Compulsory health insurance is ... Insurance premiums for compulsory health insurance

Compulsory social, pension and medical insurance are elements of the state program aimed at supporting the population. It includes a set of organizational, legal and economic measures. Let us further consider what constitutes federal compulsory health insurance.

Terminology

Compulsory health insurance is a system of legal and organizational-economic measures aimed at providing guarantees of free assistance to citizens in the event of appropriate circumstances. Financing is carried out at the expense of the MHIF within the framework of a territorial or basic state program. The main regulatory act regulating compulsory health insurance is Federal Law No. 326. It defines key concepts. In particular, the normative act defines the subject and object of compulsory medical insurance, risk and security, the content of the territorial and basic program, in accordance with which compulsory medical insurance is carried out. Federal Law No. 326 also formulates the duties and rights of the parties to the contract, their responsibility.

Relevance of the problem

Until 2011, there was a certain model of compulsory medical insurance. However, as practice has shown, it was very ineffective. The main reason for this was the lack of proper conditions under which the patient and his needs would be the center of the system. Until 2011, the citizen and his employer or the executive body had the opportunity to choose an organization that provides compulsory health insurance in Moscow or another city. In practice, this situation led to the actual removal of the population from participation in the determination of the compulsory medical insurance company. In addition, relations within the system were built on a specific principle. In particular, polyclinics and hospitals received funds from such organizations not as compensation for the costs of treatment, but to provide assistance to patients. In fact, in this way a certain budget was allocated to medical institutions. The Compulsory Health Insurance Fund did not have a stimulating effect on hospitals and clinics. Accordingly, the latter were not interested in improving the quality of services.

Current situation

Currently, compulsory health insurance is a program designed to finance the services provided, and not the medical institution as such. The above normative act contributes to a significant expansion of citizens' capabilities. So, a person can choose an insurance company, a medical institution, and doctors. At the same time, a medical institution, which is included in the register and has concluded an agreement on the provision of relevant services under the program, has no right to refuse assistance to a citizen.

Key areas

One of the main aspects in this area is the order in which compulsory health insurance is financed. Law No. 326 regulates the following areas:

1. Rules for the formation of funds.
2. The size of the premium for non-working citizens.
3. Dates, procedure, period of payment of amounts.
4. Responsibility for violations in the deduction of contributions.
5. Rules for setting tariffs for the compensation of medical care in compulsory medical insurance.

During 2011-2012, insurance premiums for compulsory health insurance were increased by 2%. This made it possible to direct about 460 billion rubles to the healthcare sector.

Tariffs

Enrollment of insurance premiums for compulsory medical insurance in the budget of FFOMS KBK is a procedure that all employers must go through. Their value depends on the tax regime and the type of activity of the enterprise. In addition, the tariff is calculated taking into account the category of the payer. An organization may assess as a general rule or use reduced rates. The category of employee for whose benefit payments are also important.

In 2016, the tariff for individual entrepreneurs with employees and organizations in the MHIF is 5.1%. The benefits are: disabled people of any group (2.9%), public type organizations (2.9%), institutions that provide free assistance (2.9%), organizations whose registered capital is deposits (2.4%).

Fundamental principles

Law No. 326 governing compulsory health insurance sets out the following provisions:

1. The universal nature of CHI.
2. Providing state guarantees to protect individuals from risks.
3. Autonomy of financing the compulsory medical insurance system.

The principles by which compulsory health insurance is implemented are:

1. Providing guarantees at the expense of the MHIF for free assistance to the entity in the event of the occurrence of relevant circumstances.
2. The stability of the financial system. Stability is ensured on the basis of equivalence of insurance support by means of compulsory medical insurance.
3. Mandatory deductions of payments in the amounts established in regulatory enactments.
4. State guarantee of the observance of the interests of insured citizens to fulfill obligations under the main compulsory medical insurance program, regardless of the financial condition of the insurer.
5. Formation of conditions for ensuring the quality and availability of medical care.
6. The parity of the representation of participants and subjects of CHI in the governing bodies.
   

The specifics of the reforms

Changes in the compulsory health insurance system act as a component of large-scale transformations of the healthcare sector in the Russian Federation. Experts believe that the adopted regulations will contribute to the effective development of the entire system. Moreover, the focus of attention of responsible persons should be exclusively on the health of the citizen. It is up to him to decide which specialist, which institution to contact. The choice of a person should not be limited to clinics and hospitals of the region of residence or registration.

Subjects

This category includes:

1. Insured persons:

• working under civil law and labor contracts, the subject of which is the performance of work or the provision of services, as well as under license and copyright agreement;
• self-employed citizens (IP, private practitioners).

2. Policyholders:

• persons making payments and other remuneration to citizens (organizations, individual entrepreneurs);
• individual entrepreneurs.

3. The Federal Fund, acting as an insurer. It is a non-profit organization formed to implement state policy in the field of compulsory medical insurance.

Members

In the compulsory medical insurance system are present:

1. Territorial funds. They are presented as non-profit organizations formed by regions for the implementation of state policy in the field of compulsory medical insurance in the territories of constituent entities of the Russian Federation. These structures exercise certain powers of insurers regarding the implementation of territorial compulsory health insurance programs.
2. Medical facilities. These include organizations included in the compulsory medical insurance register and having the right to carry out activities in the field of healthcare and compulsory medical insurance. They can be formed by individual entrepreneurs or be an organization of any legal form permitted by regulatory enactments.
3. Medical insurance companies. They carry out their activities in the field of CHI on the basis of a license granted by an authorized supervisor. Medical insurance companies exercise certain powers of insurers under Federal Law No. 326 and the MHI Financing Agreement, which it concludes with the territorial fund.

Registry

As mentioned above, medical organizations are included in it. The registry contains them:

1. Names.
2. The list of services that are provided as part of the territorial MHI programs.
3. Addresses

The territorial fund maintains a register and places it without fail on the official website. Additional publication of information in other ways is allowed.

Software development

In accordance with regulatory act No. 326, the basic and territorial directions of compulsory medical insurance were formed. In ch. 7 of this document lists the types of services that are included in each program. Since 2013, emergency medical care has been included in the basic direction, and since 2015 - high-tech. Programs are approved at the regional and federal levels. The basic direction extends to the whole country, and the territorial one operates within the subject. Regions received the right to add insurance cases and types of assistance not included in the compulsory medical insurance to the main program. At the same time, they finance their provision on their own.

Compulsory health insurance: policy

Moscow was the first city in the country to introduce these documents. In the course of the implementation of the compulsory medical insurance program, they began to be provided to citizens in other localities. Until 2011, the compulsory medical insurance policy was not uniform for all. Each company printed its own forms. They were subject to replacement upon expiration. If citizens changed jobs, he should have handed over his policy to the employer. A new document was issued to him by another employer. This procedure took some time, during which the resigned person could not receive medical care. If a citizen became unemployed, he needed to get a policy from an organization that insured unemployed persons according to the results of the competition. At present, the document is issued to all citizens and has a single form for all regions. It looks like a plastic card. On the front side , a new type of compulsory medical insurance policy (where the number is 16 digits) contains a chip. It contains information about the company issuing the document. Information about the insured person is present on the back of the card. They include full name, date of birth. On the back there is also a photograph and a signature sample.

Order of receipt

Earlier, citizens were given regional MHI policies. In order to implement the state program, their gradual replacement was carried out. POMC acts as a document confirming the citizen’s right to receive free medical care throughout the Russian Federation in the amount provided for in the basic program. To receive it, a person personally or through his representative submits an application. This can be done directly in the insurance medical organization itself or in TFOMS. On the day the application is accepted, a temporary certificate is issued to the citizen. It replaces the policy to be issued. After 2 weeks, as a rule, a citizen receives an electronic document. A plastic policy is valid indefinitely. Replacement of a document is possible in the following cases:

1. Loss / damage / depreciation.
2. Change Name

When changing the place of residence / registration, the status of a citizen (working or unemployed), the replacement of POMS is not provided.

Terms of payment for the services provided

As part of the state compulsory medical insurance program, the norms regarding the period of compensation for the care provided to patients are strictly regulated. Medical institutions now have a guarantee of payment for the services provided to a nonresident citizen. This, in turn, increases the interest of medical institutions in helping people. If the payment is delayed, the medical insurance company pays interest to the institution from its own funds. Its size is calculated at the Central Bank refinancing rate (1/300), which was in effect at the date of the delay. Calculation is carried out from unapplied amounts daily.

Compulsory medical insurance in Moscow: company rating

The list of organizations working as part of the compulsory medical insurance program is compiled according to certain indicators:

1. The number of PICs provision points.
2. Mode of operation.
3. Availability of information on the rights of citizens.

According to experts, the level of financial reliability is not significant in the preparation of the rating. This is due to the fact that the cessation of the organization’s activities will not especially affect citizens. The only thing they have to do is change the policy. The most popular organizations in the capital are:

1. RESO-MED. This company has 37 offices in which POMC is registered. Their work schedule is different, some of them operate around the clock and on weekends. For 9 months In 2012, more than 200 thousand complaints were received, of which 43 were justified complaints. The company provides information on the procedure for challenging the inaction / actions of employees; the list of medical organizations of the compulsory medical insurance has been qualitatively executed.
2. MSC "MEDSTRAKH". This company has 4 POMC distribution points. The central office is open around the clock. The company provides for the acceptance of applications in electronic form, as well as paid delivery of documents. The organization is engaged exclusively in medical insurance.
3. Ingosstrakh-M. The organization has 4 points of issuance of POMC. The company provides citizens with services to protect their interests in court. The organization has concluded agreements with more than 4.5 million customers.
   

Discussion Questions

In addition to a single compulsory medical insurance policy, it is proposed to introduce electronic instead of conventional paper medical records (medical records). This is because when taking a non-resident citizen, the doctor needs to know about the diseases and conditions of the patient. Citizens, as a rule, do not carry medical records. If there was an electronic medical history recorded in a single database, any specialist in any city could quickly get all the necessary information. At the same time, in a number of European countries the use of such electronic case histories in the global network is not allowed. This is due to the unreliability of personal data protection systems.

Conclusion

Compulsory health insurance is a significant step forward by the state in deciding on the provision of various assistance to the population. The developed programs include all the necessary volume of services that a person can get for free. Providing the population with affordable help is carried out at the expense of a source of financing guaranteed by the state. The law regulating the sphere of compulsory medical insurance was adopted relatively recently. However, during the validity of this normative act, many people were able to receive emergency, emergency and planned assistance. They were provided with services that previously these people could not use. The current law No. 326 applies to all citizens living in the country. The purpose of a normative act is primarily to strengthen guarantees of a citizen's constitutional right to free medical care. The implementation of its provisions contributes to a gradual increase in funding for the health sector. This, in turn, presupposes a balance of state guarantees for free medical care for citizens with state obligations.

The implementation of the provisions of the regulatory act helps to strengthen the material and technical base of the health sector. As a result, the goal that was set initially will be achieved - the quality and accessibility of medical care to people will increase. The law regulates in detail the duties and rights of all participants and entities, the rules in accordance with which compulsory health insurance is provided. Moscow was the first city where the established order began to operate. Today, the developed scheme is valid throughout the country. Federal Law No. 326 regulates the relationship of all parts of the system, involves the modernization of CHI and the subsequent development of the entire healthcare sector.