clinic or hospital may issue a second invoice - the insurer is obliged to check it again and, if everything is correct, pay. Money to pay the bills of medical organizations appears in the accounts of health insurance providers from the TFOMS within a strictly designated period and only for 3 business days: during this time, insurers must accept and process all invoices, pay them, and return the remaining funds (if any) to the TFOMS. Violation of deadlines threatens with strict sanctions from the Federal Compulsory Medical Insurance Fund, which monitors the quality of the work of the health insurance company. TFOMS independently carry out only inter-territorial settlements (when an insured person in one region of the Russian Federation received medical care in another region). However, the volume of such payments is negligible compared to local ones carried out by the CFR.

The system of interaction built today between participants in the compulsory health insurance system, where funds and health insurance providers ensure the functioning of the entire system and the possibility of realizing the rights of citizens to high-quality and free medical care, is recognized by experts as optimal and logical. Of course, this does not mean that there is absolutely nothing more to improve. Changes in this area occur constantly. For example, on the initiative of the Ministry of Health, an institute of insurance representatives has been created and has already begun its work, whose task is to increase patients’ awareness of their rights and protect their interests even more closely.

And yet, a lot today depends on the activity of the patients themselves, on their desire to take care of their health, and for this, to constructively interact with insurers and protect their rights. If we all demand that medical services be provided to us with high quality, we can bring the level of healthcare to a level that we can rightfully be proud of.

The law provides for compulsory health insurance for all citizens in Russia. Each person becomes the owner of a compulsory medical insurance policy, on the basis of which he has the right to guaranteed medical care. But not everyone knows what range of services is included in this program. Many citizens, even after presenting an insurance policy at a clinic, are today faced with a refusal to provide medical care of one kind or another. And not everyone is ready to defend their rights. This is often due to the low level of awareness among the population about what guarantees a blue A5 sheet or a progressive plastic electronic card provides to everyone, and what scope of services the owner of one of these documents can claim. We will talk about this in this article.

The essence and purpose of the compulsory medical insurance policy

A compulsory health insurance policy is an official document that is intended to certify the right of the insured person to receive medical care free of charge to the extent provided for in the basic compulsory medical insurance program. The functions of the policy, as well as its guarantees, are determined by the Law of the Russian Federation “On Compulsory Medical Insurance in the Russian Federation” No. 326-FZ, adopted on November 29, 2010.

According to the provisions of the above-mentioned regulatory act, the owner of the policy must have it with him at all times in order to take advantage of the opportunity to receive free medical services in the required volume in the event of an insured event. Art. 16 of the law provides that in the absence of an insurance policy, a citizen can only count on emergency assistance. The insured person has the right to use the document in the medical institution to which he is attached according to his document.

Medical care under the compulsory medical insurance policy is provided to citizens absolutely free of charge and is financed from the funds of insurance funds - territorial and federal, which accumulate their funds through regular contributions from insured persons. For workers, such contributions are made by their employers from the wage fund, and for the unemployed - by the state. As a result, the entire population of the Russian Federation, regardless of age, gender, type of employment, social or financial status, has the right to service in medical institutions in equal volumes and of the same quality.

The new type of policies, the issuance of which started in 2011, are of an indefinite nature, i.e. they will be valid throughout the life of the owner, and there will be no need to replace them when changing jobs. Also, the law discussed above freed the new document from being tied to the person’s place of registration - the medical policy became valid throughout Russia. More detailed information about the procedure for registration and types of documents can be found in the articles:

What rights and guarantees does the policy provide to its owner?

Each insured citizen has the right to receive only one copy of the document, which only he himself can present. Attempts to use other people's personal data are classified as offenses and are punishable by law. The medical insurance policy provides the following rights and guarantees for insured citizens:

• Receiving free medical care within the territorial borders of Russia: while staying within your permanent place of residence - on the basis of the regional compulsory medical insurance program, and outside of it - according to the federal compulsory medical insurance program;
• Selecting an insurance medical organization (state clinic, private center, etc.) among those institutions that participate in the implementation of the compulsory medical insurance program;
• Attachment to a medical institution not by registration, but by actual place of residence (if they differ);
• Change of medical institution due to relocation (unlimited number of times) or due to personal preferences (no more than once a year);
• Selecting a treating doctor by submitting an application to the management of the medical institution;
• Obtaining complete and accurate information about the volume and quality of medical care within the framework of regional and federal compulsory medical insurance programs;
• Confidentiality and protection of personal data;
• Compensation for damage by a medical organization as a result of its failure to fulfill its obligations to the insured person;
• Protection of personal rights in the field of compulsory medical insurance.

If the owner of a compulsory medical insurance policy is faced with the refusal of medical workers to provide him with the required medical services, with the provision of poor-quality, incomplete or untimely care, the Law of the Russian Federation “On Compulsory Medical Insurance in the Russian Federation” provides for the right to file a complaint against the specified clinic. It can be addressed either to the management of the insurance organization that issued the document, or to the territorial or federal compulsory health insurance fund.

Loss or damage to the policy does not entail a complete loss of the citizen’s right to free medical care guaranteed by law. If such cases occur, a person needs to contact the insurance company for. Until this moment, he will be issued a temporary document (for one month), allowing him to use medical services to the same extent.

What medical services can be obtained under compulsory medical insurance?

The owner of a compulsory medical insurance policy has the right to receive free of charge only those medical services that are provided for by the content of the regional and federal compulsory medical insurance program. Additional payments can be required from a citizen only if the amount of medical care necessary to preserve his life or maintain health exceeds the basic one provided for by the policy. The compulsory medical insurance policy includes the following assistance:

• Emergency, which is emergency medical care necessary to eliminate a threat to human health and life;
• Outpatient, which is provided in clinics and provides for diagnostic procedures, routine medical examination, treatment of diseases at home or in day hospitals. According to the compulsory medical insurance program, outpatient medical care does not include free provision of medicines to citizens during treatment;
• Inpatient care, which takes the form of planned and emergency hospitalization in cases such as pathologies or termination of pregnancy, childbirth, exacerbations of chronic ailments, referrals from clinic doctors, and situations involving the need for intensive care.

In addition to these types of services, the compulsory medical insurance policy guarantees its owner the opportunity to use medical care associated with the use of modern high-precision technologies and techniques - both for the purpose of conducting research to make a diagnosis, and directly for treatment (with the exception of cosmetic and plastic surgery). The document of the insured person also provides that its owner can become a participant in preventive, rehabilitation, health, and information events that are organized by doctors as part of educational work with the population. For privileged categories of the population, it is also necessary when receiving free medicines.

For what diseases can you get free medical care?

The Russian Federation Law on Compulsory Medical Insurance provides for a wide range of diseases for which the policy holder can receive free diagnostics and therapy. When contacting the health care institution to which he is attached, he will need to present a document at the reception. Free medical services can be obtained if:

Compulsory medical insurance policy holders undergo routine vaccinations, as well as annual fluorography, free of charge. Having a document, you can once every three years take advantage of the opportunity to undergo examinations and medical examinations within the framework, as well as be under dispensary supervision, call a doctor at home, and undergo other free procedures provided for by law.

On the territory of the Russian Federation, a compulsory medical insurance policy can be issued not only to residents with Russian citizenship, but also to foreign citizens, stateless persons, and those with refugee status. All categories of the population are entitled to equal services in medical institutions. The only difference between the documents is their validity period: if for Russian citizens they are unlimited, then for persons temporarily staying in the territory of the Russian Federation, they are considered valid until they leave the country.

Conclusion

A compulsory medical insurance policy is issued to the insured person after concluding an agreement with a medical insurance organization. This document is proof of the right to receive free medical care under the current state guarantee program. The guarantees provided by the state for policy holders make it possible to provide qualified assistance to the most vulnerable categories of the population, for whom it would otherwise be unavailable.

Compulsory health insurance- one of the types of compulsory social insurance of citizens. It is a system of legal, economic and organizational measures that are created by the state to ensure that the insured person receives free medical care (in the event of an insured event). Implementation is carried out at the expense of compulsory medical insurance funds within the conditions established by the compulsory health insurance program.

Object of compulsory health insurance- insurance risk associated with the occurrence of an event that is an insured event.

Insurance risk- an expected event, the occurrence of which leads to the need to pay for medical care provided to the insured person.

Insurance case- an accomplished event (illness, injury, other state of health of the insured person, preventive measures), upon the occurrence of which the insured citizen is provided with insurance coverage in accordance with the territorial compulsory medical insurance program. Insured events include illnesses, injuries, other health conditions requiring medical care, as well as preventive measures.

Insurance coverage for compulsory medical insurance- fulfillment of obligations to provide (and pay for) medical care upon the occurrence of an insured event.

Insurance premiums for compulsory health insurance- payments that must be made by policyholders. Contributions are impersonal in nature, their intended purpose is to exercise the right of the insured person to receive insurance coverage. For non-working citizens, the insured are the executive authorities of the constituent entities of the Russian Federation. For workers - employers (individual entrepreneurs; individuals not recognized as individual entrepreneurs), as well as individual entrepreneurs, notaries engaged in private practice, lawyers, arbitration managers.

Insured person- an individual who is covered by compulsory health insurance in accordance with Federal Law No. 326-FZ “On compulsory health insurance in the Russian Federation” (determines the rights and obligations of the insured).

Basic compulsory health insurance program- part of the state guarantee program designed to provide free assistance. Determines the rights of the insured, implemented at the expense of compulsory medical insurance funds throughout the Russian Federation. Establishes uniform requirements for relevant territorial programs.

Territorial compulsory health insurance program- part of the territorial program of state guarantees, designed to provide free assistance. Determines the rights of the insured, implemented at the expense of compulsory medical insurance funds in the territories of the constituent entities of the Russian Federation, which meet the uniform requirements of the basic program. AlfaStrakhovanie-OMS LLC ensures the implementation of the rights of insured citizens in Murmansk and the Murmansk region, Rostov-on-Don and the Rostov region, Kemerovo and the Kemerovo region, Tver and the Tver region, Krasnodar and the Krasnodar region; Veliky Novgorod and the Novgorod region, Chelyabinsk and the Chelyabinsk region, Tula and the Tula region, Bryansk and the Bryansk region.