The compulsory medical insurance system in Russia consists of subjects and participants, which are individuals and legal entities, as well as government agencies. Every citizen of the Russian Federation who has received insurance becomes a subject of this system. You should know more about your rights, as well as about interaction with other participants.

There are two types of health insurance in the Russian Federation: voluntary and compulsory. The purpose of the first is to provide citizens of the Russian Federation with an additional list of medical supplies. services. Payment for the procedures is carried out from a fund, which is replenished by the owner of the insurance policy.

The second type of insurance is compulsory. When the insured person needs the help of doctors, he will be able to go to the hospital and use the services of doctors free of charge. Compulsory insurance allows you to go to any clinic throughout the country. You will first need to secure a seat in one of them. This can be done by phone or at the reception.

Features of insurance in the field of medicine

Since insurance in the Russian Federation is a compulsory norm, you should learn in more detail what compulsory medical insurance is.

According to the law of the Russian Federation, you are required to be insured

• citizens of the Russian Federation;
• foreigners permanently or temporarily living in the country;
• persons who do not yet have citizenship;
• refugees from other countries.

Payment for services provided to insurance holders is made from the state budget.

The sources of its formation are:

• contributions from employers for their officially employed employees;
• fixed payments for self-employed and individual entrepreneurs;
• revenues from local budgets of constituent entities of the Russian Federation.

With insurance, you can:

• receive emergency medical care;
• take part in treatment and preventive measures;
• contact specialized specialists;
• use the services provided by the insurance company.

Subjects participating in the insurance process

The legislation of the Russian Federation distinguishes 3 insurance entities. Policyholders are legal entities that have the authority to issue policies. These are representatives of insurance companies. In some cases, this entity is the state itself.

Insured persons are citizens of the Russian Federation and other persons who have received insurance. This document gives them the right to receive a number of services from public hospitals free of charge.

The Federal Fund regulates the relationship between the two previous entities. FFOMS protects the rights of both insurers and policyholders.

In addition to the subjects, other participants are also included in the compulsory medical insurance system. Funds of the constituent entities of the Russian Federation make contributions to the budget, from which payment for services provided to policy owners is made.

Medical insurance organizations and hospitals also participate. The first are licensed institutions engaged in issuing VHI policies and. The second ones provide honey. services are free.

Subjects and participants constantly interact with each other. Relations between them are regulated by Russian legislation.

Article 41 of the Constitution of the Russian Federation: what is it about?

The article talks about the right of citizens of the state and other policy holders to receive medical care from hospital institutions free of charge. Payment for services provided by doctors is made from the state. country budget.

The Constitution also contains information about the development of the system. In Russia, programs are being financed aimed at creating new public and private funds.

Article 41 states that the government undertakes to encourage the activities of organizations that will function to improve the health of the entire society as a whole and each person who applies.

In accordance with Art. 41 persons who deliberately conceal the fact of a threat to the health or life of Russian citizens will be required to bear punishment for this action. This is also supported by federal state laws.

Types of compulsory medical insurance

The Russian compulsory medical insurance policy can be presented in three types:

• paper containing a barcode;
• plastic, in the form of a card with a chip;
• electronic, with an individual number.

Medical insurance system

Subjects and participants interact with each other, creating a system. In the process of functioning of the structure, issues of forming funds are resolved, from which payments are subsequently made. Also in the process of interaction, finances are distributed.

The bulk of medical care for the Russian population is paid for from the state budget. The Federal Compulsory Medical Insurance Fund regulates cash flows.

Rights of persons receiving insurance

The policyholder has a number of rights provided for by the legislation of the Russian Federation:

• receive assistance from doctors throughout the state or within the entity where the policy was issued, free of charge;
• choose an insurer by sending an application to the company according to the rules of state legislation;
• change the insurance company no more than once in 365 (366) days if the contract with the insurer has expired or you have changed your place of residence (the choice must be made before November 1);
• choose a medical institution from those that will be offered to the policyholder by the agent;
• choose the attending physician, indicating him in the application addressed to the head of the hospital (independently or through an official representative);
• receive from the regional fund and honey. institutions provide truthful information about the quality and conditions of procedures performed by doctors;
• require doctors to protect personal data;
• receive compensation for damages from insurance and medical organizations in the event of non-fulfillment or improper performance of services by them;
• demand protection of rights and interests provided for by the legislation of the Russian Federation.

Responsibility of medical institutions

Hospitals and clinics are required to provide free medical care. services to insured persons. At the same time, the procedures performed by doctors must be of proper quality, and the prescribed medications must relieve the symptoms of the disease.

Honey. institutions are responsible to the Federal Fund by sending reports to it in the proper form.

Hospitals are also required to:

• keep records of services provided;
• provide insurers with information about the medical care provided to their clients. help;
• post on the official website and other resources reliable information about operating hours, types of services, and also inform the Federal Fund and patients about this;
• use medicines and consumables provided by the state;
• inform patients about the availability of paid services, if any, but do not force them to purchase them.

In case of violation on the part of the medical Institution, the patient has the right to request an examination. Within its framework, specialists conduct an independent assessment of the work of one or more doctors, as well as the entire hospital (if necessary).

Monitoring the provision of medical care

The main problem of compulsory medical insurance in Russia is the provision of medical services. institutions of inadequate quality. To determine the fact of a violation based on the results of the procedure, an independent examination of the ILC is carried out in order to assess:

• the actions of the doctor and the treatment he prescribed or the functioning of the hospital as a whole;
• compliance of the doctor with the level of his qualifications;
• the quality and safety of care provided from one of four points of view (in an emergency, on the part of the patient, with and without technology deviation);
• compliance by the doctor with standards, procedures, requirements of regulatory legal acts when providing medical care. help.

If, as a result of the examination, a violation is revealed on the part of a doctor, several doctors or a medical institution as a whole, then the insured person will be issued a conclusion. Based on it, the policyholder will be able to draw up and file a claim in court for damages.

Scheme of work

To find out how honey works. insurance in Russia, you should consider the system’s functioning scheme.

For 2019-2020, its main link is the distribution of budget funds between the subjects:

• compulsory health insurance is not intended for payments to the population in cash or non-cash forms;
• medical payment services are provided directly to the account of the treated institution;
• there is no provision for payment for working days during which the policy owner was incapacitated;
• an important point is to make contributions individually for each insured person;
• contributions to the budget are made by both the state and the employer;
• employees are not sources of budget financing.

Regional programs

The prospect for the development of compulsory medical insurance in Russia lies in the development by subjects of their own insurance programs. According to them, the policyholder will be able to receive honey. assistance only in the territory where you received the policy. The services received will be paid directly from the subject’s fund.

Top 10 companies involved in issuing policies

The development of compulsory medical insurance in Russia makes it possible to choose an insurer. You should pay attention to the rating, which is compiled annually by the Federal Compulsory Medical Insurance Fund and uploaded on its official website. The table shows the 10 best insurance organizations for 2019.

Compulsory medical insurance agreement

In addition to the basic data (who signed it, from what year and for which it is valid, etc.), the contract specifies the responsibilities of both parties. The insurance company undertakes:

• provide the owner of the compulsory medical insurance policy with information about the rights and obligations of the policyholder;
• inform the policyholder in writing within 3 working days about the occurrence of the fact of insurance and receipt of the policy;
• issue a compulsory medical insurance policy in accordance with the federal legislation of Russia.

The policyholder is obliged:

• make timely payments to the fund (the amount and timing of contributions are provided for by law);
• turning to honey organization for help, submit a compulsory medical insurance policy (except for cases when the request is an emergency);
• personally or through an official representative, following the established rules, submit an application indicating the choice of an insurance company;
• send information to the insurer about changing your passport or moving within a month from the date the changes come into force;
• when changing permanent residence, select a new insurer within a month.

The compulsory medical insurance system for Russian citizens and other persons with insurance provides for the provision of services by medical institutions on a free basis. It consists of three main entities: the insurer, the policyholder and the Federal Compulsory Medical Insurance Fund. The latter acts as a regulator of the relationship between the first two.

Hello everyone, friends! Recently a friend approached me and asked for help. Once upon a time, he lived without worrying without free medicine, but then he had children, and the economic situation changed. So he asked me to explain the benefits compulsory medical insurance policy: what is included in the list of services provided and how to get them. I suggest we figure out the nuances together!

What is a compulsory medical insurance policy and what does it include?

The compulsory health insurance policy (CHI) is provided under a special program operating in the Russian Federation. It certifies that the costs associated with your treatment will be paid by the company that issued the document. The document is issued to citizens of the Russian Federation free of charge, without any expiration date. According to the law, when going to medical institutions you must have it with you: without presenting the paper, if an insured event occurs, you will only be provided with emergency assistance. If you have a compulsory medical insurance policy, you can go to the clinic to which you are attached.

Essence and purpose of the policy

What does the insurance policy guarantee? It provides free medical care to every citizen of the Russian Federation. This right is established in the Constitution, and funding comes through insurance funds at the federal and regional levels. They are replenished by regular contributions, which are made as follows:

• employers make contributions for employees;
• The state pays for the temporarily unemployed.

The list of compulsory medical insurance services is determined at the federal level. Regions are also reviewing the conditions and introducing additional items if necessary. If you are unsure whether your case is included in your area's basic plan, contact your insurance representative.

Legislative framework: how to determine what is included in compulsory medical insurance

According to the law, citizens of the Russian Federation, regardless of age, gender and social status, must receive the same medical care. This is regulated by the following provisions and acts:

• Federal Law No. 326;
• Government Decree No. 1403 (it stipulates what is included in the basic program for 2018-2019);
• regional regulations.

To receive medical care, contact institutions included in the public health insurance program. If you want to get help in medical institutions that are not included in their list, you will need a VHI policy.

What types of services are guaranteed by the state?

What are citizens entitled to free of charge under compulsory medical insurance? The main services include emergency assistance, eliminating threats to human life and health. It also turns out outpatient care:

• an appointment with a doctor at the clinic to which you are assigned;
• ambulatory treatment;
• clinical examination;
• therapy at home or in a hospital;
• gynecological services, including pregnancy management.

Inpatient assistance, provided for by the compulsory medical insurance policy, implies the following:

• planned or emergency hospitalization for exacerbation of chronic diseases;
• hospital stay when pathologies of pregnancy or childbirth are detected;
• treatment when the need for inpatient therapy arises.

The possibility of receiving treatment, if it requires high-tech methods, is separately discussed. Since 2014, this option has been included in the policy, which has ensured the availability of medicine for the population. But in order to determine whether a case falls under a type of disease requiring TMV, one has to take into account all the nuances of the condition. Difficulties also arise with quotas - the amounts allocated for treatment under the policy.

If your condition is life-threatening (you were poisoned, broke a leg, got a burn), you must be accepted regardless of whether you have a policy.

What list of services is included in the compulsory medical insurance policy: what needs to be taken into account

Services under the basic compulsory medical insurance program are provided for the following diseases:

You will also receive help for injuries, poisoning, mental disorders, and the appearance of tumors (diagnosis, treatment and, if necessary, removal are carried out). Free services are also provided for congenital defects, chromosomal abnormalities and conditions arising during the perinatal period.

Who can receive services under the compulsory medical insurance policy included in the list

Who receives services under the general program? The following categories may qualify:

• citizens of the Russian Federation who received the policy;
• nationals of another state permanently residing in Russia;
• stateless persons(refugees).

If in the first case the policy is issued on a permanent basis, then citizens of other countries do not enjoy this privilege. For them, the compulsory medical insurance will expire when the temporary residence permit expires.

How to find out if a service is included in the compulsory medical insurance program

Information about what is included in the types of basic assistance for your constituent entity of the Russian Federation can be obtained directly from the insurance company. Medical institutions also provide a list of services under the compulsory medical insurance policy, although in fact patients are rushed to sign an agreement for paid treatment. You can check the veracity of the data on the website of the Federal Compulsory Medical Insurance Fund, but it can be difficult to understand the details. If you can’t find your way around on your own, write an email or call the hotline: you can find contact information on the main page.

Where can you find out the list of compulsory medical insurance services: how to clarify the nuances

In some cases, it is enough to contact the insurance company to avoid paying for expensive services. By calling the phone number indicated on the policy, you will find out that not everything is as scary as the doctor said.

For example, there was a need to remove a cyst. Doctors are likely to say that the free option under the policy will be highly traumatic, but when concluding an agreement on paid services, the matter will involve minimal intervention. But once you involve the insurance company’s experts, the operation can be performed using modern methods.

List of free tests for compulsory medical insurance

By calling the phone number indicated on the policy, you will find out the list of free tests under compulsory medical insurance. After all, sometimes doctors themselves do not know whether the patient needs to pay: There is no approved list in the legislation.

For example, if you have diabetes, you are given a blood test to check your sugar levels. It is provided free of charge because it is part of the standard of treatment. But to identify the reasons that caused the malfunction in the body, a comprehensive examination is required. It includes a hormone test, which is not done in every clinic due to lack of equipment. As a result, the doctor recommends contacting a private laboratory. But go straight away or get free service?

Find out what is included in the free service

To find the answer to the question, proceed as follows: first, check whether the disease is included in the basic compulsory insurance program. If you find the position you need, open the standard of treatment on the Ministry of Health website and look for an analysis. Is it not on the list? Then you'll have to spend money.

Typically, all-Russian and territorial analysis lists include the following:

• testing for syphilis, HIV, etc.;
• detection of helminths in feces;
• general and clinical blood test;
• Ultrasound, MRI, CT;
• X-ray;
• biopsy;
• general analysis of urine and feces;
• glucose level test;
• skin scrapings, saliva smears.

The complete list must be clarified depending on the region of your location.

Have you been undergoing treatment for a long time, undergoing tests, doing examinations, but there is no progress? The insurer is not interested in paying the costs indefinitely. This means that after your request, he will connect experts. They will request primary medical documentation and check whether the doctor made any mistakes during treatment. In other words, the list of compulsory medical insurance services also includes free quality control of services.

Dental services under compulsory medical insurance policy

The question of whether free dental services are provided under the compulsory medical insurance policy is often asked. If you don't want to pay the dentist, expect the following:

• You will be admitted and your oral cavity examined;
• cure inflammation;
• they will put fillings;
• remove plaque (up to 6 teeth);
• splinting will be done with quick-hardening plastic;
• cure hypersensitivity or diseases of the salivary glands;
• they will remove a tooth (including complex cases), open an abscess and generally carry out surgical procedures;
• They will do an x-ray.

But not everything is rosy, because the list of free positions under compulsory medical insurance includes only the simplest options. For example, a filling is made of cement; You will have to pay money to use light-curing imported materials.

As for prosthetics, the use of metal-ceramics or the manufacture of clasp structures remains paid. Benefits are provided for some categories (disabled people, veterans), but false jaws will not be made from expensive materials.

To receive dental care within the territorial compulsory medical insurance program, contact the clinic.

When wondering what dental care is included in the compulsory medical insurance policy, take into account the differences in regions. If in prosperous Moscow, clinics offer treatment no worse than what you will receive from private providers, then in small cities the situation changes. Depending on the region, the list of free services ranges from 20 to 200 items. There is no question of prosthetics under compulsory medical insurance: in many regions they are not even provided to veterans or disabled people. How can you get dental treatment without paying?

Doctors recommend not to delay a visit to the clinic: patients often walk with carious teeth for more than one year. And they turn to help when they cannot do without expensive intervention. According to dentists, up to 70% of the funds allocated under the compulsory medical insurance program are spent on the treatment of caries complications. If you do not want to pay, apply for a preventive examination 1-2 times a year. It is possible to treat simple cases under the compulsory medical insurance policy!

How to treat teeth according to compulsory medical insurance

Please note: when you go to the dentist with acute pain, he may take the opportunity to offer paid treatment. A common reason for referrals is inflammation of wisdom teeth, and doctors were able to monetize the scheme. They say that the patient needs to undergo numerous tests, and in some cases, go to the hospital, since a complex operation is ahead. As an alternative, they offer a paid service: there is no need to test blood for hepatitis and study its biochemical composition.

When a person with acute pain is asked whether he wants to take tests and wait for the result or get help for money, the choice is clear. The main thing is that you keep the receipt and contact the insurance company, and, if necessary, the compulsory medical insurance fund. In such cases, the medical institution must compensate you for your expenses.

How to register with a clinic and receive treatment under the compulsory medical insurance policy

To receive medical care under the compulsory medical insurance program, contact the clinic to which you are assigned. If you have not yet chosen an institution, decide on the option and apply locally. You will need a package of documents:

• passport citizen of the Russian Federation;
• SNILS;
• compulsory medical insurance policy;
• if you are submitting documents for a child - representative statement;
• if you are attached personally - your completed application.

Take care of the attachment in advance, since staff are given 4 working days to verify the information provided. Also find out if the clinic has a gynecology and dentistry department. If they are available, you will not have to submit new applications; in other cases, select a suitable clinic and apply with the same documents.

How to get help if the service is included in the compulsory medical insurance policy

Once you are assigned to a clinic, seek treatment from a general practitioner or general practitioner. He will determine further measures: within the framework of the policy, you cannot simply come into the office and state that you need an X-ray or MRI.

Check out the list and find out if your condition is included in it

The timing of assistance depends on the region, so check the conditions in specific cases. For example, in St. Petersburg the following rules apply:

• primary health care must be provided within 2 hours. after treatment;
• to the doctor for treatment primary specialized care you will get there no later than in 5 days;
• to pass laboratory tests, you have to wait until 10 working days;
• do CT or MRI you are obliged within 30 working days;
• For planned hospitalization have to wait until 30 days.

Despite the agreed deadlines, you must receive emergency assistance immediately. You do not need to have compulsory medical insurance or be affiliated with a clinic.

How to get a referral for surgery under compulsory medical insurance

If you require serious treatment, proceed as follows:

1. Once attached, make an appointment with the appropriate doctor. When you are examined and tested, based on the results you will be sent to a commission.
2. She will make a decision, and you will receive a referral from your doctor for hospitalization. If necessary, you will undergo additional tests.
3. Arrange for a hospital stay.

In practice, patients are faced with having to wait a long time for a free operation. If you are not provided with the required treatment within six months, file a complaint with the Compulsory Medical Insurance Fund.

The policy also provides services for the rehabilitation of the patient: if necessary, you will receive a voucher to a sanatorium from the attending physician.

Where to get treatment free of charge if it is included in the compulsory medical insurance policy

You can go not only to a public clinic, but also to a private one. Indeed, since 2011, such institutions have received the right to participate in the compulsory health insurance system. To find out if there are private clinics involved in the program nearby, find the website of the territorial compulsory medical insurance fund for your region on the Internet. Another option is to contact your insurance company. She will provide the necessary information and help you attach to the right center.

Not everything is so rosy: commercial establishments participating in the program are pursuing their own interests. They don't just provide free treatment that is included in insurance. The main goal is to offer patients expensive “concomitant” procedures, impose examinations, and convince them of the need for additional tests. Frankly charlatan methods like “early diagnosis of cancer by blood” are also possible. If you are offered this type of treatment, contact your insurance representative. He will determine whether there is a need for the procedure and will tell you whether you need to pay for it.

You can also choose where to receive treatment in public clinics. Do you live in the same area, but want to receive medical care in a clinic located opposite your place of work? Go to the selected institution and write an application addressed to the head physician. Please provide the following:

• actual address;
• place of registration;
• Compulsory medical insurance number;
• address of the clinic to which you are assigned.

Within 12 working days, the information will be verified and you will be transferred to the selected institution.

What is not included in free treatment under the compulsory medical insurance policy?

You should not count on free treatment in the following cases:

1. You went to a clinic that does not participate in the compulsory medical insurance program. This happens even in cases where you were previously covered by insurance. There are discrepancies due to the fact that institutions annually submit an application for participation: if the period has expired and the clinic has not extended it, you will have to pay for treatment. The clinic can only serve certain areas under compulsory medical insurance (gynecology, dentistry), so check the conditions.
2. Compulsory medical insurance does not include sexually transmitted diseases, HIV, AIDS, tuberculosis, and some types of dental and orthopedic services. The program does not provide assistance for mental illness or behavioral disorders. You will also not receive palliative care services (relief of suffering in incurable cases). But this does not mean that you will have to pay for services out of your own pocket, since there are separate programs in the regions.
3. The state does not pay for examinations that you do on your own initiative. The program does not include homeopathic and cosmetological treatment, as well as anonymous services. The latter are provided only in exceptional cases provided for by law.
4. If you want increased comfort, a separate room, a specially designated bed, you will have to pay for them. The insurance does not include the cost of an individual medical worker in your room. You will also purchase additional food at your own expense.
5. Consultations and treatment at home, except in cases where the patient cannot visit a medical facility for health reasons, are subject to payment.

Conditions must be clarified in each case, so do not hesitate to contact a representative of the insurance company.

What to do if you are not provided with services included in compulsory medical insurance

Are you sure that the service should be provided free of charge under compulsory medical insurance, but you are denied? Take the following measures:

• contact your primary doctor;
• contact a representative of the insurance company;
• call the compulsory medical insurance fund (phone numbers are indicated on the stand at the medical institution).

If you don’t have time to figure it out and you are forced to pay for help, warn that you will keep the receipt. With this document, you will file a complaint against the actions of the medical institution, and it will return the money.

Still have questions? Watch the video that explains what is included in the compulsory medical insurance policy:

If you are not served on time

Please note that there is essentially no free medicine in Russia: it remained in the USSR. Our system is not free, but insurance. This means that you should not tolerate if you do not get the help you need, and humbly wait for the result. If the deadline has passed, call your insurance agent. Did he not respond to the appeal? The quality control service will help you, where you can file a complaint.

Conclusion

To avoid overpaying for services that are provided free of charge, find out what your health insurance covers. If necessary, contact a representative of the company that issued compulsory medical insurance, and he will help you register at the desired clinic.

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The insurance market is developing rapidly, so today all citizens of the Russian Federation have access to a wide range of insurance services.

It should be noted that they are all divided into compulsory and voluntary types of insurance.

The first type includes, for example, compulsory health insurance, or compulsory medical insurance, which regulates the procedure for providing various medical services.

Medical services under the compulsory medical insurance policy, if necessary, are provided to insured persons free of charge, and their list is fixed in the terms of the insurance contract.

Medical services under compulsory medical insurance policy. Characteristic

In the insurance market, each company offers its own terms of compulsory health insurance contracts, therefore services under the compulsory medical insurance policy are provided to clients in different volumes.

Despite the existing differences, compulsory medical insurance contracts are for the most part standardized, so we can identify a number of key characteristics that are inherent in most policies.

List of insured persons

First, it is necessary to determine the list of those categories of citizens of the Russian Federation who can be insured and receive free medical services under the compulsory medical insurance policy.

These include the following:

Citizens with official employment. The key feature of this category of residents of the country is that they regularly pay taxes and thereby ensure the filling of the revenue side of the budget of the Russian Federation. Subsequently, these funds are redistributed and part of them is sent to cover the costs associated with ensuring that medical services under the compulsory medical insurance policy are provided to their owners free of charge.

Thus, citizens with official employment pay in advance for services under the compulsory medical insurance policy. It is possible to obtain such insurance at your place of work, which is a definite advantage.

Unemployed or citizens with unofficial employment. Despite the fact that this category of citizens does not pay income tax at all or pays less, there is still a significant list of taxes that residents of the country encounter every day in everyday life. For example, VAT, excise taxes and many others.

Therefore, the revenue side of the budget is also replenished by contributions from these citizens, and payment of funds for treatment in the presence of a valid compulsory health insurance policy is made at the expense of the federal budget, that is, free of charge for the patient. You can buy such insurance from any insurance company.

Minors. Newborns, children, and teenagers are not taxpayers, but parents can insure their children in case of illness at any branch of the insurance company.

Attention! In the absence of a valid compulsory health insurance policy, an employee of any medical institution has the right to refuse to provide services to an applicant on all legal grounds.

Thus, the compulsory medical insurance policy is available to all residents of the Russian Federation, despite age, financial status and other differences. The importance of having such an agreement is explained by the fact that thanks to it a person has guarantees that in the event of any illness he can freely visit the hospital and receive free services under the compulsory medical insurance policy.

List of medical institutions

When signing an insurance contract, you must familiarize yourself with the list of medical institutions that provide services under the compulsory medical insurance policy free of charge. Due to the fact that payment is made from the federal budget, all public hospitals are included in it, including:

1. Children's medical centers and clinics;
2. Maternity clinics, state maternity hospitals;
3. Medical centers and clinics for adults;
4. Specialized institutions that are classified as government and many others.

An insured person can seek help at any public hospital in any region, but it is also possible to secure a position at a separate medical institution that is located in the territorial proximity of the person’s permanent place of residence.

When registering, you must provide any document that confirms the citizen’s place of residence. This could be a passport indicating registration, a rental agreement, and so on.

Rights of citizens in the field of compulsory health insurance

The insurance contract assigns the insured person a clear list of his rights and obligations. The rights of citizens in the field of compulsory health insurance include the following:

The right to receive free medical services under compulsory medical insurance throughout the Russian Federation. Any citizen who owns a valid compulsory health insurance policy does not have to worry that he will not be provided with proper treatment in the event of illness or deterioration of health during vacation or business trip.

The policy is valid throughout Russia, so if any questions or difficulties arise, you can contact the chief doctor or call the insurance company that issued the contract to resolve any disputes.

The right to choose a medical insurance organization. Citizens with official employment have a bonus in the form of the opportunity to sign up for a compulsory health insurance contract at their place of work, however, they and other categories of citizens have the right to independently choose an insurance organization to conclude a contract with.

Today, most insurance companies publicly publish information about their direct activities and the financial condition of the company, so any citizen can study this data and give preference to one of them. In addition, all residents of the country are allowed to change their chosen medical insurance organization once a year.

To do this, you must submit an application to the insurance company no later than November 1 of the current year.

The right to choose a medical institution and attending physician. Each owner of a compulsory medical insurance policy can choose any clinic and any doctor where he wants to undergo treatment, at his own discretion. In addition, you can also be assigned to a specific therapist/pediatrician/general practitioner. To do this, you need to write a corresponding application addressed to the chief physician, but this can only be done once a year.

The right to protection of rights and legitimate interests. A state medical institution that provides medical services under the compulsory medical insurance policy is obliged to provide accessible and high-quality treatment to the patient, observing all his legal rights and interests. In case of errors, the medical insurance company is obliged to help resolve disputes, including in court.

Thus, all the rights of insured persons in the field of compulsory health insurance are clearly regulated, so it is important to prevent any manifestation of their violation.

Free services under compulsory medical insurance policy

Every year the state modifies the list of free services under the compulsory medical insurance policy and approves it in a special health care program, which has regional status.

In order to find out the exact list of services, the client must contact the insurance company directly, since each insurance organization may have a slightly different list.

List of free medical services under the compulsory medical insurance policy:

1. Primary health care, including:

   – primary pre-medical care, which is provided by paramedics, midwives and other medical workers with secondary medical education on an outpatient basis, in a day hospital;

   – primary medical care, which is provided by general practitioners, local physicians, pediatricians, local pediatricians and general practitioners (family doctors);

   – primary specialized medical care, which is provided by specialist doctors.

2. Specialized medical care, which is provided in a hospital setting and in a day hospital by medical specialists, and includes the prevention, diagnosis and treatment of diseases and conditions, including during pregnancy, childbirth and the postpartum period, requiring the use of special methods and complex medical technologies.
3. High-tech medical care using new complex and (or) unique treatment methods, as well as resource-intensive treatment methods with scientifically proven effectiveness, including cellular technologies and robotic technology.

   You can find a list of types of high-tech medical care, including treatment methods and sources of financial support, in the appendix to the Program.

4. Emergency, which is provided by state and municipal medical organizations in case of diseases, accidents, injuries, poisoning and other conditions requiring urgent medical intervention. If necessary, medical evacuation is carried out.

   To get rid of pain and alleviate other severe manifestations of the disease, in order to improve the quality of life of terminally ill patients, citizens are provided with palliative medical care in outpatient and inpatient settings.

The above types of medical care include free of charge:

• medical rehabilitation;
• in vitro fertilization (IVF);
• various types of dialysis;
• chemotherapy for malignant diseases;
• preventive measures, including:
• preventive medical examinations, including for children, working and non-working citizens studying full-time in educational institutions, in connection with physical education and sports;
• medical examination, including orphans and children in difficult life situations staying in inpatient institutions, as well as orphans and children left without parental care, including adopted children, taken under guardianship (trusteeship) in the foster care or a foster family.

  Citizens undergo medical examination free of charge at the medical organization where they receive primary health care. Most medical examinations are carried out once every 3 years, with the exception of mammography for women aged 51 to 69 years and stool occult blood testing for citizens from 49 to 73 years old, which are carried out once every 2 years;

• dispensary observation of citizens suffering from socially significant diseases and diseases that pose a danger to others, as well as persons suffering from chronic diseases, functional disorders, and other conditions.

In addition, it is guaranteed that:

• prenatal (antenatal) diagnosis of child development disorders in pregnant women;
• neonatal screening for 5 hereditary and congenital diseases in newborns;
• audiological screening in newborns and children of the first year of life.

The provision of medicines to citizens is carried out at the expense of the compulsory medical insurance fund.

For more information about the types of free medical care under the compulsory medical insurance policy, the terms for receiving it, the medications that you are entitled to, and where to complain if your rights are violated, read the MEMO of the Russian Ministry of Health “On guarantees of free medical care”.

REMINDER from the Russian Ministry of Health
for citizens about guarantees of free
provision of medical care

Paid services under the compulsory medical insurance policy

Please note that not all services under the compulsory medical insurance policy are provided free of charge. Sometimes public medical institutions require the patient to pay for certain services, and it is important to understand that not all cases are a case of fraud on the part of the public hospital.

Not included in free medical services under the compulsory medical insurance policy

1. Diagnostics, research, procedures, consultations carried out at home (except for persons who, for health reasons, cannot visit medical institutions).
2. Conducting specialist consultations, medical examinations and examinations, medical support for private events on the basis of citizens’ personal initiative.
3. Hospitalization in a specially designated bed. Additional services, stay in a superior room, individual post of a medical worker, care and additional food, telephone, TV, etc.
4. Treatment and examination for a concomitant disease in the absence of an exacerbation that does not affect the severity of the underlying disease.
5. Examination, treatment, observation at home (except for cases when the patient, due to health reasons and the nature of the disease, is not able to visit a medical facility).
6. Anonymous medical services (except for cases provided for by the legislation of the Russian Federation).
7. Carrying out preventive vaccinations at the request of citizens (with the exception of vaccinations carried out under government programs).
8. Sanatorium-resort treatment (except for treatment of children and treatment in specialized sanatoriums).
9. Cosmetology services.
10. Homeopathic services.
11. Dental prosthetics (except for persons for whom it is provided for by current legislation).
12. Treatment of sexological pathology.

This often happens if the citizen was provided with services in excess of the state-guaranteed volumes of free medical care. In order not to be deceived, you can contact the relevant territorial insurance fund to clarify all the information.

Procedure for obtaining the service

In order to use compulsory medical insurance services, a citizen of the Russian Federation must perform the following algorithm of actions:

1. Contact a government medical institution.
2. Provide a valid compulsory health insurance policy issued to the person who wishes to receive the service.
3. Make an appointment with a specialist.
4. Pick up a special coupon, which indicates the date and time of the appointment and which guarantees its owner an unhindered visit to the right doctor.

Attention! Sometimes, to make an appointment, in addition to the compulsory medical insurance agreement, a referral from the attending physician is additionally required.

Refusal to provide services

The law prohibits refusing citizens of the Russian Federation who have a valid compulsory medical insurance policy the provision of medical services. However, sometimes such cases occur on the part of unscrupulous health workers, so every resident of the country should know their rights. If such a case does occur, then it is necessary to contact the Federal Compulsory Medical Insurance Fund with a corresponding complaint and certain administrative penalties will be applied to such an organization.

What services can be obtained under the compulsory medical insurance policy?

State guarantees of free medical care to citizens, approved by the Government of the Russian Federation.

2. The basic compulsory medical insurance program determines the types of medical care (including a list of types of high-tech medical care, which includes treatment methods), a list of insured events, the structure of the tariff for payment of medical care, methods of payment for medical care provided to insured persons under compulsory medical insurance insurance in the Russian Federation at the expense of compulsory health insurance, as well as criteria for the availability and quality of medical care.

3. The basic compulsory medical insurance program establishes requirements for the conditions for the provision of medical care, standards for the volume of medical care provided per one insured person, standards for financial costs per unit of volume of medical care, standards for financial support of the basic compulsory health insurance program per one the insured person, as well as calculation of the increase in cost of the basic compulsory health insurance program. The standards of financial costs per unit of volume of medical care specified in this part are also established according to the list of types of high-tech medical care, which also contains treatment methods.

(see text in the previous edition)

4. Insurance coverage in accordance with the basic compulsory medical insurance program is established on the basis of the standards of medical care and procedures for the provision of medical care established by the authorized federal executive body.

5. The rights of insured persons to free medical care established by the basic compulsory health insurance program are uniform throughout the Russian Federation.

6. Within the framework of the basic compulsory health insurance program, primary health care is provided, including preventive care, emergency medical care (with the exception of air ambulance evacuation carried out by aircraft), specialized medical care, including high-tech medical care, in the following cases :

(see text in the previous edition)

2) neoplasms;

3) diseases of the endocrine system;

4) eating disorders and metabolic disorders;

5) diseases of the nervous system;

6) diseases of the blood, hematopoietic organs;

7) certain disorders involving the immune mechanism;

8) diseases of the eye and its adnexa;

9) diseases of the ear and mastoid process;

10) diseases of the circulatory system;

11) respiratory diseases;

12) diseases of the digestive system;

13) diseases of the genitourinary system;

14) diseases of the skin and subcutaneous tissue;

15) diseases of the musculoskeletal system and connective tissue;

16) injuries, poisoning and some other consequences of external causes;

17) congenital anomalies (developmental defects);

18) deformations and chromosomal disorders;

19) pregnancy, childbirth, the postpartum period and abortions;

20) certain conditions that arise in children during the perinatal period.

7. The structure of the tariff for payment of medical care includes the cost of wages, wage accruals, other payments, the purchase of medicines, consumables, food, soft equipment, medical instruments, reagents and chemicals, other supplies, expenses for payment for the cost of laboratory and instrumental studies carried out in other institutions (in the absence of a laboratory and diagnostic equipment in the medical organization), catering (in the absence of organized catering in the medical organization), expenses for payment for communication services, transport services, utilities, works and services for the maintenance of property, expenses for rent for the use of property, payment for software and other services, social security for employees of medical organizations established by the legislation of the Russian Federation, other expenses, expenses for the acquisition of fixed assets (equipment, production and household inventory) worth up to one hundred thousand rubles per unit.

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

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

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

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

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

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

Registration of the insured and issuance of the policy

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

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

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

Professional patient support

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

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

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

Payment for medical services

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

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

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

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

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