Insurer for compulsory health insurance. The system of compulsory health insurance in the Russian Federation. How to choose an insurance company for OMS

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

Health is monitored independently of gender, race, nationality, language, social origin, official position, place of residence, relations to religion, belief, belonging to public associations and other circumstances. The state guarantees citizens to protect against any forms of discrimination associated with the presence of any diseases.

On a par with citizens of the Russian Federation, the right to protect health is a stateless persons permanently residing in the territory of the Russian Federation, and refugees. The procedure for providing medical assistance to foreign citizens, stateless persons and refugees is determined by the Ministry of Health of the Russian Federation and the relevant bodies of the subjects of the Russian Federation.

Citizens of the Russian Federation, which beyond its limits is guaranteed the right to protect health in accordance with international treaties of the Russian Federation.

Financing the health of citizens' health is carried out at the expense:

Budgets of all levels;

Compulsory and voluntary health insurance;

Trust funds;

Funds of economic entities of various forms of ownership;

Revenues from securities and other sources.

Legal, economic and organizational foundations of compulsory medical insurance are defined Federal Law "On Medical Insurance of Citizens in the Russian Federation"as a wording of the Federal Law of April 2, 1993, with subsequent changes.

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

Purpose mandatory Medical Insurance(OMS) is the provision of equal opportunities to the population of Russia in obtaining free medical and drugs within the basic federal and territorial programs and financing of preventive measures.

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

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

Ambulance medical care in injuries and acute diseases threatening life;

Treatment in outpatient conditions;

Diagnosis and treatment at home;

Implementation of preventive adventure activities, clinical examination, etc.);

Dental care;

Dosage and inpatient care.

All types of emergency medical care, as well as inpatient assistance to patients with acute diseases, are provided regardless of accommodation and regards for free at the expense of the budgets of the relevant territories.

Based on the Federal Program, the highest management bodies of the subjects of the Russian Federation approve territorial OMS programs,which cannot worsen the conditions for the provision of medical care compared to it.

The Ministry of Health of the Russian Federation has established an assortment list of medicinal, preventive, diagnostic tools and medical products for pharmacies of all forms of ownership. Decree of the Government of the Russian Federation of July 30, 1994 No. 890 approved a list of population groups and categories of diseases, with the outpatient treatment of which drugs and medical products are released on recipes of doctors for free or from 50% discount.

The rights and obligations of subjects of compulsory medical insurance.Subjects of OMS (Fig. 7) are:

Insured;

Insured;

Medical institution.

Insured faceshave rightto choose an insurance medical organization; the choice of a medical institution in accordance with OMS and voluntary health insurance agreements; obtaining medical services throughout the territory of the Russian Federation, including outside the permanent residence; obtaining medical services, the quality and volume of which complies with the federal program, regardless of the size of the contributions actually paid by the insured; At the presentation of lawsuits to the insured, insurance medical organization, a medical institution in case of non-fulfillment of obligations under the OMS contracts, etc.

The insurers are both legal and individuals contributing to the Funds of OMS. Paters of contributions 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) individuals involved in individual labor activity, and some other citizens (for example, the faces of creative professions, not combined in the union) pay contributions independently.

For the refusal of business entities from registration as payers of contributions to OMS, concealment or understatement of the amounts from which contributions should be made, a violation of their transfer of their transfer applies financial sanctions in the form of a fine and (or) penalties whose payment does not exempt the insured from fulfilling OMS . With the imposition of financial sanctions, the federal and territorial foundations of OMS use the rights of tax authorities.

Insured they have a rightto choose an insurance medical organization; Implementation of control over the implementation of the OMS contract. Insured we must:conclude agreements of the OMS; make contributions to OMS; take measures to eliminate adverse factors for the health of citizens; Provide insurance medical organization information on the health status of persons to be insurance and others.

Insurance medical organizations- These are legal entities of any forms of ownership that received the license of the bodies of the Federal Service for Insurance Operations. They are not included in the health care system.

Insurance medical organization has the right toto choose a medical institution to provide medical care under the treaties of the OMS; participation in accreditation of medical institutions; participation in determining tariffs for medical services; The presentation of a lawsuit for a medical institution or a health worker about the material compensation for harm caused by the insured by their fault, etc.

Insurance medical organization obligated:carry out activities on OMS on a non-commercial basis; enter into contracts with medical institutions to provide insured medical care on OMS; issue medical policies to the insured or policyholder; control the volume, quality and deadlines for medical care; defend the interests of the insured; To ensure the sustainability of its activities to create reserve funds.

TO medical institutionsrefines: therapeutic and preventive institutions, research institutes and other organizations that provide medical care. Individuals can also do medical activities - without the formation of a legal entity individually or collectively.

All medical facilities must have a license and accredit accreditation.

All relations of subjects of OMS are issued contracts:

1) between the territorial Fund of the OMS (or his branch) and the insurer on the financing of the OMS;

2) between the insurer and medical institution;

3) between the insured and the insurer on the organization and financing of medical care of a certain amount and quality under the CHI program.

These treaties differ from civil law contracts for a number of signs. First, the freedom of the will of the parties in determining their conditions is limited by law and the model form approved by the Government of the Russian Federation. Parties can not at their discretion to change the content of a typical form: to reduce or increase the list of free for the consumer (insured person) services; the dimensions of insurance premiums or tariffs for medical services; Free apart from responsibility for failure to fulfill the terms of the contract.

Secondly, the subjects of the OMS cannot refuse to each other in the conclusion of OMS agreements. For unreasonable refusal to conclude an Agreement, the OMS insurance medical organization may be deprived of a license by a court decision. The territorial Fund of the OMS or his branch does not have the right to refuse the insurance medical organization in the conclusion of a treaty to finance medical care if it ensures the implementation of the territorial program of the OMS in full.

The relationship between the insured and the insurer is also issued by the Treaty. The necessary conditions of the contract are: the names of the parties, the validity period, the number of insured, the size and procedure for making insurance premiums, a list of medical services in accordance with the CHAM program, the rights and obligations of the parties.

The minimum term of the contract cannot be less than a year. The contract is considered concluded from the date of payment of the first insurance premium.

Every citizen in relation to which the treaty of the CHA is concluded, gets insurance medical policy. In children under 16, the Polis receives one of the parents or a representative upon presentation of a passport and the birth certificate. Terms and equal to them categories, registered in departmental medical institutions, are not issued. Refugees and displaced persons receive temporary policies for the registration period specified in the certificate issued by the migration authorities.

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

Medical institutions are responsible for the scope and quality of medical services provided and for refusing to assist the insured person. In violation of the terms of the contract, the OMS insurance medical organization has the right to partially or not fully reimburse the costs of the provision of medical services.

Insurance medical organization carries material liability for failure to comply with the terms of the CHIA agreement. Medical Insurance Disputes are permitted by the courts within their competence

The state is ready to provide free medical care to all living on its territory, subject to the design of the relevant policy. The contract or medical insurance policy in Russia provides equal rights to obtain medical and drugs to citizens of the Russian Federation and foreigners. This system will help preserve life and health to man.

What is medical insurance

Under the Fedeania implies the protection of the interests of the population in health. Payment or provision of free medical services is guaranteed when an insured event occurred due to the funds accumulated by the Fund. Insurance medorganization carries costs in case of violation of human health since the conclusion of the contract and paying the first contribution to the Fund. At the same time, the violation should be subject to one of the registered insured events.

Types of medical insurance

It is divided into medical insurance in the Russian Federation to the following types:

1. Mandatory.
2. Voluntary.

Mandatory Faming (OMS) is part of the state social insurance system of Russian citizens. This medical insurance provides equal rights to assume the necessary patient's assistance. At the same time, the volume and conditions for obtaining medical care corresponds to the volume and conditions that are declared by the OMS program.

The service package of voluntary medical insurance (DMS) is somewhat wider than the one that provides basic OMS. The rules for DMS are installed directly by the insurance company, but the procedure for conclusions is made under the general provisions of the relevant law. Separate small moments of contracts from different insurance companies on medicine may differ.

Mandatory Medical Insurance in Russia

List of free services that provide compulsory health insurance in Russia:

1. Emergency medical care.
2. Outpatient assistance in the clinic: diagnostic examination, treatment of diseases in hospital conditions, home conditions, day hospital. In the event of the need to provide emergency medical care services are provided on holidays and weekends.
3. Help in the hospital with: pathologies of pregnancy, abortion, childbirth, exacerbation of chronic diseases, poisoning, acute diseases, injuries requiring immediate therapy, round-the-clock supervision.
4. Medical assistance, requiring the use of high technology: a complex of treatment and diagnostic services in a hospital with the use of unique and complex techniques.
5. Educational work with the population. Conducting measures of sanitary and hygienic orientation.

OMS system

OMS subjects:

1. Insured.
2. Insured.
3. Federal Fund.

OMS objects:

1. Territorial funds.
2. Insurance medical organizations.
3. Medical organizations.

Understanding the interaction of subjects and OMS objects will allow to better understand the functioning of the structure. The OMS system is a combination of subjects and relations between them on the formation of funds for insurance and the use of funds related to the provision of medical care. The main part of the OMS financing on the medical service of the population comes from the budget of Russia and is regulated by the OMS system.

Scheme of work

The key points of the OMS work scheme, how the budget between the subjects of the system is distributed:

1. Within the framework of the OMS, cash payments are not produced by the population. They go to pay honey services that prevent insurance medicine to patients for free. Cash directly enter the system of medical and preventive institutions.
2. Limited compensation is provided only for medical expenses, which does not include the coverage of temporary disability.
3. The individual principle is that the insurance premiums are made separately for each individual policyholder, in contrast to the family principle acting outside the borders of Russia.
4. Payment of fees fees is carried out by the state and the employer. At the same time, the state acts as a insurer. Workers are not participants in the financing of the OMS system.

Territorial programs

In accordance with the rules of the basic program, the OMS of Russia are developed by territorial programs (TPOMS). The document of the territorial program determines the rights to be free to provide medical assistance to insured persons on the territory of the subject of the Russian Federation. It corresponds to the unified norms of the main program of the OMS. At the same time, the financing of health care of the territorial program is carried out by payments of subjects of Russia.

Payments come to the Budget of the Territorial Fund are defined as the difference between the standard of financial support for the territorial and basic OMSA program, taking into account the number of insured persons on the territory of the subject of the Russian Federation. The amount of assistance established by the TPOMS of the subject of Russia, which issued an insurance policy, includes the volume of data of the insured persons outside the territory of a particular entity.

OMS Treaty

Responsibilities of the insured person:

1. To make insurance premiums at the expense of the OMS foundation established by the procedure.
2. To present a policy of OMS when contacting help, with the exception of emergency situations.
3. Submit an application for the choice of insurance hindrganization in accordance with the rules in person or through the representative.
4. To notify the insurance hinduction on the change in identity documents, the place of residence for 1 month from the day when there were changes and no more.
5. Choosing another insurance hinduction at a new place of residence for 1 month and no more.

Responsibilities of the medical insurance organization:

1. Inform the insured person in writing for 3 working days from the date of information about the fact of insurance and obtaining the OMS policy from the territorial Fund.
2. Ensure the issuance of the insured person of the CHI policy in the manner prescribed by this Federal Law.
3. Provide information to the insured person about his rights and responsibilities.

Mandatory Medical Insurance Policy

The OMS document is issued by the insurance of a citizen completely free. Insurance of non-working citizens is also carried out. You can get a document independently or through your representative. Who is issued a policy of OMS and its validity:

• Citizens of Russia - without limitation.
• Persons who have the right to receive medical care in accordance with the law "On Refugees" - a paper policy for the end of the year, not exceeding the period of stay specified in the documents.
• By temporarily staying on the territory of Russia to employees of the EAEU member states - a paper policy by the end of the year, not exceeding the term of the employment contract concluded with employees.
• Temporarily residing in Russia to citizens of other countries, stateless persons - a paper policy before the end of the year, not exceeding a temporary residence permit.
• Temporarily staying on the territory of Russia to foreign citizens who belong to the category of members of the Commission of officials and employees of the EAEU bodies - the paper policy by the end of the year, not exceeding the fulfillment of the relevant authority.

Voluntary medical insurance

The voluntary media system (DMS) is a personal insurance type, which guarantees free medicine provided for by the Insurance Highborhood Treaty. Voluntary health insurance policy includes preventive, rehabilitation, medical and diagnostic assistance. List of additional services DMS:

• dental assistance (consultation, reception, surgery, physiotherapeutic treatment, prosthetics);
• cosmetology procedures (manual therapy, aesthetic surgery);
• treatment of critical diseases (oncological diseases, aggravation of chronic diseases);
• personal options (inclusion of additional clinics, consultation and treatment abroad).

For citizens of Russia

Voluntary health insurance in Russia for citizens of the Russian Federation will expand the range of free medical care services, without excluding paid medical facilities. Insurance is valid on the territory of a certain subject of Russia (settlement, region). In addition, the standard DMSA agreement provides for the treatment of typical diseases in a child, a number of advantages for pregnant women and women in labor.

For foreign citizens

The PMC policy for foreign citizens provides a guarantee for assistance in the territory of the Russian Federation, due to the contract. This document is required by citizens of other countries for a legitimate stay in Russia. Its clearance must begin on the first day of stay in the country. Since 2016, a penalty has been introduced for the lack of this policy among foreign citizens. At the same time, a foreigner will receive a medical care without a DMS policy in Russia, if its health is critical, there is a direct threat to life.

When executing the PMC policy for foreign citizens, it is necessary to consult with a specialist. The document may be issued any insurance company with a relevant license. The cost of the policy is not strictly fixed. The amount depends on the list of medical services that it includes. It is necessary to take into account the place of residence of a foreigner. In addition, if a citizen of another country does not own the Russian language, it is necessary to take care that the chosen institution has had a medical staff who owns one of the foreign languages.

There is also a separate type of insurance for migrants. They preferably enjoy foreigners from neighboring countries. This document is required to cross the border with Russia and for legitimate employment. Often, the PMC policy for migrants has differences with a standard DMS contract. It includes a limited set of services at low cost.

Video

The Russian Compulsory Medical Insurance System (OMS) has recently undergo serious changes.

The joint efforts of the Ministry of Health of the Russian Federation and the Federal Fund of the OMS were implemented a number of significant innovations and reforms. Modernization of the OMS system and the law on OMS, adopted in 2010, was hotly welcomed by many experts and government officials. According to TA Golikova: "The adoption of a law on compulsory health insurance is an important stage in the modernization of health. We move to the competitive model in which the patient and the quality of medical care comes to the fore. " Unfortunately, over time, part of the experts and officials began to express the public criticism of the basic principles of the modern OMS system, in the development and implementation of which they themselves were directly involved.

So what did the Russians modernize the OMS system brought? How do insurance medical organizations (SMO) and territorial foundations of OMS interact today? This was the "MK".

The system of compulsory health insurance was introduced in the 90s with the main goal - to save health in the context of short-range budgets and guarantee the Russians free medical care. The OMS has coped with these tasks, but they came to replace the new ones: the modernization of the medical industry, the introduction and provision of the wide availability of new treatments, the transition from medical care is mainly in emergency situations to preserve health, prevent diseases and prevent the development of severe forms of hazardous diseases. Recently, the Ministry of Health and Fom made a lot for the development of the OMS system in these directions. Today, at the expense of the OMS, the population's climbing program is carried out and high-tech medical care is provided in the treatment of complex diseases.

In addition, the procedure for the work of the OMS system is also being improved: more effective methods of payment for medical services are introduced, new mechanisms for monitoring the quality of medical care and the protection of the rights of insured citizens are being created. Thus, a single-sample OMS policy was introduced, according to which every citizen can get medical care in any corner of the country. Russians received the right to choose polyclinics independently and insurance medical organization.

In the market, the SMO today is a huge competition. For patients there is a real struggle, which means there are more and more incentives to expand the range of services and improve their quality.

Accounting insured and issuing policy

Under the law, the patient can change the patient at least every year. What if you decide to change the insurer or change the policy of an old sample to a new one? One of the regional branches of insurance companies should be applied. Regardless of which company you will prefer, the insurer will tell you about the procedure for obtaining the CHAM policy, your rights in the IMS system will answer all the questions you are interested in, will accept your application and inform about the timing and procedure for obtaining the policy.

What happens? If you change the old policy to a new one, the insurer will print your data with the database, immediately prints and give you a temporary testimony (performs the role of the CHI policy before receiving the latter), will update its register of the insured, on the same day will send data to the territorial Fund of OMS. In turn, the territorial fund collects all the applications received from all the insurers of the region and verifies whether the information at the level of the edge is not duplicated. The Foundation then forwards the data obtained to the total base of the OMS Federal Fund with the application for the manufacture of a new policy. The FFOMS also adopts the data obtained for duplication throughout the country and orders the manufacturer of the OMS Personal Policy on a secure form in the lesson. As soon as he is ready, the FFOMs will switch the policy to the territorial Fund, where he will be transmitted to the insurer. The latter will inform the citizen about the preparedness of the policy and, accordingly, will give it. In general, the manufacture and delivery of the policy is no more than 30 business days.

Such an order not only makes it possible to obtain medical assistance by each insured in any country's country and prevents duplication of costs, but also ensures reliable records and proportional financing of federal programs by region.

Professional patient support

As already mentioned, today insurance medicalms are interested in providing the highest quality services to their insured. The patient can contact its SMO for almost any issues related to the provision of medical care. For example, if you are offered for a long time to wait for the doctor's reception or pull with the study, if it seems to you that the medical care has provided for you poorly or suddenly demanded money for what you are for free - boldly contact your insurer. In any of these situations, the SMO is not only obliged, but also to help you. The insurer will explain to you what to do to resolve the issue will connect to solving the problem, will call the chief doctor of your clinic or hospital, where you are treated.

If the insurer finds it necessary or at your request, an assessment of the quality of medical care provided to you will be conducted. If disturbances will be revealed during this check, the medical organization may be fined. SMO will provide you with consulting and legal support. Now these types of control have become permanent practice: for example, in the period 2014-2015, insurance organizations reviewed more than 60 million appeals from patients. However, if it seems to you that the insurers are seen from the fulfillment of their duties, you can contact the territorial Fund of the OMS with a complaint - and then the inspection is waiting for the insurers themselves.

It is worth aware of the medical and economic expertise and the examination of the quality of medical care provided. Today it is not only the main function of the insurer, but also the only mechanism for private control of medical organizations. Under the law, insurers have the right to impose sanctions on polyclinics or hospitals, if they had a medical care poorly. In some cases, this turns out to be a serious incentive to improve the quality of medical services. Such expertise today holds experts, both regular and freelance. So that such examinations are not conducted for a tick, there is selective control from the TFOMS, which can carry out reecurspertiz. And if it turns out that the initial Examination of the SMO was held poorly, the OMS territorial foundation will finish the insurer himself. To avoid conflict of interest, doctors who work not in those organizations that are subject to inspection are committed to conducting an examination. And in particularly difficult cases, insurers (as a rule - federal) are analyzed by experts by experts of other subjects and with higher qualifications, from the country's leading medical institutions. In 2014-2015, 42.6 million bills containing 52.6 million violations were revealed from the results of medical and economic control.

Payment of medical services

And a few more words about how medical care was paid today, rendered to the Russians. All money is accumulated in the FFOMs, from where are transmitted to TFOMS, which distribute them to their "ward" of the CMO depending on the number of insured and a number of other indicators. All medical organizations of each Russian region monthly collect accounts for all services and send them to insurers. For example, in the Tula region, where medical organizations included in the OMS system, more than 60, they all form account registers to pay for medical care, depending on the insurance affiliation of patients and send registers to the CMO branches present at the local market. Insurance companies before paying bills are carried out by medical and economic control to establish the legality of payment (for example, the company is the insured, whether the service is included in OMS, etc.). This is done in order for state money to be used for direct appointment.

At the end of the inspection, medical organizations receive payment from insurers. However, if the account was rejected because of the technical error, the clinic or the hospital may re-invoice - the insurer is obliged to check it again and, if everything is correct, pay. Money for payments for medical organizations appear on the CMP accounts from TFOMS in a strictly designated period and only 3 working days: during this time, insurers must accept and process all accounts, pay them, and the balance of funds (if any) is to return to TFOMS. Violation of terms is threatened with strict sanctions from the TFOMS, which monitors the quality of the work of the SMO. Independently, TFOMs are carried out only inter-dertestorial calculations (when the insured 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, carried out by the Forces of the SMO.

The system of interaction between the participants of the OMS system, where funds and SMO provide the functioning of the entire system and the possibility of realizing the rights of citizens to high-quality and free medical care, experts recognize the optimal and logical. Of course, this does not mean that there is nothing more to improve. Changes in this area are constantly. For example, at the initiative of the Ministry of Health, the Institute of Insurance Representatives has already begun and has already begun its work, the task of which is to increase the awareness of patients about their rights, protect their interests is even more denser.

And yet, a lot today depends on the activity of patients themselves, from 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 turn out to be qualitatively, in our power to bring the level of health to the level that can be rightfully proud of.

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

In the Russian Federation there are two types of health insurance: on a voluntary basis and compulsory. The purpose of the first - provision of citizens of the Russian Federation with an additional list of honey. Services. Payment for the procedures is carried out from the Fund, which replenishes the owner of the insurance policy.

The second type of insurance is made in a compulsory manner. When the insured person needs to help doctors, he will be able to contact the hospital and use the services of doctors for free. Mandatory insurance allows you to contact any polyclinics in all the country. It will take advantage of one of them. You can do this by phone or in the registration.

Medicine Insurance Features

Since insurance in the Russian Federation is a forced norm, you should learn more about what OMS is.

Inspire in the law of the Russian Federation are obliged

• citizens of the Russian Federation;
• foreigners, constantly or temporarily living in the country;
• persons who have no citizenship yet;
• refugees from other countries.

Payment of services provided by the owners of insurance is carried out from the state budget.

Sources of its formation are:

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

Having insurance, you can:

• receive ambulance medical care;
• take part in therapeutic and preventive measures;
• contact narrow-profile specialists;
• use the services provided by the insurance company.

Subjects participating in the insurance process

The legislation of the Russian Federation allocated 3 subjects of insurance. Insureders are legal entities that have authority to issue policies. These are representatives of insurance companies. In some cases, the state itself speaks as this subject.

Insured persons - citizens of the Russian Federation and other persons who have received insurance. This document will equip them with rights to receive a number of services from state hospitals free of charge.

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

In addition to the subjects, other participants are included in the OMS system. Funds of the subjects of the Russian Federation are contributions to the budget from which the services provided by the owners of the services are paid.

Insurance medical organizations and hospital institutions are also involved. The first are licensed institutions engaged in the issuance of DMS policies and. Second - provide honey. Services for free.

Subjects and participants constantly interact with each other. Relations between them are governed by the legislation of Russia.

Article 41 of the Constitution of the Russian Federation: what she

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

The constitution also contains information on the development of the system. Russia financing programs aimed at creating new public and private funds.

In 41, the article reports that the Government undertakes to encourage the activities of organizations that will function to strengthen the health of the entire society as a whole and of each person.

In accordance with one hundred. 41 persons intentionally hiding the fact of the threat to the health or life of Russian citizens must be incurred for this action. It is also supported by federal state laws.

Types of OMS

Policy of the OMS of Russia can be presented in three types:

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

Medicine insurance system

Subjects and participants, interacting with each other, creating a system. In the process of functioning the structure, issues of formation of funds are solved, of which payments are subsequently produced. Also in the process of interaction occurs the distribution of finances.

The main part of the medical care of the population of Russia is paid from the state budget. The Federal Cash Fund is engaged in the management of cash flows.

Rights of persons who received insurance

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

• receive the help of physicians throughout the state or within the subject, where the policy was issued, free of charge;
• choose an insurer by sending a statement to the company according to the rules of state legislation;
• replacing the insurance company not more than 1 time in 365 (366) days if the term of the contract with the insurer has expired or you changed the place of residence (the choice should be done before November 1);
• choose a medical institution from those that will be offered to the insured agent;
• choose your attending physician, pointing out him in a statement addressed to the head of the hospital (independently or through the official representative);
• receive from regional fund and honey. institutions are true information about the quality and conditions of medical procedures;
• require doctors to protect personal data;
• receive damage from insurance and medical organizations in case of non-fulfillment or improper implementation of the services;
• require the protection of the rights and interests provided for by the legislation of the Russian Federation.

Responsibility of medical institutions

Hospitals and clinics are required to provide free honey. Services to insured persons. At the same time, the procedures conducted by doctors should be appropriate quality, and the designated drugs are relief from the symptoms of the disease.

Honey. The institutions are responsible to the federal foundation, sending reports to it in appropriate form.

Also hospitals are required:

• keep records of services rendered;
• provide information about the medical information provided by their customers. assistance;
• post on the official website and other resources reliable information about the mode of operation, types of services, as well as inform about this federal fund and patients;
• use medicines and consumables that were provided by the state;
• to inform patients about the availability of paid services, if any, but do not force them to acquire.

In case of violation by honey. Institutions Patient in the right to demand examination. Within its framework, experts conduct an independent assessment of the work of one or several doctors, as well as the whole hospital as a whole (if necessary).

Control of the provision of medical care

The main problem of OMS in Russia is the provision of medical services. Institutions of improper quality. To determine the fact of violations on the basis of the procedure, an independent SMP examination is carried out in order to assess:

• the actions of the doctor and the treatment prescribed or the functioning of the hospital as a whole;
• compliance of the doctor level of its qualifications;
• the quality and safety of assistance rendered with one of the four points of view (in an emergency situation, by the patient, with a deviation from technology without it);
• compliance by the doctor of standards, orders, the requirements of the NPA with honey. Aid.

If, according to the results of the examination, a violation of a doctor, several doctors or a medical institution as a whole will be revealed, the insured person will be issued a conclusion. At his foundation, the insured will be able to compile and file a lawsuit to compensation for damage.

Scheme of work

In order to find out how honey works. Insurance in Russia should consider the scheme of system functioning.

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

• mandatory medical insurance is not intended for payments to the population in cash or non-cash formas;
• payment honey. services are carried out directly to the account of the treated institution;
• no payment for working days in which the owner of the policy was disabled;
• an important point is the implementation of contributions individually for each insured person;
• contributions to the budget produces both the state and the employer;
• workers are not sources of budget financing.

Programs of Regions

The prospect of the development of OMS in Russia is to develop in the subjects of their own insurance programs. According to them, the policyholder will be able to receive honey. Assistance only in the territory where he received a policy. Paying the received services will be directly from the Subject Foundation.

Top 10 companies engaged in issuing policies

The development of OMS in Russia allows you to choose an insurer. Attention should be paid to the rating that is annually by the FFOMS and unloads on its official website. The table presents the 10 best insurance organizations for 2019.

OMS Treaty

In addition to the main data in the contract (who concluded it, from which year and what it is valid, etc.) indicates the responsibilities of both parties. Insurance company undertakes:

• provide the OMS policy owner information on the rights and obligations of the insured;
• inform the insured in the written form within 3 working days on the occurrence of the fact of insurance and receipt of the policy;
• make the issuance of the CHAS policy in accordance with the federal legislation of Russia.

The insurer must:

• timely payments to the Fund (the size and timing of contributions are provided for by law);
• turning to honey. organization for help representing the Policy of the OMS (except when the appeal is emergency);
• personally or through the official representative, following the established rules, apply, indicating the choice of an insurance company;
• to send the insurer information about the change of a passport or move within a month from the date of the change in force;
• when changing permanent residence per month, to choose a new insurer.

The OMS system for citizens of Russia and other persons having insurance provides for the provision of services with medical institutions free of charge. It consists of three main subjects: insurer, insured and ffoms. The latter - acts as a regulator of relationships between the first two.

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Doctors were shocked when I showed ...

On the weekend I lay at home with an impossible sore throat and temperatures of 39.6.

Binding not the first dose of paracetamol for the day, I called Skouring. I was told that this is angina and that I call the precinct on Monday. The ambulance did not come.

Zhenya Ivanova

treated and recovered

I scored in a search bar: "What if the ambulance refuses to go." At the forum, I saw the advice: "Tell me terrible, that call the insurance. Immediately come. " I did so. The ambulance arrived. After I, twice threatened the doctor to the insured and once called the number, which is indicated on the policy. Helped every time.

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

I recovered and decided to figure out what guarantees you your mandatory medical insurance.

Meet: Your Polis Oms

Most likely, you already have a policy of compulsory health insurance. He made you parents immediately after birth. He either in your passport or in a box with all important documents.

If you do not have the policy, throw everything and make

Without the policy you do not shine any free treatment. Fortunately, you can get or exchange a policy in any city without registration and registration. To do this, take a passport with you and SNILS and go to the insurance company convenient for you, which makes out these policies.

This is a card If there is no reduce a, go first with the passport to the insurance, then we are waiting for 21 days and only then get the policy.

Citizens of the Russian Federation, constantly or temporarily living on the territory of the Russian Federation foreign citizens, refugees and stateless persons in the Russian Federation. Citizens of the Russian Federation Polis are issued without limitation. By law, even if you have a policy of an old sample and it is overdue, insurance will still work. Only until you change the passport details: the name, surname, place of residence.

If you came to the clinic with the old overdue policy and you refuse to treat it is illegal. You must take. In the clinics, they ask everyone to change the policies to the documents of the new sample, but so far it is only a recommendation. Of course, it is better to listen to this recommendation: when a law comes out that stops the action of the old-sample policies, it will not find you surprise.

What insurance companies give policies of OMS

OMS is an insurance program, that is, everyone pays on a little bit in a common boiler, and then they pay from it to those who need. The overall boiler collects a state from entrepreneurs and distributes on an extensive system of funds, which, in turn, pay hospitals. And the Insurance Company is such a mediator manager who connects you, the hospital and the state.

Insurance companies earn an OMS as at other services. They are responsible for the quality of services and discipline in the system. Your first point of contact is an insurance company.

Each region has its own registers of companies that make OMS policies. Just thug.

Where can be treated with a policy of OMS

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

1. Select a clinic. Anyone is not necessarily the fact that closer to the house.
2. Learn in the reception, which insurance work with this clinic. If there is a choice, see the company's description on the SMO website. Insurance at all is the same, but someone has more offices, and someone has round-the-clock support.
3. To come to the insurance with a passport and SNOWS, fill out an application for replacing the policy.
4. Get a temporary testimony. It works as a policy within a month.
5. Return to the clinic. To say the codes phrase "I want to attach to your clinic." Get the application form, fill it 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, you do not need to change the policy. But you need to report in the insurance that you moved and want to be treated elsewhere. Otherwise, the money for your treatment will not receive a new polyclinic.

Why need to be attached to the clinic

It is necessary to attach to the clinic, because in our country there is a system of per capita financing. Money on your treatment is issued only to the institution you are fixed. Therefore, it is impossible to attach immediately to several polyclinics. It is still officially changing the clinic not more than once a year. Previously, this can be done only if you moved. In this case, in the new polyclinic you will be offered to write an application in the name of the chief doctor.

You can't attach to research institute or hospital, only to the district clinic. And already there, the district therapist will discharge directions to narrow-profile specialists: the eye surgeon, a cardiologist, a manual therapist. Without direction from the attending physician or ambulance specialist in specialized clinics, you can only take you.

What is EMIAS

In Moscow, the data of all patients are entered into EMIAS - a single medical information and analytical system. It simplifies the process of recording to those skilled in the art: you can get a doctor to the doctor, cancel or transfer the record, to get a prescription in electronic form. Emias even has a mobile application.

Please note: if you moved and decided to attach to the new clinic, you can not just take and do it through the system. It is necessary to write an application in the name of the chief doctor and wait until the bureaucratic apparatus approves it. It can take 7-10 business days. If you are registered on the portal of the Moscow State Service, then apply in electronic form. He is promised to consider in 3 working days.

When I ran into such a problem, I needed help urgently. And according to the law, I owe me to help without any multi-day delays. But in the clinic they are afraid that if they are treated to me before the driving machine will bring new data in EMIAS, then they will not receive money for me from insurance.

Right with the attendant administrator of the hospital, I called the insurance, after which I received the necessary consultations in the hospital for free. I also examined the whole commission from the department of departments, and so far everything is very careful to me.

What is included in the treatment of OMS

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

If there is no policy with you, you can still sign up for the doctor, you do not have the right to refuse.

Although for nurses it is additional concerns, therefore, most likely, you will try to convince you to do it impossible. If this happens, just call the insurance.

In any incomprehensible situation, call insurance

The minimum amount of assistance is described in the basic Mandatory Medical Insurance Program. To add something to this list something, each region decides on their own. Accurate list of insurance claims 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 such a rule: if your life and health threatens something, they treat for free. If you are generally healthy, but you want to feel even better, then, most likely, you can do it only for money. If the state can help you, but the level of this aid seems to be too low for you, you will have to accept or pay extra.

Examples of what can and cannot be done in the OMS policy

It is impossible	Can
Whiten your teeth is aesthetic procedure	Make cleaning teeth because it is prevention of caries
Get imported Japanese diapers for adults, independently choosing a brand	Get diapers for an elderly person
Remove a couple of extra kilograms. Your figure is not insured by the state	Remove furuncul
Wait for therapeutic physical education of exercises from Hatha Yoga or the modern gym	Hack
Contact a dermatologist if you are worried about just increased fatty skin	Contact a dermatologist with a problem of severe skin on the skin
Make a dental prosthetic	Remove the tooth

Teeth whitening is aesthetic procedure

Cleaning teeth, because it is prevention of caries

Get imported Japanese diapers for adults, independently choosing a brand

Get diapers for an elderly person

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

Remove furuncul

Wait for therapeutic physical education of exercises from Hatha Yoga or the modern gym

Hack

Contact a dermatologist if you are worried about just increased fatty skin

Contact a dermatologist with a problem of severe skin on the skin

Make a dental prosthetic

Remove the tooth

When something hurts, you can get to the reception to the therapist, which will write down the direction to the specialist. In the presence of testimony, the therapist should write directions to any doctors that work in state clinics.

Without a direction, you can sign up for a surgeon, a gynecologist, a dentist and a dermatologist in a leather-venereologic dispensary. Or write a child to the children's psychiatrist, surgeon, an urologist-andrologist or a dentist. Free analyzes and surveys without the direction of the attending physician, OMS does not guarantee.

Every three years, you can pass free closerization and find out if everything is fine with health. The dispensarization is carried out for every time in three years - that is, if this year it turns 21, 24, 27 years old and so on.

The OMS program includes even free anesthesia and rehabilitation after diseases and injuries. But once or two paint, in which case you have free assistance in insurance, and where you have to pay yourself, it will not work. In this case, a lot of nuances. If you have a rare disease or a difficult situation, contact the Federal OMS Foundation.

What exactly is not included in the OMS program

The state will not pay for:

1. Any treatment without appointing a doctor.
2. Conducting examinations and expertise.
3. Treatment at home at will, and not according to special testimony.
4. Vaccinations outside government programs.
5. Sanatorium-resort treatment, if you are not a sick child or pensioner.
6. Cosmetology services.
7. Homeopathy and traditional medicine.
8. Dentures.
9. Chambers of high comfort - with special nutrition, individual care, TV and other joys.
10. Medicines and medical devices, if you do not learn in the hospital.

If the hospital is asking for services for services that are not in this list, just in case, call the insurance and specify whether it is legally.

Privileges

People with disabilities, orphans, large families, participants of hostilities and other citizens who are given social benefits, the state is ready to pay more medical services. For each category there are your own lists of benefits, you can learn them in the social protection department or find on the Internet.

Sometimes you will have free treatment according to the law, but the doctors are only bred by their hands. There may be a queue for free rehabilitation to several months, and the painkillers in your district hospital may simply not be. This is illegal, but this is a fact of life.

Extortion

Doctors are also people, and nothing human is alien to them. Like any person, to get a lot of money from you right now, some doctors are more interesting than getting a little less money from insurance and very later. Therefore, a whole illegal practice of extortion money for treatment on OMS has grown in Russia.

At the heart of this extortion - legal illiteracy. The doctor is enough to make a smart look and take a strict tone so that frightened patients began to rush into it with money. But the slightest sign that the patient's legally pitched before the doctor is replaced. Therefore, it is very helpful to know which medical services you must have free.

Remember that treatment is free only for you. Hospital and the doctor will receive money for this treatment from the Medical Insurance Fund. This money paid entrepreneurs to the fund, including your employer.

You do not need to pay a second time from your pocket for what the state guarantees you. Moreover, the doctor is most likely, and so will receive payment from the Foundation, even if you are forced to pay.

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

If you know exactly what you should and can be treated for free, but the doctor offers to pay, call the insurance. The room is written on your policy, the hotline specialists will help you.

If you can't 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 voice recorder, it is legal. Even if it does not help, call the Department of Protection of Rights of Citizens in the OMS system.

7 499 973-31-86 - Telephone department for the protection of the rights of citizens in the OMS system

Emergency help is always free

If something really bad happened - you lost consciousness, broke your leg or feel acute pain - you should help in any state clinic, even if there are no documents with you and the policy you never received.

In the hospital, it is not entitled to deny the help of newborns and children under the age of the year, even if the child's parents have no policy and regulations. Could not refuse and pregnant women - they can contact any female consultation and in any hospital even without documents.

All participants in the health system are just people: someone familiar, friends, brothers, matchmakers and kums. They have parents and children. They are all Russians and work in the same way as any of us.

• If the surgeon requires a bribe for anesthesia, then this is not a health care system, it is specifically this surgeon, his parents and teachers. So, his father somewhere in childhood submitted him as an example that the bribe is normal. Do you yourself feel about bribes?
• If the hospital says that she has no money for medicines - this is not Putin to blame, and some officials who do not know how to budgetes. Or chief physician who does not know how to dispose of money. You have full of familiar who do all the same in their works.
• In the end, when you get a salary in the envelope, this is your employers underpaid to the health insurance fund. Where did you get money on your medicine, if you allowed you to pay for them?

Light schizophrenia is obtained: the same person supports a gray salary and complains of insufficient hospital financing.

Putin, Navalny, Medvedev, Tinky or Trump will not solve our health problems. We decide this problem if we give our children an example of a conscientious attitude to work and the law. To walk the classes at the institute was not a feat, but disgrace. To rent speakers for money was ashamed. To give bribes was against our principles. To know and defend your rights, it was a duty, and not superpower.

In short: no one arrives and will not make us free medicine as in paid Israeli clinics. All the hell, which we see in hospitals, is not hospitals, it yourself. And me too.

Let's start with paying taxes and contributions. I have everything, thanks. Sorry for the moralization tone, but just got it whining.

Remember

1. If you do not have the policy, throw everything and go.
2. The Policy of the OMS should be treated for free in any state clinic throughout Russia.
3. Treatment is free only for you. Hospital and the doctor will receive money for this treatment from the Medical Insurance Fund.
4. Polis works, even if he has expired. If you came to the clinic with the old policy and you refuse to treat - it is illegal.
5. In any incomprehensible situation, call your insurance medical company. There is a room on the policy. Record it into the phone right now.
6. If the insurance is not saved - call the Federal Mandatory Medical Insurance Fund: +7 499 973-31-86.
7. If we spent money for treatment, which should be free by law, write a statement to insurance - you need to return money.
8. Extra help is always free, even if you do not have documents.

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