System of medical insurance policies. What is Compulsory Health Insurance (CHI)? Which insurance companies provide CHI policies

The right to health care. The state guarantees the protection of the health of every person in accordance with the Constitution of the Russian Federation and other legislative acts, generally recognized principles and norms international law and international treaties of the Russian Federation.

Health protection is carried out regardless of gender, race, nationality, language, social origin, official position, place of residence, attitude to religion, beliefs, membership in public associations and other circumstances. The state guarantees citizens protection from any form of discrimination associated with the presence of any disease.

Equally with citizens of the Russian Federation, stateless persons permanently residing in the territory of the Russian Federation and refugees enjoy the right to health care. The procedure for providing medical care to foreign citizens, stateless persons and refugees is determined by the Ministry of Health of the Russian Federation and the relevant authorities of the constituent entities of the Russian Federation.

Citizens of the Russian Federation who are outside its borders are guaranteed the right to health care in accordance with international treaties of the Russian Federation.

Funding for the protection of the health of citizens is carried out at the expense of:

Budgets of all levels;

Compulsory and voluntary medical insurance;

trust funds;

Funds of economic entities of various forms of ownership;

Income from valuable papers and other sources.

Legal, economic and organizational foundations of compulsory health insurance are defined Federal Law "On health insurance of citizens in Russian Federation» as amended by the Federal Law of April 2, 1993, with subsequent amendments.

Medical insurance is carried out in two types: compulsory and voluntary.

aim compulsory health insurance(CHI) is to provide the population of Russia with equal opportunities to receive free medical and drug care within the framework of the basic Federal and territorial programs and to finance preventive measures.

Voluntary health insurance is carried out on the basis of voluntary medical insurance programs and provides citizens with additional medical and other services, in addition to established programs OMS.

Federal (basic) CHI program approved by Decree of the Government of the Russian Federation of January 23, 1992 No. 41. The guaranteed list of types of medical care (basic program) includes:

Emergency medical care for injuries and acute diseases that threaten life;

Treatment on an outpatient basis;

Diagnosis and treatment at home;

Implementation of preventive measures (vaccination, medical examination, etc.);

dental care;

Medical and hospital care.

All types of emergency medical care, as well as inpatient care for patients with acute diseases, are provided free of charge, regardless of place of residence and registration, at the expense of the budgets of the respective territories.

On the basis of the Federal Program, the highest authorities of the constituent entities of the Russian Federation approve territorial CHI programs, which cannot worsen the conditions for the provision of medical care in comparison with it.

The Ministry of Health of the Russian Federation has established an assortment list of medicinal, preventive, diagnostic agents and medical products that is mandatory for pharmacies of all forms of ownership. Decree of the Government of the Russian Federation dated July 30, 1994 No. 890 approved the List of population groups and categories of diseases, in the outpatient treatment of which drugs and medical devices are dispensed free of charge or with a 50% discount on prescriptions.

Rights and obligations of subjects of compulsory medical insurance. CHI subjects (Fig. 7) are:

insured;

Policyholder;

Medical institution.

Insured persons have right to choose an insurance medical organization; selection of a medical institution in accordance with the MHI and voluntary medical insurance contracts; receiving medical services throughout the territory of the Russian Federation, including outside permanent place residence; receipt of medical services, the quality and volume of which corresponds to the Federal Program, regardless of the amount of contributions actually paid by the insured; to bring claims against the insured, the medical insurance organization, the medical institution in the event of their failure to fulfill their obligations under compulsory medical insurance agreements, etc.

The insurers are both legal entities and individuals making contributions to compulsory medical insurance funds. Contributors are:

1) for the non-working population - the highest bodies of state administration of the constituent entities of the Russian Federation and the local administration;

2) for employees - employers;

3) persons engaged in self-employment and some other citizens (for example, persons of creative professions who are not united in a union) pay contributions on their own.

For the refusal of business entities to register as payers of contributions to compulsory medical insurance, concealment or underestimation of the amounts from which contributions must be made, violation of the terms of their transfer, financial sanctions are applied in the form of a fine and (or) fine, the payment of which does not relieve the insured from fulfilling obligations under compulsory medical insurance . When imposing financial sanctions, the Federal and territorial CHI funds enjoy the rights of tax authorities.

Policyholders they have a right to choose an insurance medical organization; monitoring the implementation of the CHI agreement. Policyholders are obliged: conclude MHI agreements; make contributions to compulsory health insurance; take measures to eliminate adverse factors affecting the health of citizens; provide the insurance medical organization with information on the state of health of persons subject to insurance, etc.

Insurance medical organizations- these are legal entities of any form of ownership that have received a license from the authorities Federal Service Russia for the supervision of insurance activities. They are not part of the healthcare system.

Insurance medical organization has the right to the choice of a medical institution for the provision of medical care under compulsory medical insurance agreements; participation in the accreditation of medical institutions; participation in the determination of tariffs for medical services; filing a claim against a medical institution or a medical worker for material compensation for harm caused to the insured through their fault, etc.

Insurance medical organization is obliged: carry out CHI activities on a non-commercial basis; conclude contracts with medical institutions for the provision of medical care to the insured under CHI; issue medical policies to the insured or the insured; control the volume, quality and timing of medical care; protect the interests of the insured; create reserve funds to ensure the sustainability of its activities.

To medical institutions include: medical institutions, research institutes and other organizations providing medical care. Individuals can also engage in medical activities - without forming a legal entity individually or collectively.

All medical institutions must be licensed and accredited.

All relations of subjects of CHI are formalized contracts:

1) between the territorial CHI fund (or its branch) and the insurer on the financing of CHI;

2) between the insurer and the medical institution;

3) between the insured and the insurer on the organization and financing of medical care of a certain volume and quality under the compulsory medical insurance program.

These contracts differ from civil law contracts in a number of ways. Firstly, the freedom of expression of the will of the parties in determining their conditions is limited by law and a standard form approved by the Government of the Russian Federation. The parties may not change the content at their own discretion. standard form: reduce or increase the list of free services for the consumer (insured person); amounts of insurance premiums or tariffs for medical services; release each other from liability for non-fulfillment of the terms of the contract.

Secondly, MHI subjects cannot refuse each other to conclude MHI agreements. For an unreasonable refusal to conclude a CHI contract, an insurance medical organization may be deprived of a license by a court decision. The territorial CHI fund or its branch does not have the right to refuse a medical insurance organization to conclude a contract for financing medical care if it ensures the implementation of the territorial CHI program in full.

The relationship between the insured and the insurer is also formalized by the contract. The necessary terms of the contract are: the names of the parties, the validity period, the number of insured persons, the amount and procedure for making insurance premiums, the list of medical services in accordance with the CHI program, the rights and obligations of the parties.

Minimum term the duration of the contract cannot be less than one year. The contract is considered concluded from the moment of payment of the first insurance premium.

Each citizen in respect of whom a compulsory medical insurance agreement is concluded receives medical insurance policy. For children under 16 years old, one of the parents or a representative receives a policy upon presentation of a passport and birth certificate of the child. Military personnel and categories equated to them, registered in departmental medical institutions, are not issued policies. Refugees and internally displaced persons receive temporary policies for the period of registration specified in the certificate issued by the migration service.

When applying for medical assistance, the insured person is obliged to present an insurance medical policy. The policy is valid throughout the territory of the Russian Federation, as well as in the territories of other states with which the Russian Federation has relevant agreements.

Medical institutions are responsible for the volume and quality of medical services provided and for refusing to provide assistance to the insured person. In case of violation of the terms of the MHI agreement, the insurance medical organization has the right to partially or completely not reimburse the costs of providing medical services.

The insurance medical organization is liable for failure to comply with the terms of the MHI agreement. Disputes on health insurance are resolved by the courts within their competence

Final qualifying work

Introduction

medical insurance economic

Health insurance is a set of types of insurance that provide for the obligation of the insurer to make insurance payments in the amount of partial or full compensation for the additional expenses of the insured person, caused by the insured person applying to medical institutions for medical services included in the health insurance program.

AT legal relation this type of insurance is based on the law that defines the legal, economic and organizational foundations of medical insurance for the population of Russia. The law ensures the constitutional right of Russian citizens to medical care.

The relevance of the topic lies in the fact that health insurance in the Russian Federation is a form of social protection of the interests of the population in protecting health.

Object of study– CHI system in the Russian Federation

Subject of study– activity of the insurance company Ak Bars-Med LLC in the CHI system.

Purpose of the study– study of the essence and structure of compulsory medical insurance in the Russian Federation.

Based on the purpose of the work, the following tasks:

1.Consider and study the system of compulsory medical insurance in the Russian Federation.

2.To identify the main participants in the compulsory health insurance system and its financing.

.Analyze the activities of the insurance company Ak Bars-Med LLC

To solve the tasks, the following research methods: analysis of scientific and methodological literature; observation; analysis, synthesis, comparison.

1. Theoretical foundations of the system of compulsory medical insurance in the Russian Federation

.1 Economic entity systems of compulsory medical insurance in the Russian Federation

According to Art. 2 of the Federal Law of November 27, 1992 No. 4015-1 (as amended on July 21, 2005) “On the organization of insurance business in the Russian Federation”: “Insurance is a relationship to protect property interests physical and legal entities upon the occurrence of certain events (insured events) at the expense of cash funds formed from the insurance contributions (insurance premiums) they pay” .

The system of compulsory medical insurance (CHI) is one of the forms of social protection of the interests of the population. It is based on two laws: "Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens" and the Law of the Russian Federation "On medical insurance of citizens in the Russian Federation".

Compulsory health insurance is integral part state social insurance and provides all citizens of the Russian Federation with equal opportunities to receive medical and medicinal care provided at the expense of compulsory medical insurance in the amount and on conditions that correspond to compulsory medical insurance programs (Article 1 of the Law of the Russian Federation dated June 28, 1991 No. 1499-1 "On the health insurance of citizens in the Russian Federation").

The purpose of compulsory medical insurance is to guarantee citizens of the Russian Federation in the event of insured event receive medical care at the expense of accumulated funds and finance preventive actions. Under the insured event in health insurance, they understand not only the appearance of a disease, but the very fact of providing medical care for a disease. Insurance compensation here it takes the form of payment for medical care provided to the population, consisting of a set of specific medical services (diagnosis, treatment, prevention). Medical insurance is carried out at the expense of deductions from the profits of enterprises or personal funds of the population through the conclusion of relevant agreements. A health insurance contract is an agreement between the insured and the health insurance organization. The latter undertakes to organize and finance the provision of medical care of a certain type and quality (or other services in accordance with programs of compulsory or voluntary medical insurance) to insured persons. Medical insurance on the territory of the Russian Federation is carried out in two types: mandatory and voluntary. Compulsory insurance is carried out by virtue of law, and voluntary is carried out on the basis of an agreement concluded between the insured and the insurer. Each of these forms of insurance has its own characteristics.

Take care of your health and the sooner the better. In countries with developed market economy health insurance is one of essential elements health care systems.

Figure 1 - Subjects of compulsory health insurance

CHI is based on the following basic organizational, economic and legal principles:

Universality. All citizens of the Russian Federation, regardless of gender, age, state of health, place of residence, level personal income have the right to receive medical services included in the territorial programs of compulsory medical insurance.

Statehood. Compulsory health insurance funds are in state property Russian Federation, they are managed by the Federal and Territorial CHI Funds. Specialized insurance medical organizations. The state acts as a direct insurer for the non-working population and exercises control over the collection, redistribution and use of compulsory medical insurance funds, ensures the financial stability of the compulsory medical insurance system, and guarantees the fulfillment of obligations to insured persons.

Non-commercial character. All profits from CHI operations are directed to replenish the financial reserves of the compulsory health insurance system.

Mandatory. Local executive authorities and legal entities (enterprises, institutions, organizations, etc.) are required to make contributions at the established rate of 3.6% of the wage fund to the territorial CHI fund and in a certain order, and in addition bear economic responsibility for violation of payment terms in the form of interest and / or a fine.

Social solidarity and social justice. All citizens have equal rights to receive medical care at the expense of compulsory medical insurance. Insurance premiums and payments for compulsory medical insurance are transferred for all citizens, but the demand financial resources carried out only when applying for medical care (the principle of "healthy pays for the sick"). The range and volume of services provided do not depend on the absolute amount of contributions to CHI.

1.2 The mechanism for implementing the system of compulsory medical insurance in the Russian Federation

In accordance with this Law, compulsory medical insurance in Russia is state and universal for the population. This means that the state, represented by its legislative and executive bodies, determines the basic principles of CHI organizations, sets the contribution rates, the circle of insurers, and creates special state funds for the accumulation of contributions for compulsory health insurance. The universality of compulsory medical insurance is to provide all citizens with equal guaranteed opportunities to receive medical care in the amounts established by government programs OMS.

The main goal of CHI is to collect insurance premiums and provide medical care to all categories of citizens at the expense of the collected funds on legally established conditions and in guaranteed amounts. Therefore, the CHI system should be considered from two points of view. On the one hand, it is an integral part state system social protection along with pension, social insurance and unemployment insurance. On the other hand, OMS is financial mechanism providing additional to budget appropriations Money to finance health care and pay for medical services. It should be noted that only medical care for the population is included in the scope of CHI. Compensation for earnings lost during illness is already carried out within the framework of another state system - social insurance and is not the subject of compulsory medical insurance.

On the basis of the Basic Program in the subjects of the Russian Federation, territorial CHI programs are developed, the volume of medical services provided cannot be less than the volume established by the Basic CHI Program. However, in practice, the cost of territorial programs has to be determined based not on the criteria laid down in the Basic Program, but on the basis of the amount financial resources collected by territorial funds for the implementation of compulsory health insurance in the given territory of a constituent entity of the Russian Federation.

The system of compulsory medical insurance was created to ensure the constitutional rights of citizens to receive free medical care, enshrined in Article 41 of the Constitution of the Russian Federation.

Health insurance is a form of social protection of the population's interests in health protection.

The most important regulatory legal act regulating compulsory health insurance is the Law of the Russian Federation "On health insurance of citizens in the Russian Federation", adopted in 1991. From that moment, the development of a new branch of health care, insurance medicine, was initiated.

The law established the legal, economic and organizational foundations of health insurance for the population in the Russian Federation, identified compulsory health insurance funds as one of the sources of financing for medical institutions, and laid the foundation for creating an insurance model for health care financing in the country.

Compulsory medical insurance is an integral part of the 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.

For implementation public policy in the field of compulsory medical insurance of citizens, the Federal and territorial funds of compulsory medical insurance have been created.

How are compulsory medical insurance funds formed to finance medical care?

The financial resources of the compulsory medical insurance fund are formed from part of the unified social tax at the rates established by the legislation of the Russian Federation, part of the unified tax on imputed income for certain types of activities in the amount established by law, insurance premiums for compulsory medical insurance of the non-working population paid by the executive authorities of the subjects Russian Federation, local self-government, taking into account the territorial programs of compulsory medical insurance within the funds provided for in the relevant budgets for health care, other revenues provided for by the legislation of the Russian Federation.

Sources of financing of medical care.

The Federal Law of the Russian Federation of December 29, 2006 No. 258-FZ “On Amendments to Certain Legislative Acts of the Russian Federation in Connection with the Improvement of the Delimitation of Powers” ​​from January 1, 2008 specifies the list of types of medical care provided to citizens within the framework of state guarantees. Now it includes primary health care, emergency medical care, emergency medical care, including specialized (sanitary and aviation), specialized medical care, including high-tech. The law defines the sources of funding.

Compulsory medical insurance pays for medical care provided in accordance with the basic compulsory medical insurance program, which is an integral part of the State Guarantee Program and provides for primary health care, specialized (except for high-tech) medical care, as well as the provision of necessary medicines in accordance with the law of the Russian Federation in cases of diseases (with the exception of sexually transmitted diseases, tuberculosis, HIV infection and acquired immunodeficiency syndrome), injuries, poisoning, congenital anomalies (malformations), deformities and chromosomal diseases, during pregnancy, childbirth, the postpartum period, abortions , individual conditions that occur in children in the perinatal period.

Through budget allocations federal budget provided:

1.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;

2.High-tech medical care provided in medical organizations in accordance with the state task, formed in the manner determined by the Ministry of Health and Social Development of Russia;

.Medical care provided for by federal laws for certain categories of citizens, provided in accordance with the formed state task and in the manner determined by the Government of the Russian Federation;

.Additional measures to develop the preventive direction of medical care (medical examination of orphans and children in difficult life situations staying in stationary institutions, additional medical examination of working citizens, immunization of citizens, early diagnosis of certain diseases) in accordance with the legislation of the Russian Federation;

5.Additional medical care provided by district general practitioners, district pediatricians, general practitioners (family doctors), district nurses of district general practitioners, district nurses of district pediatricians, nurses of general practitioners (family doctors) of federal state institutions under the jurisdiction of the Federal Medical and Biological Agency;

6.Additional medical care provided by district general practitioners, district pediatricians, general practitioners (family doctors), district nurses of district general practitioners, district nurses of district pediatricians, nurses of general practitioners (family doctors) of health care institutions municipalities providing primary health care (and in their absence - by the relevant health care institutions of the constituent entity of the Russian Federation), subject to the placement of a municipal order for the provision of primary health care in these institutions;

.Emergency medical care, as well as primary health care and specialized medical care provided by federal government agencies, subordinate to the Federal Medical and Biological Agency, employees of organizations included in the list of organizations of certain industries with especially dangerous working conditions, as well as the population of closed administrative-territorial formations, science cities of the Russian Federation, territories with physical, chemical and biological factors hazardous to human health, with the exception of expenses financed from the funds of compulsory health insurance;

.Medicinal products intended for the treatment of patients with malignant neoplasms of the lymphoid, hematopoietic and related tissues, cystic fibrosis, pituitary dwarfism, Gaucher's disease, multiple sclerosis, as well as after organ transplantation and (or) according to the list of drugs approved by the Government of the Russian Federation.

It should be noted that the provision of high-tech medical care to citizens is carried out at the expense of the federal budget in accordance with the established state task and in the manner determined by the executive body authorized by the Government of the Russian Federation in any, regardless of the form of ownership and level of subordination, specialized medical organizations. In accordance with Part 6 of Article 51 of Federal Law No. 326-FZ of November 29, 2010 “On Compulsory Medical Insurance in the Russian Federation”, financial provision of high-tech medical care is carried out at the expense of compulsory medical insurance from January 1, 2015.

According to Part 5 of Article 51 of the Federal Law of November 29, 2010 No. 326-FZ “On Compulsory Medical Insurance in the Russian Federation”, the financial provision of emergency medical care (with the exception of specialized (sanitary and aviation) emergency medical care) is carried out at the expense of compulsory medical insurance with January 1, 2013. The procedure for transferring budget appropriations from the budgets of the budgetary system of the Russian Federation to the budgets of the compulsory medical insurance fund for the financial provision of emergency medical care (with the exception of specialized (sanitary and aviation) emergency medical care) is established by federal law, which determines the rate of insurance premium for compulsory medical insurance of the non-working population.

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 oncological dispensaries (in terms of maintenance), in dermatological and venereal, anti-tuberculosis, narcological dispensaries and other specialized medical institutions of the constituent entities of the Russian Federation that are included in the nomenclature of healthcare institutions approved by the Ministry of Health and social development Russian Federation, for sexually transmitted diseases, tuberculosis, HIV infection and acquired immunodeficiency syndrome, mental and behavioral disorders, including those associated with the use of psychoactive substances;

High-tech medical care provided in medical institutions of the constituent entities of the Russian Federation in addition to the state task, formed in the manner determined by the Ministry of Health and Social Development of Russia;

Medications according to:

1.With a list of population groups and categories of diseases, in the outpatient treatment of which medicines and medical products are dispensed by prescription of doctors free of charge, including the provision of citizens with medicines intended for patients with hemophilia, cystic fibrosis, pituitary dwarfism, Gaucher disease, malignant neoplasms of the lymphoid, hematopoietic and related them with tissues, multiple sclerosis, as well as after transplantation of organs and (or) tissues, taking into account the drugs provided for in the list approved by the Government of the Russian Federation;

2.With a list of population groups, in the outpatient treatment of which medicines are dispensed by prescription with a 50% discount from free prices.

.Through budget allocations 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 federal state institutions subordinate to the Federal Medical and Biological Agency, are provided:

.Ambulance, with the exception of specialized (sanitary and aviation);

.Primary health care provided to citizens with sexually transmitted diseases, tuberculosis, mental and behavioral disorders, including those associated with the use of psychoactive substances.

In accordance with the legislation of the Russian Federation, the expenditures of the relevant 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, at the expense of budgetary investments of the federal budget, the budgets of the constituent entities of the Russian Federation and local budgets, medical care and other services are provided in accordance with the established procedure in medical institutions included in the nomenclature of healthcare institutions approved by the Ministry of Health and Social Development of the Russian Federation, as well as in medical organizations who do not participate in the implementation of the territorial CHI program.

Who manages the CHI funds.

Compulsory medical insurance funds are managed by the Federal Compulsory Medical Insurance Fund and territorial compulsory medical insurance funds, which were created on the basis of the “Regulations on the Federal Compulsory Medical Insurance Fund” and “Regulations on the Territorial Compulsory Medical Insurance Fund”, approved by Resolution of the Supreme Council of the Russian Federation No. 4543-1 dated February 24. 93 years old.

The provisions on compulsory health insurance funds are based on a legal structure that takes into account world experience in the most effective protection of public funds from their misuse. The creation of compulsory health insurance funds makes it possible to ensure financial conditions to maintain free medical care for citizens.

Financing the system of compulsory medical insurance in the Russian Federation.

Figure 1 - Financial flows in the system of compulsory health insurance

The financial resources of the state compulsory medical insurance system are formed at the expense of targeted obligatory payments of insurers:

From the budgets of the constituent entities of the Russian Federation, funds are deducted for compulsory medical insurance for the non-working population (children, pupils, students, pensioners, the unemployed, etc.). Organs government controlled in the regions are responsible for making payments.

Employers are the payers of compulsory medical insurance premiums for working citizens. Insurance premium rates are set at the federal level. Until 2001, they amounted to 3.6% of the wages of the insured. From 01.01.2002, insurance premiums for compulsory medical insurance of working citizens are included in the unified social tax, which also combines employers' contributions to Pension Fund and the Social Security Fund.

For calculus tax rate(contribution to CHI) use the so-called regressive scale, according to which the procedure for determining tax base for every worker. This takes into account the size of the organization (enterprise), the income of the employee, etc. However, for most workers with an average income of up to 100,000 rubles. per year, deductions for compulsory medical insurance remained unchanged: 3.6% of wages - 3.4% - to the territorial fund and 0.2% to the Federal Compulsory Medical Insurance Fund.

Figure 3 - Dynamics of the share of assets of organizations and insurance premiums

Insurance medical organizations pay for the provision of medical care (under the CHI program) to the insured, provided by medical institutions operating in the CHI system.

Currently, several methods are used to pay for medical services.

To pay for treatment in hospitals apply:

1)payment according to the cost estimate;

2)the average cost of a treated patient;

)for the treated patient according to clinical and statistical groups (CSG) or medical and economic standards (MES);

)by the number of bed-days;

Payment for treatment in outpatient clinics is made by:

)according to the cost estimate;

2)according to the average per capita standard;

)for individual services;

)for the treated patient;

)combined payment method.

Currently, there is no unified system of payment for medical services in the CHI system. This situation is typical for the transitional period in the organization of CHI. Today, experts consider payment for the treated patient to be the most effective way to pay for medical services. finished treatment case .

The practice of introducing compulsory medical insurance in the constituent entities of the Russian Federation shows that at present it is not possible to achieve full compliance of the functioning territorial systems of compulsory medical insurance with the requirements of the legislation.

1.3 Main participants in the compulsory health insurance system

Compulsory medical insurance 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 an insured event, guarantees of free provision of medical care to the insured person at the expense of compulsory medical insurance within the territorial program of compulsory medical insurance and in cases established by this Federal Law within the framework of the basic program of compulsory medical insurance;

The subjects of health insurance are: insured persons, policyholders and the Federal Fund.

Insured persons are citizens of the Russian Federation, foreign citizens permanently or temporarily residing in the Russian Federation, stateless persons (with the exception of highly qualified specialists and members of their families in accordance with the Federal Law of July 25, 2002 No. foreign citizens in the Russian Federation”), as well as persons entitled to medical care in accordance with the Federal Law “On Refugees” (See Appendix 4):

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

) who are members of peasant (farmer) households;

) non-working citizens:

and) other citizens not working under an employment contract and not specified in subparagraphs "a" - "e" of this paragraph, with the exception of military personnel and persons equated to them in the organization of medical care (See Appendix 4).

Insurers:

b) organizations;

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

The insurers for non-working citizens referred to in paragraph 5 are the executive authorities of the constituent entities of the Russian Federation, authorized by the highest executive authorities of the constituent entities of the Russian Federation. These insurers are payers of insurance premiums for compulsory medical insurance of the non-working population.

Federal fund.

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

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

Members of the CHI system:

) Territorial funds.

Territorial funds - non-profit organizations, created by the constituent entities of the Russian Federation in accordance with Federal Law No. 326-FZ of November 29, 2010 “On Compulsory Medical Insurance in the Russian Federation” (hereinafter referred to as the Federal Law) for the implementation of state policy in the field of compulsory medical insurance in the territories of the constituent entities of the Russian Federation.

Carry out:

a) certain powers of the insurer in terms of the implementation of territorial programs of compulsory medical insurance within the framework of the basic program of compulsory medical insurance in accordance with this Federal Law.

b) managing the means of compulsory medical insurance on the territory of a constituent entity of the Russian Federation, designed to guarantee the free provision of medical care to insured persons within the framework of compulsory medical insurance programs and in order to ensure financial stability compulsory medical insurance on the territory of a constituent entity of the Russian Federation.

The Territorial Fund exercises the following powers of the insurer:

.participates in the development of territorial programs of state guarantees for the free provision of medical care to citizens and the determination of tariffs for paying for medical care in the territory of a constituent entity of the Russian Federation;

2.accumulates funds of compulsory medical insurance and manages them, provides financial support for the implementation of territorial programs of compulsory medical insurance in the constituent entities of the Russian Federation, forms and uses reserves to ensure the financial stability of compulsory medical insurance in the manner established by the Federal Fund;

.ensures the rights of citizens in the field of compulsory medical insurance, including by monitoring the volume, timing, quality and conditions for the provision of medical care, informing citizens about the procedure for ensuring and protecting their rights in accordance with this Federal Law;

.exercises control over the use of compulsory medical insurance funds by insurance medical organizations and medical organizations, including conducts inspections and audits;

.collects and processes personalized records of information about insured persons and personalized records of information about medical care provided to insured persons in accordance with the legislation of the Russian Federation.

The territorial fund at the place of provision of medical care makes payments for medical care provided to insured persons outside the territory of the subject of the Russian Federation in which the compulsory medical insurance policy was issued, in the amount established by the basic program of compulsory medical insurance, no later than 25 days from the date of submission of the medical bill organization, taking into account the results of the control over the volume, timing, quality and conditions of medical care. The territorial fund of the subject of the Russian Federation, in which the compulsory medical insurance policy was issued, reimburses the funds to the territorial fund at the place of medical care no later than 25 days from the date of receipt of the invoice presented by the territorial fund at the place of medical care, in accordance with the tariffs for paying for medical care, established for the medical organization that provided medical care, taking into account the results of the control over the volume, timing, quality and conditions for the provision of medical care.

Insurance medical organizations operating in the field of compulsory medical insurance.

Insurance medical organizations (HIOs) that have a license issued by federal agency executive power, carrying out the functions of control and supervision in the field of insurance activities. Features of licensing the activities of insurance medical organizations are determined by the Government of the Russian Federation.

Carry out:

a) certain powers of the insurer in accordance with the Federal Law and the agreement on the financial provision of compulsory medical insurance concluded between the territorial fund and the insurance medical organization.

b) its activities in the field of compulsory health insurance on the basis of an agreement on the financial support of compulsory medical insurance, an agreement for the provision and payment of medical care under compulsory medical insurance, concluded between an insurance medical organization and a medical organization.

For a more complete implementation of the tasks laid down in the proposed draft law, it is necessary to harmonize the regulatory and legal framework of the federal and regional levels in the healthcare system and its financing. The system should also be improved financial control and streamline the reporting system. Finally, arbitration and mediation mechanisms should be created to resolve conflict situations between insured citizens, compulsory health insurance organizations and health care providers.

No. Areas Years of implementation Expected results new system CHI:2005-2008 Ensuring a balance between the income of the CHI system and its obligations to provide guaranteed medical care to insured citizens in those constituent entities of the Russian Federation that conclude multilateral agreements; ensuring equal access of citizens to receive medical care within the framework of the basic CHI program; transparency financial flows and rational use of CHI system resources; creation of a unified system of personalized accounting with the formation of individual personal accounts; determination of a single insurance premium rate for non-working citizens in the amount that ensures the fulfillment of the state's obligations under the basic CHI program for the provision of free medical care; in 25 constituent entities of the Russian Federation that have concluded multilateral agreements on co-financing the non-working population; 2005 in 47 constituent entities of the Russian Federation of the Russian Federation that have concluded multilateral agreements on co-financing of the non-working population; 2006 in 69 constituent entities of the Russian Federation of the Russian Federation that have concluded multilateral agreements on co-financing of the non-working population; on optimizing the network of medical organizations. 2004-2008 replacement technologies, reprofiling. to reduce and re-profile about 15% of inefficiently operating hospitals with bringing the indicator of provision with beds per 100,000 population in 2004-2006 from 113-110; in 2007-2008 - up to 90-100, and by 2010 up to 80-85 beds; Transformation of the status of a significant part of medical institutions into state (municipal) non-profit organizations, autonomous non-profit organizations. This will make it possible to switch from the system of directing funds for the maintenance of health facilities to paying for the volume of medical care for a specific patient. Gradual formation of a competitive environment, rationalization of costs and improvement of the quality of services ensuring the availability of quality medical care to all citizens of the country. Changing the organizational and legal form of the main part of state (municipal) institutions 2005-20074. Improving the structural efficiency of the healthcare system, creating and implementing a system of hospital-replacing technologies. Changing the structure of spending in health care with a shift in emphasis to outpatient care2004-2010This will allow: to reduce the volume of inpatient care in 2005-2006 by 3-5%, in 2007-2008 by 10-15%, in 2009-2010 to 30 – 35 percent; increase the volume of outpatient care for the above stages by 5-9%, respectively; 18-26%; up to 55 percent, with a corresponding redistribution of funding for these types of medical care. Differentiation of hospital beds depending on the intensity of the treatment and diagnostic process. 5. Gradual introduction of medical and economic standards in the new system of compulsory medical insurance will optimize the cost of the CHI program; Phased recalculation of CHI programs as medical and economic standards are introduced. Efficiency and transparency of the use of financial resources of the MHI system. 6. Development of primary health care. 2004-2008 Introduction of general medical practices (family doctor), development of health care. 7. Introduction of new mechanisms for combining voluntary and compulsory medical insurance. 2006-2007 Attraction of additional sources of financing for paying for medical services. 8. Transfer of benefits for drug provision of certain categories of the population to targeted social assistance. 2005-2006 Reduction of budget expenditures. .Transition to the system of state and municipal orders for the provision of medical care by healthcare organizations to the population within the budgetary part of the State Guarantee Program. 2005-2008 mi organizations. Improving the efficiency of the use of financial, material and labor resources, development of a competitive environment.11. Introduction of new methods of remuneration medical workers 2005-2007 The transformation of medical institutions into other organizational and legal forms will increase wages medical workers.12.Sector development paid services in health care. 2004-2007 Creation of conditions conducive to the increase in the volume and development of the market for high-tech medical services. Participation of citizens in the co-financing of medical

2. Applied aspects of the implementation of the system of compulsory medical insurance in the Russian Federation on the example of the insurance company LLC "AK Bars-Med"

2.1 a brief description of insurance company "Ak Bars-Med" LLC

The insurance company AK BARS-Med LLC was founded in 2004. The main activities are compulsory and voluntary medical insurance. The authorized capital of the company is 150 million rubles. Since 2004, more than 3.2 million people have entrusted their health to the company's partners - medical organizations participating in the implementation of the Territorial CHI Program in the Republic of Tatarstan.

45 branches and representative offices of the Company successfully operate in all administrative regions of the Republic of Tatarstan.

The insurance company has entered into contracts and cooperates with all medical and preventive institutions of the Republic of Tatarstan participating in the implementation of the Territorial Compulsory Medical Insurance Program in the Republic of Tatarstan.

The main tasks of the insurance company are:

1)issuance of compulsory medical insurance policies to insured persons residing in the territory of the Republic of Tatarstan;

2)conclusion of contracts with medical organizations for the provision and payment of medical care under compulsory medical insurance;

)control of volumes, terms, quality and conditions of providing medical care in accordance with the terms of the contract. Carrying out scheduled inspections of the quality of medical care provided to the insured (in LLC IC AK BARS-Med a new approach to assessing the quality of medical services by the method of automated technology for the examination of the quality of medical care (ATE KMP) for various medical profiles has been introduced). Conducting an examination of the quality of medical care provided (ECMP) based on written applications of insured citizens. It is carried out mainly in two cases: when resolving issues of reimbursement of unreasonable expenses of citizens during the period of their diagnosis and treatment in a hospital and if there are complaints about the quality of medical care provided to citizens in a medical institution.

)protection of the rights and interests of the insured: assistance to the insured in solving problems that arise when receiving medical services in medical institutions participating in the implementation of the Territorial Program of Compulsory Medical Insurance of the Republic of Tajikistan;

)advising and promptly solving problems that arise when insured citizens receive medical care in the system of compulsory medical insurance by calling the round-the-clock dispatch service.

)conclusion of voluntary medical insurance contracts with the issuance of insurance medical policies;

)conclusion of contracts for the provision of medical, health and social services to citizens under voluntary medical insurance with any medical and other institutions.

In order to meet the needs of insured citizens in effective methods of treatment, the specialists of the insurance company have developed a number of voluntary medical insurance programs. Contracts have been concluded with private clinics, leading medical institutions in Russia, near and far abroad.

The Company successfully operates a powerful expert service - 120 freelance doctors-experts of the highest category in various medical specialties regularly conduct examinations of the quality of medical care provided.

The insurance company "AK BARS-Med" is a member of the All-Russian Union of Insurers, the Interregional Union of Medical Insurers, the Union of Insurers of Tatarstan.

In 2008, the insurance company "AK BARS-Med" became a laureate in the nomination "Best medical company” – nomination of the Volga National Insurance Award “Silver Umbrella”

In 2010, he is nominated and becomes the winner in the nomination

"Best Medical Insurance Company"

In 2011, it also becomes a nominee for the title of "Best Regional Insurance Company 2011".

Currently, AK BARS-Med LLC has good potential, significant human, financial and administrative resources. The company has a high credibility of its shareholders, partners and customers, and is developing dynamically.

According to the results of 2013, LLC AK BARS-Med ranked 251st in the medical insurance segment, having collected insurance premiums in the amount of 86 million rubles.

Economic environment in which the Group operates The Republic of Tatarstan is a major donor region, industrial, commercial, cultural and scientific centre. On the territory of the republic there are many industrial enterprises developed trade. All this creates the prerequisites for the existence of a rapidly developing market of insurance services. It is important to emphasize that the insurance market of the Republic of Tatarstan is the most developed among the 14 regions of Russia included in the Volga Federal District. For a number of years, the republican insurance market has been a confident leader in the Volga region. federal district. One of the objective indicators of the development of a particular insurance market is the amount of collected insurance premiums.

Economic indicators According to the results of 2014, Tatarstan speaks about the successful development of the republic. Yes, gross regional product increased by 2.3% and amounted to 1.520 trillion. rubles.

In 2014, the foreign trade turnover of the Republic of Tatarstan is estimated to amount to 26 billion US dollars, an increase of 102.3%. The interregional trade turnover of the Republic of Tatarstan, according to estimates, will amount to 600 billion rubles, an increase of 112%.

The above facts testify to the investment attractiveness of Tatarstan for the development of the insurance business.

The insurance market of the region is a subordinate part of the region's economy. Potential demand for insurance services, both among individuals and legal entities are determined by the social and economic potential of the region. Thus, the population of the region gives an idea of ​​the possible volume of development of the insurance market, the share of the urban population indirectly reflects the degree of perception of new types of insurance by the population, average level per capita income is taken into account in development planning voluntary types insurance, volume industrial production characterizes the level of property interests, etc. .

The company receives income under a compulsory medical insurance contract, which is classified as a service contract, as it does not contain any material insurance risk. Under an agreement concluded with the Territorial Compulsory Medical Insurance Fund (hereinafter referred to as TFOMS), LLC IC AK BARS-Med participates in the compulsory medical insurance program in order to provide citizens of the Russian Federation with free medical care through a number of designated insurers. The Company receives prepayments from TFOMS and, in turn, makes prepayments to medical institutions for the services provided by these institutions under the TFOMS program. Target funds received from TFOMS, but not transferred to medical institutions on reporting date, are recorded as commitments for special purpose financing under compulsory medical insurance. For these services, the Company receives a commission, which is reflected in the consolidated income statement. total income as part of commission income from compulsory health insurance.

Unearned premium reserve.

The unearned premium reserve is created in the amount of the part of the accrued premium under the insurance contract relating to the remaining term of the insurance contract as of the reporting date and is calculated in proportion to the remaining term of the contract based on the amount of gross premium accrued, that is, excluding acquisition costs.

Compulsory health insurance.

Free medical services under the CHI policy:

Emergency medical care (ambulance).

Outpatient care, including carrying out activities for the diagnosis and treatment of diseases in the clinic, at home and in the day hospital, if necessary, the provision of emergency care on weekends and holidays(Drug provision for outpatient treatment is not included in the CHI program).

Stationary assistance for:

)acute diseases and exacerbations of chronic diseases, poisoning, injuries requiring intensive care, round-the-clock medical supervision and isolation of the patient according to indications.

)pathology of pregnancy, childbirth, abortion.

)planned hospitalization for the purpose of treatment and rehabilitation, requiring round-the-clock medical supervision, in hospitals, departments and day care wards.

High-tech medical care, which includes a complex of medical and diagnostic services carried out in a hospital using complex and unique medical technologies.

Sanitary and hygienic education of the population, measures for diagnosis, prevention, medical rehabilitation.

Not included in free medical services under the CHI policy:

Diagnostics, examinations, procedures, consultations carried out at home (except for persons who, for health reasons, cannot visit medical institutions).

Carrying out, on a personal initiative of citizens, consultations of specialists, medical examinations and examinations, medical support for private events.

Hospitalization in a dedicated bed. Additional services, stay in the ward superior comfort, an individual post of a medical worker, care and additional food, telephone, TV, etc.

Treatment and examination for a concomitant disease in the absence of an exacerbation that does not affect the severity of the course of the underlying disease.

Examination, treatment, observation at home (except when the patient is unable to visit a medical institution due to health reasons and the nature of the disease).

Anonymous medical services (except as provided by the legislation of the Russian Federation).

Carrying out preventive vaccinations at the request of citizens (with the exception of vaccinations performed under state programs).

Sanatorium-resort treatment (except for the treatment of children and treatment in specialized sanatoriums).

Cosmetic services.

Homeopathic services.

Dental prosthetics (with the exception of persons for whom it is provided for by the current legislation).

Treatment of sexological pathology.

The rights of citizens in the field of CHI:

In accordance with the Federal Law of the Russian Federation dated November 29, 2010 No. 326-FZ "On Compulsory Medical Insurance in the Russian Federation", insured persons have the right to:

Free provision of medical care to them by medical organizations in the event of an insured event:

a) throughout the territory of the Russian Federation in the amount established by the basic program of compulsory medical insurance;

b) on the territory of the subject of the Russian Federation in which the compulsory medical insurance policy was issued, in the amount established by the territorial program of compulsory medical insurance;

Choosing an insurance medical organization by submitting an application in the manner prescribed by the rules of compulsory medical insurance;

Replacement of the insurance medical organization in which the citizen was previously insured, once during the calendar year no later than November 1, or more often in the event of a change of residence or termination of the agreement on the financial provision of compulsory medical insurance in the manner prescribed by the rules of compulsory medical insurance, by filing applications to the newly selected medical insurance organization;

Selection of a medical organization from medical organizations participating in the implementation of the territorial program of compulsory medical insurance in accordance with the legislation of the Russian Federation;

Choosing a doctor by submitting an application personally or through his representative addressed to the head of a medical organization in accordance with the legislation of the Russian Federation;

Obtaining from the territorial fund, insurance medical organization and medical organizations reliable information about the types, quality and conditions for the provision of medical care;

Protection of personal data necessary for maintaining personalized records in the field of compulsory health insurance;

Compensation by the insurance medical organization for damage caused in connection with the non-fulfillment or improper fulfillment of its obligations to organize the provision of medical care, in accordance with the legislation of the Russian Federation;

Compensation by a medical organization for damage caused in connection with its failure to perform or improper performance of its obligations to organize and provide medical care, in accordance with the legislation of the Russian Federation;

Protection of rights and legitimate interests in the field of compulsory health insurance.

2.2 The main tasks of the compulsory medical insurance system on the example of the insurance company LLC "Ak Bars - Med"

Compulsory medical insurance 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 an insured event, guarantees of free provision of medical care to the insured person at the expense of compulsory medical insurance within the territorial program of compulsory medical insurance and in cases established by the Federal Law of November 29, 2010 No. 326-FZ “On Compulsory Medical Insurance in the Russian Federation” within the framework of the basic program of compulsory medical insurance.

1.For the non-working population - the executive authorities of the constituent entities of the Russian Federation, authorized by the highest executive bodies of state power of the constituent entities of the Russian Federation.

2.For the working population - persons making payments and other remuneration to individuals (organizations, individual entrepreneurs, individuals not recognized as individual entrepreneurs), individual entrepreneurs engaged in private practice, notaries, lawyers.

The compulsory medical insurance policy is a document certifying the right of the insured person to free medical care throughout the Russian Federation in the amount provided for by the basic program of compulsory medical insurance.

Table 2 - The number of insured persons under the compulsory health insurance system in the period from 2012 to 2014.

Number of people insured under the CHI system YearNumber of insured people, thousand people.As of 01.01.2012448 640As of 01.01.2013454 482As of 01.01.2014456 406

Figure 4 - Dynamics of changes in the number of insured persons under the compulsory medical insurance system in the insurance company "Ak Bars - Med" LLC.

From the presented diagram it can be seen that the number of those insured under the CHI system is practically equal in all periods.

2.3 Evaluation of the effectiveness of the work of the IC LLC "Ak Bars-Med"

Table 3 - Initial data on profits and losses of a medical insurance organization in the system of compulsory medical insurance on the intended use of funds for 2012, 2013, 2014

For 2014For 2013For 2012Balance earmarked funds at the beginning of the reporting year806 662363 35810 145 ReceivedFunds received from the territorial fund for the financial support of compulsory medical insurance in accordance with the agreement on financial support for compulsory medical insurance25 404 45522 034 81616070185 974 Including: As a result of medical and economic control709 2742313 As a result of an examination of the quality of medical care21 86322 41130 051 As a result of payment for medical organization of fines for non-provision for untimely provision of medical care of inadequate quality 8283 011620 Funds received from legal entities. Or physical. Persons who caused harm to the health of the insured3312466Other receipts of targeted funds4920 5231 198 466 usedMedical payment. assistance to insured persons under compulsory medical insurance agreements29 009 13021 715 53016 169 069 Directed to the income of insurance honey. organizations15 97811 88911 428 Including: From funds received from medical organizations as a result of applying sanctions to them for violations identified during the control of the volume, timing, quality and conditions of medical care15 97811 88911 428 As a result of the examination of the quality of medical care6 4924 6976 884 medical and economic expertise9 0805 7044 234Funds received from legal entities. Or physical. Persons who have caused harm to the health of the insured—as a result of payment for honey. organization of fines for non-provision for untimely provision of medical care of inadequate quality4061 506310

Figure 5 - Dynamics of received and used funds

As of January 1, 2015, the number of citizens insured under compulsory health insurance in the Company amounted to 3,181,144 people.

Figure 6 - Dynamics of insurance payments and premiums under the MHI agreement.

2.4 Prospects for the development of the CHI system in the Russian Federation

Under conditions of hard budget deficit the organization of the system of compulsory medical insurance (CHI) was an effective political and economic solution, which laid the foundation for the formation of a fundamentally new system of legal and financial relations in the field of providing medical care to the population, as well as a more rational use of available health care resources.

For 5 years, the system of compulsory medical insurance has been organizationally formed and is functioning throughout the country practically from scratch. It consists of 90 territorial CHI funds, 1176 branches, 424 medical insurance organizations (HMIs).

More than 82% of the population of the Russian Federation are provided with compulsory medical insurance policies. A system has been created and is functioning for collecting insurance premiums, recording and registering premium payers, the number of which amounted to 3.7 million.

In less than 5 years of implementing the law on health insurance, more than 90 billion rubles have been collected. Of this amount, insurance premiums for employees amounted to almost 56 billion rubles, payments from the budget for compulsory health insurance of the non-working population - more than 21 billion rubles. Due to the collection of fines, penalties from payers, income from the use of temporarily free funds attracted almost 13 billion rubles.

In total, more than 84 billion rubles were allocated to the healthcare system over 5 years in addition to budgetary funds, which is more than 30% of all healthcare expenditures. The main part of the funds (72.4 billion rubles) was used to finance medical care under the territorial programs of compulsory medical insurance. Over the past three years, more than 50% of these funds have been spent by healthcare institutions on the salaries of medical workers, and more than 18% on paying for medicines.

For the current year alone, the Federal Compulsory Health Insurance Fund provided financial assistance in the form of subventions to 88 constituent entities of the Russian Federation for total amount more than 900 million rubles. In addition, taking into account the particular complexity and uniqueness of federal healthcare institutions, they received assistance in the amount of more than 107 million rubles.

The main strategic direction of the work of the Federal and territorial funds has been and remains to ensure the implementation of the Law of the Russian Federation "On the health insurance of citizens" .

One of the strategic tasks in CHI is to ensure the constitutional right of citizens to free medical care. To this end, the Government of the Russian Federation approved the Program of State Guarantees for Provision of Citizens of the Russian Federation with Free Medical Care. This program for the first time at the level normative document the concept of a per capita standard of healthcare financing is introduced.

The implementation of territorial programs in the constituent entities of the Russian Federation will make it possible to start a real restructuring of medical care.

The amount of the deficit of funds to finance compulsory health insurance is increasing every year. As a result of an acute shortage of funds, the actual financing of the territorial programs of compulsory medical insurance amounted to 9 months. 1998 only 37.5% of the approved annual volume.

It should be noted that in the face of a threatening increase in the financial deficit of the compulsory medical insurance system, out of 17 territorial funds, in which, during inspections of the KRU of the Federal Fund, misappropriation of funds was revealed, only one fund fully restored the money spent. The Federal Fund will continue to strictly control the territorial funds for the return of MHI funds for misappropriation.

The main reasons for the current financial situation are:

1)non-compliance by the executive authorities of the constituent entities of the Russian Federation with the law regarding the transfer of payments for compulsory medical insurance of the non-working population;

2)destabilization of the financial and economic situation in the country;

)low level of the insurance premium rate for compulsory health insurance of working citizens (3.6% with a need of 7.2%).

One of the options for solving the above problem could be the approval of a differentiated standard and granting the right to the constituent entities of the Russian Federation to approve the insurance premium rate within the limits of the minimum and maximum size.

About payments. Of particular concern is the situation with payments for compulsory medical insurance of unemployed citizens of the Russian Federation.

Considering that non-working citizens exceed 60% of the total population of the Russian Federation, payments directed to the compulsory medical insurance funds for insurance of non-working citizens should be at least 60-70% of all system revenues. The real situation is the opposite: admission budget funds not only in compulsory medical insurance, but in general, is constantly decreasing, and the insurance premiums of workers instead of additional ones become the main ones.

The solution of these problems is facilitated by the formation of a new information and analytical support for the CHI system based on a comprehensive program of informatization of the industry.

The main tasks of the Federal Compulsory Medical Insurance Fund are:

Improving the financial and credit mechanism for the stability of the CHI system.

Perfection legislative regulation in the field of providing medical care to the population at the federal and regional levels, the implementation of measures to implement the law on health insurance in the constituent entities of the Russian Federation.

Improving measures to improve the quality and accessibility of medical care to the population.

Implementation of the main directions of informatization of the CHI system.

In conclusion, it is necessary to note the importance and relevance of educational support for the reorganization of the medical care system as CHI. For the public, including the medical community, the goals and paths of the transition to compulsory health insurance are still largely unclear. Required to the maximum short term change the situation, be heard and understood by millions Russian citizens in all Russian regions without exception. Ordinary citizens, public organizations and associations representing their interests, political parties and movements, representatives of state authorities at the federal level and, above all, Russian legislators, should understand with our help: why CHI is the real driving force behind health care reform, why without CHI it is impossible to seriously protect the interests of citizens in the field of health protection.

Conclusion

1.Having studied the system of compulsory medical insurance in the Russian Federation, we came to the conclusion that the system of compulsory medical insurance (CHI) is one of the forms of social protection of the interests of the population. It is based on two laws: "Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens" and the Law of the Russian Federation "On medical insurance of citizens in the Russian Federation". The purpose of compulsory medical insurance is to guarantee citizens of the Russian Federation, in the event of an insured event, the receipt of medical care at the expense of accumulated funds and to finance preventive measures. Medical insurance is carried out at the expense of deductions from the profits of enterprises or personal funds of the population through the conclusion of relevant agreements.

2.The main participants in the system of compulsory medical insurance and its financing are: insured persons, insurers and the Federal Fund.

Insured persons are citizens of the Russian Federation, foreign citizens permanently or temporarily residing in the Russian Federation, stateless persons (with the exception of highly qualified specialists and members of their families in accordance with the Federal Law of July 25, 2002 No. Russian Federation"), as well as persons entitled to medical care in accordance with the Federal Law "On Refugees":

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

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

) who are members of peasant (farmer) households;

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

) non-working citizens:

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

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

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

G) unemployed citizens registered in accordance with employment legislation;

e) one of the parents or guardian involved in caring for a child until he reaches the age of three years;

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

7)other citizens not working under an employment contract and not specified in subparagraphs "a" - "e" of this paragraph, with the exception of military personnel and persons equated to them in the organization of medical care.

Insurers:

)persons making payments and other remuneration to individuals:

2) organizations;

)individual entrepreneurs;

)individuals who are not recognized as individual entrepreneurs;

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

The insurers for non-working citizens referred to in paragraph 5 are the executive authorities of the constituent entities of the Russian Federation, authorized by the highest executive authorities of the constituent entities of the Russian Federation. These insurers are payers of insurance premiums for compulsory medical insurance of the non-working population.

Federal fund.

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

Members of the CHI system

Territorial funds are non-profit organizations established by the constituent entities of the Russian Federation in accordance with Federal Law No. 326-FZ dated November 29, 2010 “On Compulsory Medical Insurance in the Russian Federation” (hereinafter referred to as the Federal Law) to implement state policy in the field of compulsory medical insurance in the territories of the constituent entities of the Russian Federation. Federation.

3.In the context of a severe budget deficit, the organization of a system of compulsory medical insurance (CHI) was an effective political and economic decision that initiated the formation of a fundamentally new system of legal and financial relations in the field of medical care for the population, as well as a more rational use of available health care resources

1.On medical insurance of citizens in the Russian Federation: Law of the Russian Federation of July 28, 1991 No. 1499-1 Gazette of the Congress of People's Deputies of the Russian Federation and the Supreme Council of the Russian Federation. 1991. No. 27. Art. 920.

2.On the procedure for financing compulsory medical insurance of citizens for 1993: Decree of the Supreme Council of the Russian Federation of February 24, 1993 No. 4543-1 Gazette of the Congress of People's Deputies of the Russian Federation and the Supreme Council of the Russian Federation. 1993. No. 17. Art. 591.

.On measures to implement the Law of the Russian Federation "On Amendments and Additions to the Law of the RSFSR "On Medical Insurance of Citizens in the RSFSR":

.Decree of the Council of Ministers - Government of the Russian Federation dated October 11, 1993 No. 1018 Collection of acts of the President and Government of the Russian Federation. 1993. No. 44. Art. 4198.

.Tax Code of the Russian Federation (part one): Federal Law of July 31, 1998 No. 147-FZ Collection of Legislation of the Russian Federation. 1998. No. 31. Art. 3824.

.On the basics of compulsory social insurance: Federal Law of July 16, 1999 No. 165-FZ "Collected Legislation of the Russian Federation" 1999. No. 29. Art. 3686.

.About general principles organizations of legislative (representative) and executive bodies of state power of the constituent entities of the Russian Federation: Federal Law of October 6, 1999 No. 184-FZ

8.Collection of legislation of the Russian Federation. 1999. No. 42. Art. 5005.

.The Constitution of the Russian Federation was adopted by popular vote on December 12, 1993. WG. - 1993. - No. 237.

10.On the basics of compulsory social insurance: Federal Law of the Russian Federation of July 16, 2000 No. 165, - FZ, as amended. November 29, 2010 Reference and legal system "Consultant Plus": [ Electronic resource] "Consultant Plus" company.

.On the budget of the Federal Compulsory Medical Insurance Fund for 2008 and for the planning period of 2009 and 2010: Federal Law of the Russian Federation of July 21, 2007 No. 184-FZ Reference and legal system "Consultant Plus".

.On the implementation of the budget of the federal fund for compulsory medical insurance for 2008: Federal Law of the Russian Federation of December 27, 2009 No. 372-FZ.

.On compulsory health insurance in the Russian Federation (adopted by the State Duma of the Federal Assembly of the Russian Federation on November 19, 2010): Federal Law No. 326-FZ dated November 29, 2010 Reference and legal system "Consultant Plus": [Electronic resource. Consultant Plus. – Last. update 01/12/2011

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The system of compulsory medical insurance in the Russian Federation

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

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

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

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

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

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

Insured person - individual covered by compulsory health insurance under federal law No. 326-FZ "On Compulsory Medical Insurance in the Russian Federation" (defines the rights and obligations of the insured).

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

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

The Russian system of compulsory medical insurance (CMI) has recently undergone major changes

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

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

The compulsory medical insurance system was introduced in the 1990s with the main goal of saving healthcare in the face of shrinking budgets and guaranteeing free medical care to Russians. CHI coped with these tasks, but they were replaced by new ones: the modernization of the medical industry, the introduction and wide availability of new treatment technologies, the transition from medical care mainly in emergency situations to maintaining health, preventing diseases and preventing the development of severe forms of dangerous diseases. Recently, the Ministry of Health and the MHIF have done a lot to develop the compulsory medical insurance system in these areas. Today, at the expense of compulsory health insurance, a program of clinical examination of the population is being carried out and high-tech medical care is provided in the treatment of complex diseases.

In addition, the procedure for the operation of the compulsory medical insurance system is being improved: more effective methods of paying for medical services are being introduced, new mechanisms are being created to control the quality of medical care and protect the rights of insured citizens. Thus, a single-form CHI policy has been introduced, according to which every citizen can receive medical care in any corner of the country. The Russians received the right to independently choose polyclinics and an insurance medical organization.

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

Accounting for the insured and issuing the policy

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

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

Such an order not only makes it possible for every insured person in any locality of the country to receive medical care and prevents duplication of costs, but also ensures reliable accounting and proportional funding. federal programs by regions.

Professional Patient Support

As already mentioned, today insurance medical organizations are interested in providing the highest quality services to their insured. The patient can contact his HMO for almost any issue related to the provision of medical care. For example, if you are offered a long wait for a doctor's appointment or are being delayed with a study, if it seems to you that the medical care you received was of poor quality, or if you suddenly demanded money for what you were supposed to do for free, feel free to contact your insurer. In any of these situations, the CMO is not only obliged, but also interested in helping you. The insurer will explain to you what needs to be done to resolve the issue, get involved in solving the problem, call the head physician of your clinic or hospital where you are being treated.

If the insurer deems it necessary or at your request, an assessment will be made of the quality of your care. If violations are found during this check, the medical organization may be fined. CMO will provide you with consulting and legal support. Now these types of control have become a permanent practice: for example, in the period 2014-2015, insurance organizations considered more than 60 million requests from patients. However, if it seems to you that insurers are evading their duties, you can contact the territorial CHI fund with a complaint - and then the check is waiting for the insurers themselves.

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

Payment for medical services

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

Upon completion of the audit, medical organizations receive payment from insurers. However, if the invoice was rejected due to a technical error, the clinic or hospital may issue a second invoice - the insurer is obliged to check it again and, if everything is correct, pay. Money to pay the bills of medical organizations appears on the accounts of HMOs from the TFOMS within a strictly designated period and only for 3 working days: during this time, insurers must accept and process all invoices, pay them, and return the balance (if any) to TFOMS. Violation of the deadlines threatens with strict sanctions from the TFOMS, which monitors the quality of the work of the HMO. Independently, TFOMIs carry out only inter-territorial settlements (when an insured person in one region of the Russian Federation received medical care in another region). However, the volume of such payments is negligible compared to the local, conducted by the forces of the CMO.

The system of interaction built today between the participants of the CHI system, where funds and HIOs ensure the functioning of the entire system and the possibility of exercising the rights of citizens to quality and free medical care, experts recognize as optimal and logical. Of course, this does not mean that there is nothing more to improve at all. Changes in this area are happening all the time. For example, at the initiative of the Ministry of Health, an institute of insurance representatives has been created and has already begun its work, the task of which is to raise patients' awareness of their rights and protect their interests even more closely.

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