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Health insurance is the main regulatory act. Concept, features and legal regulation of health insurance. What does he look like

State guarantees of free medical care to citizens, approved by the Government of the Russian Federation.

2. The basic compulsory medical insurance program determines the types of medical care (including a list of types of high-tech medical care, which includes treatment methods), a list of insured events, the structure of the tariff for payment of medical care, methods of payment for medical care provided to insured persons under compulsory medical insurance insurance in the Russian Federation at the expense of compulsory health insurance, as well as criteria for the availability and quality of medical care.

3. The basic compulsory medical insurance program establishes requirements for the conditions for the provision of medical care, standards for the volume of medical care provided per one insured person, standards for financial costs per unit of volume of medical care, standards for financial support of the basic compulsory health insurance program per one the insured person, as well as calculation of the increase in cost of the basic compulsory health insurance program. The standards of financial costs per unit of volume of medical care specified in this part are also established according to the list of types of high-tech medical care, which also contains treatment methods.

(see text in the previous edition)

4. Insurance coverage in accordance with the basic compulsory medical insurance program is established on the basis of the standards of medical care and procedures for the provision of medical care established by the authorized federal executive body.

5. The rights of insured persons to free medical care established by the basic compulsory health insurance program are uniform throughout the Russian Federation.

6. Within the framework of the basic compulsory health insurance program, primary health care is provided, including preventive care, emergency medical care (with the exception of air ambulance evacuation carried out by aircraft), specialized medical care, including high-tech medical care, in the following cases :

(see text in the previous edition)

2) neoplasms;

3) diseases of the endocrine system;

4) eating disorders and metabolic disorders;

5) diseases of the nervous system;

6) diseases of the blood, hematopoietic organs;

7) certain disorders involving the immune mechanism;

8) diseases of the eye and its adnexa;

9) diseases of the ear and mastoid process;

10) diseases of the circulatory system;

11) respiratory diseases;

12) diseases of the digestive system;

13) diseases of the genitourinary system;

14) diseases of the skin and subcutaneous tissue;

15) diseases of the musculoskeletal system and connective tissue;

16) injuries, poisoning and some other consequences of external causes;

17) congenital anomalies (developmental defects);

18) deformations and chromosomal disorders;

19) pregnancy, childbirth, the postpartum period and abortions;

20) certain conditions that arise in children during the perinatal period.

7. The structure of the tariff for payment of medical care includes the cost of wages, wage accruals, other payments, the purchase of medicines, consumables, food, soft equipment, medical instruments, reagents and chemicals, other supplies, expenses for payment for the cost of laboratory and instrumental studies carried out in other institutions (in the absence of a laboratory and diagnostic equipment in the medical organization), catering (in the absence of organized catering in the medical organization), expenses for payment for communication services, transport services, utilities, works and services for the maintenance of property, expenses for rent for the use of property, payment for software and other services, social security for employees of medical organizations established by the legislation of the Russian Federation, other expenses, expenses for the acquisition of fixed assets (equipment, production and household inventory) worth up to one hundred thousand rubles per unit.

Compulsory health insurance in the Russian Federation is a system that is aimed at protecting the health of the population. An essential task is to ensure that citizens receive guaranteed free medical services in situations where an insured event occurs.

The objects here are the risks included in the insurance, which entail costs as a result of a person applying for the necessary services.

System participants include:

  • . insurers;
  • . individuals who have entered into an agreement and have a special-type policy;
  • . medical institutions that have the appropriate license, which gives the right to carry out a certain type of activity;
  • various compulsory medical insurance funds.

There are two programs that determine the amount and conditions for the provision of medical care as part of free services.

  • Basic program . Forms a list of cases, determines the methods by which payment can be made through the use of compulsory insurance funds. In addition, this includes the formation of criteria that determine the level of quality and accessibility of the services provided.
  • Territorial . It is a component that provides guarantees for receiving medical care free of charge exclusively within the territory of the constituent entity of the Russian Federation in the amount established by the program.

Compulsory medical insurance funds

Special funds play a significant role in compulsory medical insurance. They regulate and finance the costs associated with providing health care to the insured population.
The main tasks are:

  • control over the proper and correct use of compulsory health insurance funds;
  • formation of target programs included in the Compulsory Medical Insurance Fund.

The budget of compulsory health insurance funds is formed thanks to:

  • allocations from the state budget;
  • payments made by enterprises;
  • voluntary contributions;
  • income from the turnover of temporarily available funds of the Federal Compulsory Medical Insurance Fund.

Compulsory health insurance contributions for the working population are paid directly by employers on a monthly basis according to the established interest rate.

For compulsory medical insurance of the population who is temporarily and permanently unable to work, payments to the funds are made at the place of residence by bodies that are part of the executive branch.

Commercial insurance companies are direct participants in compulsory insurance. They have the right to carry out insurance activities only if they have the appropriate license. Their responsibilities include concluding agreements with medical institutions to provide free assistance to their clients, issuing compulsory health insurance policies, and monitoring the quality and timing of services.

Insured citizens turn for help directly to a medical institution. In this case, it is necessary to have a policy of the established form with you.

A compulsory health insurance policy is a document that confirms the right of an insured citizen to receive free services on the territory of the Russian Federation to the extent provided for by the basic compulsory medical insurance program.

It must indicate the personal data of the owner, the validity period and number of the insurance contract, a note about which clinic the insured person is attached to, and contact details of the insurer. The policy gives the owner the right to receive free care in all medical institutions included in the compulsory medical insurance register.

According to Federal Law No. 326, every citizen has the right to choose an insurance company where he can receive a compulsory medical insurance policy.

Re-issue of the policy is provided in cases where:

  • the name of the insured person, his place of residence, in passport data, date or place of birth are changed;
  • Errors have been identified in the information provided.

In this case, within a month from the moment the changes occur, the citizen must inform the relevant company about this fact and provide documents confirming it.

When changing the place of residence, if there is no insurance company to which the citizen belongs, an application for a change of organization is submitted to any office operating in the given region.

A duplicate policy is issued only if there is an application from the insured under the following circumstances:

  • the policy has become unusable (some parts of it have been lost, faded text, tears and other damage);
  • the document was lost.

Currently, there are three types of compulsory medical insurance policy:

  • a plastic card;
  • A5 sheet;
  • an electronic application with a number that is applied to a universal electronic card.

Law of the Russian Federation No. 326

Today, the activities of compulsory health insurance are regulated by No. 326-FZ “On Compulsory Health Insurance in the Russian Federation”. Its main function is to control all persons operating in the compulsory medical insurance system. In addition, his responsibilities include determining the legal provisions of objects and subjects included in the compulsory health insurance system.

Other regulations and acts of the regions also control the relationships of all participants in the system. For each insured event that occurs, its own individual procedure for its consideration is used.

Each institution has its own legal department, which monitors compliance with the provisions of this law.

Local government bodies and local government officials, on issues within their jurisdiction, adopt (issue) legal acts.

The legal nature of this type of legal acts is determined by the essence and purpose of local self-government in the Russian Federation, as a territorial-local organization of citizens of the Russian Federation in urban and rural settlements for independent, under their own responsibility, resolution of issues of local importance, both directly and through local government bodies. Based on this. legal acts of compulsory health insurance and local government officials are local in nature, that is, their legal force cannot extend beyond the boundaries of specific municipalities, and their content is only issues of local importance.

Secondly, legal acts of local self-government bodies and local government officials are of a subordinate nature, that is, their publication and content must fully comply with and not contradict the Constitution of the Russian Federation,

federal laws, constitutions, charters and laws of the relevant constituent entities of the Russian Federation.

Federal Law No. 154 will define acts adopted by local self-government bodies and local government officials as legal, that is, having a generally binding nature on the territory of the municipality, the failure or improper execution of which entails the use of state coercive measures.

The name and types of legal acts of local self-government bodies, elected and other local government officials, the powers to issue them, the procedure for their adoption and entry into force are determined by the Charter of the municipality in accordance with the laws of the constituent entities of the Russian Federation.

What types of legal acts are issued by local self-government bodies and local government officials? The most typical are the following:

Decisions made by representative 0\1(“ in a collegial manner. Decisions made by representative local self-government bodies are, as a rule, normative and legal in nature, that is, they establish certain rules of conduct for subjects of municipal law on the territory of the corresponding municipality. As is known, one of The exclusive powers of the representative compulsory medical insurance in accordance with Article 15, paragraph 3 of Federal Law No. 154 are<принятие общеобязательных прав по предметам ведения муниципального образования, предусмотренных Уставом муниципального образования>. Decisions of the representative compulsory medical council are made in

in accordance with a rather complex procedure enshrined in the regulations of representative compulsory medical insurances;

Resolutions and orders of the head of the municipality, which the latter adopts on the basis of the principle of unity of command. These legal acts in the hierarchy of local acts, from the point of view of legal force, occupy a place below the decisions of the representative compulsory medical insurance. They must be issued by the head of the municipality, firstly, within the framework of his competence, that is, only on those issues that are assigned to his jurisdiction by the Charter of the municipality, and, secondly, not only do not contradict the legislation of the Russian Federation and the constituent entities of the Russian Federation, but also The charter of the municipality and regulatory decisions of the representative local self-government body. Why does the head of a municipality adopt two types of acts? This is explained by the special nature of the activities of the head of the municipality and the local administration headed by him, as a rule: this activity is of an executive and administrative nature. Resolutions of the head of a municipality, as a rule, are normative in nature. Orders are adopted by him on issues of an individual, specific, operational nature;


Orders, instructions, methodological letters, instructions and orders are legal acts issued by the heads of departments, directorates, services and other structural units of the local administration. They are controlled by the head of the municipality, who has the right to cancel acts of the heads of structural divisions of the local administration. Regulatory legal acts of local self-government bodies and local government officials affecting the rights, freedoms and responsibilities of individuals and citizens come into force after their official publication (promulgation).

Legal acts of representative local self-government bodies, elected officials, and local government officials can be canceled by the bodies and officials who adopted them, or declared invalid by a court decision.

Voluntary health insurance (VHI) makes it possible to receive additional medical services and emergency assistance in those areas of health protection that are not provided by compulsory medical insurance. There is no law on voluntary health insurance yet, but there are related legal acts regulating this area of ​​insurance. If contradictions arise during the implementation of a particular VHI program, as well as when resolving disputes between the insurer and the insured, lawyers use several legislative acts, federal laws and articles of the Civil Code of the Russian Federation.

Legislative regulation

Paragraph 1 of Article 41 of the Constitution of the Russian Federation establishes that “everyone has the right to health care and medical care.” Compulsory health insurance (compulsory health insurance), financed from the state budget or the budgets of constituent entities of the Russian Federation and other sources, guarantees assistance in emergency situations that threaten a person’s life, and should be provided free of charge even in the absence of a policy.

Until January 2011, insurance activities in the country were regulated by the Law of the Russian Federation No. 1499-I of June 28, 1991 “On medical insurance of citizens in the Russian Federation” (last edition dated July 24, 2009). It defined the basic concepts, rules, participants and their interaction, and regulated the work of insurance companies and medical institutions. The law considered VHI as an additional type of insurance to compulsory medical insurance. With the termination of this document, voluntary health insurance became an independent activity. And on January 1, 2011, Federal Law No. 326-FZ of November 29, 2010 “On Compulsory Health Insurance in the Russian Federation” came into force, addressing the following issues:

  • Definition and principles of the compulsory medical insurance system;
  • The role of the state and constituent entities of the Russian Federation in insurance;
  • Interaction between the parties to the health insurance contract;
  • Sources of funding for compulsory medical insurance;
  • Compulsory medical insurance programs and services included in them;
  • Contractual relations between insurers, policyholders and health care facilities;
  • Exercising control and supervision.

However, this Federal Law does not address voluntary health insurance, therefore most litigation and other legal practice in the field of VHI are based on scattered legislative acts, as well as on the Insurance Rules, which are developed by the insurer itself, an association of insurers or the state. Typically, such rules stipulate the main provisions of the health insurance contract.

What is regulated by VHI?

Today, the rules governing voluntary health insurance, or rather their individual parts, terms, concepts and some legal situations can be found on the pages of two main acts - in the Civil Code of the Russian Federation and Law of the Russian Federation No. 4015-1 of November 27, 1992 “On the Organization insurance business in the Russian Federation". Thus, the main issues of insurance are discussed in the second part of the Civil Code of the Russian Federation (Chapter 48). In accordance with paragraph 1 of Article 927 of the Civil Code of the Russian Federation, insurance is carried out on the basis of contracts “concluded by a citizen or legal entity (insured) with an insurance organization (insurer).” Articles 934 and 940 introduce the concept of “personal insurance contract”.

In accordance with it, the insurer must pay for medical services provided to the insured person upon the occurrence of an insured event in an amount not exceeding the insured amount, and the policyholder must pay insurance premiums. The agreement is concluded in writing. Article 942 contains the essential terms of the contract: the insured person (this can be the policyholder or another person), insured events, amount of insurance, duration of the contract. According to Article 943, the terms of the contract are determined by the rules in force in the insurance company (or association of insurance companies), and the policyholder and the insurer can “agree to change or exclude certain provisions of the insurance rules and to supplement the rules.”

Law of the Russian Federation No. 4015-1 covers such issues as the purposes of insurance, participants in insurance activities, and offers basic definitions: insurance risk, amount, premium, tariff, case, financial support of insurance companies, supervision in the insurance industry. According to Law No. 4015-1, insurance rules have the force of an internal regulatory document of the insurance company and must be observed by both parties entering into the contract. In addition, the documents signed by the parties to the transaction for the implementation of voluntary health insurance also have legal force.

Health insurance rules and contract features

The relationship between the insurance company and the policyholder is determined by the contract and insurance rules. These documents are of great importance in resolving disputes. At the time of drawing up the contract, the policyholder needs to carefully read the conditions and operating principles of the insurer and check that the agreement contains all the necessary points. The insurance rules and the composition of the voluntary health insurance contract for most insurers are largely similar, and they contain:

  • Basic terms;
  • Participants and objects of health insurance;
  • Determination of insurance risk and event;
  • Sum insured and policyholder contributions;
  • Conditions for concluding and terminating the contract, period of validity;
  • Rights and obligations of participants;
  • Insurance payment;
  • Personal information;
  • Resolution of disputes;
  • Other conditions.

In accordance with the Rules, a VHI agreement is drawn up, defining the procedure and conditions for the insured person to receive medical services. It is agreed upon and signed by both parties. The main sections of the document include information about the policyholder, the insured persons and the insurance company; insurance program; composition of services, procedure and time for receiving them; medical organizations; procedure for paying insurance premiums; insurance amount; responsibilities and rights of participants. In addition to these sections, the agreement must also have sheets with appendices. They include all the necessary additions, as well as non-standard solutions or services for a specific policy. In addition, the annexes detail VHI programs, insurer rates, and the appearance of the policy. A medical questionnaire is attached to the document, if necessary.

MS- the branch of personal insurance, within which the insurer is obliged, for a specified insurance premium (insurance premium), to organize and finance the provision of medical care and other medical services to the insured persons.

Legal regulation:

Compulsory medical insurance- Law on compulsory medical insurance, On the fundamentals of protecting the health of citizens.

Compulsory medical insurance rules - order of the Ministry of Health and Social Development - check.

VHI- general norms - Chapter 48 of the Civil Code of the Russian Federation, the law on the organization of insurance business in the Russian Federation.

VHI rules are developed by the insurer. Mandatory indication of the sum insured. Exhaustion of the amount entails termination of the contract.

Peculiarities:

    Availability of compulsory medical insurance and voluntary medical insurance

    MC can be provided by insurers engaged exclusively in medical insurance

    Possibility to choose a voluntary health insurance program

    According to compulsory medical insurance - a list of services in the law

    VHI - the insurer can determine how justified the application was.

Medicalinsurance is a form of social protection of the interests of the population in the field of health care; its main goal is to guarantee citizens, in the event of an insured event, receiving medical care from accumulated funds and financing preventive measures. Medicalinsurance is a set of types of insurance that provide for the insurer’s obligations to make insurance payments (payments of insurance coverage) in the amount of partial or full compensation for additional expenses of the insured caused by the insured’s application to medical institutions for medical services included in the health insurance program.

Unlike classical types of insurance, with medical insurance payment is made not in cash, but in kind, in the form of a complex of medical and other services paid for by the insurer. At the same time, the insured is a consumer of insurance and at the same time medical services, which determines a high degree of responsibility of the insurer for the quality of the organization of medical care, for the safety and effectiveness of the medical services provided.

The legislation provides for two types of health insurance - compulsory and voluntary. Mandatorymedical insurance (CHI) is an integral part of state social insurance and provides all citizens of the Russian Federation with equal opportunities to receive medical and pharmaceutical care provided at the expense of compulsory health insurance in the amount and on conditions that correspond to compulsory health insurance programs. The compulsory medical insurance system is built on the principle of social solidarity, when the rich pay for the poor, the healthy for the sick, and it is based on a stable source of healthcare financing through a targeted contribution.

In this system, payment for medical care should be carried out depending on the volume and quality of work done, while simultaneously monitoring the intended use of funds.

Compulsory medical insurance is based on the following principles:

      Universal character. All citizens of the Russian Federation, regardless of gender, age, health status, place of residence, or level of personal income, have the right to receive medical services included in the state (basic) compulsory medical insurance program.

      State character. Compulsory medical insurance funds are state property of the Russian Federation.

      The state, represented by local executive authorities, acts as the direct insurer of the non-working population. It exercises control over the collection, redistribution and use of compulsory health insurance funds, ensures the financial stability of the compulsory medical insurance system, and guarantees the fulfillment of obligations to the insured.

      Social solidarity and social justice.

All members of society have equal rights to receive medical care at the expense of compulsory medical insurance, but in fact, the consumption of medical services is carried out only by individual individuals who need them and seek medical help.

Federal Law of July 24, 2009 N 212-FZ "On insurance contributions to the Pension Fund of the Russian Federation, the Social Insurance Fund of the Russian Federation, the Federal Compulsory Medical Insurance Fund and territorial compulsory medical insurance funds"

Article 12. Insurance premium rates

1. Insurance premium rate - the amount of insurance premium per unit of measurement of the base for calculating insurance premiums.

2. The following insurance premium rates apply, unless otherwise provided by this Federal Law:

1) Pension Fund of the Russian Federation - 26 percent;

2) Social Insurance Fund of the Russian Federation - 2.9 percent;

3) Federal Compulsory Medical Insurance Fund - from January 1, 2011 - 3.1 percent, from January 1, 2012 - 5.1 percent;

    Sources of compulsory medical insurance funds are:

    parts of the deductions of enterprises, organizations and other legal entities to the compulsory medical insurance fund from accrued wages;

other income provided for by the legislation of the Russian Federation.

Financial resources of territorial compulsory health insurance funds are generated from:

parts of the unified social tax at rates established by the legislation of the Russian Federation; parts of the single tax on imputed income for certain types of activities in the amount established by law;

insurance premiums for compulsory medical insurance of the non-working population, paid by executive authorities of the constituent entities of the Russian Federation, local governments, taking into account territorial programs of compulsory medical insurance within the limits of funds provided for in the relevant budgets for healthcare;

other income provided for by the legislation of the Russian Federation.

Thus, insurance payments under compulsory medical insurance are paid for all citizens, but the demand for financial resources is carried out only when they seek medical help.

The range and volume of services provided does not depend on the absolute amount of the compulsory medical insurance payment.

Citizens with different income levels (for example, a large businessman, a housewife, a janitor) and, accordingly, with different amounts of wage accruals have the same rights to receive medical services included in the compulsory health insurance program. The protocols and standards for diagnosis and treatment, and the basic lists of medicines approved by the federal executive body in the field of healthcare are intended to serve as the implementation of guarantees for citizens of the Russian Federation to provide free medical care and provide vital and essential medicines.

Such a federal executive body in the field of healthcare is the Ministry of Health of the Russian Federation (from May 21, 2012, formerly the Ministry of Health and Social Development), which carries out the functions of developing state policy and legal regulation in the field of healthcare, social development, labor and consumer protection, including issues of organizing medical care. prevention, including infectious diseases and AIDS, medical care and medical rehabilitation, pharmaceutical activities, quality, effectiveness and safety of medicines, sanitary and epidemiological well-being, living standards and incomes of the population, demographic policy, health care provision for workers in certain sectors of the economy with especially hazardous working conditions, medical and biological assessment of the impact on the human body of especially dangerous factors of physical and chemical nature, etc.

The standard rules for compulsory medical insurance of citizens (approved by the Federal Compulsory Medical Insurance Fund on October 3, 2003 N 3856/30-3/i) establish that citizens of the Russian Federation are guaranteed the provision of medical care and its payment through the compulsory medical insurance system in the volume and on the terms in force in the territory of the subject Russian Federation territorial compulsory health insurance program.

In accordance with the Law of the Russian Federation “On the organization of insurance business in the Russian Federation” (Article 3), voluntary insurance is carried out on the basis of an insurance contract and insurance rules that define the general conditions and procedure for its implementation. Insurance rules are adopted and approved by the insurer or an association of insurers independently in accordance with the Civil Code of the Russian Federation and the specified Law and contain provisions on the subjects of insurance, on the objects of insurance, on insured events, on insurance risks, on the procedure for determining the insured amount, insurance tariff, insurance premium ( insurance premiums), on the procedure for concluding, executing and terminating insurance contracts, on the rights and obligations of the parties, on determining the amount of losses or damage, on the procedure for determining insurance payment, on cases of refusal of insurance payment and other provisions.

Voluntary health insurance is carried out on the basis of voluntary health insurance programs and provides citizens with additional medical and other services in addition to those established by compulsory health insurance programs. Insurance premiums are made in various forms (cash payment, non-cash transfer, use of plastic cards, etc.). Voluntary medical insurance is provided in the form of collective and individual insurance.