The demographic situation and the change in government priorities in the field of budget expenditures have led to an increase in the role of private sources of health financing. In all countries where medical insurance is developing intensively, individual products are appearing to protect the life and health of clients. Russia is no exception. Consider the main types of health insurance in the Russian Federation.
Essence
It is necessary to distinguish between the terms "insurance medicine" and "medical insurance". In the first case, we are talking about a method of financing the healthcare sector, and in the second, about the type of activity. Consider in more detail the nature and types of health insurance.
This term refers to a form of social protection of the population in the field of healthcare. Its purpose is to provide citizens with the opportunity to receive medical care at the expense of the accumulated money and to finance preventive procedures when an insured event occurs. Types of health insurance are mandatory and voluntary protection of the population.
The essence of this process is to transfer the risks associated with the loss of health (temporary or permanent) and compensation for the costs associated with its recovery. The transaction with the insurer is made out by the contract. The object is the risk of receiving expenses incurred in connection with the insured person applying to a medical institution for medical assistance. The amount of the contribution is calculated based on the probability of the occurrence of the insured event, the state of health of the client, his age and other factors. The subjects are: citizens, the insured, a medical organization.
The principles of functioning of insurance medicine are fixed at the legislative level:
- participation of Russians in compulsory health insurance (MHI) programs;
- scope and conditions of assistance to the population in the framework of the compulsory medical insurance;
- number of free services provided;
- participation of citizens of RV in voluntary insurance (VMI), which covers services in excess of the compulsory medical insurance program;
- combination of VHI and CHI.
The legal side of the issue
The rights of citizens in the field of health are enshrined in Art. 41 of the Constitution of the Russian Federation and the law "On medical insurance in the Russian Federation." These regulations say that all citizens have the right to medical care. In state and municipal institutions, it is free of charge, that is, at the expense of the budget, insurance premiums and other income. Residents and non-residents residing in the territory of the Russian Federation are subject to mandatory medical insurance. That is, health care must satisfy the need of people to maintain their health regardless of their material capabilities.
Health insurance: types, differences
In the territory of the Russian Federation it is possible to apply for a compulsory, voluntary and international medical insurance policy. All three types differ in cost, quality and quantity of services provided. The MHI policy is compulsory for all persons residing in the territory of the Russian Federation. Without it, only emergency medical care is provided free of charge. If the insurer wants to receive more or better quality services, then it acquires the VHI policy. Tourists traveling outside the territory of the Russian Federation are required to take out international insurance for themselves.
Compulsory medical insurance
The risk of disability refers to risks, the occurrence of which is not dependent on the person, but leads to significant costs. They concern not only individual citizens, but also society as a whole. It is interested in maintaining the health of all members.
Compulsory health insurance is a type of social insurance. It guarantees protection in case of illness to all persons equally. Compulsory health insurance is a type of property protection that provides all citizens, regardless of gender, age and social status, equal opportunities for receiving medical care. It is implemented through a system of funds (Federal, territorial) and specialized organizations. The latter carry out CHI operations on a non-commercial basis. Insurers are intermediaries between foundations and institutions that provide services to citizens. Organization and control of the entire system is carried out through funds - non-profit institutions that operate in accordance with the legislation of the Russian Federation.
Compulsory medical insurance is financed from insurance contributions (deductions from the single tax in the amount of 3.6%), payments from the budget. In this system, the insurers are the employers, who must conclude contracts in favor of employees, individual entrepreneurs and government bodies at all levels.
Policy of compulsory medical insurance
This document certifies the right of a citizen of the Russian Federation to receive free medical care in the framework of the provided program. It contains information about the policy holder, the number of the contract with the insurance company, a note on attaching to a particular clinic.
You can apply for a policy at any insurance company from among those included in the register for compulsory medical insurance. It operates throughout the territory of the Russian Federation. In the event of a change of name, place of residence, data of a document or identification of any inaccuracies, the policy must be reissued within one month. You must inform the insurance company in writing about the loss of the policy, and then proceed with the replacement procedure.
Service Programs
The scope and conditions for obtaining guaranteed assistance is fixed by a special document. The basic program is developed by the Ministry of Health and approved by the government. On its basis, territorial programs are developed. They indicate the main types of health insurance, the quantity and quality of services provided, the tariff structure, and methods of payment for assistance. The rights of insured persons to receive compulsory medical insurance are uniform throughout the Russian Federation.
As part of the basic program, primary sanitary, preventive, and specialized medical care is provided to persons with such diseases:
- infectious, parasitic (except for sexually transmitted diseases, tuberculosis and AIDS);
- oncological, skin, diseases of the endocrine system;
- eating disorders, the work of the nervous, genitourinary system;
- diseases of the circulatory system;
- ophthalmic, ear and respiratory diseases;
- injuries
- diseases of the musculoskeletal system;
- congenital malformations in adults;
- disorders of the immune system;
- chromosomal abnormalities;
- pregnancy, childbirth and abortion.
The territorial program includes:
- a list of diseases and types of assistance that is provided to citizens at the expense of budgetary allocations and funds of the territorial compulsory health insurance fund;
- the procedure for providing medical care to certain categories of the population;
- lists of essential medicines and medical devices, without which the provision of medical care is impossible;
- a list of medicines that are available on prescription for free or with a 50% discount;
- list of organizations that participate in the implementation of the program.
The medical organizations participating in the territorial program can provide paid services:
1. On conditions that differ from those provided by the program, including at the request of the client:
- the establishment of an individual medical observation post during inpatient treatment;
- the use of drugs that are not essential.
2. The provision of services anonymously.
3. Non-residents, stateless persons who do not have a compulsory medical insurance policy.
4. In case of independent appeal of the insured person, except in cases of emergency, specialized assistance.
Paid services are provided in excess of guaranteed volumes of mandatory medical insurance. The contract sets out the types and volumes of medical care, which is provided on a free basis. Refusal to conclude an agreement does not cause a decrease in the quality or quantity of services provided under the state program.
Voluntary health insurance
To get medical services in excess of the established minimum, you need to apply for a VHI policy. An agreement is drawn up between the client and the insurance company, according to which, in exchange for the premium paid, the insurer agrees to finance the costs of treating the disease or traumatic injuries.
Depending on the form of payment, these types of voluntary medical insurance are distinguished: primary and secondary. In the first case, we are talking about paying for the costs of treatment (that is, the insurer does not receive money on hand). Additionally, insurance provides for payment of procedures that are not included in the compulsory medical insurance (experimental treatment, dental and prosthetics services, treatment of cancer, etc.) and indirect costs (loss of earnings due to disability, parental leave, etc.) .
VHI can be carried out individually or collectively. The second option is more popular all over the world. In this case, the insurer is the enterprise (employer), and the insured person is its employees. In accordance with the contract, citizens can receive medical care in certain circumstances. These types of health insurance in the Russian Federation are voluntary. That is, the policy is purchased at the request of the client, and not necessarily.
Payouts
Tariff rates for VHI are calculated based on medical statistics, basic demographic indicators (life expectancy, mortality), indicators of morbidity and hospitalization. Payment depends on the duration of the contract. For an annual policy, tariffs are calculated based on the insured’s membership in a specific age group. Payments are made from current contributions. Tariffs in long-term contracts take into account not only age, but also demographic factors, statistics of incidence during the term of the contract. Contributions finance current payments and form reserves for future payments.
Tariffs
Health insurance, the purpose, the types of which were considered earlier, are aimed at protecting the property interests of individuals in the event of disability. But VHI is subject to persons whose individual health features differ from average characteristics and the likelihood of disease onset is higher.
Tariff rates for such policies are very differentiated. They are adjusted for such groups depending on the results of a medical examination:
- Group 1 - healthy individuals who have no burdened heredity. There are children's, colds, appendicitis, hernia; without bad habbits; not working in hazardous industries.
- Group 2 - persons with an increased risk of the disease, burdened by heredity of diabetes, cardiovascular, renal and gallstone, mental illness. A history of traumatic brain injury; bad habits; working with harmful production conditions.
- Group 3 - able-bodied persons with chronic diseases; alcohol abusers taking tranquilizers; suffering from neurosis, hypertension, coronary heart disease without angina pectoris.
Tariff rates are differentiated by all these indicators and are calculated separately for each direction.
Violation of rights
All considered types of health insurance operate on the same principles. If one of these facts is revealed, the rights of citizens to receive quality medical care are considered violated:
- Illegal collection of funds by medical staff for assistance in the amounts provided by the state program;
- illegal collection of funds at the cash desk of medical institutions for providing assistance, issuing directions, prescriptions for medicines;
- purchase of drugs and medical devices from the list approved by the programs at the expense of patients;
- non-compliance with the terms of medical care;
- refusal to provide assistance under the compulsory medical insurance.
Detailed information on what types of health insurance are available in a particular region can be obtained from the company, the territorial compulsory health insurance fund, and the Health Committee.
International practice
Availability of healthcare services is a key issue in any country. Priority types of health insurance are largely dependent on historical traditions. In the United States, all types of health insurance are funded through voluntary contributions. Most countries do not have a government funding program. For them, VHI is an urgent need. Elderly and poor people participate in state programs. But all employers pay employers a VHI policy. There is a National Health Service in the UK. VHI policies are designed in such a way that clients can pay for unplanned surgical treatment or improve the quality of medical services. In some countries, types of medical insurance of citizens are being developed on the secondary market, aimed at additional payments that are not covered by the usual policy. In Europe, state support programs are in place. But the most significant source of financing are compulsory insurance policies.