The need for health insurance stems from the main features of the medical services market, one of which is "uncertainty".
For each person, the disease is most often unpredictable, therefore it is impossible to “plan” its onset, and with it the need for financial costs (for medicines, examinations, treatment, for everyday needs in case of disability) is impossible. Moreover, assistance can be very costly and unaffordable if a one-time payment is needed. Insurance can counter the financial burden of unpredictable and uncertain costs. At the same time, people, as a rule, are not insured against ill health, but against future financial costs associated with this.
Health insurance - this is a set of measures for the formation (accumulation) of financial resources (insurance reserves) by insurance institutions at the expense of monetary contributions from enterprises, organizations, the administration of the territory of the corresponding level, personal funds of citizens in order to pay for medical care to insured citizens.
The concept of "insurance medicine" is broader. Taking into account the three classical systems of health care financing discussed above (state, insurance, private), insurance medicine is a system for providing medical, medical, social and preventive care to the population, based on commodity-market relations, where the product is a paid medical service, the producer is a medical institution or a privately practicing medical worker, as a consumer of the service - an insured citizen.
Insurance medicine as a system is an independent structure that has a complex of material, technical, human and financial resources, which it quickly maneuvers in the interests of the most complete and timely implementation contractual obligations to the insured or policyholder.
object health insurance is the property (material, financial) interest of the insured associated with the health and working capacity of the insured persons.
Insurance case in the health insurance system - a specific disease, injury, accident, therapeutic and prophylactic or medico-social benefit, special condition (pregnancy, postpartum period, patient care, etc.) included in the insurance program.
Insurance program- a list of insured events payable from the insurance funds. The insurance program is drawn up on the basis of existing legislative and regulatory acts on health insurance in accordance with agreements concluded between insurance companies and enterprises, insurance organizations and medical institutions (medical workers).
Medical insurance policy - a document certifying the conclusion of a health insurance contract; It is issued by an insurance company. The policy must indicate: full name, gender, age, place of work, address of the insured, as well as the duration of the contract.
Subjects of health insurance - enterprises, organizations, institutions, government structures, citizens interacting during the implementation of insurance.
As health insurance purposes can be called:
1. A guarantee to citizens at the expense of funds accumulated in insurance funds for receiving medical care of a certain quality in the event of an insured event - illness, injury, accident, etc.;
2. A guarantee to the manufacturer of medical care to pay for the costs associated with the provision of medical care to insured citizens.
The set goals can be achieved by solving the following complex health insurance tasks :
Creation of a system of subjects - legal entities legally responsible for the formation of medical and technical conditions to ensure the provision of high-quality medical care to the population;
Decentralization of a rigid system of healthcare management, granting the right to make decisions to healthcare institutions, ensuring from a legal point of view their activities as independent economic entities;
Demonopolization of the state healthcare system, ensuring the participation of medical service providers in the health insurance system, regardless of their form of ownership;
Ensuring legal and socio-economic protection of the interests of consumers of medical services using the institution of qualified intermediaries (insurance companies);
Strengthening and expanding the use of economic methods of management: on the part of the manufacturer - the creation of economic interest in the results of their work, on the part of the consumer - the cultivation of personal responsibility for their health, as well as the creation of conditions of interest in maintaining and strengthening health.
The law "On health insurance of citizens of the RSFSR" was adopted on June 28, 1991, but it turned out to be not entirely efficient, since it did not contain a clear implementation mechanism. Therefore, by the law of April 2, 1993 No. “On Amendments and Additions to the Law of the RSFSR “On Medical Insurance of Citizens in the RSFSR”, amendments were made to the original law of June 28, 1991, which actually marked the beginning of a large-scale development of the medical insurance system.
The law determined two kinds health insurance, each of which has its own principles and financial mechanism for implementation - mandatory and voluntary (comparative analysis is presented in Table 1). According to Art. 1 of the law "On health insurance of citizens in the Russian Federation" compulsory health insurance is an integral part of state social insurance, which provides all citizens of the Russian Federation with equal opportunities to receive medical and drug assistance in the amount and on conditions corresponding to compulsory medical insurance programs. That is, compulsory medical insurance has a state character, is universal and is a form of social protection of the interests of the population in the preservation and restoration of health in the difficult socio-economic conditions of the country's transition to tough market relations. y Main principles of CHI:
The positive aspects of the state health care system remain - free medical care (at the time of receipt) within the CHI program, universality and accessibility;
The principles of "social justice" and "social solidarity" are used, when "the rich pay for the poor", "healthy for the sick" (such principles are incorporated into the health insurance systems of most states with a socially oriented economy);
Due to the high degree of financial risk, this type of insurance is irrevocable;
The choice of a doctor and health care facility by a patient (within the framework of compulsory medical insurance agreements) essentially implies the abolition of the precinct-territorial principle of organizing medical care, and the role of primary medical and social care is significantly increasing.
Voluntary health insurance- allows citizens to receive additional and other services in addition to CHI programs, but at the expense of personal funds of citizens, funds of enterprises, organizations deducted voluntarily from profits.
The principles of DMS include:
The possibility of a collective approach - when insurance is carried out at the expense of enterprises, and an individual approach - when a citizen is insured at the expense of personal funds;
The amounts of insurance premiums are contractual in nature and are established by agreement of the parties;
Insurance is refundable or partially refundable, that is, it is possible to return funds to the insured or the insured.
Compulsory health insurance is one of the most important elements of the system of social protection of the population in terms of protecting health and obtaining the necessary medical care in case of illness. Compulsory (social) insurance originated 110 years ago in Germany and now forms the basis of health care financing in many countries. A compulsory form of health insurance is used, as a rule, in those countries where public health is of great importance. The choice of the form of health insurance depends on the characteristics of the development of health care and the country as a whole. The principle of compulsory health insurance prevails in France, Canada, Germany, the Netherlands.
In Russia, CHI is state and universal for the population. This means that the state, represented by its legislative and executive bodies, determines the basic principles for the organization of compulsory medical insurance, sets the rates of contributions, the circle of insurers, and creates special state funds for contributions to compulsory medical insurance. The universality of compulsory medical insurance is to provide all citizens with equal guaranteed opportunities to receive medical, medicinal and preventive care in the amounts established by government programs OMS.
Compulsory health insurance (CHI) is a form of social protection of the interests of the population in health care, which guarantees citizens, in the event of an insured event, receiving medical care at the expense of accumulated funds, and financing preventive measures established by the Federal Law, within the framework of the basic program of compulsory medical insurance. With paid medicine, this type of insurance is a tool to cover the costs of medical care; with free medicine, it is an additional source of financing medical expenses. With health insurance, the insured person is interested in the possibility of compensating the costs of medical care at the expense of the insurer.
The MHI system has three main tasks (see Appendix I):
1. Ensuring equal opportunities for obtaining medical care for all residents of the territory;
2. Ensuring financial stability;
3. Full insurance coverage of the population Russian Federation.
According to global standards, health insurance covers two groups of risks arising from a disease:
1. the cost of medical services for the restoration of health, rehabilitation and care;
2. loss of labor income caused by the impossibility of carrying out professional activities, both during the illness and after it with the onset of disability.
Medical expenses insurance is damage insurance and protects the client's condition from unexpected expenses.
Like any system, insurance medicine must be based on certain principles. The most important are the following:
1. Health insurance is subject to the entire population: working and non-working. Coverage of insured persons should be comprehensive and universal, including prevention, treatment, rehabilitation.
2. All insured under this program must be provided with equal medical care of the highest level. This means that each type of medical care must be provided on the basis of medical and economic standards, including a certain amount and quality of medical services. Anything that goes beyond the scope of the program must be additionally paid by the patient himself with prior notification.
3. The system of compulsory medical insurance is based on a non-refundable basis. An insured citizen who has an insurance policy has the right to receive medical care in any territory of the country, regardless of the place of residence, as well as the choice of a medical institution and the attending physician (within the medical institutions with which the insurance company has concluded an agreement).
4. Every citizen has the right to voluntary health insurance, even for such medical services that go beyond the established minimum.
5. Insurance medicine is medicine that does not recognize deficits. The patient is guaranteed the provision of highly qualified medical care.
6. Insurance medicine requires high medical culture and professionalism. Each doctor must be licensed and obtain permission for a certain type of activity.
Insurance services in Russia are developing progressively. Most Russians already know what compulsory medical insurance is and are the owners of a medical policy. At the same time, not everyone has complete information about voluntary health insurance and its benefits. Both of these species, with apparent similarity, have a lot of differences (see appendix II).
As in any subject of economic research, in insurance, including medical insurance, there are objects and subjects.
The subjects of health insurance are: a citizen, an insured, an insurance medical organization (insurer), a medical institution.
An insurer is a special organization (state or non-state) in charge of the creation and use of a monetary fund. In health insurance, these are medical insurance organizations - legal entities who carry out health insurance and have the right to engage in health insurance.
Policyholder - a legal or natural person who makes fixed payments to the named fund. In voluntary and compulsory health insurance, policyholders differ. The insurers for compulsory health insurance are: for the non-working population - government bodies of republics, territories, regions, cities, local administrations; for the working population - enterprises, institutions, self-employed persons. Insurers in voluntary medical insurance are individual citizens with civil capacity, or enterprises and organizations representing the interests of citizens.
Medical institutions in the insurance system are licensed medical and preventive treatment institutions (HCIs), research and medical institutes, other institutions providing medical care, as well as persons engaged in medical activities, both individually and collectively.
The object of compulsory medical insurance is the medical services provided for by compulsory medical insurance programs. The object of voluntary medical insurance is the insured risk associated with the costs of providing medical care in the event of an insured event.
Each insured person or insured person, in the manner prescribed by the MHI agreement, is issued by a medical insurance organization an insurance medical policy of compulsory medical insurance. On the territory of the Russian Federation, there is an insurance policy of compulsory medical insurance of a single sample.
An insurance policy is a document that guarantees a person the provision of medical care under compulsory medical insurance or voluntary medical insurance. If a person, for any reason, cannot obtain a policy in person, it can be obtained by another person by a power of attorney certified at the place of residence. If the policy is lost, a duplicate is issued free of charge.
Upon receipt of a policy, citizens are required to familiarize themselves with the CHI program, its conditions, the obligations of insurance companies, medical institutions, their responsibilities, as well as the rights and obligations of citizens to preserve and promote health.
Compulsory health insurance is a form of social protection for citizens in the transition of the country's economy to market relations and is designed to provide affordable and free medical care of a guaranteed volume and quality with the rational use of available health care resources.
CHI funds are state-owned by the Russian Federation.
Medical care within the framework of compulsory medical insurance is provided in accordance with the basic and territorial programs of compulsory medical insurance developed at the level of the Federation as a whole and in the subjects of the Federation. The basic CHI program for Russian citizens contains the main guarantees provided under the CHI.
The composition of the board of the Federal Compulsory Medical Insurance Fund is approved by the legislative authority of the Russian Federation. The composition of the board of the territorial CHI fund is approved by the representative authority of the territory. The chairman of the board is elected by the members of the board of the Federal (territorial) compulsory medical insurance funds.
The board of the Federal (territorial) compulsory medical insurance funds provides for the participation of two representatives of the insurers.
The Board of the Compulsory Medical Insurance Fund operates on a voluntary basis. The insured members of the fund's board participate in determining the directions for the development of compulsory medical insurance in the territory of a constituent entity of the Russian Federation and control the correct use of compulsory medical insurance funds.
Health insurance is a form of social protection of the population's interests in health protection. The purpose of health insurance is to guarantee citizens, in the event of an insured event, receiving medical care at the expense of accumulated funds and to finance preventive measures.
There are two types of health insurance: compulsory and voluntary.
Compulsory medical insurance is an integral part of the state social insurance and provides all citizens of the Russian Federation with equal opportunities to receive medical and drug assistance provided at the expense of compulsory medical insurance in the amount and on conditions corresponding to compulsory medical insurance programs. Therefore, the system of compulsory medical insurance should be considered from two sides: on the one hand, it is an integral part of the state system of social protection along with pension and social insurance, on the other hand, it is a financial mechanism for providing additional funds to the budget allocations for financing health care and paying for medical services.
Voluntary medical insurance is carried out on the basis of voluntary medical insurance programs and provides citizens with additional and other medical services in excess of those established by compulsory medical insurance programs. Voluntary health insurance can be collective and individual. Voluntary health insurance is an important addition to the system of public health and compulsory health insurance. The main purpose of voluntary medical insurance is to compensate insured citizens for financial expenses and losses associated with illness or injury that are not covered by state or compulsory insurance medicine.
The subjects of health insurance are:
- - citizen;
- - the insured;
- - insurance medical organization;
- - medical institution.
The insurers under compulsory health insurance are:
- - for the non-working population - government bodies of regions, cities, local administration;
- - for the working population - enterprises, institutions, organizations, self-employed persons and freelancers (hereinafter referred to as enterprises).
The insurers in case of voluntary medical insurance are individual citizens with legal capacity and/or enterprises representing the interests of citizens.
Insurance medical organizations are legal entities that provide medical insurance and have a state permit (license) to engage in medical insurance. Medical institutions in the health insurance system are licensed medical and preventive institutions, research and medical institutes, as well as persons engaged in medical activities both individually and collectively.
The object of voluntary medical insurance is the insured risk associated with the cost of medical care in the event of an insured event.
Medical insurance is carried out in the form of an agreement concluded between the subjects of medical insurance. Subjects of health insurance fulfill obligations under the concluded contract in accordance with the legislation of the Russian Federation.
A medical insurance contract is an agreement between the insured and the insurance medical organization, according to which the latter undertakes to organize and finance the provision of medical care of a certain volume and quality or other services to the insured contingent under compulsory and voluntary medical insurance programs.
Each citizen in respect of whom a medical insurance contract has been concluded or who has concluded such an agreement on his own, receives an insurance medical policy, which is constantly in his hands.
The insurance medical 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 agreements on medical insurance of citizens.
In the health insurance system, citizens of the Russian Federation have the right to:
- - obligatory and voluntary medical insurance;
- - choice of medical insurance organization;
- - the choice of a medical institution and a doctor in accordance with the contracts of compulsory and voluntary medical insurance;
- - receiving medical care throughout the Russian Federation, including outside the permanent place of residence;
- - receipt of medical services corresponding in volume and quality to the terms of the contract, regardless of the amount of the actually paid insurance premium;
- - filing a claim against the insured, medical insurance organization, medical institution, including for material compensation for damage caused through their fault, regardless of whether this is provided for in the medical insurance contract or not;
- - refund of a part of insurance premiums for voluntary medical insurance, if it is determined by the terms of the contract.
On the territory of the Russian Federation, stateless persons have the same rights and obligations in the health insurance system as citizens of the Russian Federation.
Medical institutions, in accordance with the legislation of the Russian Federation and the terms of the contract, are responsible for the volume and quality of the medical services provided and for the refusal to provide medical assistance to the insured party. In case of violation by the medical institution of the terms of the contract, the insurance medical organization has the right to partially or completely not reimburse the costs of providing medical services.
For an unreasonable refusal to conclude a compulsory medical insurance contract, a medical insurance organization may be deprived of a license for the right to engage in medical insurance by a court decision.
In the health insurance system, the insured has the right to:
- - participation in all types of health insurance;
- - free choice of insurance company;
- - control over the fulfillment of the terms of the medical insurance contract;
- - repayment of a part of insurance premiums from an insurance medical organization in case of voluntary medical insurance in accordance with the terms of the contract.
Compulsory health insurance is part of the state social insurance system. Compulsory medical insurance contract is an agreement according to which insured citizens have the right to receive medical services. The list and volume of such services are established by the territorial programs of compulsory medical insurance in medical institutions included in the system of compulsory medical insurance.
Compulsory health insurance is regulated by the Law "On Health Insurance of Citizens in the Russian Federation" and is based on the following organizational, legal and economic principles:
- - universality, i.e. all citizens of the Russian Federation, regardless of gender, age, state of health, level of personal income, have the right to receive medical services;
- - statehood, i.e. funds of compulsory medical insurance are state-owned by the Russian Federation, they are managed by the Federal and territorial funds of compulsory medical insurance, specialized insurance organizations;
- - non-commercial nature, i.e. insurance medical organizations, in accordance with the requirements of the law, carry out activities on compulsory medical insurance on a non-commercial basis, therefore, all profits from compulsory medical insurance operations are directed to replenish the financial reserves of the compulsory medical insurance system.
Implementation public policy in the field of compulsory medical insurance, the Federal and territorial funds of compulsory medical insurance are implemented.
The compulsory health insurance contract is concluded between the insured - the employer or the body state power and the insurer on insurance of the working or non-working population, respectively.
Persons insured under a compulsory health insurance contract are individuals in whose favor an insurance contract has been concluded, i.e. all citizens of the Russian Federation, as well as Foreign citizens permanently residing in Russia. Insured citizens are required to have a compulsory medical insurance policy, which is nominal, it must indicate the insurance medical organization and medical institutions in which the insured person has the right to receive medical care.
Model of health insurance as a basis for the development of the health care system. Purpose and principles of health insurance. Types of health insurance. Objects and subjects of compulsory medical insurance (CHI) and voluntary medical insurance (VHI). The program of state guarantees for providing citizens of the Russian Federation with medical care.
The main sources of financing of health care institutions.
The purpose and objectives of the state policy in health care.
At the heart of the Russian healthcare reform is the idea of transition to a model of health insurance. Health insurance is a type of social insurance, a form of social protection of the interests of the population in the protection of health.
The purpose of health insurance is to provide a guarantee to citizens in the event of an insured event, receiving medical care at the expense of accumulated funds and financing measures to prevent diseases. Health insurance is carried out in two forms: compulsory and voluntary.
Compulsory health insurance (CHI) - state social insurance providing all citizens with equal opportunities to receive medical and pharmaceutical assistance provided at the expense of compulsory medical insurance in the amount and on conditions corresponding to compulsory medical insurance programs. Voluntary medical insurance (VHI) provides citizens with additional medical or other services in excess of those established by compulsory medical insurance programs.
The object of medical insurance is the insured risk associated with the costs of providing medical care in the event of an insured event (illness, injury, poisoning) for individual citizens. The subjects of insurance are: citizen, policyholder, insurer, medical organization. The insured under compulsory health insurance in the Russian Federation are:
For the working population - enterprises, institutions, organizations, persons involved in ITD, i.e. employers;
For the non-working population - bodies of state power and local self-government. Insurers under VHI are individual citizens with civil capacity and (or) enterprises and organizations that represent the interests of citizens.
The insurers are insurance organizations - legal entities that provide medical insurance and have a state permit (license) for the right to engage in medical insurance. Medical institutions in the health insurance system are licensed medical institutions providing medical care, as well as individuals providing medical care individually.
Health insurance can be carried out according to the principle of solidarity and according to the accumulative principle. The principle of solidarity implies the responsibility and costs of the whole society for the protection of the health of each individual. When it is implemented, insurance premiums are accumulated in special state funds. The state is responsible for the collection and spending of these funds, while ensuring the territorial alignment of both the possibilities for using the financial resources of insurance, and the volume and quality of medical care provided. Insurance premiums in this case are non-refundable. The accumulative principle of health insurance implies the responsibility of each citizen for the amount of insurance funds accumulated in his personal account (personification of insurance). This principle provides for personal accounting of insurance savings, their inheritance, payment of insured events in amounts exceeding the savings, payment (in the absence of insured events) of insurance premiums formed from funds unused for a certain period of time.
The insurance premium for compulsory health insurance is set as a percentage of the accrued wages. In the Russian Federation, the insurance premium rate since 01/01/2005 is 2.8% of the wage fund. Each citizen in respect of whom a medical insurance contract has been concluded or who concludes such an agreement independently receives an insurance medical policy.
The fundamental principle of compulsory medical insurance (CMI) is the possibility of providing free and accessible medical care to the patient within the framework of compulsory medical insurance programs. The existing federal and the territorial CHI programs developed on its basis determine the list of diseases and morbid conditions, the diagnosis and treatment of which is carried out at the expense of the CHI. This list includes most of the existing acute and chronic diseases and conditions. In addition, such areas of medicine as psychiatry, the provision of anti-tuberculosis, emergency medical care, sanitary and anti-epidemic activities, the operation of blood transfusion stations and some others are provided by law and are financed from budgets at various levels. Currently, one of the main problems is the creation of a financial mechanism in health care.
Financial mechanism in healthcare- this is a system of interaction of elements, expressed in planning, organizing and stimulating financial resources. The CHI system is an integral part of health care, which in turn is part of the national financial system RF, therefore, all sources from which funds are received can be divided into two groups:
1. Centralized sources:
- Income from different levels budget system RF;
- Federal CHI Fund; territorial CHI Funds;
- State loans, loans, etc.
2. Decentralized sources:
- Funds of enterprises aimed at financing medical institutions;
- Funds of voluntary medical insurance;
- Funds from the provision of paid medical services;
- Investment income (deposits, government securities, etc.)
Medical insurance in the Russian Federation- a form of social protection of the interests of the population in the protection of health. 5
In the Conditions for Licensing Insurance Activities on the Territory of the Russian Federation health insurance concept is defined as “a set of types of insurance that provide for the obligations of the insurer to make insurance payments (payments of insurance coverage) in the amount of partial or full compensation for the additional expenses of the insured person caused by the insured person applying to medical institutions for medical services included in the health insurance program”.
Purpose of health insurance is to guarantee citizens of the Russian Federation in the event of an insured event receiving medical care at the expense of accumulated funds and to finance preventive measures. 6
On the territory of the Russian Federation, stateless persons or foreign citizens permanently residing in Russia have the same rights and obligations in the health insurance system as citizens of the Russian Federation.
Medical insurance on the territory of the Russian Federation is carried out in two types: mandatory and voluntary. Compulsory insurance is carried out by virtue of law, and voluntary insurance is carried out on the basis of an agreement concluded between the insured and the insurer. Each of these forms of insurance has its own characteristics.
Differences between compulsory medical insurance (CMI) and voluntary medical insurance (VHI) are as follows:
1. The obligation of insurance under CHI follows from the law, and under VMI - is based only on contractual relations, which, however, does not exclude the need for CHI by concluding an insurance contract between the insured and the insurer (Article 936 of the Civil Code of the Russian Federation, part 2).
2. The main difference between compulsory medical insurance and voluntary medical insurance lies in the sphere of relations that arise between their subjects in the provision of medical care at the expense of insurance funds. If CHI is carried out in order to ensure the social interests of citizens, employers and the interests of the state, then VHI is implemented only in order to ensure the social interests of citizens (individual or collective) and employers.
3. From the previous difference follows, in particular, the difference in who are the insurers under CHI and VHI: under CHI - these are executive authorities and employers, with CHI - citizens and employers.
4. Relations under VHI, like CHI, relate to social insurance, which aims to organize and finance the provision of medical care to the insured contingent of a certain volume and quality, but under VHI programs (Table 3.1).
Table 3.1 The main differences between VHI and CHI systems
|
VOLUNTARY HEALTH INSURANCE |
MANDATORY HEALTH INSURANCE |
|
A type of financial and commercial activity related to personal insurance. |
Part of the state social insurance system. |
|
Individual and collective voluntary insurance. |
General compulsory insurance. |
|
Insurers - legal entities and individuals. |
Insurers - employers, the state (local and executive authorities). |
|
It is carried out at the expense of insurance premiums of employers or personal funds of citizens. |
For the working population, it is carried out at the expense of contributions deducted by enterprises without fail. For the non-working population, it is carried out at the expense of the relevant budgets of the bodies state administration and local administration. |
|
The insurance program (list of services) is determined by the agreement between the insurer and the Insured. Provides citizens with an additional volume of medical services in excess of those established by compulsory medical insurance programs. |
The insurance program (guaranteed minimum of services) is determined by the Territorial Compulsory Medical Insurance Funds and approved by the state authorities of the subject of the Federation, the Federal Compulsory Medical Insurance Fund. Provides all citizens of the Russian Federation with equal opportunities to receive medical care. |
5. As a result of the foregoing, pursuing common goals and having a common object of insurance - CHI and VHI differ significantly in insurance subjects - they have different not only insurers, but also insurers. For VHI, these are non-governmental organizations that have any organizational and legal form, for OMS, they are state organizations.
6. MHI and VHI also differ in terms of sources of funds. VHI has personal income of citizens or income of organizations, CHI has fees and taxes.
Many differences can be listed, for example, in terms of legal regulation mechanisms, but only the most basic ones were listed.
Medical insurance in the Russian Federation is regulated:
Civil Code of the Russian Federation, part II of 26.01.1996. (as amended on 02.02.2006);
Tax Code of the Russian Federation (part two) (as amended on December 31, 2001);
Law "On the organization of insurance business in the Russian Federation" dated 27.11.97. (as amended on July 21, 2005);
Law "On health insurance of citizens in the Russian Federation" dated June 28, 1991 (as amended on December 23, 2003);
"Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens" dated 02.02.2006;
other special regulations.
Compulsory health insurance
In compulsory health insurance, its main subjects include:
Insured, or citizen;
Insurance medical organization (insurer);
Medical institutions;
Policyholder;
Federal and Territorial CHI funds.
To insured persons includes persons in whose favor health insurance is provided. Such persons, for example in Russia, are citizens of the Russian Federation, both working and not working, as well as foreign citizens and stateless persons working under labor contracts, persons who independently provide themselves with work. In the event of an insured event, they are provided with medical services at the expense of insurance funds.
Currently in OMS insurers are insurance medical organizations (SMO) , which act as legal entities providing health insurance and having a state permit (license) for the right to engage in health insurance. They are independent business entities of any form of ownership.
The insurance medical organization performs: settlements and payment for medical services to medical institutions, organization of direct control over the volume and quality of medical care, protection of the rights and interests of its customers, ensures the issuance and accounting of insurance policies.
Participants of the insurance process in the CHI system are also medical institutions . Such in the CHI system are licensed medical institutions, research and medical institutes, other institutions providing medical care, as well as persons engaged in medical activities, both individually and collectively.
Policyholders there may be individual citizens who pay insurance premiums from personal earnings to compulsory medical insurance funds. This applies both to employees and to other categories of the population (self-employed, individual entrepreneurs, etc.). In this case, the insured and the insured are combined in one person.
The state also acts as an insurer. It performs this role, firstly, by making contributions for employees of state-owned enterprises, and secondly, it acts as a payer of insurance premiums for the non-working population.
Federal Compulsory Medical Insurance Fund (FFOMS) is an independent state non-profit financial and credit institution, accountable to the federal government. The fund's budget and report on its execution are annually approved by the Federal Assembly of the Russian Federation.
The financial resources of the fund are formed by:
Unified social tax in terms of unified social tax funds in the amount of 1.1% of the wage fund;
Contributions of territorial CHI funds for the implementation of joint programs;
Appropriations from the federal budget for the implementation of republican compulsory medical insurance programs;
Income from the use of temporarily free funds of the fund by placing these funds on bank deposits and in highly liquid government securities.
To functions of the Federal FundCHI relate:
Alignment of the conditions for the activities of the territorial funds of compulsory medical insurance to ensure financing of compulsory medical insurance through the provision of financial assistance;
Financing of targeted programs within the framework of CHI;
Approval of model rules for compulsory medical insurance of citizens;
Development of regulatory documents;
Participation in the development of the basic CHI program for the entire territory of the Russian Federation;
Participation in the organization of territorial CHI funds;
International cooperation in the field of health insurance;
Implementation of financial and credit activities to fulfill the tasks of financing CHI;
Carrying out research work and training of specialists for CHI.
Territorial Compulsory Medical Insurance Fund (TFOMS) are created in the territories of the constituent entities of the Russian Federation, are independent state non-profit financial and credit institutions and are accountable to the relevant bodies of representative and executive power. The financial resources of the TFOMS are state-owned, are not included in budgets, other funds, and are not subject to withdrawal. They are formed by:
Unified social tax in terms of compulsory medical insurance in the amount of 2.0% of the wage fund;
funds provided in the budgets of the constituent entities of the Russian Federation for compulsory medical insurance of the non-working population (there is no tariff or standard);
income received from the use of temporarily free funds by investing them in bank deposits and government securities;
funds collected as a result of the presentation of recourse claims against insurers, medical institutions and other entities;
funds received from the application of financial sanctions against policyholders for violating the procedure for paying insurance premiums.
The main task of the Territorial CHI Funds is to ensure the implementation of CHI in each territory of the constituent entities of the Russian Federation on the principles of universality and social justice. The TFOMS is entrusted with the main work to ensure the financial balance and sustainability of the compulsory medical insurance system.
Contribution payers - insurers (employers, local administrations) conclude medical insurance contracts with insurance medical organizations. An insurance medical organization enters into contracts with medical institutions chosen by it for the provision of medical services to its insured. If the insurance organization has: a) a license, b) contracts concluded with insurers of the working and (or) non-working population, and c) contracts with service providers (medical institutions). The Territorial Compulsory Medical Insurance Fund transfers to it, on the basis of a trust management agreement, funds in an amount proportional to the number of insured citizens.
Thus, a system of interrelated contracts is formed, concluded in the interests and in favor of the insured citizens: policyholders<=>CMO,CMO<=>Territorial Fund, CMO<=>memedical institutions.
According to basic CHI program RF citizens are guaranteed:
Provision of primary health care, including emergency medical care;
Diagnosis and treatment on an outpatient basis (including emergency and first aid);
Implementation of disease prevention measures;
Stationary help.
The volume and conditions of drug assistance are determined by the territorial CHI programs. Payment for the necessary medicines and medical products in a hospital and in the provision of emergency and emergency medical care is carried out at the expense of insurance premiums for compulsory medical insurance, and in outpatient clinics - at the expense of citizens' personal funds.
In accordance with the standard MHI agreement, the insurer assumes payment for medical and other services provided to citizens in the amount determined by the insurance program; issues to each insured person an insurance medical policy (identification card) of the established form with an insurance program attached to it and a list of medical institutions that will provide the services specified in the program. The medical insurance policy is valid throughout the territory of the Russian Federation. The maximum liability of the insurer for individual risk (the cost of medical care provided to a specific person during the term of the contract) is not determined.
If it is impossible to provide the insured with assistance properly and in the scope of compulsory medical insurance programs, the medical institution is obliged at its own expense to provide the patient with the required assistance in another institution with notification of this to the medical insurance organization.
If it is necessary to provide a patient with a medical service for which this institution does not have a license, it is obliged to organize the transfer of the patient at the expense of the insurer to another institution that has the appropriate license.
Voluntary health insurance
Law of the Russian Federation "On health insurance of citizens in the Russian Federation" as an object of voluntary medical insurance determines the risk associated with the costs of providing medical care in the event of an insured event. At the same time, the Law states that voluntary health insurance “provides citizens with additional medical services and other services in excess of those established by compulsory insurance programs.”
VMI objects There are two groups of insurance risks:
1) the occurrence of expenses for medical services for the restoration of health, rehabilitation, care;
2) loss of income due to the impossibility of carrying out labor activity, both during the illness and after - in the event of disability.
Thus, the legislation of the Russian Federation limited the object of medical insurance only to reimbursement of costs for medical care.
From an economic point of view, VHI is a mechanism for compensating citizens for the costs and losses associated with the onset of insured event - (in VHI) the insured person's appeal to a medical institution (doctor) for medical assistance. An insured event is considered settled when, for medical reasons, the need for further treatment disappears.
With VMI, the insurer does not make cash payments directly to the insured or to a person designated by him (as in property insurance), but only pays for the services of medical organizations.
Policyholders Voluntary health insurance is provided by individual citizens with legal capacity and/or enterprises representing the interests of citizens.
In accordance with the law, VHI can be engaged in both specialized medical insurance companies and companies licensed to carry out various types of insurance, including medical insurance. The mechanism for implementing the Russian model of voluntary health insurance is shown in the figure in Appendix 12.
Insurance companies operating in the voluntary market health insurance, can be divided into three groups.
First group : subsidiaries of large financial and industrial holdings. Their main task is to organize medical care for the parent structure and its affiliated companies. As a rule, these insurers operate in the regions, in accordance with the geography of the business of the founders. They also offer their services to their partners and other businesses operating in these regions. Often, these companies resort to return insurance, when part of the insurance premiums unspent on the provision of medical services, at the end of the contract, the insurer returns to the current account of the insured.
Almost all leaders can be attributed to the first group: Gazprommedstrakh and Sogaz (established by Gazprom), insurance company Siberia, which has partnership relations with NK Slavneft, and members of the LUKOIL insurance group, the companies Medved LK and LUKOIL ”, insurance companies Progress-Garant (NK Yukos), Interros-Consent (Interros holding), Energogarant, which traditionally insures regional energy enterprises and companies close to the electric power industry. Among the listed insurers, Interros-Accord, Progress-Garant and Sibir operate on the Moscow risk VMI market.
second group represent companies operating in the MHI system and building their marketing policy on its basis. A well-known name for potential insurers, the ability to coordinate financial flows through the CHI and VHI channels, as well as established relationships with leading polyclinics and hospitals, allow these insurers to occupy leading positions in VHI as well. First of all, MAKS, ROSNO and Spasskiye Vorota can be attributed to the number of such companies.
Third group - These are companies focused exclusively on the market clientele. They work only with those clients who managed to attract competent marketing. In each of these companies, you can buy any of the insurance programs on the market that provide outpatient, inpatient or rehabilitation treatment. Among such insurers are the leading Russian universal insurance companies: Ingosstrakh, RESO-Garantiya, Renaissance Insurance, etc.
Insurance companies implement VHI programs on the basis of contracts for the provision of medical care, which they conclude with medical institutions regardless of their form of ownership or with private practitioners. At the same time, any medical, social and health organizations (institutions) that have licenses for the right to engage in medical activities can be involved on a contractual basis, with the establishment of payment for specific medical services. Tariffs for medical and other services under VHI are approved by agreement between the medical insurance company and the medical institution.
Treatment-and-prophylactic establishments, as well as under CHI, in accordance with the contract, bear administrative, economic and other types of responsibility established by Russian legislation for the timing, volume and quality of the medical services they provide. In case of non-compliance by a medical institution or other medical organization with medical and economic standards, the insurance organization has the right not to partially or completely pay the cost of medical services.
The rules of voluntary medical insurance are developed by insurers individually, approved by the insurance supervisory authority (FSIS) and are an indispensable condition when concluding VHI agreements.
If the VMI Rules characterize the economic and legal aspects of the types of health insurance offered by the insurer, then etc VHI programs contain:
List of medical services included in the insurance coverage;
The scale of sums insured within which an insurance contract can be concluded;
Limits of liability of the insurer by types of medical services;
Options indicating the size of the additional insurance premium;
Scale of insurance premiums corresponding to the scale of sums insured;
List of medical institutions serving this program;
period of insurance.
Depending on the insurance coverage distinguish:
Full medical expenses insurance;
Partial medical expenses insurance;
Cost insurance for only one risk.
Comprehensive health insurance provides a guarantee to cover the costs of both outpatient and inpatient care. Unlike full insurance, partial insurance covers the costs of either outpatient treatment, or inpatient or specialized treatment (dentistry, spa treatment, etc.) at the choice of the insured.
By types of applied insurance rates health insurance is classified as follows:
Full (combined) tariff;
According to the tariff with the insured's own participation;
at the rate with the limit of liability of the insurer;
Full rate insurance involves the payment by the insured of a premium to guarantee coverage of all outpatient and / or inpatient treatment costs, including additional payment for selected options.
Insurance based on the principle of own participation of the insured involves a deductible, depending on which medical expenses are covered either starting from the amount specified in the contract, or in each insured event, the insured independently pays the part of the treatment costs agreed with the insurer.
Liability Limit Tariffs allow the insurer to limit its participation in the coverage of the insured's medical expenses to the amount for which the insured is able to pay the premium and which corresponds to his needs. Leemit responsibility can be installed in three ways:
The amount of insurance coverage for the year is agreed upon, within which the insurer pays the medical expenses of the insured;
Coverage limits are set for certain types of medical services;
The share of participation of the insurer in covering the medical expenses of the insured is determined.
Full VHI coverage guarantees the payment of the following expenses:
costs associated with outpatient treatment, including: medical care (doctor visits, examinations, specialist consultations, outpatient surgeries); laboratory tests and diagnostics; medicines; medicinal products of a different nature (physiotherapy, massage, optics, prostheses, devices for analysis, cardiac stimulation, wheelchairs, etc.);
costs associated with inpatient treatment: medical care, including operations, transportation to the clinic, hospital stay, diagnostic costs, medicines and other medical products.
costs for dental services.
The VHI insurance rules, similarly to other types of insurance, provide standard set of exceptions from insurance coverage I . The insurance payment is not made by the insurer if:
The disease was the result of an accident due to military operations or military service;
The disease has occurred as a result of the intentional actions of the insured;
The treatment was carried out by methods not recognized by official medicine or in clinics that do not have official accreditation or license;
The illness or injury was the result of an attempted suicide;
The disease or injury was the result of alcohol, drugs or toxic intoxication.
In Russia, standard VHI insurance programs that include the above combinations of medical services (or risks) can be:
With the possibility of free visits by the insured to any medical institution from all included in the program (the so-called network service);
With visits to medical facilities included in the network service program, only with the referral of a “personal doctor”;
Attached to a specific medical institution (the so-called managed care program).
According to article 255 Tax Code of the Russian Federation (Chapter 25), which entered into force on January 1, 2002, insurance premiums for voluntary medical insurance of employees can be excluded from the tax base for income tax (included in the cost of products, works, services) within 3% of the amount of labor costs at the enterprise.
Based on the Tax Code of the Russian Federation (part two), art. 238, p. 7 "the unified social tax is not charged on the insurance premium paid under a voluntary medical insurance contract."
In accordance with paragraph 5 of Article 213 of the Tax Code, when determining the tax base for income tax individuals the amounts of insurance premiums under voluntary medical insurance contracts, which provide for the payment by insurers of medical expenses of insured individuals, provided that there are no payments to insured individuals, are not taken into account.