One of the conditions of social protection of the population of our country is to provide citizens with the necessary medical care. All health services that allow you to get medical care are based on the formation of a medical insurance system.
The country is witnessing the development of a system of both voluntary and compulsory medical insurance with a wide range of services. In this article, we consider the characteristics of the main subjects of health insurance.
Health insurance concept
Today it is a very popular and widespread aid in our country. This insurance covers most Russians and provides a full range of medical services to everyone who has the status of an insured. The main person responsible for the organization of health care in the country is the compulsory health insurance fund, while the entities operate as part of its activities. His tasks include managing financial resources, financing benefits, and recovering drug costs.
Health insurance is determined by the following factors:
- labor contracts and contracts;
- business activity;
- registration with the labor office as unemployed.
In health insurance, there are two types of insurance - compulsory and voluntary. Both groups of insured persons can use public health services on a single basis.
Subjects
The subjects of medical insurance are: the insured, the medical insurance company and the medical institution itself.
The insurers are:
- for compulsory health insurance for non-working people - executive authorities and local self-government, and for working people - companies, institutions, organizations, persons engaged in personal labor work, as well as individuals of individual activity;
- in the case of voluntary medical insurance - individual citizens or companies that represent the interests of people.
Insurance medical institutions are organizations that have a special license and carry out insurance. Such health facilities are not part of the healthcare system.
Medical institutions in the health insurance system are health facilities, medical institutes and other institutions and individuals who have a special license and provide medical assistance.
Honey insurance is made on the basis of a contract between the insured and the medical organization. The agreement of the parties can be considered valid from the date of payment of the first insurance premium.
System feature
Any citizen who has signed a contract receives a medical insurance policy. A citizen of Russia has the right to:
- the choice of insurance organization, medical institution and doctor;
- obtaining medical support throughout Russia, as well as outside the borders of the place of permanent residence;
- obtaining medical services in accordance with the criteria of the contract, regardless of the amount of insurance premiums actually paid;
- making a claim to the insurer, insurance medical organization, medical institution about material compensation for harm caused through their fault, regardless of whether this is foreseen by the contract or not;
- refund of a part of insurance payments in case of voluntary medical insurance, if it is determined by the criteria of the contract.
Residents who do not have Russian citizenship, and foreign citizens who live in Russia, have the same rights to provide medical care as Russian residents.
Medical insurance for residents of Russia who are abroad is carried out on the basis of bilateral agreements between Russia and the host countries of residents of Russia.
Consider the basic rights of subjects of health insurance.
Rights of the insured
These rights are enshrined in Federal Law No. 323 “On the Basics of Health Protection” as amended. from 01/09/2017.
Such subjects of compulsory medical insurance as insured have the following rights:
- choice of a doctor, medical institution at will;
- obtaining services for diagnosis, prevention and examinations, rehabilitation;
- getting advice from doctors;
- receiving medication and medical intervention if necessary;
- the choice of citizens who may be given the opportunity to inform about health;
- refuse any kind of medical care.
Patients who are treated in polyclinics during a 24-hour and full-day stay, or who receive emergency and ambulance care, are entitled to receive pharmaceuticals free of charge.
This is done in accordance with a special list of essential and essential pharmaceuticals. It contains the most important and necessary medicines.
There are cases when a citizen who has a compulsory medical insurance policy is offered to undergo a procedure, examination for money, or to purchase medicines. In this case, it is worth checking if these services and medicines are included in the CHI program.
In a situation where the staff of one institution cannot provide assistance, the patient is redirected to another institution. This is ensured by the medical organization, to which the citizen initially applied, if the health damage was recorded as a result of incorrect actions by the medical staff.
All residents of Russia have the same rights to protect health, receive medical support. But some categories of people, for example, military, minors, people with disabilities, owing to their specificity by age or state of health, have special health rights.
Obligations of the insured
Subjects and participants in compulsory health insurance have certain responsibilities. For the second, they are enshrined in Article 27 of the Federal Law No. 323. These include:
- submit the necessary application when choosing a medical institution;
- it is obligatory to present a compulsory medical insurance policy when applying to medical facilities;
- notify the insurance company when changing passport data and address.
Rights and obligations of the insured
These include medical insurance entities that pay insurance premiums.
Their rights are as follows:
- participation in all types of health insurance;
- free choice of medical organization;
- monitoring the implementation of the terms of the contract;
- repayment of a part of funds for VHI.
The responsibilities of this health insurance entity are as follows:
- conclusion of a compulsory medical insurance agreement with a medical organization;
- registration within 30 days;
- payment of fees in accordance with established standards;
- elimination of harmful factors;
- providing the required information to the medical institution about the health status of the working contingent.
Insurer Rights
The subject of compulsory health insurance are insurers.
The latter include medical insurance companies, which are legal entities and are created in accordance with the legislative framework, act on the basis of a license.
Basic rights:
- free choice of a medical institution to provide assistance and services for VHI;
- participation in accreditation;
- determination of the amount of contributions for VHI;
- calculation of tariffs for medical services in compulsory medical insurance.
The main responsibilities of this subject of health insurance:
- compulsory medical insurance activities;
- conclusion of contracts with medical institutions for compulsory medical insurance;
- conclusion of contracts with medical institutions for VHI;
- issuance of policies;
- control measures under the terms of the contract;
- protecting the interests of insured persons.
Features of voluntary health insurance
VHI is considered a form of social protection of residents in the field of health, expressed as a guarantee of payment of medical support in the case of an insurance option at the expense of funds accumulated by insurers. The objective of this form of insurance is to guarantee people in case of illness, damage to health, the provision of medical support and services that are not covered by the compulsory medical insurance program, but are included in voluntary medical insurance.
Citizens are guaranteed full or partial reimbursement of costs by insurers. The competitiveness between insurance companies forces them to create voluntary medical insurance programs with an improved list of services of different composition, some of which are in the compulsory medical insurance program.
VMI features from other types of insurance are:
- implementation of social functions: reducing the shadow allocation of financial resources in the healthcare system and increasing its productivity in general (according to experts, the amount of hidden contributions amounts to 30% of the entire market for paid services in the field of medicine);
- the formation, distribution of high standards of medical support to residents (VHI involves high-quality medical care with a high level of service).
OMS features
Mandatory medical insurance is a set of measures to protect health, to provide free medical support in accordance with applicable legal acts and to implement preventive measures.
Insurance provides citizens with equal opportunities as needed medical exposure. Art. 41 of the Constitution of Russia guarantees every citizen the right to protection of health and free medical care in municipal (city) institutions, carried out by the method of paying insurance payments, financial resources of the treasury and other income.
The provision of medical services is carried out at the expense of previously formed funds. The main guaranteed services include:
- emergency medical assistance;
- primary care;
- medical and preventive measures;
- special assistance;
- the provision of services under the existing system of mandatory medical insurance.
The implementation of compulsory medical insurance is carried out through special legal organizations - insurance companies. Providing residents with the necessary medical care by the method of concluding contracts is considered one of the main tasks. Also, at the expense of funds, payment is made for the services that are provided to insured persons (clients) of medical institutions, and the protection of the rights of residents of the country.
Conclusion
Health insurance is insurance in case of illness, accident, injury, poisoning, life-threatening condition, etc. In order to be able to use such insurance, you must pay insurance premiums under an insurance contract (for example, every month).
In the framework of this article, subjects and participants of medical insurance, their rights and obligations in the market under study, are examined.
