Medical insurance: the nature, purpose and types of medical insurance in the Russian Federation

The demographic situation, the changing priorities of the government in the area of expenditure items of the budget led to an increase in the role of private sources of health financing. In all countries where health insurance is intensively developing, individual products are emerging to protect the lives and health of customers. Russia is no exception. Consider the main types of health insurance in the Russian Federation.

The Essence

It is necessary to distinguish between the terms "insurance medicine" and "medical insurance". In the first case it is a question of a method of financing of sphere of public health services, and in the second - about a kind of activity. Let's consider in more detail the nature and types of health insurance.

This term means a form of social protection of the population in the field of health care. Its purpose is to provide citizens with the opportunity to receive medical care at the expense of accumulated money and to finance preventive procedures. Types of health insurance are mandatory and voluntary protection of the population.

The essence of this process is the transfer of risks associated with the loss of health (temporary or permanent) and compensation for the costs associated with its restoration. The deal with the insurer is formalized by the contract. The object is the risk of receiving expenses incurred in connection with the treatment of the insured person in a medical institution for medical assistance. The amount of the contribution is calculated based on the probability of occurrence of the insured event, the state of the client's health, his age and other factors. Subjects are: citizens, policyholder, medical organization.

The principles of functioning of insurance medicine are fixed at the legislative level:

• Participation of Russians in compulsory health insurance (MHI) programs ;
• The scope and conditions of rendering assistance to the population in the framework of MHI;
• The number of free services provided;
• Participation of citizens of the Republic of Belarus in voluntary insurance (VHI), which covers services in excess of the CHI program;
• Combination of LCA and OMS.

Legal aspect of the issue

The rights of citizens in the field of health are fixed art. 41 of the Constitution of the Russian Federation and the law "On medical insurance in the Russian Federation". These normative acts 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 budgetary funds, insurance premiums and other receipts. Residents and non-residents residing in the territory of the Russian Federation are subject to CHI. That is, health care must meet the need for people to maintain a level of health regardless of their financial possibilities.

Medical insurance: types, differences

On the territory of the Russian Federation, you can draw up a policy of compulsory, voluntary and international medical insurance. All three types differ in the cost, quality and quantity of services provided. The MHI policy is mandatory 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 wishes to receive a volume of services in a larger quantity or better quality, then it acquires an LCA policy. Tourists traveling outside the territory of the Russian Federation are obliged to arrange international insurance for themselves.

OMS

The risk of loss of ability to work refers to risks, the occurrence of which does not depend on a 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 the event of illness to all persons in equal measure. Compulsory health insurance is a type of property protection that provides all citizens, regardless of gender, age and social status, equal opportunities for obtaining 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 funds and institutions that provide services to citizens. The 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.

The MLA is financed by insurance contributions (deductions from the single tax of 3.6%), payments from the budget. In this system, the insured are employers who must enter into contracts for the benefit of workers, entrepreneurs and public administration at all levels.

MHI policy

This document certifies the right of a citizen of the Russian Federation to receive free medical care under the envisaged program. It contains information about the owner of the policy, the number of the contract with the insurance company, a note on the attachment to a particular polyclinic.

You can apply for a policy in any insurance company included in the MHI registry. It operates throughout the territory of the Russian Federation. In the event of a change in the name, residence, data of the document or the detection of any inaccuracies, the policy must be reissued within one month. On the loss of the policy, you must inform the insurance in writing, and then proceed with the replacement procedure.

Service programs

The scope and conditions for obtaining guaranteed assistance are 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 being developed. They indicate the main types of health insurance, the number and quality of services provided, the structure of the tariff, how to pay for assistance. The rights of insured persons to receive CHI are unified throughout the territory of the Russian Federation.

In the framework of the basic program, primary sanitary, preventive, specialized medical care is provided to persons with such diseases:

• Infectious, parasitic (except venereal diseases, tuberculosis and AIDS);
• Oncological, skin, diseases of the endocrine system;
• Malnutrition, work of the nervous, genitourinary system;
• Diseases of the circulatory system;
• Eye, ear and respiratory diseases;
• Injuries;
• Diseases of the musculoskeletal system;
• Congenital anomalies 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 MHIF fund;
• The procedure for providing medical assistance to certain categories of the population;
• Lists of vital medicines and medical products, without which it is impossible to provide medical assistance;
• A list of medicines that are given for free or with a 50% discount;
• List of organizations that participate in the implementation of the program.

The organizations participating in the territorial program can provide paid services:

1. On terms that are different from those stipulated by the program, including at the request of the client:

• Establishment of an individual medical monitoring post for inpatient treatment;
• The use of drugs that are not essential.

2. Provision of services anonymously.

3. Non-residents, stateless persons who do not have a MHI policy.

4. If the insured person independently applies, except for cases of emergency, specialized assistance.

Paid services are provided in excess of the guaranteed amounts of CHI. The contract prescribes the types and volumes of medical care, which is provided free of charge. The refusal to conclude a contract should not be a reason for the reduction in the quality or quantity of services provided within the framework of the state program.

Voluntary health insurance

To get medical services in excess of the established minimum, you need to issue an LCA policy. Between the client and the insurance company, an agreement is made that, in exchange for the premium paid, the insurer undertakes to finance the costs of treating the disease or traumatic injuries.

Depending on the form of payments, these types of voluntary medical insurance are allocated: primary and secondary. In the first case, it is a question of paying for the costs of treatment (that is, the insurer does not receive cash on hand). In addition, insurance provides for the payment of procedures that are not included in the compulsory medical insurance (experimental treatment, dental and prosthetic services, treatment of oncological diseases, etc.), and indirect costs (loss of earnings due to disability, leave for child care, etc.) .

VHI can be carried out individually or collectively. The second option is more popular all over the world. In this case, the insured is the enterprise (the employer), and the insured person is its employees. In accordance with the contract, citizens can receive medical assistance upon the occurrence of certain circumstances. These types of health insurance in the Russian Federation operate on a voluntary basis. That is, the policy is purchased at the request of the client, and not necessarily.

Payments

Tariff rates on VHI are calculated based on medical statistics, basic demographic indicators (life expectancy, mortality), morbidity and hospitalization rates. Payment depends on the duration of the contract. For an annual policy, tariffs are calculated based on the insured's belonging to a particular age group. Payments are made from current contributions. Tariffs in long-term contracts take into account not only age, but also demographic factors, morbidity statistics during the term of the contract. Due to contributions, current payments are financed and reserves for future payments are formed.

Rates

Medical insurance, the purpose, the types of which were considered earlier, are aimed at protecting the property interests of persons in case of disability. But VHI is subject to persons whose individual health characteristics differ from the average characteristics and the probability of the onset of the disease is higher.

Tariff rates for such policies are very differentiated. They are adjusted for such groups depending on the results of the medical examination:

• Group 1 - practically healthy persons, who do not have burdened heredity. There are children's, colds, appendicitis, hernia; without bad habbits; Not working in hazardous industries.
• Group 2 - people with an increased risk of a disease, burdened by hereditary diabetes, cardiovascular, renal and gallstone, mental illness. In the anamnesis there are craniocerebral injuries; There are bad habits; Working with hazardous production conditions.
• Group 3 - able-bodied persons with chronic diseases; Abusing alcoholic drinks, taking tranquilizers; Suffering from neuroses, hypertension, IHD without angina pectoris.

Tariff rates are differentiated for all these indicators and are calculated separately for each direction.

Violations of rights

All the types of health insurance considered operate according to the same principles. If one of these facts is revealed, the citizens' right to receive quality medical care is considered to be violated:

• Illegal collection of medical personnel for providing assistance in the amounts stipulated by the state program;
• Illegal collection of funds to the cash desk of medical institutions for providing assistance, issuing directions, prescriptions for medicines;
• Purchase of drugs and medical products from the list approved by the programs at the expense of patients' funds;
• Non-observance of the terms of granting medical assistance;
• Refusal to provide assistance within the MHI.

Detailed information on what kinds of health insurance are available in a particular region can be obtained from the company, the Territorial MHIF Fund, the Health Committee.

International practice

Accessibility of health care services is a key problem in any country. Priority types of health insurance largely depend on historical traditions. In the United States, all types of health insurance operate through voluntary contributions. In most countries there is no public finance program. For them, VHI is an urgent necessity. Elderly and needy people participate in state programs. But all employers employ employers pay for VHI policies. The National Health Service operates in the UK. VHI policies are formed in such a way that customers can pay for unscheduled surgical treatment or improve the quality of medical services. In some countries, the types of health insurance for citizens are being developed in the secondary market, aimed at additional payments that are not covered by the usual policy. In Europe, there are state support programs. But the most significant source of funding are compulsory insurance policies.