When receiving medical care under the compulsory medical insurance policy, patients may encounter such inconveniences as long queues, insufficient volume free services, low quality of service.
To avoid these troubles, the Compulsory Medical Insurance+ program was developed.
Background
At the beginning of 2015, the Ministry of Health developed new project as part of the strategy for the development of the Russian healthcare system for the next 15 years.
The project was called “Compulsory Medical Insurance+”, and its essence was to create additional health insurance.
Patients who want to receive the package medical services, larger than the mandatory package, can purchase the “Compulsory Medical Insurance+” policy. Thanks to this program, all paid procedures that were previously carried out through the clinic’s cash desk can only be provided under the new policy.
With the help of the policy, it was planned to increase funding for the healthcare system, since all hidden payments could now be made only through Compulsory Medical Insurance +.
The creation of such a program does not imply a reduction in services under an ordinary policy. "OMS+" acts as a supplement. There is no obligation to purchase a policy.
The program was not implemented throughout Russia, but only pilot versions of the project were launched in five regions: Tyumen, Lipetsk, Kirov, Belgorod regions, and the Republic of Tatarstan. A limited number of insurance companies and hospitals participated in the project.
What is compulsory medical insurance+
Compulsory medical insurance plus is an additional package of services to the compulsory health insurance program. The insurance company does not provide additional financing within the framework of compulsory insurance.
The patient must purchase a “Compulsory Medical Insurance+” policy and the insurance company, using this policy, will pay the cost of additional services. Typically, patients pay for them themselves at the clinic’s cash desk.
The target audience of the program was considered to be citizens who actively use additional services in regular clinics. Such people had the opportunity to pay in advance at a discount for specific medical services or specialist care at home, rather than in a clinic.
In the scope of the “Compulsory Medical Insurance+” policy, such services should have become cheaper for the end consumer than those paid for on the spot.
The project does not imply the intrusive distribution of medical insurance services of individual organizations. The price of packages depends not only on the number of services included in it, but also on the degree of responsibility of the citizen for his health. Responsibility depends on the regularity of medical examinations, medical examinations, general health, etc.
Compulsory Medical Insurance+ includes 16 programs. The project participants calculated their tariffs and prices themselves, based on the content and direction. With the help of this program, the Ministry of Health is trying to replenish the financial support of healthcare.
Insufficient funds to ensure not only quality medical care, but improve the level of service.
Patients who want to improve the quality of service often pay extra to doctors and staff without any guarantees. The innovation is an attempt to bring shadow payments to the official level.
The first pilot programs launched in several areas did not live up to expectations. This happened for a number of reasons:
- Economic situation in the country
The development of the project took place during a period with a more stable economy, and its implementation began at a time of regression in the economy. The expected demand for innovation did not materialize. - No understanding of operating principles
The creators failed to draw a clear line between compulsory medical insurance policy and the compulsory medical insurance + package. Citizens did not fully understand the need for additional expenses. Some services within the package may seem optional to patients. - Lack of human and time resources
Medical institutions do not have the staff to provide a larger volume of medical services. The compulsory medical insurance plus package provides for a long-term doctor’s appointment. To implement it, it is necessary to either cut down the time of appointment under compulsory medical insurance (which cannot be done), or hire more specialists, but the project does not imply funding for an increase in staff. - Inconsistency of some conditions
Compulsory medical insurance + has a limitation on the number of laboratory tests. Help within compulsory insurance- No. It turned out that the paid package contains fewer services than the free one. - Lack of specific information
Citizens do not want to buy a service that they do not understand.
Compulsory medical insurance + or voluntary medical insurance
At first glance, the Compulsory Medical Insurance+ package may seem like voluntary health insurance. In fact, this is one of its forms, which differs from a standard VHI policy in the following:
| Compulsory medical insurance+ | VHI |
|---|---|
| The insured is the patient himself | The insured may be the employer |
| The program is applied only in those institutions that use the compulsory medical insurance system (in a regular clinic) | The policy can be applied in any institutions provided for in the insurance contract (you can choose) |
| You can purchase an additional package only from an insurance company that serves a citizen under compulsory medical insurance. | Buy VHI policy possible in any company, regardless of the compulsory medical insurance insurer |
| Low price (on average from 10,000 rubles per year) | Depending on the services included in the contract, the price can increase tenfold |
| Has a very limited range of services | Includes a large number of privileges |
| There is no possibility to choose a specialist | There is an opportunity to choose a specialist |
The program is similar to those developed by insurance organizations licensed for compulsory and voluntary insurance at the same time.
The Ministry of Health tried to combine the two policies, creating something in between. This program turns out to be cheaper than the one, but provides a little more opportunities than compulsory insurance.
But, if by taking out a VHI policy, you can be sure that the expenses are justified, then there are still many questions around the “plus program”.
Does it work now and in which regions?
A trial version of the “Compulsory Medical Insurance+” program was launched in 5 regions: Tatarstan and Tyumen, Lipetsk, Belgorod, Kirov regions.
Later, private clinics in Moscow and the Moscow region joined the project.
During the first year, only a few hundred policies were sold in all regions participating in the project.
Residents of the Tyumen region can apply for programs for newborns with medical care at home. Packages are divided into 3 levels depending on the number of medical services. Also Insurance companies offer programs for adults with video techniques.
Pediatrics and dentistry programs for children have been launched in the Lipetsk region.
In Kirovskaya there are programs for newborns.
In Belgorodskaya - for adults and children.
Two programs were introduced in Tatarstan: “Heart under control” and “Medical support for the patient.” The largest number of policies were sold in the republic.
The price of the policy varies from 2,000 rubles to 50,000 rubles.
The network of clinics “Doctor Nearby” in Moscow issues compulsory medical insurance + policies costing from 7 thousand rubles.
ABC-Medicine clinics also use innovation.
Some insurance companies create VHI products almost identical to compulsory medical insurance. For example, the program from VTB Insurance.
At the moment, you can apply for a Compulsory Medical Insurance+ policy through the VHI Selection Center. On the website you can calculate the approximate price and compare different types programs and get specialist advice.
The first unsuccessful experience allowed the Ministry of Health to conduct an analysis and continue to improve Compulsory Medical Insurance+. Therefore, the final version of the project does not yet exist.
Health insurance is a form social protection interests of the population in health care.
The most important regulatory legal act regulating compulsory health insurance is the Federal Law Russian Federation dated November 29, 2010 No. 326-FZ “On compulsory health insurance in the Russian Federation” (hereinafter referred to as the Law).
The law establishes the legal, economic and organizational foundations of health insurance for the population in the Russian Federation, defines compulsory health insurance as one of the sources of financing of medical institutions and lays the foundations for the insurance model of health care financing in the country.
Compulsory health insurance is an integral part of state social insurance and provides all citizens of the Russian Federation with equal opportunities to receive medical and pharmaceutical care provided at the expense of compulsory health insurance in the amount and on conditions corresponding to compulsory health insurance programs.
The Law defines the following as subjects and participants of compulsory health insurance: insured persons, policyholders, the Federal Compulsory Health Insurance Fund, territorial funds, medical insurance organizations, medical organizations.
Currently, the implementation of state policy in the field of compulsory health insurance, in addition to the Federal Compulsory Medical Insurance Fund, is carried out by 86 territorial compulsory health insurance funds.
In 2018, in the Russian Federation as a whole, the compulsory medical insurance system received 12,722.4 rubles in insurance premiums per compulsory medical insurance insured person, which is 1,081.4 rubles (9.3%) more than in 2017. At the same time, per 1 working person insured under compulsory medical insurance, 19,544.1 rubles were received in insurance contributions for compulsory medical insurance, which is 1,802.5 rubles (10.2%) more than in 2017, per 1 non-working person - 7,789.1 rubles , which is 532.3 rubles (7.3%) more than in 2017.
The revenues of the TFOMS budgets in 2018 were generated in the amount of 2067.6 billion rubles, which is 340.8 billion rubles or 19.7% more than in 2017. Subventions from the Federal Compulsory Medical Insurance Fund, the amount of which amounted to 1,870.6 billion rubles (90.4%), were the main source of financial support for the implementation of territorial compulsory health insurance programs. In addition, the budgets of the Federal Compulsory Medical Insurance Fund received interbudgetary transfers from the budgets of the constituent entities of the Russian Federation for additional financial support for the implementation of territorial compulsory medical insurance programs in the amount of 95.4 billion rubles (4.6%).
In 2018, medical care in the field of compulsory medical insurance was provided by 9,303 medical organizations, 36 medical insurance organizations (IMOs) and their 205 branches in 85 constituent entities of the Russian Federation and in the city of Baikonur.
In the structure of receipts of compulsory health insurance funds in health insurance organizations, the main share is made up of funds transferred by territorial compulsory health insurance funds to pay for medical care in accordance with the agreement on the financial support of compulsory medical insurance. In 2018, 1,784.0 billion rubles were received for these purposes (which is 19.4% more than in 2017) or 95.4% of the total amount of funds received. 18.1 billion rubles (1.0%) were received for the conduct of the CMO case.
In the overall structure of spending of compulsory medical insurance funds by health insurance in 2018, 98.5% (1,834.4 billion rubles) are expenses for payment of medical care provided to insured persons in accordance with contracts concluded with medical organizations for the provision and payment of medical care. 20.3 billion rubles, or (1.1%) were allocated to form the own funds of health insurance companies in the field of compulsory health insurance.
In 2018, medical organizations received 1,933.1 billion rubles, which is 19.3% more than in 2017. Spending funds compulsory medical insurance organizations in 2018 amounted to 1,908.4 billion rubles, which is 18.4% more than in 2017. In the structure of expenses of medical organizations, the share of expenses for wages and accruals for wage payments amounted to 70.7%, for the purchase of medicines and dressings - 10.0%, food products - 1.1%, soft equipment - 0.1 %, other expenses 18.1%.
The number of persons insured under compulsory health insurance as of April 1, 2017 amounted to 146.4 million people, including 61.4 million working and 85.0 million non-working citizens.
One of the important conditions for the social protection of the country’s population is providing its citizens with the necessary medical care. Health services that allow you to receive timely medical intervention are based on health insurance. The state provides the opportunity for its citizens and other persons to obtain compulsory health insurance (CHI) with a sufficient range of services that can support people’s health in the event of insured events. So what is compulsory health insurance (CHI)? How are citizens' rights to free medical care constitutionally protected? What does the compulsory medical insurance system guarantee to citizens? We will answer these and other questions in this article.
Basics of Compulsory Medical Insurance
Compulsory health insurance is a set of measures to protect health, provide free medical care within the framework of current legislation, as well as carry out preventive measures. Insurance provides citizens with equal opportunities when medical intervention is necessary. Article 41 of the Constitution of the Russian Federation guarantees every citizen the right to health care and free medical care in state (municipal) institutions, which is carried out through the payment of insurance premiums, funds from the budget and other revenues. The provision of medical services is carried out at the expense of previously generated funds. The main guaranteed services include:
- Emergency medical care (this does not include air ambulance services);
- Primary health care delivery;
- Therapeutic and preventive measures;
- Specialized assistance;
- Provision of services within the framework of the current compulsory medical insurance.
The implementation of compulsory health insurance occurs through specialized legal organizations - insurance companies. Providing the population with necessary medical care through the conclusion of contracts is considered among the main tasks. In addition, through the funds, payment is made for services provided to insured persons (patients) in medical institutions, and protection of the rights of the population.
Source of financing for health insurance
To implement a program of providing free medical care, it is necessary to have a significant financial base. Battery Money in the compulsory medical insurance system is the federal compulsory health insurance fund (MHIF). The main goal of the fund is to provide all persons participating in insurance with the necessary medical and medicinal assistance. Funds are generated from the following sources:
- Contributions to the Compulsory Medical Insurance Fund of employers for their employees;
- Receipts in the form of fixed payments from individual entrepreneurs and self-employed persons;
- Receipts from the budgets of the constituent entities of the Russian Federation for non-working people.
Insurance premiums as receipts from employers are accrued at established rates for wages hired workers. Payers are most organizations and entrepreneurial employers, with the exception of some representatives of small businesses, which are exempt from paying payments of this type.
Previously, the compulsory insurance fund was divided into federal and territorial; payments had to be transferred to each of these structures. Starting in 2012, the territorial Compulsory Medical Insurance Fund was abolished. Currently, payments are made only to the federal Compulsory Medical Insurance Fund at the basic rate of 5.1%.
Compulsory medical insurance policy
Guaranteed medical care is confirmed by the presence of a policy. Get this document You can contact a medical insurance company after concluding an appropriate agreement with it. The issuance of these documents in the compulsory medical insurance system is carried out to almost all persons, including:
- Citizens of the country;
- Non-working population and persons under the age of majority;
- Temporarily or permanently residing in the territory of the Russian Federation;
- Stateless persons;
- To refugees.
The validity period of the policy depends on the status of the insured person. For citizens of the Russian Federation and those permanently residing in the country, the document has no expiration date. For temporary stayers, including refugees, the validity of the policy is limited to the established period of stay within the country.
The provisions on the rights of insured persons in the presence of a policy are listed in the law of November 29, 2010 No. 326-FZ “On compulsory health insurance on the territory of the Russian Federation.” Without presenting a document individual can only count on emergency free medical care. The policy covers the entire territory of the Russian Federation. In case of refusal of medical institutions to provide free services within the framework of compulsory medical insurance, it is possible to file a complaint at the location of the insurance company. Having a compulsory medical insurance policy gives some rights to its owners. With the help of the document, the following types of medical care become available:
- Emergency provision of medical services;
- Outpatient treatment in clinics, including diagnostic procedures and medical examinations, with free provision medicines in this case, as a rule, it is not provided;
- Inpatient treatment, which includes emergency hospitalization for the purpose of maintaining health, including during childbirth and exacerbation of chronic diseases.
Often, a medical policy provides the opportunity to diagnose diseases using special equipment. The owner of the document, if indicated, can become a participant in rehabilitation, preventive and health measures. For benefit categories of the population, a policy is required to confirm the right to free medicines. In addition, the owners compulsory medical insurance document has the right to receive routine vaccinations and undergo a fluorographic examination. The presence of a compulsory medical insurance policy makes basic medical services accessible to the general public. This factor is especially important for low-income and socially vulnerable people.
How to get a compulsory medical insurance policy?
The policy as a document confirming the right of its owner to receive free medical care must be carried with you. It is presented during treatment in hospitals, clinics and ambulance services.
The policy is issued by insurance companies in any region of the country. The choice of the insurance company itself is the right of any citizen and other person. Although, as a rule, the result is determined by the territorial presence of the insurance organization. At the same time, there are no significant differences in the choice of companies. The range of services provided is the same, although some insurance companies have the right to attract clients in a variety of ways. bonus programs. To obtain a compulsory medical insurance policy, you must provide insurance companies with the following documents:
- Identification;
- SNILS;
- Other documents, depending on the status of the insured person (birth certificate, proof of temporary residence, etc.).
Often, upon application, insurance companies initially issue a temporary policy. Its validity is limited to a period of 1 month, after which the current document is replaced with a current sample. A temporary policy has the same powers as a permanent one. If the policy is lost or the owner's last name is changed, a replacement is expected.
The policy, as a document of compulsory health insurance, is better to do in advance. In this case, if unexpected health problems arise, there will be no bureaucratic obstacles to obtaining medical care.
What does free medical care include?
Free medical care, which citizens insured under the compulsory medical insurance system can count on, is included in the basic program. The list of diseases for which assistance is available under the compulsory medical insurance system is quite extensive. This includes the following insurance cases:
- Pregnancy, childbirth, child care;
- Infectious and bacterial diseases;
- Diseases of the endocrine system;
- Digestive problems;
- Diseases of the ears, eyes;
- Diseases resulting from chromosomal abnormalities;
- Decreased immune strength of the body;
- Poisoning;
- Diseases of the nervous system;
- Other insurance cases.
The right to receive free assistance is regulated by the legislation of the Russian Federation, and assistance included in the basic program (preventive, special, high-tech, emergency) is regulated by Article 35 Federal Law dated November 29, 2010 No. 326-FZ (as amended on December 28, 2016) “On compulsory health insurance in the Russian Federation.”
Conclusion
The rights of citizens to receive free medical care are regulated by the Constitution of the Russian Federation, according to which special programs are in place to protect the health of the population of Russia. The general compulsory medical insurance mechanism is an obligation imposed on certain persons by law to make contributions to the compulsory medical insurance fund for insurance and protection of interests related to the costs of medical care. For the working population, such persons are employers, for the non-working population - regional authorities.
A citizen with a compulsory medical insurance policy reserves the right to count on undergoing basic types of examinations within the framework of a specially developed program.
If the current condition threatens the patient’s life, the medical institution assumes the responsibility to admit the patient, regardless of whether there is compulsory medical insurance or not.
Free services with compulsory medical insurance policy
The list of free services according to the compulsory medical insurance policy in 2019 includes consultations, surgery, tests, diagnostics, etc.
Operations
Free operation before our eyes possible in case:
- cataracts of the eye lens;
- detection of strabismus, including strabismus in children;
- identified traumatic deformation of the retina;
- definitions of glaucoma;
- various anomalies.
Senoplasty according to compulsory medical insurance is prescribed if there is next indications:
- problems with respiratory function;
- no sense of smell;
- establishing mucosal edema;
- persistent acute respiratory viral infections;
- presence of abnormal breathing, snoring;
- presence of dryness in the sinuses, continuous pain, etc.
Possibility of free removal gallbladder in the presence of cholecystitis and disorders of the gastrointestinal tract.
Can be carried out Marmara operation(venous disease of the reproductive system in men) in the presence of the following indications:
- varicocele of the second and subsequent stages;
- lack of possibility of fertilization;
- severe pain;
- aesthetics;
- changes in scrotal tissue;
- joint arthroscopy.
Additionally, surgical intervention is possible:
- in case of venous diseases - on the veins;
- in the field of gynecology;
- on oncology, pathological changes, including lungs.
The varieties listed are far from exhaustive. It is necessary to understand that surgical intervention of a cosmetic nature cannot be performed free of charge.
Analyzes
Free tests are usually prescribed for the following purposes:
- treatment and detection of the disease;
- identifying accompanying disorders in the human body;
- disease prevention.
For example, the treating specialist makes a preliminary diagnosis based on the patient’s symptoms. Moreover, if the analysis for the presence of the underlying disease is carried out free of charge, then in order to determine the accompanying pathology, it is paid for by the insurance agent.
The key medical standards on the basis of which drug or other treatment will be initiated are set out in specially developed basic and additional programs listed on the official portal of the Russian Ministry of Health.
Among the most significant free types of analyzes are: following types:
- blood test to detect syphilis, HIV, hepatitis, tuberculosis;
- diagnostics of blood and plasma for the content of the main components - red bodies;
- biochemical examination of blood and lymph;
- hormone analysis;
- tissue biopsy, hysteroscopy;
- laparoscopy;
- high-tech analytical diagnostics of tissues and organs in particular;
- smears of the skin, saliva, etc.
Important: only an expensive type of research may be paid if there are suspicions of rare autoimmune or genetic diseases, which are very rare (in approximately 0.01% of situations).
Diagnostics
According to the terms of the contract under the compulsory medical insurance policy, it is possible to carry out the following types of free diagnostics:
- fluorography;
- Ultrasound of the pelvic organs and the thyroid gland in particular;
- Ultrasound of the mammary glands, provided that the patient’s age does not exceed 35 years;
- mammography - if age is over 35 years;
It is necessary to pay attention to the fact that the shelf life of the results obtained varies from three months to a year.
Dental
Patients of a medical institution who participate in the compulsory health insurance system have the right to count on:
- reception, consultation and examination;
- prevention and treatment of diseases associated with the oral cavity;
- dental filling;
- surgical intervention, including: tooth extraction, abscess, etc.:
- X-ray diagnostics.
There are also some restrictions on the services of professional dentists. For example, filling does not require any financial costs provided that standard cement mortar is used. The light seal is installed exclusively on a paid basis.
Certain types of services are provided only if there is an appropriate referral; for example, a surgeon can trim the frenulum of the tongue only with a certificate from an orthodontist.
Other examinations
In most cases, all-Russian and territorial lists of analyzes are as follows:
- taking tests to detect syphilis, HIV, etc.;
- general and clinical blood test;
- performing ultrasound, MRI, CT;
- X-ray, fluorography;
- biopsy;
- stool analysis.
Please note: depending on the region of residence, the detailed list of medical services varies.
How to apply the compulsory medical insurance policy
To be able to organize treatment, each patient must be assigned to a specific medical institution. It is installed:
- remoteness;
- ease of use;
- other factors.
It is possible to change the clinic at intervals once a year.
Regardless of whether there is a compulsory insurance policy or not, all Russian citizens have the right to use emergency services.
There are specially developed standards that regulate the activities of ambulance services.
The ambulance service assumes the responsibility to respond to an accepted emergency call within the first 20 minutes in the event of a threat to life, namely:
- accident;
- getting injured or injured;
- exacerbation of the disease;
- poisoning, burns of any degree, etc.
In the absence of a threat to life ambulance will arrive within two hours.
How to file complaints about free service if it is unavailable or of insufficient quality
In case of conflict situations, for example, rude treatment or insufficient level of services provided, it is possible to file a complaint:
- addressed to the head physician of the clinic;
- to the Ministry of Health;
- insurance agent;
- to Roszdravnadzor.
Maximum period for consideration of a complaint does not exceed 30 calendar days . Based on the inspection carried out, an appropriate decision is made.
If necessary, the patient reserves the right to change the doctor - just write a statement.
List of new services for 2019
In 2019, the list of services provided under the compulsory insurance policy was expanded to include joint replacement of the lower and upper extremities in the event of obvious deformity, dysplasia and ankylosis, including the use of computer navigation.
Additionally, the list includes coronary myocardial revascularization using angioplasty directly with stenting in case of ischemia.
New treatment methods in the field of maxillofacial surgery are being added to the basic compulsory medical insurance program. In particular, citizens will have access to free surgical intervention to eliminate defects and deformations with the additional use of materials for the purpose of transplantation and implantation, and to exclude neoplasms.
The rights of patients to receive free services under the compulsory medical insurance policy are presented in the video below.
