The system of compulsory health insurance is funded. Compulsory health insurance
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Discipline: finance COURSE WORK
ontopic:« Fundscompulsorymedicalinsurance,theirroleVfundingexpensesonhealthcareVRussianFederations"
Introduction
1.3 Income and expenses of the MHIF
Conclusion
Bibliography
medical insurance financing income
Introduction
"Required health insurance”, this topic is very relevant at the present time, since compulsory medical insurance is one of the most important elements of the health care system and obtaining the necessary medical care in case of illness.
In conditions when, as a result of deepening market reforms, the social and property stratification of society is clearly visible, it was necessary to develop a clear concept of social and medical protection.
The object of compulsory medical insurance (CHI) is the cost of medical care, health-related costs. A mandatory form of organization of health insurance should serve as a guarantee of providing all citizens of the country with medical care on the same terms.
The general assessment of the state of public health of the population of Russia is very unfavorable and indicates a serious ill-being, which can lead to a deterioration in the quality of life of the population and limit its creative participation in improving the socio-economic situation in the country.
The purpose of the work is to dwell on the most important part of this concept - compulsory health insurance for Russian citizens, to consider the problems associated with the development and implementation of this system in the Russian Federation.
Achieving the goals of course work involves solving the following tasks: consideration of the need to create CHI; essence of health insurance, its forms and subjects; income and expenses of the MHIF; calculation and use of the CHI fund; analysis of incomes and expenses of the federal compulsory medical insurance fund; problems of CHI in Russia and ways to solve them.
Compulsory health insurance is an integral part of the social insurance system. The creation of off-budget funds (pension, employment, social insurance, compulsory medical insurance) was the first organizational step in an attempt to reform the social insurance system in Russia.
As a result of the reform of the social insurance system with a socially oriented market economy The following main goals must be achieved:
the formation of various types of social insurance and its extensive infrastructure, which makes it possible to provide social guarantees to insured citizens;
construction of insurance systems, taking into account professional and regional characteristics, providing accurate calculation financial resources sufficient to fulfill obligations under specific types of insurance;
mandatory participation of employees in contributions to most types of social insurance and increasing their responsibility for shaping their living conditions;
implementation of social insurance by structures under the direct jurisdiction of the state;
development of self-government and self-regulation mechanisms in insurance structures.
All of the above can be attributed to the system of compulsory health insurance. Of course, it is very difficult to achieve these goals right away. However, despite all the problems associated with the introduction of compulsory medical insurance in Russia, organizationally this system has already been introduced.
In the course of writing term paper it is necessary to consider and study legal acts: including presidential decrees; government regulations; federal laws, as well as official sources of information, such as the official website of the Mandatory Medical Insurance Fund, the website of the Ministry of Finance of the Russian Federation and others. In the process of analyzing and summarizing information, various methods were used:
Theoretical - analysis of literature, materials, documentation, terms, etc.;
Empirical - knowledge by experience: comparison, measurement, calculation.
The first chapter deals with the theoretical foundations of the compulsory health insurance system.
The second chapter analyzes the income and expenses of the Compulsory Medical Insurance Fund of the Russian Federation and identifies the main problems of its development.
The time period for which the calculations were made is from 2013 to 2015.
1. Theoretical foundations of the compulsory health insurance system
1.1 The need to create CHI
One of the main reasons for the introduction of compulsory health insurance was the need to improve health care, since previously allocated funds from the state budget did not reach polyclinics and hospitals, being scattered for needs far from the needs of medicine.
The second reason was the urgent need to improve the quality of medical care. No wonder it was said: "to be treated for nothing - to be treated for nothing."
The third reason was, in essence, the "serf" attachment of the inhabitants to their district, rural and city polyclinics at the place of residence.
The purpose of the organization of compulsory medical insurance was to provide medical care on legislative terms in guaranteed amounts to all categories of citizens at the expense of capitalized Money received by collecting taxes paid by employers and insurance premiums of executive authorities and local self-government. The system of compulsory health insurance has become an integral part of the state system social protection of the population and a financial mechanism for providing additional funds to budget allocations for financing health care and paying medical services. Asotova T.A., Prokhorov E.V. Influence of the fund of obligatory medical insurance on the effectiveness of the development of the healthcare system // Bulletin of the North-Eastern State University. - No. 19. - 2013. - S. 68-71. The introduction of compulsory health insurance essentially turned into a simple redistribution of funds in health care. Since there were not enough funds to fully finance the provision of medical care to the population, the state authorities decided to delegate powers to regional authorities to introduce compulsory medical insurance on their territory, which led not only to significant territorial differences in the speed and scope of the reform, but also in the formation various models of compulsory health insurance in the regions. Matinyan N.S. Reforming national health care systems as an adaptation to global processes // [Electronic resource]: Information and analytical bulletin "Social aspects of public health". - 2008 - № 3. - URL:: http://vestnik.mednet.ru/content/view/74/30/lang,ru/. It is clear that the system compulsory insurance became unwieldy, the money spent on insurance was not controlled by the main payers, and as a result, the activities carried out did not have a significant impact on the main trends in the development of health care. At the same time, voluntary medical insurance in Russia has not been developed due to the imperfection of the legal and regulatory legislation. In contrast to the Dutch model, in our country this insurance was provided as additional, provided that the majority of the country's population is insolvent. Alekseev V.A., Borisov K.N. Problems of health care reorganization in Russia // Mir. - 2011. - No. 2. - S. 66 - 72.
In the context of the lack of funds allocated for healthcare and the difference in financing of medical organizations at various levels and various subjects, the state guaranteed free medical care inherited from Soviet times, which includes a wide range of services for all population groups. The reality of the established set of free medical care was that the actual availability of services differed significantly for different groups of the population, depending on the territorial residence and their social affiliation.
In turn, in the conditions of formation market system in Russia, in order to ensure equal opportunities for citizens to receive medical care, one of the elements of health care policy has become the constitutional fixing private system healthcare. In practice, the necessary legislative, economic, and social conditions for the development of the private sector were not created. The way out was a simple market solution, allowing state medical organizations to provide additional paid services to the population in excess of the free medical care standards. Antonova N.L. Formation of the practice of compulsory medical insurance in Russia: problems and contradictions // Scientific and theoretical journal "Scientific problems of humanitarian research". - 2011. - Issue. 2 - S. 230 - 235.
Yu.T. Akhvlediani and V.V. Shakhov. According to the interpretation of scientists, health insurance is a set of types of insurance in case of loss of health due to illness or accident, providing for the obligations of the insurer to make insurance payments that compensate additional expenses the insured, caused by applying to a medical institution for medical services included in the insurance program. Akhvlediani Yu.T., Shakhov V.V. Insurance. M.: UNITI-DANA, 2012. S. 318.
The compulsory health insurance system was created to ensure the constitutional rights of citizens to receive free medical care, enshrined in Article 41 of the Constitution Russian Federation.
Health insurance is a form of social protection of the population's interests in health protection. The Constitution of the Russian Federation was adopted by popular vote on December 12, 1993//Rossiyskaya Gazeta. -2010. -st. 41
The most important regulatory legal act regulating compulsory health insurance is the Federal Law of the Russian Federation of November 29, 2010 No. 326-FZ "On Compulsory Health Insurance in the Russian Federation" (hereinafter - Law FZ No. 326).
Law FZ No. 326 establishes the legal, economic and organizational foundations for medical insurance of the population in the Russian Federation, determines the means of compulsory medical insurance as one of the sources of financing medical institutions and lays the foundations for the insurance model of healthcare financing in the country. Federal Law of the Russian Federation of November 29, 2010 No. 326-FZ "On Compulsory Medical Insurance in the Russian Federation"
Compulsory medical insurance is an integral part of state social insurance and provides all citizens of the Russian Federation with equal opportunities to receive medical and drug assistance provided at the expense of compulsory medical insurance in the amount and on conditions corresponding to compulsory medical insurance programs.
To implement the state policy in the field of compulsory medical insurance of citizens, the Federal and territorial funds of compulsory medical insurance have been created.
The introduction of CHI in our country makes it possible not only to choose a polyclinic, but also an attending physician. According to only one insurance company, 10% of patients chose to change the medical institution to which they were attached. Insurance companies are an important factor in raising the quality of medical care, since, according to the decision of the expert council, the doctor can pay out of his own pocket for poor patient treatment.
In health insurance, the figure of a private practitioner has appeared. By legalizing private specialists, putting them on equal starting conditions, including in taxation, with other doctors, they created the conditions for the development of competition in healthcare, which, of course, is only to the benefit of patients.
According to the law, a doctor working in the primary care system was given the opportunity to become the manager of the entire amount of funds allocated for the medical care of patients. In other words, fundamentally change functional responsibilities doctor. He becomes responsible for everything - both for the provision of primary care and for the rehabilitation of the patient, paying for the services of consultants, treatment in a hospital, etc.
1.2 The essence of compulsory health insurance, its forms and subjects
Compulsory health insurance (CHI) is a type of compulsory social insurance, which is a system of legal, economic and organizational measures created by the state aimed at ensuring, in the event of insured event, guarantees of free provision of medical care to the insured person at the expense of compulsory medical insurance within territorial program compulsory medical insurance and, in cases established by the Federal Law, within the framework of the basic program of compulsory medical insurance. Federal Law No. 326-FZ of November 29, 2010 (as amended on December 28, 2013) “On Compulsory Medical Insurance in the Russian Federation”
Within the framework of the basic program of compulsory medical insurance, primary health care is provided, including preventive care, emergency medical care (with the exception of specialized (sanitary and aviation) emergency medical care).
In addition, the following types of medical care are provided to residents of the Russian Federation at the expense of the Russian budget:
· emergency medical care provided by stations (departments, points) of emergency medical care;
outpatient clinic and inpatient care provided in specialized dispensaries, hospitals (departments, offices) for the following diseases: sexually transmitted diseases; contagious skin diseases (scabies, microsporia); tuberculosis; diseases caused by especially dangerous infections; acquired immunodeficiency syndrome; mental and behavioral disorders; narcological diseases;
provision of expensive types of medical care, the list of which is approved by the Health Committee;
• preferential drug provision and prosthetics (dental, eye, ear);
· Vaccination prophylaxis of the decreed contingent and the population according to epidemiological indications;
Carrying out preventive fluorographic examinations for the purpose of early detection of tuberculosis;
medical care for congenital anomalies (malformations), deformities and chromosomal disorders in children and certain conditions that occur in the perinatal period, in accordance with the list approved by the Health Committee;
· dental and oncological medical care, in accordance with the list approved by the Health Committee of the Russian Federation.
The CHI insured - in the Russian Federation - is a subject of compulsory medical insurance (CHI), obliged in accordance with the Law "On Compulsory Medical Insurance in the Russian Federation" dated November 29, 2010 N 326-FZ to conclude CHI agreements in relation to a certain category of citizens, endowed with for this purpose certain rights and burdened with certain duties.
An exhaustive list of categories of insurers is defined by the specified law:
1. executive authorities of the constituent entities of the Russian Federation or local governments in relation to non-working citizens living in the relevant territory,
2. organizations (legal entities),
3. individuals registered as individual entrepreneurs,
4. Notaries dealing with private practice,
5. lawyers,
6. individuals who have entered into employment contracts with employees and paying insurance premiums on them - in relation to their employees, as well as in relation to themselves for categories. Law "On Compulsory Medical Insurance in the Russian Federation" dated November 29, 2010 N 326-FZ
Insurance medical organizations are specialized organizations that exercise certain powers of insurers in the CHI system and exercise financial control over the work of medical institutions. Work in compulsory medical insurance not on the basis of insurance contracts, but on the basis of contracts for the provision and payment of medical care under compulsory health insurance. Letter of the Russian Ministry of Finance No. 02-05-11/39643 dated September 24, 2013 The largest medical insurance organizations at the beginning of 2012 were MAKS-M (14% of the market), ROSNO-MS (12% of the market), SOGAZ-Med ” (9% of the market), Rosgosstrakh-Medicina LLC (6% of the market) and CJSC Capital Medical Insurance (5% of the CHI market) (the last two companies are part of the Rosgosstrakh group of companies) . Presentation of Rosgosstrakh Group
· with regard to the form and conditions of its conclusion, it is regulated by the Government of the Russian Federation;
· is an agreement between the insured and the insurer - an insurance medical organization (CMO), according to which the latter undertakes to organize and finance the provision of medical care to citizens subject to insurance;
contains the name of the parties, the validity period, the number of citizens subject to insurance, the procedure for providing and updating the list of citizens subject to insurance, as well as the procedure for making insurance premiums;
includes as integral parts: (1) Territorial Program state guarantees provision of free medical care to the population of a constituent entity of the Russian Federation, approved in accordance with the established procedure and determining the volume, quality and conditions for the provision of medical care to citizens subject to insurance; (2) a list of medical institutions agreed by the parties that provide medical care to citizens under compulsory medical insurance;
rights, obligations, responsibilities of the parties and other conditions that do not contradict the laws.
On January 1, 2011, a new federal law on compulsory medical insurance in the Russian Federation came into force, according to which, from May 1, 2011, new rules for issuing compulsory medical insurance policies are introduced and a uniform compulsory medical insurance policy is introduced. Those citizens who receive such a document for the first time should contact their chosen medical insurance organization. First, the citizen is issued a "temporary certificate" confirming the execution of the policy, which is valid for 30 working days. During this time, a personal policy will be prepared for the citizen. As soon as the document is ready, the insured will be notified of this and exchanged for him a "temporary certificate" for a policy. New CHI policies a single sample will not need to be changed upon dismissal, changing jobs or moving to a new place of residence. Replacement of old policies with new ones will be carried out gradually during 2011-2013. CHI reform: overripe fruit turned green // Finmarket. -- June 7, 2010.
participation in all types of health insurance;
Free choice of insurance medical organization;
Monitoring the fulfillment of the terms of the MHI agreement.
The listed rights of the insured are determined by the above Law and are actually declarative.
So the right of the insured under CHI to participate in all types of health insurance means only the possibility of his simultaneous participation in voluntary health insurance (VHI).
The right of certain categories of the insured (executive authority of a constituent entity of the Russian Federation, local government, state, federal, municipal organizations, etc.) to freely choose an insurance company is limited by the requirement of another Law of the Russian Federation to hold a tender for its selection. The result of the tender is, as a rule, a significantly narrowed list of one or two CMOs.
Because of this, the right of citizens declared by law to freely choose HIOs is limited, in particular, the right to free choice of HMOs for all non-working citizens. Finally, the right of the insured to control the fulfillment of the terms of the MHI agreement directly follows from the essence of the relevant agreement between the parties - the insured and the insurer (IMO).
· register as an insurer in the Territorial Compulsory Medical Insurance Fund;
· conclude compulsory medical insurance contracts with insurance medical organizations in respect of citizens subject to insurance;
pay insurance premiums in the prescribed manner;
take measures to eliminate adverse factors affecting the health of citizens (within their competence);
provide information to the insurance medical organization on the health indicators of citizens subject to insurance.
The listed obligations are also declared by the above-named Law.
The obligation of the insured to register with the Territorial CHI Fund - an independent non-profit financial and credit institution that implements the state policy in the field of CHI, accumulates funds for CHI and distributes them among HMOs in accordance with the need of citizens insured by them for medical care - is associated with the need to control and accounting of means of payments of insurers in the territory of the subject of the Russian Federation.
The obligation of the insured to conclude compulsory medical insurance agreements with insurance medical organizations in relation to citizens subject to insurance is his main obligation.
The obligations of the insured to take measures to eliminate adverse factors affecting the health of citizens and provide information to the HMO on the health indicators of citizens subject to insurance are declarative.
· for violation of the obligation to register as an insurer in the Territorial CHI Fund, shall entail the imposition of an administrative fine in the amount of five hundred to one thousand rubles;
for violation of the deadlines established by the legislation of the Russian Federation on insurance premiums for submitting a calculation of accrued and paid insurance premiums to the bodies of state extra-budgetary funds that control the payment of insurance premiums, entails the imposition of an administrative fine on officials in the amount of three hundred to five hundred rubles.
Insurance medical organizations are responsible for the qualitative fulfillment of obligations to control the quality of medical services, for the payment of which they allocate funds from the compulsory medical insurance fund. The activities of insurance medical organizations are controlled by the territorial funds of compulsory medical insurance (TFOMS). If a violation of the law is detected as a result of inspections by the MHIF in accordance with paragraph 13 of Article 38 of the Federal Law No. 326 and with the order of the MHIF dated December 01, 2010 No. 230 “On approval of the Procedure for organizing and monitoring the volume, timing, quality and conditions for the provision of medical compulsory health insurance” a fine is imposed on the insurance company. Russian newspaper: Order Federal Fund of compulsory health insurance of December 1, 2010 N 230, February 2, 2011
The Federal Law "On Compulsory Medical Insurance in the Russian Federation" imposes on insurance medical organizations the obligation to control the proper procedure and quality of medical services provided by medical institutions. Major medical insurance companies have special departments for the examination of the quality of medical services and the protection of the rights of the insured. These departments conduct expertise (including independent, with the involvement of experts from other regions). The examination is carried out selectively in the working order, as well as on the basis of complaints from patients (free of charge for the applicant). In case of violations, the medical institution is liable in the form of withholding part of the payment for the services rendered and fines. A number of insurance companies help injured patients in litigation with doctors and medical institutions. The results of a standard and independent examination can be strikingly different from each other. The right to an independent examination is enshrined in paragraph 3 of article 58 federal law No. 323 "On the basics of protecting the health of citizens in the Russian Federation". Federal Law of November 21, 2011 N 323-FZ (as amended on December 28, 2013) “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” Although this paragraph comes into force only from January 1, 2015, in some cases the applicant can achieve the appointment of such an examination and before this date.
Thus, health care is obliged to satisfy the need of citizens to maintain an optimal level of health, regardless of what material resources it has.
1.3 Income and expenses of the MHIF
Financial resources state system compulsory health insurance are formed at the expense of insurers' deductions for compulsory health insurance. CHI funds are intended to accumulate financial resources for compulsory health insurance, ensure the financial stability of the state system of compulsory health insurance and equalize financial resources for its implementation.
Budget revenues territorial fund generated from projected income. Fund balances at the beginning and end of the reporting period do not relate to the income of the territorial fund and are sources of internal financing of the budget deficit of the territorial fund.
The financial resources of the MHIF are formed from:
Parts of insurance premiums of enterprises, institutions, organizations and other economic entities;
Contributions of territorial funds;
Appropriations from federal budget;
Voluntary contributions from legal and individuals;
Income from the use of temporarily free financial resources of the federal fund;
Normalized insurance stock of the fund's financial resources and other receipts.
The amount of funds necessary to provide state guarantees to the non-working population under the territorial compulsory medical insurance program is determined in accordance with the Methodological recommendations on the procedure for the formation and economic justification of territorial programs of state guarantees for the provision of free medical care to citizens of the Russian Federation.
In case of insufficiency of these funds, when forming the relevant budgets for the coming year, a targeted subsidy is provided from the budget of higher executive authorities of the constituent entities of the Russian Federation in accordance with the Subsidy Procedure local budgets for compulsory medical insurance of the non-working population, as well as citizens working in budget institutions, organizations and temporarily unprofitable state-owned enterprises.
The amount of debts of previous years on insurance premiums for compulsory health insurance of the non-working population is included in the revenue part of the budget of the territorial fund if there are appropriate amounts in the approved budgets of municipalities, the budget of the constituent entity of the Russian Federation, directed to pay off this debt.
The amount of debt of previous years on employers' insurance premiums, as well as the amount of debt on a single social tax are included in the revenue part of the budget of the territorial fund in case of submission to the territorial funds of the relevant forecast data on the indicated indicators by the territorial tax authorities Ministry of the Russian Federation for taxes and fees.
Other receipts include other projected receipts of financial resources provided for by the legislation of the Russian Federation on compulsory medical insurance (refunds for the treatment of citizens of other constituent entities of the Russian Federation, repayment of loans, etc.).
The calculation of the amount of these funds is carried out on the basis of the dynamics of the actual indicators for the previous period, taking into account the predicted changes.
Other receipts also include the income of the territorial fund from the placement of temporarily free financial resources and the normalized insurance reserve in bank deposits and government securities. http://www.ffoms.ru/portal/page/portal/top/protect/
At the expense of compulsory medical insurance funds in accordance with the Basic CHI Program, primary health care, emergency and specialized medical care is provided, which includes, among other things, the provision of necessary medicines in accordance with the legislation of the Russian Federation for all diseases (with the exception of diseases transmitted by sexual way, tuberculosis, HIV infection and acquired immunodeficiency syndrome).
The following funds are financed from the federal budget:
Specialized medical care provided in federal medical institutions, the list of which is approved by the executive body authorized by the Government of the Russian Federation;
High-tech medical care provided in specialized medical organizations in accordance with the established state task and in the manner determined by the Government of the Russian Federation;
Medical care provided for by federal laws for certain categories of citizens, provided in accordance with the established state task and in the manner determined by the Government of the Russian Federation;
Implementation side events on the development of the preventive direction of medical care (medical examination, immunization of citizens, early diagnosis of certain diseases) in accordance with the legislation of the Russian Federation;
Additional free medical care, including provision certain categories citizens with medicines in accordance with the legislation of the Russian Federation. Financing of the specified medical care is carried out by the MHIF at the expense of funds transferred from the federal budget, based on the standard financial costs per one citizen entitled to state social assistance in the form of a set of social services included in the federal register of persons entitled to receive state social assistance;
Medical and sanitary provision of the population of certain territories, the list of which is approved by the Government of the Russian Federation in accordance with federal laws establishing the features of the organization of local self-government;
Additional medical care on the basis of a state order, provided by district general practitioners, district pediatricians, doctors general practice(family doctors), district nurses of district general practitioners, district nurses of district pediatricians, nurses of general practitioners (family doctors) of health care institutions of municipalities providing primary health care (and in their absence - by the relevant health care institutions subject of the Russian Federation). The movement of funds in the system of compulsory medical insurance is shown in Fig. 1.
Rice. 1 Movement of funds in the compulsory health insurance system
The expenditures of the budgets of the constituent entities of the Russian Federation include:
Specialized (sanitary and aviation) emergency medical care;
Specialized medical care provided in skin and venereal, anti-tuberculosis, narcological, oncological dispensaries and other specialized medical institutions of the constituent entities of the Russian Federation, included in the nomenclature of healthcare institutions approved by the Ministry of Health and Social Development of the Russian Federation, for sexually transmitted diseases, tuberculosis, HIV - infections and acquired immunodeficiency syndrome, mental and behavioral disorders, narcological diseases, certain conditions that occur in children during the perinatal period, as well as high-tech medical care provided in medical institutions of the constituent entities of the Russian Federation;
Medical care provided for by the legislation of the constituent entity of the Russian Federation for certain categories of citizens.
In accordance with the procedure established by the executive authority of the subject of the Russian Federation, the costs of paying for medicines dispensed to the population are financed in accordance with the list of groups and categories of diseases, in the outpatient treatment of which medicines and medical devices are dispensed free of charge by prescription of doctors, and the list of population groups, for outpatient treatment of which drugs are dispensed with a 50% discount from free prices.
At the expense of local budgets (with the exception of municipalities, medical assistance to the population of which, in accordance with the legislation of the Russian Federation, is provided by the authorized federal executive body):
Ambulance (with the exception of specialized air ambulance);
Primary health care, including for sexually transmitted diseases, tuberculosis, mental disorders, drug addiction;
Medical care for women during pregnancy, childbirth and after childbirth, and for children with certain conditions that occur during the perinatal period. A.G. Gryaznov. E.V. Markina Finance. Textbook. 2nd ed. - M.: 2012. - 496
In accordance with the legislation of the Russian Federation, the expenditures of all budgets include the provision of medical organizations with medicines and other means, medical devices, immunobiological preparations and disinfectants, donated blood and its components. In addition, the provision of medical care, the provision of medical and other services in medical institutions included in the nomenclature of health care institutions, as well as in medical organizations that do not participate in the implementation of the territorial CHI program are financed from the funds of the relevant budgets in the prescribed manner.
2. The role of the compulsory health insurance system in public health financing in the constituent entities of the Russian Federation
2.1 Calculation and use of the CHI fund
In connection with the introduction of compulsory medical insurance, the problem arose of determining the size of insurance rates and the volume of insurance funds for CHI. Correctly calculated tariff rate provides financial stability insurance operations. To date, only the mechanism for the formation of the compulsory health insurance fund has been most developed. Contribution payers identified - employers, entrepreneurs without education legal entity, citizens engaged in private practice, and citizens using the labor of hired workers. The taxable base is the accrued wages for all reasons, including overtime work, weekend work and holidays, payment for a part-time job. The insurance premium rate is 3.6%, of which 0.2% goes to the federal fund and 3.4% stays locally. Contributions for the non-working population must be made by local authorities.
Tariff rate underlying insurance premium, is called the gross rate. It consists of a combination of net rates and loads. The basis for calculating the risk net rate is the cost of a course of treatment and the probability of an insured event.
The risk net rate expresses the part of the insurance premium in cash intended to cover the risk. It is considered as a function derived from the probability of realization of the risk of an insured event in time, its value is equal to the product of the sum insured (the cost of a course of treatment) by the probability of an insured event.
It should be noted that the risk premium is intended to form a reserve fund. These are temporarily free funds, they can be used as credit resources on the basis of repayment at the end of the tariff year. The net risk rate and the risk premium constitute the combined net rate.
Second part insurance rate, the load is 30% of the gross rate and includes the cost of preventive measures - 5%, the cost of doing business of the insurance company - 10%. Profit is not included in the structure of the CHI tariff rate.
Preventive expenses are intended for health-improving, physical education activities aimed at improving health, improving the production and household areas among those insured under compulsory medical insurance. Expenses for preventive measures must comply with the approved standards for financing preventive measures.
The costs of doing business are divided into organizational, liquidation, management and other types.
When allocating funds for CHI, it is necessary to differentiate tariff rates depending on the gender and age composition of insurers, taking into account differences in the need for medical care.
Each region independently develops and approves tariffs for medical services. At the same time, the salary in the tariff for a specific service, with the same complexity, does not depend on the category of hospital. Tariffs for services not included in the clinical and statistical groups are calculated additionally. Tariffs do not even provide for the cost of repairing equipment, not to mention financing the development of the material and technical base of healthcare. Only a small part of hospitals and polyclinics are equipped with modern equipment, 38% of outpatient clinics are located in unsuitable premises, do not have modern diagnostic centers, physiotherapy rooms, etc. and many more unanswered questions.
Determining the rate of health insurance.
The method of determining health insurance tariffs presented below is based on the fact that the initial statistics are not the probability of getting sick or seeking medical help, but the number of visits by the insured.
The main part of the net rate is calculated by the formula:
where - the average number of insured calls during the year;
The maximum number of hits during the year.
Where t is the number of years covered by honey. insurance;
The number of people for which medical statistical reporting is compiled (100 people, 10,000 people);
The number of calls to medical institution in year t,
Risk part of the net rate:
where is the quantile of the normal distribution of the level;
and - coefficients of variation of the cost of treatment per person and the number of requests for medical care. help.
Number of insured;
, where is the standard deviation of the number of requests for medical care.
Full net rate: .
2.2 Analysis of income and expenditures of the federal compulsory medical insurance fund
Ensuring the obligations of the state in the field of healthcare, including the implementation of the tasks set in the Decrees of the President of the Russian Federation “On measures to implement state social policy”, “On improving state policy in the field of healthcare”, “On measures to implement demographic policy”, are one of the main social priorities of the budget policy in 2013-2015.
In 2013-2015, a number of key problems will have to be solved in the healthcare sector:
Transition from 2013 to predominantly single-channel financing of medical care through the system of compulsory medical insurance;
Providing medical care in accordance with the standards of medical care;
Introduction of a unified standard for subventions to the budgets of territorial compulsory medical insurance funds for the implementation of the territorial program of compulsory medical insurance;
Transition to a single insurance premium for compulsory medical insurance of the non-working population.
In accordance with the Federal Law “On Compulsory Medical Insurance in the Russian Federation”, in 2013, a transition to single-channel financing of medical care through the system of compulsory medical insurance at the full rate is being carried out. In this regard, federal budget expenditures on healthcare in 2013 are reduced by 8.7% compared to the level of 2012, with a further decrease in 2014 and 2015.
The share of health care expenditures in the total amount of budget expenditures budget system Russian Federation will decrease from 9.8% in 2012 to 9.5% in 2015. By 2015, the share of public spending on health care in GDP will remain at the level of 2011 - 3.5%.
At the same time, 985.4 billion rubles are planned to be allocated from the budget of the MHIF in 2013 for the implementation of measures in the field of healthcare, primarily to ensure the expenditure obligations of the constituent entities of the Russian Federation arising from the exercise of delegated powers to organize compulsory medical insurance in the territories of the constituent entities of the Russian Federation. In 2014, it is planned to allocate 1,154.5 billion rubles for these purposes, in 2015 - 1,406.4 billion rubles.
The predicted volume of income of the MHIF for 2013 increases by 18.8% compared to 2012, the volume of income of the MHIF in the planned period of 2014 and 2015 increases annually by 14.1% and 19.3%, respectively.
Data on the compliance of the changes introduced with the grounds provided for by the Federal Law "On the budget of the Federal Compulsory Medical Insurance Fund for 2013 and for the planning period of 2014 and 2015" are presented in the following table:
Table 1
Income and expenses of the compulsory health insurance fund for 2013, 2014, 2015
|
Name |
2015 |
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|
TOTAL INCOME |
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|
Transfers from the federal budget |
|||||
|
TOTAL EXPENSES |
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|
Subvention for the implementation of the territorial CHI program |
|||||
|
Subsidy for balance, transferred to the federal budget from the budget of the Federal Compulsory Medical Insurance Fund, as part of other activities in non-program areas of activity of the governing bodies of state extra-budgetary funds of the Russian Federation (Interbudgetary transfers) |
|||||
|
Payment for high-tech medical care |
|||||
|
Funds transferred to the budget of the FSS of the Russian Federation (birth certificate) |
|||||
|
Financial and logistical support of the Fund |
|||||
|
Deficit (-), surplus (+) |
Despite the annual increase in the volume of compulsory medical insurance funds in 2013-2015, the question of the adequacy of compulsory medical insurance funds allocated for the implementation of measures in the healthcare sector remains.
A significant burden also falls on the budgets of the constituent entities of the Russian Federation: in terms of participation in the financing of regional programs and measures to modernize healthcare, insurance of the non-working population, co-financing lump sum payments young doctors who came to work in villages and workers' settlements, which in 2013 should be carried out, including at the expense of regional budgets.
2.3 Problems of MHI in Russia and ways to solve them
Significantly updated recently the legislative framework in the field of health care, compulsory medical insurance, circulation of medicines, and the fight against smoking. Health care modernization programs have been implemented in the constituent entities of the Russian Federation. However, there are a number of pressing problems in the improved compulsory medical insurance system that require special attention and immediate resolution.
The key negative point is the quality, availability and efficiency of the medical services provided.
The problem of the quality of medical care is important in all aspects of its provision: for the prevention of diseases, maintaining health, increasing life expectancy and improving its quality in case of illness and disability, as well as at the end of life.
The financing of medical care is largely transferred to the citizens and employers themselves. The population's spending on medicines and medical services is steadily growing at a high rate. The growth of paid medical care is intensifying, despite the growth of state funding in recent years. The quality of free medical care is declining. The low-income segments of the population suffer the most from this. The inequality of opportunities for various social groups in obtaining quality medical care is increasing.
The reasons for the current problem, in my opinion, are the lack of motivation medical workers, low professional level of doctors, a significant degree of deterioration of medical equipment, lack of necessary equipment and medicines.
This results in such problems as the shortage of personnel and the lack of qualified young specialists in the regions. In many district hospitals, the average age of working doctors is 47-48 years. The staff is only half staffed.
Also, a serious difficulty in the development of CHI at the present stage is the underfunding of the system and the almost complete lack of unification of rules and standards in different territories of our single country. According to the Accounts Chamber of the Russian Federation, most of the regional programs of state guarantees for the provision of free medical care are in short supply. As a result, in most regions, the basis for planning the volume of medical care is not the actual need for it by the population, but the financial capacity of the region and the existing network of healthcare institutions.
In 2013, the shortage of compulsory medical insurance funds was revealed in 40 programs in the amount of 26.1 billion rubles, and in 2014 - already in 59 programs for 55.3 billion rubles.
It is believed that this is due to a high level of corruption in healthcare, a trend towards an increase in the average life expectancy of the population, the rapid development of expensive medical technologies, a reduction in the tax base due to a decrease in employment and income in the official sector of the economy, and an increase in the share of the disabled population.
Problems with the calculation of the cost of medical services have led to significant differences across regions. For example, according to the results of 2013, the cost of calling an ambulance (VMP) in the Tambov region amounted to 1 thousand rubles, and in North Ossetia - 3.5 thousand rubles. Since 2014, 459 types of VMPs have been transferred to CHI. But unlike federal institutions, where the cost of the VMP is approved by order, the regions formed tariffs on their own in the absence of federal regulation.
Some experts argue that “medicine cannot be free, and it is high time to dispel this Soviet myth. All over the world, programs of state guarantees for the provision of medical care to citizens involve a strict division into paid and free medicine. We, declaring out of habit that our healthcare is free, pay a much higher price for these services.”
The budget of our health care system is not balanced, patients, deducting considerable funds to the Compulsory Medical Insurance Fund (and since 2016, employers want to oblige them to pay contributions to the Compulsory Medical Insurance Fund from the entire income of the employee), they still have to pay extra to doctors from their own pocket. And this is usually done informally. At the same time, there are no guarantees for the less well-off segments of the population.
Another problem is the distribution of medical care between organizations. During the audit, cases of their unreasonable underestimation and overestimation were revealed. This forms the risks of postscripts in order to receive money. To eliminate such distortions, it is necessary to strengthen control over the activities of the commissions and develop uniform regional criteria for distributing the volume of medical care.
There is also a lack of proper control by the Ministry of Health and the CHI Fund over the implementation of programs, the imperfection of the regulatory legal framework.
In addition, there are negative aspects associated with SMO. These are private structures that directly carry out insurance of medical services. The CHI system has two main functions. The first is mediation. QMS distribute cash flows from TFOMS to health care facilities for a "small share". This share is so small that there is fierce competition in the medical services insurance market. The insurance company with the most administrative resources wins. The second function of the QMS is controlling. Control over the “quality” of treatment comes down to control over the quality of medical documentation, or rather, it is a tool for withdrawing part of the money earned by health facilities in the form of penalties.
Thus, the main, in my opinion, problems in the development of the CHI system in Russia were identified. To address them, the following areas for improvement can be proposed:
Increasing public funding of health care through the compulsory health insurance system;
Introduction of mechanisms for financial planning and payment for medical care, stimulating the growth of efficiency in the use of resources in healthcare;
Creation of a stable financial basis for the provision of free medical care to the population within the framework of compulsory medical insurance;
The program of state guarantees for the provision of medical care to the population should be deficit-free;
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It is difficult to give preference to one or another model (mixed or pure) of compulsory health insurance, because all subjects of the Russian Federation, being in different economic situations, choose the model of implementation of the law, which, in their opinion, is more consistent with their conditions. Scientists - economists and health care organizers - recognize the most effective mixed model of compulsory health insurance, in which almost 99% of the funds of compulsory health insurance reach medical institutions, which is much more than when using other models.
This state of affairs can be explained, first of all, by the fact that in the mixed model of compulsory medical insurance, potential competition is possible between insurance medical organizations and branches of territorial compulsory medical insurance funds. However, to this day, Russia remains the only country where funds allocated to finance healthcare go first through funds, and then through Insurance companies. IN developed countries the administrative apparatus has only one of these links. In our country, in accordance with the Law, these organizations duplicate each other and are largely interchangeable.
Having considered the schematically depicted directions of the main financial flows in the healthcare system of the Russian Federation, we note that with the introduction of compulsory medical insurance, the entire healthcare system in the Russian Federation began to be a combination of two systems: the state (municipal) healthcare system and the state system of compulsory medical insurance. “The sources of financial resources for the healthcare system in the Russian Federation are:
* Funds from the federal budget, territorial budgets of subjects of the Federation, local budgets;
* funds of organizations, enterprises and other economic entities, regardless of the form of ownership;
* personal funds of citizens;
* income from valuable papers;
* gratuitous and charitable contributions and donations;
* other sources not prohibited by the legislation of the Russian Federation” 1 .
At the same time, it should be noted that the funds of the state and municipal health care systems are almost completely formed at the expense of the budgets of various levels. These funds are used to public policy in the field of health care, which includes:
* development and implementation of targeted programs;
* ensuring professional training of personnel;
* funding scientific research;
* development of the material and technical base of health care institutions;
* payment for especially expensive types of treatment;
* financing of medical institutions providing assistance in socially significant diseases;
* provision of medical care in case of mass diseases, in areas of natural disasters and catastrophes.
“The financial basis of the state system of compulsory medical insurance is deductions from insurers for compulsory medical insurance and budgetary payments for compulsory medical insurance of the non-working population. Financial resources are accumulated in the compulsory medical insurance funds: Federal and territorial, which are independent non-profit financial and credit institutions and created to ensure the stability of the state system of compulsory medical insurance. The financial resources of the funds are not included in the composition of budgets, other funds and are not subject to withdrawal” 1 .
The next element of the compulsory health insurance system is a medical insurance organization that performs the following main functions:
* organization and financing of compulsory medical insurance by paying for medical care provided in accordance with the territorial program and compulsory medical insurance contracts;
* monitoring the volume, timing and quality of medical services provided.
The funds received from the territorial compulsory health insurance fund in accordance with the contract concluded by the insurance medical organization are of a targeted nature and are used to pay for medical services, form a reserve for paying for medical services and financing preventive measures, and pay for the costs of doing business, including for the remuneration of employees of medical insurance organizations according to the standards established by the territorial fund.
The main element of the healthcare system is medical institutions that are the final recipient of funds and provide direct medical services to the population. Medical care in the system of compulsory health insurance is provided by institutions with any form of ownership, having the appropriate licenses. The procedure for providing medical care to the population, financed from the funds of compulsory medical insurance, is determined jointly by the territorial health authorities and the compulsory medical insurance funds.
The procedure for paying for medical services provided for by the territorial program and provided to insured citizens within the territory of the constituent entity of the Russian Federation where they live is determined by the territorial rules of compulsory medical insurance and the regulation on the procedure for paying for medical services.
Financing of medical institutions is carried out in accordance with the chosen method of payment for medical care at agreed rates. Tariffs for medical and other services in the system of compulsory insurance are established on the basis of uniform methodological approaches determined by the regulation on the procedure for paying for medical services. The procedure for harmonization and indexation of tariffs for medical services is established by the territorial rules of compulsory medical insurance.
Medical institutions keep records of the services provided to the insured and provide information to insurance medical organizations and the fund according to established reporting forms. Settlements with medical institutions are made by paying their bills.
Despite the introduction of the CHI system, the amount of state financing of health care, including budget allocations and contributions to CHI system, must be recognized as insufficient to fulfill the existing state obligations to the population. As a result, with a reduction in state funding, there is a reduction in the scale of disease prevention and an increase in paid medical care. The data of household expenditure surveys show that the volume of personal expenditures of the population on medical services and medicines is comparable to the amount of state financing in this area. This significantly reduces the availability of medical care, with the poorest groups of the population in the most difficult situation. A growing number of patients are forced to refuse treatment and purchase the necessary drugs.
The imbalance between government commitments and real financial opportunities has a devastating effect on the entire health care system. There is a reduction in the scale of disease prevention and an increase in paid medical care. Medical expenses are passed on to the population. Legal and shadow payments for medical services and the purchase of medicines by the population today, according to various estimates, make up from 25 to 45% of the total expenditures of the state and the population on health care. In the current situation, when formally free medical care has to be paid for, the poorer segments of the population and families living outside large cities are in a worse position. They are forced to spend a large part of their income on medical care and more often refuse treatment and purchase the necessary medicines. All this leads to deepening social tension. To achieve a real balance of state guarantees of medical care for the population with their financial support, today, apparently, it is impossible to do without making certain adjustments to the constitutional norm on free medical care for all citizens. This norm, defined in Article 41 of the Constitution, is to ensure equal access and free medical care to all citizens. It is necessary to revise this article and legalize what exists in reality.
The possibility of introducing a system of financial participation (co-financing) in Russian public medicine - a question at its core political - represents perhaps the most radical change in the concept of reforming domestic healthcare. Moreover, in existing co-financing projects, co-payments from the population should make up a significant part of the health care system's income and play a decisive role in normalizing the functioning of the industry.
I. Health financing in conditions
compulsory health insurance
In the former Soviet Union, health care guaranteed citizens free and publicly available medical care. In practice, the financing of the industry at the expense of the state budget led to a constant decrease in the share of spending on medicine in the total amount. budget appropriations, as a result, insufficient funding and irrational use of funds led the industry to a critical state. The sharp drop in most of the indicators characterizing the level of medical care has made it obvious that there is a need for a fundamental restructuring of domestic health care. One of the ways the industry emerged from the crisis was the introduction of new forms of management, planning and financing into the healthcare system, starting in the early 1990s.
Based on an analysis of the practice of financing and organizing healthcare in foreign countries, three basic models can be distinguished economic mechanism healthcare:
1. Mostly public free medical care, as, for example, in England, Denmark, Greece, Ireland.
2. Financing of the main volume of medical care by private insurance companies, for example, in the USA.
3. Mixed budget-insurance nature of health care financing, when the state pays for targeted programs, capital investments and some other expenses, and the financing of basic medical care is carried out through the health insurance system: France, Germany, Italy, etc.
In the modern period, insurance systems of medical and social assistance continue to develop. Health insurance systems are usually government-run, but funded from three sources: earmarked contributions from employers, government subsidies, and employee contributions. In some countries, there are no government subsidies for paying for medical care, and health insurance premiums are provided by entrepreneurs and employees.
insurance system health care is financed, like the budgetary one, from public consumption funds and is formed on a targeted basis, it is more protected from the residual principle of financing, which is typical for many budgetary health care systems. That is why in our country, in order to combine the positive aspects of public and private medicine, a budget-insurance model was chosen. On June 28, 1991, the Law of the Russian Federation "On the health insurance of citizens in the Russian Federation" was adopted, which defines a fundamentally new model for financing and organizing health care in the new economic conditions.
The law establishes two types of health insurance: compulsory and voluntary. The purpose of the introduction of compulsory medical insurance was to provide all citizens of the Russian Federation with equal opportunities to receive medical and drug assistance provided at the expense of compulsory medical insurance in the amount of relevant programs. Voluntary health insurance allows citizens to receive additional medical services.
economic basis health insurance are state funds health care and mandatory health insurance funds. With the introduction of compulsory medical insurance, the entire healthcare system in the Russian Federation began to represent a combination of two systems: the state (municipal) healthcare system and the state system of compulsory medical insurance.
The sources of financial resources for the healthcare system in the Russian Federation are:
Funds from the federal budget, territorial budgets of subjects of the Federation, local budgets;
Funds of organizations, enterprises and other economic entities, regardless of the form of ownership;
Personal funds of citizens;
Income from securities;
Free and charitable contributions and donations;
Other sources not prohibited by the legislation of the Russian Federation.
The financial basis of the state system of compulsory medical insurance is the deductions of insurers for compulsory medical insurance and budgetary payments for compulsory medical insurance of the non-working population. Financial resources are accumulated in compulsory medical insurance funds - federal and territorial, which are independent non-profit financial and credit institutions and created to ensure the stability of the state system of compulsory medical insurance. Financial resources of the funds are not included in the composition of budgets, other funds and are not subject to withdrawal.
Non-departmental control over the activities of healthcare institutions is carried out by licensing and accreditation commissions, insurance medical organizations, territorial compulsory medical insurance funds, executive bodies of the Social Insurance Fund of the Russian Federation, etc. and checking the effectiveness of the use of health resources and financial resources of compulsory health and social insurance. It is carried out in the following areas:
Analysis of the results of providing medical care to the population,
Verification of the fulfillment of contracts between health care institutions and insurance medical organizations, between the insured and the insurer and other types of control.
The experience of implementing the Law of the Russian Federation "On the health insurance of citizens in the Russian Federation" showed the prospects of the system of compulsory health insurance and posed a number of problems, without the solution of which further development is impossible. First of all, this is the insufficient legal support of the system of compulsory medical insurance, the need to improve the quality control system of medical care in medical institutions and the creation of a system for ensuring the rights of the insured.
II. Planning and financing activities
medical institutions
In accordance with the approved nomenclature of health care institutions are divided into groups:
1. Medical institutions.
A) Outpatient clinics - when they receive help both at home and in the clinic (polyclinics, medical centers, dispensaries, feldsher points, antenatal clinics, children's clinics, pharmacies, pharmaceutical plants).
B) Hospitals - when the patient receives treatment in bed (hospitals, clinics at scientific medical institutes, military hospitals, sanatoriums, dispensaries (beds).
1.1. Hospital institutions, including: city hospital, city emergency hospital, hospital for war veterans, medical unit, specialized hospitals, hospice, territorial medical association.
1.2. Health care institutions of a special type: leprosarium, center for the prevention and control of AIDS, bureau of forensic medical examination, bureau of medical statistics.
1.3. Dispensaries: medical physical education, cardiology, narcological, dermatovenerological, oncological, anti-tuberculosis, neuropsychiatric.
1.4. Outpatient clinics: an outpatient clinic, a city clinic, a children's city clinic, a dental clinic, a medical unit, a consultative and diagnostic center for children, etc.
1.5. Ambulance and blood transfusion facilities: ambulance station, blood transfusion station.
1.6. Maternity and childhood institutions: children's home, maternity hospital, etc.
1.7. Sanatorium-resort institutions: sanatorium, children's sanatorium, sanatorium-preventorium, etc.
2. Institutions of preventive medicine.
3. Pharmacy establishments.
The costs of maintenance of medical institutions occupy the largest share in the cost of health care. The work of each healthcare institution is characterized by operational network indicators, such as: the average annual number of beds (total and by bed profiles), the number of days a bed operates per year, the number of bed days, the average annual number of staff units for all categories of personnel, the number of medical visits.
A medical institution can provide medical care to the population in two forms: inpatient and outpatient. One of the main indicators of the work of the hospital is the number of beds, and the number of medical posts and visits in an outpatient clinic. Depending on this, the method of calculating costs is chosen. In the modern period, only in-kind norms for spending on food and medicines (depending on the type of institution) are centrally established. Calculations of the value of in-kind indicators are carried out by local departments independently. In an outpatient clinic, the main indicators for planning costs are: the average annual number of medical positions and the number of medical visits.
The main document that determines the total volume, target direction and quarterly distribution of the institution's funds is an estimate of expenses compiled for the calendar year in the prescribed form for economic items budget classification. The estimate may include only expenses that are necessary due to the nature of the activities of the institution. The appropriations provided for in the estimate must be justified by calculations for each cost item. The main economic items for which the cost planning of the institution is carried out include the costs of paying wages, purchase of goods, payment for services, purchase of durable equipment, overhaul.
In accordance with Article 21. Federal Law No. 323-FZ, compulsory medical insurance funds are formed at the expense of:
1) income from payment:
a) insurance premiums for CHI;
b) arrears in contributions, tax payments;
c) accrued penalties and fines;
2) federal budget funds transferred to the budget of the Federal Fund in the cases established by the Federal Law, in terms of compensating for shortfalls in income due to the establishment of reduced rates of insurance premiums for CHI;
3) funds from the budgets of the constituent entities of the Russian Federation transferred to the budgets of territorial funds in accordance with the legislation of the Russian Federation and the legislation of the constituent entities of the Russian Federation;
4) income from the placement of temporarily free funds;
5) other sources provided for by the legislation of the Russian Federation.
The main source of the formation of financial resources for compulsory health insurance, the legislator considers income from the payment of insurance premiums of insurers for compulsory health insurance. Insurance premiums are mandatory payments, the purpose of which is to ensure the rights of the insured person,
The financial support of compulsory health insurance provides for the consolidation of revenue sources generated through employers' insurance premiums for compulsory health insurance of the working population, as well as insurance premiums of the executive authorities of the constituent entities of the Russian Federation authorized by the highest executive authorities of the constituent entities of the Russian Federation for compulsory medical insurance of the non-working population (h 2 article 11 of the Federal Law No. 326-FZ, article 158 of the RF BC), the amount and procedure for calculating the tariff are determined by art. 23 of Federal Law No. 326-FZ.
Article 22. Insurance premiums for compulsory health insurance of the working population
1. The obligation to pay insurance premiums for compulsory health insurance of the working population, the amount of the insurance premium for compulsory health insurance of the working population and relations arising in the process of monitoring the correctness of the calculation, completeness and timeliness of payment (transfer) of the said insurance premiums and bringing to responsibility for violation of the procedure for their payment, are established by the Federal Law of July 24, 2009 No. 212-FZ "On insurance premiums in Pension Fund of the Russian Federation, the Social Insurance Fund of the Russian Federation, the Federal Compulsory Medical Insurance Fund and the Territorial Compulsory Medical Insurance Funds.
2. The territorial bodies of the Pension Fund of the Russian Federation submit information on the payment of insurance premiums for compulsory health insurance of the working population to the territorial funds in the manner determined by the agreement on information exchange between the Pension Fund of the Russian Federation and the Federal Fund.
Payers of insurance premiums are obliged to pay insurance premiums in a timely manner and in full. In case of non-payment or incomplete payment of insurance premiums within the established period, the arrears on insurance premiums are collected in the manner prescribed by Law No. 212-FZ (part 13, article 25 of Federal Law No. 326-FZ). In accordance with Part 1 of Art. 3 of Law No. 212-FZ, since 2010, control over the correct calculation, completeness and timeliness of payment (transfer) of insurance premiums paid to compulsory medical insurance funds (FOMS / TFOMS) is assigned to the Pension Fund of the Russian Federation. Thus, thanks to these novelties, payers of insurance premiums will have fewer questions and they will have to apply to one state body.
Article 23
1. The amount and procedure for calculating the rate of insurance premium for compulsory medical insurance of the non-working population are established by federal law.
2. The annual volume of budget allocations provided for by the budget of a constituent entity of the Russian Federation for compulsory medical insurance of the non-working population cannot be less than the product of the number of non-working insured persons as of April 1 of the year preceding the next one in the constituent entity of the Russian Federation and the rate of insurance premium for compulsory medical insurance of the non-working population established by federal law.
3. The annual volume of budget allocations for compulsory medical insurance of the non-working population is approved by the law on the budget of the subject of the Russian Federation in relation to the insured persons specified in paragraph 5 of Article 10 of this Federal Law.
In accordance with Decree of the Government of the Russian Federation of October 21, 2011 No. 856 “On the Program of State Guarantees for the Provision of Free Medical Care to Citizens of the Russian Federation for 2012”, the amount of the insurance premium for compulsory medical insurance of the non-working population is established by the law of the constituent entity of the Russian Federation no later than December 25, 2011. , wherein:
- the amount of the insurance premium for compulsory medical insurance of the non-working population is established in accordance with the legislation of the Russian Federation on compulsory medical insurance and cannot be less than the indicator established for 2011;
– the amount of the insurance premium for compulsory health insurance of the non-working population should take into account, among other things, more high level consumption of medical care and, accordingly, its cost for the non-working population (in particular, the coefficient of appreciation of medical care for children from 0 to 4 years old is 1.62, and for people aged 60 years and older - 1.32 in relation to the per capita standard of financial provision, provided by the territorial program of compulsory medical insurance).
The per capita standards of financial support provided for by the program are set per 1 person per year (excluding federal budget expenditures) and average 7,633.4 rubles, of which:
RUB 4102.9 - at the expense of compulsory medical insurance;
3530.5 rubles - at the expense of the relevant budgets provided for the provision of emergency, including specialized (sanitary and aviation), medical care, specialized, including high-tech, medical care, medical care for sexually transmitted diseases, tuberculosis, HIV infection and acquired immunodeficiency syndrome, mental and behavioral disorders, including those associated with the use of psychoactive substances, as well as the maintenance of medical organizations participating in compulsory medical insurance, and financial support for the activities of medical organizations that are not involved in the implementation of the territorial program of compulsory medical insurance, specified in the last paragraph section III Programs.
The formation of tariffs for medical care provided at the expense of compulsory medical insurance is carried out by the executive authority of the subject of the Russian Federation in accordance with the legislation of the Russian Federation and taking into account the standards determined by the program.
From 2011, the amount of budget allocations for the payment of insurance premiums for compulsory health insurance of the non-working population should include full financial support for the types of medical care and items of expenditure included in the tariff for paying for medical care in accordance with the basic program of compulsory medical insurance for the corresponding year previously financed from the consolidated budget of the constituent entity of the Russian Federation (part 12 of article 51 of Federal Law No. 326-FZ).
Article 24
1. The settlement period for insurance premiums for compulsory medical insurance of the non-working population is a calendar year.
2. If the policyholder was empowered after the beginning of the calendar year, the first settlement period for him is the period from the date of empowerment until the end of this calendar year.
3. If the policyholder's authority was terminated before the end of the calendar year, the last settlement period for him is the period from the beginning of this calendar year until the day of termination of authority.
4. If the policyholder, vested with powers after the beginning of the calendar year, terminated the powers before the end of this calendar year, the settlement period for him is the period from the date of granting his powers to the day of termination of powers.
5. During the billing period, the payment of insurance premiums for compulsory medical insurance of the non-working population is carried out by insurers by transferring the amount of the monthly mandatory payment to the budget of the Federal Fund.
6. Monthly mandatory payment payable no later than the 25th day of the current calendar month. If the specified deadline for the payment of the monthly mandatory payment falls on a day recognized in accordance with the legislation of the Russian Federation as a day off and (or) a non-working holiday, the expiration date for the payment of the monthly mandatory payment is the next working day.
7. The amount of the monthly insurance premium for compulsory medical insurance of the non-working population, paid by the insurers, must be one-twelfth of the annual volume of budgetary appropriations provided for these purposes by the law on the budget of the constituent entity of the Russian Federation. At the same time, the amount of insurance premiums for compulsory medical insurance of the non-working population paid for the year cannot be less than the annual volume of budget allocations provided for by the law on the budget of a constituent entity of the Russian Federation.
8. The amount of insurance premiums for compulsory medical insurance of the non-working population to be transferred is determined in full rubles. The amount of insurance premiums for compulsory health insurance of the non-working population less than 50 kopecks is discarded, and the amount of 50 kopecks or more is rounded up to the full ruble.
9. The obligation of policyholders to pay insurance premiums for compulsory medical insurance of the non-working population is considered fulfilled from the moment the amount of the payment is debited from the accounts of the budgets of the constituent entities of the Russian Federation or from the accounts for accounting for federal budget funds.
10. Insurers are required to keep records of funds transferred for compulsory medical insurance of the non-working population to the Federal Fund.
11. On a quarterly basis, no later than the 25th day of the month following the reporting period, insurers shall submit to the territorial funds at the place of their registration a calculation of the accrued and paid insurance premiums for compulsory medical insurance of the non-working population in the form approved by the authorized federal executive body.
12. Reporting periods are the first quarter, six months, nine months of a calendar year, a calendar year.
The procedure for paying insurance premiums for compulsory medical insurance of the non-working population in 2011 is regulated by Part 11 of Article 51 of Federal Law No. 326-FZ.
Since 2012, in accordance with Part 5 of Article 24 of Federal Law No. 326-FZ, the payment of insurance premiums for compulsory medical insurance of the non-working population is carried out by insurers to the budget of the Federal Fund.
Article 25
1. In case of non-payment or incomplete payment of insurance premiums for compulsory health insurance of the non-working population within the established period, the arrears in insurance premiums for compulsory health insurance of the non-working population, accrued penalties and fines shall be collected.
2. Penalties are recognized as the amount of money established by this article, which the insurer must pay in case of payment of the due amounts of insurance premiums for compulsory medical insurance of the non-working population at a later date than those established by this Federal Law.
3. The amount of the relevant penalties shall be paid in addition to the amounts of insurance premiums due for payment for compulsory medical insurance of the non-working population and regardless of the application of liability measures for violation of the legislation of the Russian Federation.
4. Penalties are accrued for each calendar day of delay in fulfilling the obligation to pay insurance premiums for compulsory health insurance of the non-working population, starting from the day following the deadline established by this Federal Law for paying the amounts of insurance premiums for compulsory health insurance of the non-working population.
5. The insured independently accrues penalties for the entire amount of arrears for the period of delay and reflects it in the form of calculation of accrued and paid insurance premiums for compulsory medical insurance of the non-working population, approved by the authorized federal executive body.
6. Penalties are not charged for the amount of arrears, which the insured could not pay due to the fact that, in accordance with the legislation of the Russian Federation, the operations of the insured in the body were suspended Federal Treasury. In this case, penalties are not charged for the entire period of the specified circumstances.
7. Penalties for each day of delay are determined as a percentage of the unpaid amount of insurance premiums for compulsory health insurance of the non-working population.
8. Interest rate interest is taken equal to one three hundredth of the refinancing rate effective on the date of accrual of interest Central Bank Russian Federation.
9. Penalties are paid simultaneously with the payment of insurance premiums for compulsory health insurance of the non-working population or after payment of such amounts in full.
10. If the last day of the deadline for paying insurance premiums for compulsory medical insurance of the non-working population coincides with a weekend and (or) a non-working holiday, interest is charged starting from the second working day following the weekend and (or) non-working holiday.
11. The following sanctions are applied to the insured who violates the procedure for paying insurance premiums for compulsory medical insurance of the non-working population:
1) failure by the insured to submit, within the period established by this Federal Law, the calculation of the accrued and paid insurance premiums for compulsory health insurance of the non-working population at the place of registration in the territorial fund shall entail a fine in the amount of two percent of the amount of insurance premiums for compulsory health insurance of the non-working population, payable or additionally payable based on this
calculation, for each full or incomplete month from the date set for its submission, but not more than five percent of the specified amount and not less than one thousand rubles;
2) non-payment or incomplete payment of insurance premiums for compulsory health insurance of the non-working population as a result of incorrect calculation of these insurance premiums entails a fine in the amount of twenty percent of the unpaid amount of insurance premiums. Payment of the fine does not relieve the insured from paying the amount of unpaid insurance premiums for compulsory health insurance of the non-working population.
12. In case of detection of violations of the legislation on compulsory health insurance specified in Part 11 of this Article, officials of the Federal Fund or territorial funds, the list of which is approved by the Federal Fund in accordance with Part 5 of Article 18 of this Federal Law, draw up acts on violation of the legislation on compulsory medical insurance, consider cases of violations and impose fines in accordance with Parts 3 and 4 of Article 18 of this Federal Law.
13. Collection of arrears, penalties and fines from policyholders is carried out in the manner similar to the procedure provided for in Article 18 of the Federal Law of July 24, 2009 No. medical insurance and territorial funds of obligatory medical insurance””.
So, Article 25 defines the responsibility of insurers for non-working citizens for violations in terms of paying insurance premiums for compulsory health insurance of the non-working population.
Responsibility that is assigned for violations committed by the payer of insurance premiums, within the framework of this article, is of a property and compensation nature. The legislator has provided for non-payment or incomplete payment of insurance premiums within the prescribed period, the possibility of recovering from the obligated person in court:
1) arrears on insurance premiums for compulsory medical insurance of the non-working population;
2) accrued penalties and fines on insurance premiums for compulsory health insurance of the non-working population.
Article 26
1. Revenues of the budget of the Federal Fund are formed in accordance with the budget legislation of the Russian Federation, the legislation of the Russian Federation on insurance premiums, the legislation of the Russian Federation on taxes and fees, and the legislation of the Russian Federation on other mandatory payments. The income of the budget of the Federal Fund includes:
1) insurance premiums for compulsory health insurance;
2) arrears on contributions, tax payments;
3) accrued penalties and fines;
4) funds from the federal budget transferred to the budget of the Federal Fund in cases established by federal laws;
6) other sources provided for by the legislation of the Russian Federation.
2. Budget expenditures of the Federal Fund are carried out for the purpose of financial support:
1) provision of subventions from the budget of the Federal Fund to the budgets of territorial funds for financial support of the expenditure obligations of the constituent entities of the Russian Federation arising from the exercise of powers transferred in accordance with Part 1 of Article 6 of this Federal Law;
2) fulfillment of expenditure obligations of the Russian Federation arising from the adoption of federal laws and (or) regulatory legal acts of the President of the Russian Federation, and (or) regulatory legal acts of the Government of the Russian Federation in the field of protecting the health of citizens;
3) performing the functions of the management body of the Federal Fund.
3. As part of the budget of the Federal Fund, a normalized insurance reserve is formed. The size and purpose of using the funds of the normalized insurance reserve of the Federal Fund are established by the federal law on the budget of the Federal Fund for the next financial year and for the planning period. The procedure for using the funds of the normalized insurance reserve of the Federal Fund is established by the authorized federal body
executive power.
4. Revenues of the budgets of territorial funds are formed in accordance with the budgetary legislation of the Russian Federation. The revenues of the budgets of territorial funds include:
1) subventions from the budget of the Federal Fund to the budgets of territorial funds;
2) interbudgetary transfers transferred from the budget of the Federal Fund in accordance with the legislation of the Russian Federation (with the exception of subventions provided for in clause 1 of this part);
3) payments of constituent entities of the Russian Federation for additional financial support for the implementation of the territorial program of compulsory medical insurance within the framework of the basic program of compulsory medical insurance in accordance with this Federal Law;
4) payments of subjects of the Russian Federation for financial support additional species and conditions for the provision of medical care not established by the basic program of compulsory medical insurance, in accordance with this Federal Law;
5) income from the placement of temporarily free funds;
6) interbudgetary transfers transferred from the budget of a constituent entity of the Russian Federation, in cases established by the laws of a constituent entity of the Russian Federation;
7) accrued penalties and fines to be credited to the budgets of territorial funds in accordance with the legislation of the Russian Federation;
8) other sources provided for by the legislation of the Russian Federation.
5. The expenses of the budgets of territorial funds are carried out for the purpose of financial support:
1) implementation of territorial programs of compulsory medical insurance;
2) fulfillment of expenditure obligations of the constituent entities of the Russian Federation arising from the implementation by state authorities of the constituent entities of the Russian Federation of the delegated powers of the Russian Federation as a result of the adoption of federal laws and (or) regulatory legal acts of the President of the Russian Federation, and (or) regulatory legal acts of the Government of the Russian Federation in the field of protection of the health of citizens;
3) fulfillment of expenditure obligations of the constituent entities of the Russian Federation arising from the adoption of laws and (or) regulatory legal acts of the constituent entities of the Russian Federation;
4) conducting business on compulsory medical insurance by insurance medical organizations;
5) performance of the functions of the management body of the territorial fund.
6. As part of the budget of the territorial fund, a normalized insurance reserve is formed. The size and purposes of using the resources of the normalized insurance reserve of the territorial fund are established by the law on the budget of the territorial fund in accordance with the procedure for using the resources of the normalized insurance reserve of the territorial fund established by the Federal Fund. The amount of the normalized insurance reserve of the territorial fund should not exceed the average monthly amount of the planned receipts of the territorial fund for the next year.
7. The amount and procedure for paying the payments of the subject of the Russian Federation specified in paragraphs 3 and 4 of part 4 of this article are established by the law of the subject of the Russian Federation.
8. Funds from the budget of the Federal Fund and the budgets of territorial funds are not included in other budgets of the budgetary system of the Russian Federation and are not subject to withdrawal.
Part 1 of Article 26 establishes the sources at the expense of which the revenue part of the budget of the Federal Compulsory Medical Insurance Fund is formed. When forming both the federal budget and the budget of the state off-budget fund, which is the Federal Compulsory Medical Insurance Fund, the norm provided for by Art. 32 of the Budget Code of the Russian Federation, which establishes the principle of completeness of the reflection of income, expenses and sources of financing budget deficits. This principle is that all income, expenses and sources of financing budget deficits are mandatory and fully reflected in the relevant budgets.
The amount of insurance premiums is calculated and paid separately to each state off-budget fund.
From the federal budget, the Federal Compulsory Medical Insurance Fund receives the following targeted funds in the form of interbudgetary transfers:
- conducting medical examinations of orphans and children in difficult life situations staying in stationary institutions;
– carrying out additional medical examination of working citizens;
- federal budget funds transferred to the budget of the Federal Compulsory Medical Insurance Fund to cover expenses due to shortfalls tax revenue to the budget of the Federal Fund;
- other funds of the federal budget established by federal laws.
next view income specified in Article 26 is defined as income from the placement of temporarily free funds of compulsory health insurance. In accordance with the rules for placing temporarily free funds of the Federal Compulsory Medical Insurance Fund and territorial compulsory medical insurance funds, temporarily free funds of these funds can be placed exclusively on bank deposits.
Other funds received by the Federal Compulsory Medical Insurance Fund, not prohibited by the legislation of the Russian Federation, may be:
- income from the lease of property under the operational management of the Compulsory Medical Insurance Fund, and other income from the use of this property;
– income from rendering paid services and cost compensation, etc.
Article 27
1. Subventions from the budget of the Federal Fund to the budgets of territorial funds for the implementation of the powers transferred in accordance with Part 1 of Article 6 of this Federal Law are provided in the amount established by the federal law on the budget of the Federal Fund for the next financial year and for the planning period. The procedure for distribution, provision and spending of subventions from the budget of the Federal Fund to the budgets of territorial funds is established by the Government of the Russian Federation.
2. The total amount of subventions provided to the budgets of territorial funds is determined based on the number of insured persons, the standard of financial support for the basic program of compulsory medical insurance and other indicators established in accordance with the procedure specified in part 1 of this article.
3. Subventions are provided subject to the volume of budget allocations for compulsory medical insurance of the non-working population, approved by the law on the budget of the constituent entity of the Russian Federation, to the amount of the insurance premium for compulsory medical insurance of the non-working population, calculated in accordance with Article 23 of this Federal Law, and subject to transfer to the budget of the Federal Fund on a monthly basis one twelfth of the annual volume of budget allocations for compulsory medical insurance of the non-working population, approved by the law on the budget of the constituent entity of the Russian Federation, no later than the 25th day of each month.
4. Subventions for the exercise of the powers specified in Part 1 of Article 6 of this Federal Law are of a target nature and cannot be used for other purposes.
5. Subventions provided to the budgets of territorial funds and used for other than their intended purpose are reimbursed to the budget of the Federal Fund in the manner established by the authorized federal executive body.
In accordance with paragraph 6 of Art. 5 of Federal Law No. 326-FZ, establishing the procedure for distributing, providing and spending subventions from the budget of the Federal Compulsory Medical Insurance Fund to the budgets of territorial compulsory medical insurance funds refers to the powers in the field of compulsory medical insurance of the Russian Federation.
Article 133.1 of the Budget Code of the Russian Federation establishes the forms of interbudgetary transfers provided from the budget of the Federal Compulsory Medical Insurance Fund, including subventions to the budgets of territorial compulsory medical insurance funds.
Based on Art. 133.2 subventions to the budgets of territorial compulsory medical insurance funds from the budget of the Federal Compulsory Medical Insurance Fund are interbudgetary transfers provided to the budgets of territorial compulsory medical insurance funds in order to financially secure the expenditure obligations of the constituent entities of the Russian Federation arising from the exercise of the powers of the Russian Federation in the field of compulsory medical insurance, transferred for implementation by state authorities of the constituent entities of the Russian Federation by federal laws. Subventions to the budgets of territorial compulsory medical insurance funds from the budget of the Federal Compulsory Medical Insurance Fund are distributed in accordance with the methodology approved by the Government of the Russian Federation.
Article 28. Formation of funds of the insurance medical organization and their spending
1. Target funds of an insurance medical organization are formed at the expense of:
1) funds received from the territorial fund for the financial provision of compulsory medical insurance in accordance with the agreement on the financial provision of compulsory medical insurance;
2) funds received from medical organizations as a result of the application of sanctions to them for violations identified during the control of the volume, timing, quality and conditions for the provision of medical care, in accordance with Article 41 of this Federal Law:
a) funds based on the results of medical and economic control;
b) 70 percent of the amounts unreasonably presented for payment by medical organizations, identified as a result of an examination of the quality of medical care;
c) 70 percent of the amounts unreasonably presented for payment by medical organizations, identified as a result of a medical and economic examination;
d) 50 percent of the amounts received as a result of the payment of fines by a medical organization for failure to provide, untimely provision or provision of medical care of inadequate quality;
3) funds received from legal entities or individuals that caused harm to the health of the insured persons, in accordance with Article 31 of this Federal Law, in terms of the amounts spent on paying for medical care.
2. The medical insurance organization sends targeted funds to the medical organization to pay for medical care under contracts for the provision and payment of medical care in the amount and on the terms established by the territorial program of compulsory medical insurance.
3. Receipt by an insurance medical organization of the funds of compulsory medical insurance does not entail the transfer of these funds to the ownership of the insurance medical organization, except for the cases established by this Federal Law.
4. Own funds of an insurance medical organization in the field of compulsory medical insurance are:
1) funds earmarked for the costs of doing business on compulsory health insurance;
2) 30 percent of the amounts unreasonably presented for payment by medical organizations, identified as a result of an examination of the quality of medical care;
3) 30 percent of the amounts unreasonably presented for payment by medical organizations, identified as a result of a medical and economic examination;
4) 50 percent of the amounts received as a result of payment of fines by a medical organization for failure to provide, untimely provision or provision of medical care of inadequate quality;
5) 10 percent of the funds generated as a result of savings calculated for the annual amount of funds calculated for the insurance medical organization, determined based on the number of insured persons in this insurance medical organization and differentiated per capita standards;
6) funds received from legal entities or individuals that caused harm to the health of the insured persons, in accordance with Article 31 of this Federal Law, in excess of the amounts spent on paying for medical care.
5. Shaping own funds insurance medical organization is carried out in the manner prescribed by the agreement on the financial support of compulsory medical insurance.
6. Operations with the funds of compulsory medical insurance in the insurance medical organization are subject to reflection in the report on the execution of the budget of the territorial fund on the basis of the reporting of the insurance medical organization without amending the law on the budget of the territorial fund.
From January 1, 2012, the funds intended to pay for medical care and received by the insurance medical organization are targeted financing funds (Article 53 of this Law). In connection with these
amendments to Article 28 spell out the procedure for the formation of funds of an insurance medical organization and their spending. It lists the sources of earmarked funds insurance medical organization.
The procedure for the formation of own funds of an insurance medical organization is carried out in accordance with the agreement on the financial support of compulsory medical insurance, approved by order of the Ministry of Health and Social Development of the Russian Federation of December 24, 2010 No. 1185n "On approval of the form standard contract on financial provision of compulsory health insurance for 2011”. Insurance medical organizations carry out compulsory medical insurance on the basis of agreements on financial
provision of compulsory medical insurance, which are the main documents that determine the procedure for the formation of financial resources by an insurance medical organization and the procedure for their use.
In order to fulfill the main tasks, insurance medical organizations carry out:
1) payment for medical care provided in accordance with the territorial program of compulsory medical insurance and compulsory medical insurance contracts;
2) control over the volume and quality of medical services;
3) formation of a reserve for payment for medical services, a reserve reserve, as well as a reserve for financing preventive measures for compulsory medical insurance;
The volume of medical care and their cost at the rates for paying for medical care, planned for the coming year under the territorial program of compulsory medical insurance, are communicated to each insurance medical organization operating in the territory, based on the number and gender and age structure of citizens insured by it in this territory. The insurance medical organization receives funds (insurance payment) from the TFOMS in accordance with the financial security agreement with the established frequency.
Each medical organization is notified limit values planned volumes of medical care in physical terms (number of visits, bed-days, patient-days - task) based on the total volume of medical care for this profile and the capacity of the medical organization.
The task characterizes the volume of medical care established medical solution commissions for the formation of a territorial program of compulsory medical insurance. If there are several insurance medical organizations that have contracts with this medical organization, the tasks of the medical organization are distributed
between them in proportion to the number of insured by each HMO.