The insured is compulsory health insurance. Medical insurance in Russia is compulsory and voluntary - the procedure for concluding an agreement and issuing a policy

29.05.17 265 495 15

The doctors were shocked when I showed...

At the weekend I lay at home with an impossible sore throat and a temperature of 39.6.

Throwing not the first dose of paracetamol for the day, I called an ambulance. They told me that it was a sore throat and that I should call the district police officer on Monday. The ambulance didn't come.

Zhenya Ivanova

treated and recovered

I typed in the search bar: "What to do if the ambulance refuses to go." I saw advice on the forum: “Say menacingly that you should call the insurance company now. They'll come right away." I did so. The ambulance arrived. After that, I threatened the doctors twice more with a call to the insurance company and once I actually called the number indicated on the policy. Helped every time.

The insurance company protects my rights and really guarantees free treatment. But if you do not know the laws, then unscrupulous doctors will be able to deceive you, refuse treatment, demand an additional fee.

I recovered and decided to find out what your mandatory health insurance guarantees you.

Get to know your CHI policy

Most likely, you already have a compulsory health insurance policy. It was made for you by your parents right after you were born. It is either in your passport or in a box with all important documents.

If you don't have a policy, drop everything and go to apply

Without a policy, you won't get any free treatment. Fortunately, you can get or exchange a policy in any city without a residence permit and registration. To do this, take your passport and SNILS with you and go to a convenient place for you. insurance company that issues these policies.

This is a card If there is no SNILS, go first with your passport to the insurance company, then wait 21 days and only then receive the policy.

Citizens of the Russian Federation, foreign citizens permanently or temporarily residing on the territory of the Russian Federation, refugees and stateless persons can obtain a policy. Citizens Russian Federation The policy is issued for an unlimited period of validity. By law, even if you have an old-style policy and it is overdue, insurance will still work. Only until you change your passport details: first name, last name, place of residence.

If you come to the clinic with an old expired policy and you are denied treatment, this is illegal. You must be accepted. In polyclinics, everyone is asked to change policies for new documents, but so far this is only a recommendation. Of course, it is better to heed this recommendation: when a law comes out that terminates old-style policies, it will not take you by surprise.

Which insurance companies provide CHI policies

Compulsory health insurance is an insurance program, that is, everyone pays a little bit into the common pool, and then they pay out of it to those who need it. The common cauldron collects the state from entrepreneurs and distributes it through an extensive system of funds, which, in turn, pay hospitals. And the insurance company is such an intermediary manager that connects you, the hospital and the state.

Insurance companies earn on CHI in the same way as on other services. They are also responsible for the quality of services and discipline in the system. Your first point of contact is the insurance company.

Each region has its own registers of companies that make CHI policies. Just google it.

Where can I get treatment with a CHI policy

To get to a clinic in another city or district, you need:

Select a clinic. Any, not necessarily the one closer to home.
Find out at the reception which insurance companies work with this clinic. If you have a choice, look at the description of the company on the CMO website. Everyone has the same insurance, but some have more offices, and some have round-the-clock support.
Come to the insurance company with a passport and SNILS, fill out an application to replace the policy.
Get a temporary license. It works like a policy for a month.
Return to the clinic. Say the code phrase “I want to attach to your clinic” at the reception. Get the application form, fill it out and return it to the registry.

Now you can be treated for free in this clinic.

If your insurance company serves the clinic to which you are going to attach, then you do not need to change the policy. But you need to inform the insurance that you have moved and want to be treated elsewhere. Otherwise, the new clinic will not receive money for your treatment.

Why you need to join the clinic

You need to join a polyclinic, because our country has a system of per capita financing. Money for your treatment is issued only to the institution to which you are assigned. Therefore, you can not attach to several clinics at once. You can also officially change the clinic no more than once a year. Previously, this could only be done if you moved. In this case, the new clinic will offer you to write an application addressed to the head physician.

You cannot attach yourself to a research institute or a hospital, only to a district polyclinic. And already there, the local therapist will write out referrals to highly specialized specialists: an eye surgeon, a cardiologist, a chiropractor. Without a referral from the attending physician or an ambulance specialist, you can only be admitted to specialized clinics for a fee.

What is EMIA

In Moscow, the data of all patients are entered into EMIAS - a unified medical information and analytical system. This simplifies the process of making an appointment with specialists: you can get a ticket to the doctor, cancel or reschedule an appointment, get a written prescription in in electronic format. EMIAS even has mobile app.

Please note: if you have moved and decided to attach to a new clinic, then you cannot just take it and do it through the system. You need to write an application addressed to the head physician and wait until the bureaucracy approves it. This may take 7-10 business days. If you are registered on the Moscow public services portal, then you can apply electronically. It is promised to be reviewed within 3 working days.

When I faced such a problem, I needed help urgently. And by law they are obliged to help me without any many days of delay. But the polyclinic is afraid that if they treat me before the clumsy machine enters new data into EMIAS, then they will not receive money for me from the insurance.

Right in front of the hospital administrator on duty, I called the insurance company, after which I received the necessary consultations at the hospital for free. I was also examined by a whole commission of department heads, and until now everyone treats me very carefully.

What is included in CHI treatment

The law on obligatory medical insurance gives the right to all of us to be treated free of charge. And even if your policy has expired, you can use it.

If you don’t have a policy with you, you can still make an appointment with a doctor, they don’t have the right to refuse you.

Although for nurses this is an additional concern, therefore, most likely, they will try to convince you that it is impossible to do this. If this happens, just call your insurance company.

In any unclear situation, call the insurance

The minimum amount of assistance is described in the basic program of compulsory health insurance. Whether to add something else to this list, each region decides independently. The exact list of insured events can be found in any clinic or found on the website of the Ministry of Health in your region.

In any case, you can apply this rule: if something threatens your life and health, it is treated for free. If you are generally healthy, but want to feel even better, then you can most likely do it just for money. If the state can help you, but the level of this assistance seems too low for you, you will have to accept or pay extra.

Examples of what can and cannot be done under the CHI policy

It is forbidden	Can
Teeth whitening is an aesthetic procedure	Do brushing your teeth because it is the prevention of caries
Get imported Japanese adult diapers by choosing the brand yourself	Get diapers for the elderly
Remove a couple of extra pounds. Your figure is not insured by the state	Remove boil
Wait for exercise therapy exercises from hatha yoga or a modern gym	Go to physical therapy
See a dermatologist if you're just worried about oily skin on your face.	See a dermatologist for severe skin rashes
Make a denture	Remove the tooth

Teeth whitening is an aesthetic procedure

Brushing your teeth, because it is the prevention of caries

Get imported Japanese adult diapers by choosing the brand yourself

Get diapers for the elderly

Remove a couple of extra pounds. Your figure is not insured by the state

Remove boil

Wait for exercise therapy exercises from hatha yoga or a modern gym

Go to physical therapy

See a dermatologist if you're just worried about oily skin on your face.

See a dermatologist for severe skin rashes

Make a denture

Remove the tooth

When something hurts, you can get a free appointment with a therapist who will write a referral to a specialist. When indicated, the GP should issue referrals to any doctors who work in public clinics.

Without a referral, you can make an appointment with a surgeon, gynecologist, dentist and dermatologist at a dermatological and venereal dispensary. Or enroll your child to a child psychiatrist, surgeon, urologist-andrologist or dentist. CHI does not guarantee free tests and examinations without a referral from the attending physician.

Once every three years, you can go through a free medical examination and find out if everything is in order with your health. Medical examination is carried out for everyone every three years - that is, if this year you turn 21, 24, 27 years old and so on.

The CHI program also includes free pain relief and rehabilitation after illnesses and injuries. But it’s impossible to write down once or twice in which case you are entitled to free insurance assistance, and where you have to pay on your own. There are a lot of nuances in this case. If you have a rare disease or a difficult situation, contact the Federal CHI Fund.

What exactly is not included in the CHI program

The state will not pay for:

Any treatment without a doctor's prescription.
Carrying out surveys and examinations.
Treatment at home is optional, not by special indications.
Immunizations outside of government programs.
Spa treatment, if you are not a sick child or a pensioner.
Cosmetic services.
Homeopathy and traditional medicine.
Dentures.
Chambers superior comfort- with special meals, individual care, TV and other joys.
Medicines and medical devices, if you are not in a hospital.

If the hospital asks for money for services that are not on this list, just in case, call the insurance company and check if it is legal.

Privileges

People with disabilities, orphans, large families, participants in hostilities and other citizens who are entitled to social benefits, the state is ready to pay more medical services. Each category has its own list of benefits, you can find them in the department social protection or find it on the internet.

Sometimes you are legally entitled to free treatment, but doctors just shrug. There may be a waiting list for free rehabilitation for several months, and painkillers in your district hospital may simply not be available. It's illegal, but it's a fact of life.

Extortion

Doctors are people too, and nothing human is alien to them. Like any person, some doctors are more interested in getting a lot of money from you right now than getting a little less money from the insurance company and much later. Therefore, a whole illegal practice of extorting money for treatment under compulsory medical insurance has grown in Russia.

At the heart of this extortion is legal illiteracy. It is enough for a doctor to make a smart face and take a strict tone so that frightened patients begin to throw money at him. But the slightest sign that the doctor is in front of a legally savvy patient - and the tone changes. Therefore, it is very useful to know what medical services you are required to provide for free.

Remember that treatment is free only for you. The hospital and doctor will receive money for this treatment from the health insurance fund. This money was paid to the fund by entrepreneurs, including your employer.

You do not need to pay a second time out of your own pocket for what the state guarantees you. Moreover, the doctor, most likely, will receive payment from the fund anyway, even if you are forced to pay.

You do not pay for treatment, but the hospital will receive money for it

If you know for sure that you should and can be treated for free, but the doctor offers to pay, call the insurance company. The insurance number is written on your policy, experts hotline will help you.

If you cannot do this, ask your doctor to write a written refusal to provide free medical care. If the doctor behaves defiantly, you can turn on the recorder, this is legal. Even if this does not help, call the department for the protection of the rights of citizens in the CHI system.

7 499 973-31-86 - phone number of the department for the protection of the rights of citizens in the CHI system

Emergency assistance is always free

If something really bad happened - you lost consciousness, broke your leg or feel acute pain - you should be helped in any state clinic, even if you don’t have any documents with you and you never received a policy.

The hospital has no right to refuse assistance to newborns and children under the age of one year, even if the child's parents do not have a policy and registration. They cannot refuse pregnant women either - they can go to any antenatal clinic and any maternity hospital, even without documents.

All participants in the healthcare system are just people: someone's acquaintances, friends, brothers, matchmakers and godfathers. They have parents and children. They are all Russians and they work just like any of us.

If a surgeon demands a bribe for pain relief, then this is not the healthcare system, it is this particular surgeon, his parents and teachers. It means that his father, somewhere in his childhood, set an example for him that a bribe is normal. How do you feel about bribes?
If a hospital says it doesn't have money for medicines, it's not Putin's fault, but some officials who don't know how to draw up budgets. Or the head physician who does not know how to manage money. You have a lot of acquaintances who do the same thing at their jobs.
After all, when you get paid in an envelope, it's your employers who underpay your health insurance. Where will the money for your medicines come from, if you have allowed not to pay for them?

It turns out to be mild schizophrenia: the same person maintains a gray salary and complains about insufficient funding for hospitals.

Putin, Navalny, Medvedev, Tinkov or Trump will not solve our health problems. We will solve this problem ourselves if we give our children an example of a conscientious attitude to work and the law. To skip classes at the institute was not a feat, but a shame. It was embarrassing to take tests for money. To give bribes was against our principles. To know and stand up for your rights was a duty, not a superpower.

In short: no one will fly in and give us free medicine as in paid Israeli clinics. All the hell that we see in hospitals is not hospitals, it is ourselves. And me too.

Let's start with paying taxes and contributions. I have everything, thanks. Sorry for the moralizing tone, but I just got tired of this whining.

Remember

If you don't have a policy, drop everything and go apply.
With a compulsory medical insurance policy, you should be treated free of charge at any state clinic throughout Russia.
Treatment is free only for you. The hospital and doctor will receive money for this treatment from the health insurance fund.
The policy works even if it has expired. If you come to the clinic with an old policy and you are denied treatment, this is illegal.
In any unclear situation, call your health insurance company. The number is on the policy. Write it down on your phone right now.
If your insurance does not save you, call the Federal Compulsory Medical Insurance Fund: +7 499 973-31-86.
If you spent money on treatment, which should be free by law, write a statement to the insurance company - you should get your money back.
Emergency assistance is always free, even if you do not have documents.

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. Modernization CHI systems and its underlying CHI law, adopted in 2010, were warmly welcomed by many experts and representatives state power. 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 health 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: modernizing the medical industry, introducing and ensuring the wide availability of new treatment technologies, the transition from medical care mainly in emergency situations to maintaining health, preventing diseases and preventing development severe forms 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. Yes, introduced compulsory medical insurance policy uniform pattern, 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 CHI policy, your rights in the CHI 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 to a new one, the insurer will check your data with the database, immediately print and issue you a temporary certificate (acts as a CHI policy until the latter is received), update its register of insured persons, send the data to the territorial office on the same day CHI fund. 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 a common database Federal Fund CHI with an application for 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 each insured person to receive medical assistance in any locality countries and prevents duplication of costs, but also provides reliable accounting and proportional funding of federal programs by region.

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 companies processed more than 60 million requests from patients. However, if it seems to you that the insurers are evading their duties, you can apply to 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, to conduct an examination in without fail doctors are involved who do not work in those organizations that are being tested. 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 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 health 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.

Compulsory health insurance- one of the mandatory social insurance 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 (upon the occurrence 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 who are not recognized as individual entrepreneurs), as well as individual entrepreneurs engaged in private practice - notaries, lawyers, arbitration managers.

Insured person- an individual who is covered by compulsory health insurance in accordance with 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 state guarantees designed to provide free help. 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 the Rostov region, Kemerovo and the Kemerovo region, Tver and the Tver region, Krasnodar and the Krasnodar Territory; Veliky Novgorod and the Novgorod region, Chelyabinsk and Chelyabinsk region, Tula and the Tula region, Bryansk and the Bryansk region.

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 of 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 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 bases compulsory health insurance are defined Federal Law "On health insurance of citizens in the Russian Federation" edited federal law dated April 2, 1993, as amended.

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 excess of those established by compulsory medical insurance programs.

Federal (basic) CHI program approved by Decree of the Government of the Russian Federation of January 23, 1992 No. 41. 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 Russian Federation, including outside the permanent place of 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 economic 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 education 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 agreements are different from civil law contracts on a number of grounds. 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, at their own discretion, change the content of the 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 unreasonable refusal to conclude a contract CHI insurance a 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. Necessary conditions 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.

The minimum term 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 care the insured 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