1. Health insurance system in Russia

Created in Russia health insurance system, containing a system of measures intended for the social protection of the interests of the population in the protection of health. Health insurance is provided in two types - compulsory (CMI) and voluntary (VHI)– in accordance with health insurance programs.

The legal, economic and organizational foundations of medical insurance are contained in the Law of the Russian Federation "On the medical insurance of citizens in the Russian Federation". The law is aimed at strengthening the interest and responsibility of the population and the state, enterprises, institutions, organizations in protecting the health of citizens in the new economic conditions. The law ensures the constitutional right of citizens of the Russian Federation to medical care. Purpose of health insurance– to guarantee citizens, in the event of an insured event, the receipt of medical care through the accumulation of funds and to finance preventive measures. The object of health insurance is the insured risk associated with the cost of medical care in the event of an insured event. Compulsory health insurance is an integral part of state social insurance. It provides all citizens of the Russian Federation with equal opportunities to receive medical and pharmaceutical assistance provided at the expense of compulsory medical insurance in the amount and on terms corresponding to the programs of compulsory medical insurance. Voluntary medical insurance (VHI) is carried out on the basis of the free will of the insured and the insurer and is an additional health insurance.

The health insurance system provides for:

1) medical insurance of citizens of the Russian Federation;

2) medical insurance for citizens of the Russian Federation who are abroad, carried out on the basis of bilateral agreements between the Russian Federation and the countries of residence of citizens;

3) medical insurance of foreign citizens temporarily staying in the Russian Federation;

4) medical insurance of foreign citizens permanently residing in the Russian Federation and having the same rights and obligations in the field of medical insurance as citizens of the Russian Federation, unless otherwise provided by international treaties.

The rights of citizens of the Russian Federation in the system of medical insurance are determined. 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.

Citizens have the right to:

1) compulsory and voluntary medical insurance;

2) choice of a medical insurance company;

3) the choice of a medical institution and a doctor in accordance with the contracts of compulsory and voluntary medical insurance;

4) receiving medical care throughout the territory of the Russian Federation, including outside permanent place residence;

5) receipt of medical services corresponding in volume and quality to the terms of the contract, regardless of the amount actually paid insurance premium;

6) filing a claim against the policyholder, medical insurance organization, medical institution, including for material compensation for damage caused through their fault, regardless of whether this is provided for or not in the medical insurance contract;

7) repayment of a part of insurance premiums for voluntary medical insurance, if it is determined by the terms of the contract.

2. Compulsory health insurance

Compulsory health insurance currently subject to all citizens of Russia (working and non-working) from birth. From the moment of conclusion of an employment contract, a working citizen is subject to the norms relating to compulsory medical insurance in accordance with the Law of the Russian Federation “On Medical Insurance of Citizens in the Russian Federation” and regulations adopted in accordance with it. In other words, the employer is obliged to provide the employee with a compulsory medical insurance policy. Non-working citizens independently receive compulsory medical insurance policy in a medical insurance company. For newborn children, the parents receive the CHI policy by applying to the insurance medical organization on their own.

A citizen, having a compulsory insurance policy, when applying for medical care in a medical institution receives free of charge medical services. However, he has the right to receive free of charge only a list of medical services specified by law. For young children who have a nominal compulsory medical insurance policy, this document is submitted by parents when applying to a medical institution. Medical services are free for citizens because they are paid from the compulsory health insurance funds.

3. Compulsory health insurance program

The state has developed a basic program of compulsory health insurance, on the basis of which territorial programs of obligatory medical insurance. The volume of medical care provided to insured persons in accordance with the contract of compulsory medical insurance is determined by the approved territorial program of compulsory medical insurance of the population. The scope and conditions for the provision of medical care provided for by territorial programs cannot be lower than those established in the basic program (Article 22 of the Law of the Russian Federation “On Medical Insurance of Citizens in the Russian Federation”). The territorial program of compulsory medical insurance must contain a state-guaranteed list, volume and conditions for the provision of medical services to the population of a certain territory, payment for which is made at the expense of compulsory medical insurance.

Territorial programs operate in certain areas throughout the country. For example, on the territory of the Saratov region, a territorial fund for compulsory medical insurance of the Saratov region was created, from which the territorial program of compulsory medical insurance for residents of the Saratov region is financed. The territorial program of compulsory medical insurance is approved by the bodies of territorial administration in pursuance of the Law of the Russian Federation "On medical insurance of citizens in the Russian Federation". An example is the resolution of the governor of the Saratov region dated March 18, 1998 No. 143 "On the territorial program of compulsory medical insurance of the population of the Saratov region for 1998". This territorial program contains a list of types of medical institutions and activities (see Appendix 1), conditions and scope of medical care (see Appendix 2), types of medical care (see Appendix 3), volume and conditions for the provision of medical services financed from the territorial fund of obligatory medical insurance of the Saratov region.

4. Mandatory health insurance funds

The financial resources of the state system of compulsory medical insurance are formed at the expense of deductions from insurers for compulsory medical insurance. For implementation public policy in the field of compulsory medical insurance, the Federal and territorial funds of compulsory medical insurance have been established as independent non-profit financial and credit institutions. Mandatory health insurance funds are designed to accumulate financial resources for compulsory health insurance, ensure the financial stability of the state system of compulsory health insurance and equalize financial resources for its implementation. The financial resources of the mandatory medical insurance funds are state-owned by the Russian Federation. They are not included in the composition of budgets, other funds and are not subject to withdrawal. Due to insurance premiums paid by all categories of insurers, insurance reserves of these funds are formed. The normative base for the payment of insurance premiums to the compulsory health insurance funds is made up of annually adopted laws on the tariffs of insurance premiums, according to which insurers must pay insurance premiums. For quite a long time, insurers paid these contributions as independent contributions, but from January 1, 2002, the indicated insurance contributions for compulsory health insurance were canceled as independent due to the fact that Ch. 24 tax code Russian Federation(TC RF) introduced a unified social tax. Insurance premiums intended for the formation of reserves of compulsory medical insurance funds are included in the unified social tax (Article 234 of the Tax Code of the Russian Federation).

The normative base for the payment of insurance premiums to the compulsory health insurance funds is formed by the annually adopted laws on the tariffs of insurance premiums, according to which, since 1993, notaries engaged in private practice are subject to compulsory medical insurance and must pay insurance premiums.

5. Subjects of compulsory health insurance, their legal status

Compulsory health insurance is carried out in the form of an agreement concluded between subjects of health insurance. The subjects of compulsory health insurance are a citizen, an insured, a medical insurance organization, a medical institution. Subjects of health insurance must fulfill their obligations under the concluded contract in accordance with the legislation of the Russian Federation. An insurance medical organization and a medical institution perform different functions, which are discussed in detail during the lecture.

CHI insurers, The following persons are payers of insurance premiums:

1) for the non-working population(pensioners, children, schoolchildren and full-time students) - executive authorities of the constituent entities of the Russian Federation and local governments;

2) for the working population:

a) organizations and individual entrepreneurs that are employers;

b) private notaries, lawyers;

c) individuals who have concluded employment contracts with employees, as well as paying remuneration under civil law contracts, on which, in accordance with the legislation of the Russian Federation, taxes are charged in the part to be credited to the compulsory medical insurance funds.

1) conclude an agreement on compulsory medical insurance with an insurance medical organization;

2) pay insurance premiums in accordance with the procedure established by the Law and the medical insurance contract;

3) within its competence, take measures to eliminate adverse factors affecting the health of citizens;

4) provide the insurance medical organization with information on the health indicators of the contingent subject to insurance;

5) register as an insurer in the territorial compulsory health insurance fund in the manner prescribed by Art. 9.1 of the Law of the Russian Federation "On medical insurance of citizens in the Russian Federation".

Insurers are required to register with the territorial compulsory health insurance fund and conclude a compulsory health insurance contract with an insurance medical organization. The insurers are obliged to issue an insurance medical policy in the hands of every citizen in respect of whom a medical insurance contract has been concluded.

The procedure for registration of policyholders in the territorial fund of compulsory medical insurance and the form of the certificate of registration of the policyholder are established by the Government of the Russian Federation (Article 9.1 of the Law of the Russian Federation "On Medical Insurance of Citizens in the Russian Federation"). Insurers-organizations and individual entrepreneurs must register with the territorial CHI fund within five days from the date of their state registration, insurers - private notaries - no later than 30 days from the date of receipt of a license for the right to notarial activities. Advocate insurers are required to register no later than 30 days from the date of issuance of an advocate's certificate. Insurers are individuals those who have concluded employment contracts with employees, as well as those who pay remuneration under civil law contracts on which taxes are charged, are required to register no later than 30 days from the date of conclusion of the relevant contracts. Insurers-organizations with separate subdivisions must register no later than 30 days from the date of creation of a separate subdivision. Insurers - state authorities and local governments are required to register no later than 30 days from the date of their establishment.

Insurance medical organizations can only be legal entities - economic entities of any form of ownership that have the authorized capital necessary for the implementation of medical insurance and have received licenses in the prescribed manner from Rosstrakhnadzor, which is under the jurisdiction of the Ministry of Finance of the Russian Federation. According to the Decree of the Council of Ministers - the Government of the Russian Federation dated October 11, 1993 No. 1018 "On measures to implement the Law of the Russian Federation" On the introduction of amendments and additions to the Law of the RSFSR "On medical insurance of citizens in the RSFSR", medical insurance organizations providing compulsory medical insurance must have an authorized capital in the amount of at least 1200 times the minimum monthly wage on the day of registration of the legal entity. The license is valid for carrying out compulsory health insurance in the territory specified in it.

Insurance medical organizations that carry out compulsory medical insurance should not be part of the healthcare system, and health authorities and medical institutions do not have the right to be founders of insurance medical organizations.

An insurance medical organization, except for medical insurance, is not entitled to carry out other types of insurance activities, but has the right to simultaneously conduct compulsory and voluntary medical insurance. The insurance medical organization is not entitled to refuse the insured if he has applied for the conclusion of a contract of compulsory medical insurance.

The main task of the insurance medical organization, which is engaged in the implementation of compulsory medical insurance, is:

1) payment for medical care provided to the population in accordance with the territorial program of compulsory medical insurance and compulsory medical insurance contracts;

2) control over the volume and quality of medical services (“Regulations on insurance medical organizations providing compulsory medical insurance”.

The insurance medical organization has the right:

1) freely choose medical institutions for the provision of medical care and services under medical insurance contracts;

2) participate in the accreditation of medical institutions;

3) establish the amount of insurance premiums for voluntary medical insurance;

4) take part in the determination of tariffs for medical services;

5) file a claim in court against a medical institution and/or a medical worker for material compensation for physical or moral damage caused to the insured through their fault.

The insurance medical organization is obliged:

1) carry out activities on compulsory health insurance on a non-commercial basis;

2) conclude contracts with medical institutions for the provision of medical care to insured persons under compulsory medical insurance;

3) conscientiously fulfill all the conditions of the concluded contracts;

4) create insurance reserves in accordance with the established procedure;

5) protect the interests of the insured.

Licensing of insurance medical organizations. In order to streamline the activities of insurance medical organizations providing compulsory medical insurance, the Government of the Russian Federation approved Resolution No. 251 dated March 29, 1994 “On Approval of the Rules for Licensing the Activities of Medical Insurance Organizations Providing Compulsory Medical Insurance”. This resolution approved the Rules for Licensing the Activities of Medical Insurance Organizations Providing Compulsory Medical Insurance. In accordance with the Rules, the licensing of the activities of insurance medical organizations that carry out compulsory medical insurance is carried out by the Federal Insurance Supervision Service. Licensing of the activities of insurance medical organizations providing voluntary medical insurance is also carried out by the Federal Insurance Supervision Service, but in accordance with the Law of the Russian Federation “On the organization of insurance business in the Russian Federation”. The activities of an insurance medical organization, the licensing procedure of which is determined by the Rules, is understood as the conduct of compulsory medical insurance on a non-commercial basis in accordance with:

1) with a territorial program of compulsory medical insurance;

2) with compulsory medical insurance contracts;

3) with agreements with medical institutions on the provision of medical care to insured persons;

4) with the provision of insured persons with medical insurance policies;

5) with the implementation of control over the volume, quality and duration of the provision of medical services and protection of the interests of the insured persons.

The rules are mandatory for all insurance medical organizations, regardless of their form of ownership, that carry out compulsory medical insurance in the territory of the Russian Federation. To obtain a license, an insurance medical organization submits to the Federal Service for Insurance Supervision an application in the form in accordance with Appendix 2 as follows: documentation:

1) notarized copies of constituent documents and a document confirming the fact of making an entry about a legal entity in the Unified State Register of Legal Entities;

2) documents confirming the payment of the authorized capital (bank certificate, acts of acceptance and transfer of fixed assets, other documents);

3) a copy of the balance sheet of the medical insurance organization as of the last reporting date with the statement of financial results attached;

4) a territorial program of compulsory medical insurance, approved in accordance with the legislation of the Russian Federation;

5) the rules of compulsory medical insurance, approved by the executive authority of the constituent entity of the Russian Federation. The rules of compulsory medical insurance must be accompanied by samples of contracts with insurers and medical institutions and insurance policies that correspond to those approved in the prescribed manner;

6) information about the head of the insurance medical organization and his deputies in the prescribed form.

Insurance medical organizations bear the responsibility provided for by the legislation of the Russian Federation for the accuracy of the information specified in the documents submitted for consideration of the issue of issuing a license. The Federal Insurance Supervision Service is obliged to consider applications from medical insurance organizations for the issuance of licenses within a period not exceeding 60 days from the date of submission of documents by the license applicant. The Federal Insurance Supervision Service bears responsibility, provided for by the legislation of the Russian Federation, for the timely issuance of licenses, the safety of documents submitted by an insurance medical organization for obtaining a license, and non-disclosure of information specified in these documents. The license is issued in the prescribed form for a period of 1 year or more on the grounds determined by the Federal Insurance Supervision Service, and contains the following details:

1) full name of the insurance medical organization;

2) legal address of the insurance medical organization;

3) the name of the territory where the license is valid;

4) the number and date of the decision of the Federal Insurance Supervision Service to issue a license;

5) signature of the head (his deputy) of the Federal Insurance Supervision Service and official seal;

6) registration number according to the State Register of Medical Insurance Organizations.

The license number must be indicated in the compulsory medical insurance contracts that the insurance medical organization concludes with the insured. For the issuance of each license, the Federal Insurance Supervision Service charges insurance medical organizations a fee in the amount of five times the minimum monthly wage established by the legislation of the Russian Federation; if it is necessary to issue a duplicate license, the fee is charged in the same amount. The funds received are directed by the Federal Insurance Supervision Service to the federal budget. The insurance medical organization is obliged to inform the Federal Insurance Supervision Service of changes made to the constituent documents within one month from the date of registration of these changes in the prescribed manner and submit copies of documents confirming the registration of the changes made.

The basis for refusal to issue a license to a legal entity may be the non-compliance of the documents attached to the application with the requirements of the legislation of the Russian Federation. The Federal Insurance Supervision Service shall notify the medical insurance organization in writing of the refusal to issue a license, indicating the reasons for the refusal. The Federal Service for Insurance Supervision exercises control over the activities of an insurance medical organization in the following way. If violations of the requirements of the legislation of the Russian Federation and the Licensing Rules are revealed, the Federal Insurance Supervision Service may suspend or terminate the license. The basis for this are:

1) systematic non-fulfillment by the insurance medical organization of obligations under the contracts of compulsory medical insurance;

2) the refusal of the insurance medical organization to submit the documents requested by the Federal Insurance Supervision Service related to the conduct of compulsory medical insurance;

3) establishing the fact that the insurance medical organization provided false information in the documents that served as the basis for issuing a license;

4) systematic untimely notification by the medical insurance organization about making changes and additions to the constituent documents;

5) representation of the territorial fund of compulsory medical insurance, which established violations of the legislation of the Russian Federation in the activities of an insurance medical organization.

An insurance medical organization, by a court decision, may be deprived of a license for the right to engage in medical insurance for an unreasonable refusal to the insured to conclude a contract of compulsory medical insurance. The insurance organization bears legal and financial responsibility to the insured party or the insured for failure to comply with the terms of the medical insurance contract. Liability is provided for by the terms of the medical insurance contract. Payment for the services of medical institutions by insurance organizations is carried out in the manner and within the terms stipulated by the agreement between them, but no later than one month from the date of submission of the payment document. Responsibility for late payments is determined by the terms of the health insurance contract.

If violations are detected in the activities of an insurance medical organization, the Federal Insurance Supervision Service issues an order to eliminate them, and in case of failure to comply with the instructions, suspends or terminates the license (from the date such a decision is made). The Federal Insurance Supervision Service informs the insurance medical organization in writing about the decision made. The Federal Insurance Supervision Service has the right to revoke the license if the violations that served as the basis for the termination of the license are not eliminated within the established time limits. The Federal Insurance Supervision Service notifies the Federal Compulsory Medical Insurance Fund, the Territorial Compulsory Medical Insurance Fund and publishes information about these decisions in the press.

The decision to cancel the suspension of a license is made by the Federal Insurance Supervision Service when the insurance medical organization submits a report on the elimination of violations that caused the suspension of the license, and, if necessary, based on the results of an audit of the activities of the insurance medical organization.

In case of termination of the license, its re-issuance is allowed no earlier than 6 months after the termination of the previous license and is carried out in the manner prescribed by the Licensing Rules.

The actions of the Federal Insurance Supervision Service may be appealed by the insurance medical organization in the manner prescribed by the legislation of the Russian Federation.

In the event of liquidation or reorganization of an insurance medical organization, the license is returned to the Federal Insurance Supervision Service, and the entry in the register is cancelled.

The Federal Insurance Supervision Service publishes monthly data on insurance medical organizations that have been issued (suspended or terminated) licenses, indicating:

1) name, location of the insurance medical organization;

2) territories where the license is valid;

3) the number and date of the decision of the Federal Insurance Supervision Service to issue (suspend, terminate) the license.

Medical institutions- these are independent business entities with any form of ownership that provide medical care to citizens in the health insurance system (Article 20 of the Law of the Russian Federation "On Medical Insurance of Citizens in the Russian Federation"). Medical institutions build their activities on the basis of contracts with insurance medical organizations that pay for medical services to help citizens. An agreement concluded by a medical institution with an insurance medical organization is an agreement providing for the provision of therapeutic and preventive care (medical services) and is an agreement under which a medical institution undertakes to provide medical care of a certain volume and quality to the insured contingent within a specific time frame within the framework of health insurance programs . The relationship between the parties is determined by the terms of the contract. The contract must contain:

1) names of the parties;

2) the number of insured persons;

3) types of medical and preventive care (medical services);

4) cost of work and payment procedure;

5) the procedure for monitoring the quality of medical care and the use of insurance funds;

6) the responsibility of the parties and other conditions that do not contradict the legislation of the Russian Federation.

Medical institutions are subject to licensing. Licensing is the issuance of state permission to a medical institution to carry out certain types of activities and services under the programs of compulsory and voluntary medical insurance. All medical institutions are subject to licensing, regardless of ownership. Licensing is carried out by licensing commissions created under state administration bodies, city and district local administrations from representatives of health authorities, professional medical associations, medical institutions, public organizations (associations). Under licenses, medical institutions have the right to implement both voluntary and compulsory medical insurance programs. Voluntary health insurance programs should be implemented without prejudice to compulsory health insurance programs. In addition, licensed medical institutions that carry out health insurance programs have the right to provide medical care outside the health insurance system. Medical institutions in the health insurance system have the right to issue documents certifying the temporary disability of the insured.

Medical institutions are also subject to accreditation. Accreditation of medical institutions– determination of their compliance with established professional standards. All medical institutions are subject to accreditation, regardless of ownership. Accreditation of medical institutions is carried out by accreditation commissions created from representatives of health authorities, professional medical associations, and medical insurance organizations. A certificate is issued to an accredited medical institution.

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 care 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.

6. Compulsory medical insurance contract

Compulsory 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 the programs of compulsory medical insurance and voluntary medical insurance.

The health insurance contract must contain:

1) names of the parties;

2) the duration of the contract;

3) the number of insured persons;

4) the amount, terms and procedure for making insurance premiums;

5) a list of medical services corresponding to programs of compulsory or voluntary medical insurance;

6) rights, obligations, responsibilities of the parties and other conditions that do not contradict the legislation of the Russian Federation.

The form of a standard contract of compulsory medical insurance, the procedure and conditions for their conclusion are established by law:

one) " Standard contract Compulsory Medical Insurance for Working Citizens” (Appendix No. 1 to the Decree “On Measures to Implement the Law of the Russian Federation “On Amendments and Additions to the Law of the RSFSR “On Medical Insurance of Citizens in the RSFSR”);

2) "Standard contract for compulsory medical insurance of non-working citizens" (Appendix No. 2 to the resolution "On measures to implement the Law of the Russian Federation" On Amendments and Additions to the Law of the RSFSR "On Medical Insurance of Citizens in the RSFSR").

The health insurance contract is considered concluded from the moment the insured pays the first insurance premium, unless otherwise provided by the terms of the contract.

7. Voluntary health insurance

Voluntary health insurance is carried out on the basis of voluntary medical insurance programs that are not regulated by the state, but they are independently developed by insurers licensed for medical insurance, as part of their own activities.

8. Subjects of voluntary medical insurance, their legal status

Voluntary health insurance provides citizens with additional medical and other services provided in excess of the norms established by compulsory health insurance programs.

In voluntary medical insurance, the subjects of insurance are a citizen, an insured, an insurer, a medical institution.

Insurers providing voluntary medical insurance may be:

1) insurance medical organizations that carry out compulsory health insurance (a medical insurance organization, in accordance with the law, except for medical insurance, is not entitled to carry out other types of insurance activities, but has the right to simultaneously conduct compulsory and voluntary medical insurance);

2) other insurance organizations that have licenses to carry out voluntary types of medical insurance.

An insurance organization for the implementation of voluntary medical insurance first concludes an agreement with a medical institution that will provide services to citizens. When concluding such an agreement, by agreement of the parties, tariffs for medical and other services are established. Then the insurance organization attracts clients who, on a voluntary basis, wish to conclude health insurance contracts. Citizens with civil legal capacity and (or) enterprises representing the interests of citizens can be clients-insurers in voluntary medical insurance. At the same time, payment of contributions for voluntary health insurance is carried out at the expense of personal funds of citizens or profits (revenues) of enterprises. The amount of insurance premiums for citizens or enterprises representing the interests of citizens and organizations that wish to conclude a contract for voluntary medical insurance are established by agreement of the parties (the insured and the insurer). Voluntary health insurance can be collective and individual. This means that a legal entity acting as an insured can insure both one employee and the whole team, and then a large (or small) list of persons will appear in the contract. Or, for example, the head of the family can conclude a voluntary medical insurance contract for himself, but he also has the right to conclude such an agreement in which the whole family will be represented on the list.

9. Medical insurance for persons traveling abroad

When leaving the Russian Federation provision of medical care to citizens of the Russian Federation is carried out only at the expense of insurance (Federal Law of August 15, 1996 No. 114-FZ “On the procedure for leaving the Russian Federation and entering the Russian Federation.”) Article 14 of this Law states that payment for medical care to a citizen of the Russian Federation when leaving the Russian Federation ( with the exception of a citizen of the Russian Federation sent to business trip) is carried out:

1) in accordance with the conditions stipulated by the medical insurance policy or a document replacing it, valid for receiving medical care outside the territory of the Russian Federation;

2) if there is a guarantee of an individual or legal entity inviting a citizen of the Russian Federation, to reimburse the costs of providing medical care (treatment in a medical institution) to a citizen of the Russian Federation.

In the event that there is no medical insurance policy or guarantees of the person inviting a citizen of the Russian Federation, the costs of providing medical care outside the territory of the Russian Federation are borne by the citizen himself.

Assistance in insured events for citizens of the Russian Federation staying on the territory of a foreign state is provided by a diplomatic mission or consular office of the Russian Federation in the manner established by the Government of the Russian Federation (unless otherwise provided by an international treaty of the Russian Federation with the corresponding foreign state). The Government of the Russian Federation approved by its Decree of October 1, 1998 No. 1142 "On the implementation of certain norms of the Federal Law" On the procedure for leaving the Russian Federation and entering the Russian Federation "" Provision on the provision of assistance in insurance cases to citizens of the Russian Federation located on the territory of a foreign state .

Insured events according to the Regulations are determined by the content of the insurance contract concluded by a citizen of the Russian Federation with an insurance organization. It follows from the Regulations that the same rules apply to the medical insurance of citizens traveling abroad as to voluntary medical insurance. Health insurance is a type of personal insurance, while both individuals and legal entities (for example, travel agencies) can act as insurers, and only citizens can be insured.

A person traveling abroad, if he does not want to bear the costs of providing medical care outside the territory of the Russian Federation, determines on his own which insurer to apply for insurance, and of course it must be an insurer licensed to provide VHI. Typically, travel agencies cooperate with insurers and can tell the client the addresses of insurance companies. If a travel agency directs its client to a specific insurer, this does not mean that the insured is obliged to apply to this particular insurance company. The policyholder has the right to freely choose the insurer.

Currently, domestic insurance companies selling VHI policies cooperate with international systems assistance, concluding directly or through an intermediary contract with a company specializing in organizing the provision of medical care and other services in a particular country. A person traveling abroad and choosing an insurer, before concluding an insurance contract with a domestic insurer, must ask the insurer the following questions about:

1) whether this insurance organization has an agreement (agreement) on joint work with foreign assistance companies;

2) what services are provided by the foreign partner to Russian citizens and on what terms;

3) in what territory the insurance policies of this insurance company are valid and what category they are.

When contacting the insurer for the conclusion of a health insurance contract, the insured writes an application. Sum insured selected according to the country of destination and classified according to the need for minimum coverage. The insurer attaches a memo to the contract, which contains instructions on what and how to do in the event of an insured event, when and where to report it, what documents to submit, etc. The instructions also indicate cases in which insurance coverage is not provided (for example , use of alcohol or drugs, participation in fights, rallies, processions, production of crossbows, suicide). In order to avoid problems with medical insurance in a foreign country, its owner must clearly follow the instructions.

Under insurance for persons traveling abroad, the following types of services are provided:

1) emergency medical assistance during a trip abroad in case of a sudden illness or accident;

2) transportation to the nearest hospital capable of providing quality treatment under appropriate medical supervision;

3) evacuation to the country of permanent residence under proper medical supervision;

4) nosocomial control and informing the family and the patient;

5) provision of medical supplies if they cannot be obtained locally;

6) consulting services of a medical specialist (if necessary);

7) payment of transportation costs for the delivery of a sick tourist or his body to the country of permanent residence;

8) repatriation of the remains of a tourist;

9) provision of legal assistance to a tourist in the investigation of civil and criminal cases abroad.

Insured events must be specified in the contract, as well as in the terms and conditions of insurance. Payment of insurance coverage is made if the insured event corresponds to that indicated in the contract. When insuring persons traveling abroad, insured events include death (death), short-term, unexpected, unintentional diseases and accidents (poisoning, injury, etc.) that occurred only in the places provided for by the tour package, and not in random bars , cafes, during pleasure rides on water skis, hang-gliders, horses, etc. Insured events for insurance of persons traveling abroad do not include diseases of a chronic, infectious and recurrent disease (cardiovascular, oncological, tuberculosis, prosthetic and other disease).

Introduction

The policy for the development of domestic health insurance, especially at the level of the constituent entities of the Russian Federation, should be based on the urgent need to create promising legislative and regulatory support not only for the strategy, but also for the tactics of reforms in the field of health insurance.

Therefore, like other social services, the proper management of the reform process is of great importance in the operation of the health insurance system. For more effective legal support of this process, the adoption of regulatory documents is required to create the necessary management structures with a clearer distribution of responsibilities, the establishment of leading management bodies and specific executors at different levels, as well as the definition of the area and level of their legal responsibility.

Currently, the Russian Federation has divided medical insurance into state, municipal and private. Also, a new system of compulsory medical insurance (hereinafter referred to as MHI) has emerged, which has two sectors - budgetary and insurance.

As you know, already in the late 90s. The state of health protection of citizens in the country was defined as critical due to the high mortality rate in all age groups, the lack of sufficient reproduction of the country's inhabitants due to low birth rates and natural population decline, amounting to about 500 thousand people annually. In addition, it should be noted a significant increase in the incidence of infectious diseases, diseases of the nervous system in the Russian Federation, high morbidity and mortality among children and adolescents, a sharp increase in drug addiction and mortality from the use of narcotic drugs, a steady increase in mental disorders, suicides, murders, alcoholism and disability of the population. . Based on this, it should be stated that the current situation is a consequence of the weakening of the state legal regulation in the field of health insurance, a shift in emphasis towards adequate provision of adequate funding and the failure of federal targeted programs in the field of health insurance.

Currently, the country, in my opinion, lacks fundamental comprehensive, especially system-analytical, studies not only on the problem of legal support for health insurance, but also on the implementation of the rights of various subjects of legal relations in the analyzed area.

On the present stage implementation of reforms in the country, Russian health insurance is an important branch of the social sphere, consisting of numerous bodies and institutions of various organizational and legal forms of management that are involved in the provision of insurance services to the population.

Therefore, the most important condition for carrying out reforms in the field of health insurance is the creation of a fundamental legal framework that provides them with prospects and strategies for the further development of the industry. A number of basic laws made it possible to start legal reform.

The urgency of the problem lies in the fact that in connection with the consolidation in the Constitution of the Russian Federation of the right to adopt laws and other regulatory legal acts at the level of the subjects of the Federation, the current federal and regional legislation needs to be supplemented and amended by the legal support of a number of issues of medical insurance. Strengthening the role of law in the insurance sector today is of particular importance, since many legal relations still remain unsettled.

Some authors note that the processes of democratization of our society inevitably lead to the expansion of consumer rights, which include patients. At the same time, the professional responsibility of medical workers is being strengthened. In this regard, there is a need for reasonable legal protection for each of the parties.

All of the above determines the special significance of a systematic legal study of the state of legislation in the field of medical insurance, as well as the technology of legal regulation in this area of ​​the population of the constituent entities of the Russian Federation.

Subject: current state and development of the compulsory health insurance system.

Thus, the purpose of this work is to consider the legal foundations of compulsory health insurance.

Based on the goal, the following tasks can be formulated:

Make an analysis of the positive and negative aspects of the compulsory health insurance model;

Consider the system of financing and use of resources in the system of compulsory health insurance;

Describe the elements of interaction between medical institutions and insurance companies in terms of freedom of choice of a healthcare institution;

To characterize insurance companies in the field of compulsory health insurance;

Describe the problems of interaction between compulsory and medical insurance;

Consider options for improving the Russian model of health insurance.

Object of study: the system of compulsory medical insurance.

The theoretical and methodological basis of this study was the concepts and hypotheses substantiated and presented in modern legal literature. Within the framework of a systematic approach, methods of theoretical analysis were used in the work. The empirical basis of the study is analytical data published in the literature, expert opinions and assessments of Russian lawyers, as well as the author's own conclusions.

A lot of research has been devoted to the issues of the legal foundations of health insurance, and considerable experience has been accumulated in this area. Therefore, it is important to summarize the main provisions in this area. Scientific interest in the problem of health insurance makes us turn to the analysis of the accumulated theoretical material. A great contribution to the development of those currently used was made by domestic scientists Arkhipov A.P., Gomellya V.B., Tulenty D.S., Galaganov V.P., Denisova I.P., Kosarenko N.N., Pimenova E. N., Protas E.V., Rassolova T.M., Roik V.D., Sakhirova N.P., Chernova G.V., Shakhov V.V., Grigoriev V.N., Shiripov D.V. , Shikhov A.K., Shikhov A.A.

1. Organization of medical insurance in the Russian Federation

.1 Development of health insurance in the Russian Federation

The ongoing healthcare reform in Russia, the introduction of compulsory medical insurance, involves a structural, investment restructuring of the industry aimed at increasing the economic and clinical efficiency of its functioning, improving the quality of medical care and ensuring the constitutional rights of the population of the Russian Federation to the state-guaranteed volume of medical care.

The emergence of elements of social insurance and insurance medicine in Russia began in the XVIII - early XIX centuries, when the first mutual benefit funds appeared at the first capitalist enterprises that had arisen. The workers themselves began to create at their own expense (without the participation of employers) mutual aid societies - the forerunners of sickness funds. The first insurance partnership in Russia, which dealt with accident and life insurance, appeared in 1827 in St. Petersburg.

The development and formation of the system of compulsory medical insurance in Russia took place in several stages.

Stage 1. March 1861 to June 1903In 1861, the first legislative act was adopted, introducing elements of compulsory insurance in Russia. In accordance with this law, partnerships were established at state-owned mining plants, and auxiliary cash desks at partnerships, whose tasks included: issuing temporary disability benefits, as well as pensions to participants in the partnership and their families, accepting deposits and issuing loans.

In 1866, a law was passed providing for the establishment of hospitals at factories and factories. According to this Law, employers, owners of factories and factories were required to have hospitals, the number of beds in which was calculated according to the number of workers in the enterprise: 1 bed per 100 employees.

Opened in the 70-80s of the XIX century. in large factories, hospitals were small and could not provide for all those in need of medical care. In general, medical care for factory workers was extremely unsatisfactory.

Factory insurance offices began to be created at the beginning of the 20th century. mainly at large enterprises in Moscow and St. Petersburg. The principles of their organization and functioning were similar to Western European ones.

Stage 2. June 1903 to June 1912Of particular importance in the development of compulsory health insurance in Russia was the Law “On the remuneration of citizens who suffered as a result of an accident, workers and employees, as well as members of their families at enterprises of the factory, mining and mining industry” adopted in 1903. Under this Law, the employer was liable for damage caused to health in case of accidents at work, the obligation of the entrepreneur and the treasury to pay remuneration to the victims or members of their families in the form of benefits and pensions was envisaged.

Stage 3. From June 1912 to July 1917In 1912, the III State Duma did a lot for the social renewal of the country, including on June 23, 1912, the Law “On Insurance of Workers in Case of Sickness and Accidents” was adopted - a law on the introduction of compulsory medical insurance for working citizens.

In January 1914, insurance partnerships began to appear to provide workers in case of accidents. According to the law of 1912, medical assistance at the expense of the entrepreneur was provided to the participant of the sickness fund in four types:

.Initial assistance in case of sudden illnesses and accidents;

.Ambulatory treatment;

.obstetrics;

.Hospital (bed) treatment with the full content of the patient.

By 1916, there were already 2,403 sickness funds in Russia, with 1,961,000 members. Such cash desks existed before the revolution, and after the adoption of the ban on the introduction of a state monopoly in insurance, they lost not only their relevance, but also their legitimacy.

Stage 4. From July 1917 to October 1917.After the February Revolution of 1917, the Provisional Government came to power, which, from the first steps of its activity, began reforms in the field of compulsory medical insurance (Novel dated 07/25/1917), including the following main conceptual provisions:

expansion of the circle of the insured, but not for all categories of workers (since it was technically impossible to do it all at once, the categories of the insured were singled out);

granting the right to sickness funds to unite, if necessary, into general funds without the consent of entrepreneurs and the Insurance Presence (county, citywide health funds);

increased requirements for independent health insurance funds in terms of the number of participants: they had to have at least 500 people;

full self-management of sickness funds by employees, without the participation of entrepreneurs. The provisional government adopted four legislative acts on social insurance, which seriously revised and corrected many shortcomings of the Law adopted by the Third State Duma in 1912.

Stage 5 October 1917 to November 1921The Soviet government began its activities on the reform of social insurance with the Declaration of the People's Commissar of Labor of October 30 (November 12), 1917 on the introduction of "complete social insurance" in Russia.

The main provisions of the Declaration were as follows:

the extension of insurance to all hired workers without exception, as well as to the urban and rural poor;

distribution of insurance for all types of disability (in case of illness, injury, disability, old age, motherhood, widowhood, orphanhood, unemployment).

The reforms carried out by the Soviet government contributed to the implementation of full social insurance on the basis of complete centralization.

February 1919 V.I. Lenin signed the Decree "On the transfer of the entire medical part of the former hospital funds to the People's Commissariat of Health", as a result of which the entire medical business was transferred to the People's Commissariat of Health and its local departments. Thus, by this Decree, cash medicine was abolished. The results of such a reform at first in the fight against infectious diseases were quite convincing. The incidence of social diseases (tuberculosis, syphilis, etc.), infant mortality, etc., have significantly decreased.

Stage 6 November 1921 to 1929Since 1921, a new economic policy (NEP) was proclaimed in the country, and the Government again turned to the elements of insurance medicine, as evidenced by the decisions of the Council of People's Commissars and the All-Russian Central Executive Committee for the period from 1921 to 1929.

On 11.1921, the Decree “On Social Insurance of Persons Engaged in Wage Labor” is issued, according to which social insurance is reintroduced, covering all cases of temporary and permanent disability. For the organization of social insurance in case of illness, insurance premiums were established, the rates of which were determined by the Council of People's Commissars and differentiated depending on the number of people employed at the enterprise and working conditions.

According to the Decree of the Council of People's Commissars No. 19 Art. 124 of March 23, 1926, the following operating funds were formed from all social insurance funds:

)Funds directly at the disposal of social insurance bodies.

)Funds for medical assistance to the insured (FMPZ), which are at the disposal of the health authorities.

Stage 7. 1929 to June 1991This stage can be characterized as a period of public health, during which, due to objective political and economic situation the residual principle of financing the health care system has been formed.

In Soviet times, there was no need for medical insurance, since there was universal free medical care, and the healthcare sector was completely maintained at the expense of state budget, government departments, ministries and social funds of the enterprises themselves.

Stage 8. From June 1991 to November 2010With the adoption of the Law of the RSFSR "On the health insurance of citizens in the RSFSR" on June 28, 1991, we can begin to talk about a new stage in the development and further promotion of the socially significant idea of ​​compulsory medical insurance in our country.

During the period of economic and social reforms, a sharp decline in living standards, and an acute shortage of budgetary and departmental funds for the maintenance of medical institutions, in 1991 a law was adopted on the introduction of medical insurance for citizens in Russia in two forms: compulsory and voluntary. Moreover, all the provisions of this law that related to compulsory health insurance were put into effect only from 1993. Until that time, it was necessary to prepare an organizational and regulatory framework for managing and financing the new state insurance system.

Stage 9 November 2010 to present.On January 1, 2011, the Federal Law “On Compulsory Medical Insurance in the Russian Federation” dated November 29, 2010 No. 326-FZ came into force. The insured persons have new rights and obligations. The law provides for the development of basic and territorial programs of compulsory medical insurance.

.2 Compulsory health insurance system in Russia

Compulsory health insurance (CHI) 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. 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 health insurance, sets the rates of contributions, the circle of insurers, and creates special state funds for the accumulation of contributions for compulsory health 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 state programs of compulsory medical insurance. The health of the population is the most important element of the social, cultural and economic development country.

In this regard, providing the population with a guaranteed volume of free medical care, financed from the budgets of all levels and funds from compulsory health insurance, is the most important state task. And this provision is especially emphasized in the Program for the Socio-Economic Development of the Russian Federation for the Medium Term.

Central problems of compulsory health insurance

In the current economic situation, maintaining state obligations to provide free medical care on a universal basis is practically unrealistic. Under the most favorable conditions (implementation of the obligations of the state budget for compulsory medical insurance contributions, attraction of additional sources of financing), financial resources will not be enough to ensure free of charge all types of medical care. At the same time, it is important to take into account that the excessive obligations of the state lead to a deformation of economic relations in the industry, since in the context of an imbalance in compulsory health insurance programs, the possibilities of full-fledged contractual relations between the financing party and medical institutions are limited, and hence the increase in the efficiency and quality of medical care. This violates the most important condition for the implementation of health care reform - the predictability of the flow of financial resources.

No less obvious is the negative social and political effect of excessive declarativeness of state obligations: free medical care is becoming more and more illusory, and public dissatisfaction with the state of health services is growing. Having declared medical care completely free of charge, the state is increasingly losing the ability to provide such assistance to those who need it most. At the same time, the shadow market of medical services is activated, with far-reaching social and economic consequences. On the one hand, physicians are more responsive to incentives emerging in the shadow economy than to attempts by insurers to build a reasonable performance-based pay system in the public health sector. On the other hand, patients are sometimes forced to pay out of their own pocket amounts that do not correspond to the real contribution of physicians.

Within the framework of compulsory health insurance, the provision of outpatient and inpatient care provided in healthcare institutions, regardless of their organizational and legal forms, and the provision of first aid are guaranteed.

The amount of damages compensated for claims satisfied in court increases every year. The importance of conducting a non-departmental examination of the quality of medical care should not be underestimated. In fact, we divided the functions of providing medical care and the functions of its assessment between the subjects, involving professionally trained highly qualified specialists in protecting the interests of patients.

In this situation, it is necessary to abandon the declarations and soberly assess the financial possibilities of healthcare. In practice, this means the need to adopt a new procedure for the formation of the basic CHI program. The minimum social standard, below which the volume and conditions for the provision of medical care in the territorial CHI programs cannot be established, must be approved together with the amount of the CHI contribution and budget revenues necessary to achieve this standard.

The government develops and submits the basic CHI program, along with financial and economic justifications, for approval by the State Duma.

To avoid excessive declarative obligations under the basic CHI program, it should be calculated as a minimum social standard in the form of a minimum funding standard per inhabitant. This standard should be a guideline for calculating the territorial CHI program at the level of a subject of the federation. In other words, each territory should have its own basic program in the amount of minimum state obligations. After evaluating its capabilities, the subject of the federation accepts additional obligations, which are financed in the territorial program of compulsory medical insurance.

Members of the compulsory health insurance system

The main participants in the compulsory health insurance system, in addition to citizens, are the insurers themselves and the insurers themselves.

Policyholders in the CHI system are individuals and legal entities that have entered into an insurance contract with an insurer. The insurers for the working population are enterprises, institutions, organizations, self-employed persons and freelancers; for the unemployed - executive authorities of different levels.

CHI insurers, i.e. those who pay insurance premiums to provide all citizens with health insurance are employers and local executive authorities.

Employers are required to pay insurance premiums for the working population. The rate of insurance premiums is set by federal law and currently amounts to 5.1% of the wage fund. The rules for calculating and paying insurance premiums are presented in the Instructions on the procedure for collecting and accounting for insurance premiums (payments) for compulsory health insurance, approved by the Decree of the Council of Ministers of the Government of the Russian Federation of October 11, 1993 No. 1018. In accordance with this document, insurance contributions to compulsory medical insurance funds are required to be paid by all business entities, regardless of ownership and organizational and legal forms of activity.

Public organizations of the disabled and enterprises, associations, institutions that are owned by them and established for the implementation of their statutory goals are exempted from paying insurance premiums for compulsory medical insurance.

Policyholders are responsible for the correct calculation and timely payment of insurance premiums. For violation of the procedure for paying insurance premiums, various financial sanctions (fines, penalties) are applied to them.

The amounts of accrued contributions are paid to the CHI funds monthly, no later than the 15th day of the next month. The amount of contributions in the amount of 5.1% of the payroll fund is transferred to the account of the territorial CHI fund, and 0.2% - to the account of the federal MHIF.

Compulsory medical insurance funds are independent state credit institutions that implement the state policy in the field of compulsory medical insurance. CHI funds are designed to accumulate insurance premiums, ensure the financial stability of the state CHI system and equalize financial resources for its implementation.

Federal CHI funds are created supreme body legislature and the Government of the Russian Federation. Territorial CHI funds are created by the relevant legislative and executive authorities of the constituent entities of the Federation. Financial resources of compulsory medical insurance funds are state-owned by the Russian Federation, are not included in budgets, other funds and are not subject to withdrawal.

The third level of insurance in the CHI system is represented by the Federal Compulsory Medical Insurance Fund (FFOMS), which carries out general regulatory and organizational management of the CHI system. He himself does not carry out insurance operations and does not finance the compulsory medical insurance system of citizens. The Fund was created to implement the state policy in the field of health insurance, and its role in the MHI is reduced to the general regulation of the system, which is achieved both through the regulatory regulation of the main provisions of the MHI in the territory of the Russian Federation, and through financial regulation of the implementation of medical insurance for citizens in the subjects of the Federation .

The MHIF is an independent state non-profit financial and credit institution, accountable to the Legislative Assembly and the Government of the Russian Federation. The budget of the fund and the report on its implementation are approved annually by the State Duma.

The fund's financial resources are formed from part of the insurance premiums of enterprises (0.2% of the FOP), contributions from territorial compulsory medical insurance funds for the implementation of joint programs and other sources determined by the legislation of the Russian Federation.

The fund's activities are managed by its board and permanent executive directorate. The board includes representatives of federal legislative and executive authorities and public associations.

The th level of organization of compulsory medical insurance is represented by territorial compulsory medical insurance funds and their branches. This level is the main one in the system, since it is the territorial funds that collect, accumulate and distribute the financial resources of the MHI.

Territorial MHIFs 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 representative and executive authorities.

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:

parts of insurance premiums paid by enterprises for compulsory health insurance of the working population (5.1% payroll);

funds provided in the budgets of the constituent entities of the Russian Federation for compulsory medical insurance of the non-working population;

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

The main task of the TFOMS is to ensure the implementation of compulsory medical insurance 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.

TFOMS collect insurance premiums for compulsory medical insurance, finance territorial compulsory medical insurance programs, conclude contracts with insurance medical organizations to finance ongoing compulsory medical insurance programs in accordance with approved standards. They carry out investment and other financial and credit activities, form financial reserves to ensure the sustainability of the functioning of compulsory medical insurance, equalize financing conditions, develop and approve the rules for compulsory medical insurance of citizens in the relevant territory, organize a data bank for all insurers and monitor the procedure for calculating and timely payment of insurance premiums and perform other important functions.

The th level in the implementation of compulsory health insurance is represented by medical insurance organizations (HIOs). It is they who, by law, are given the direct role of the insurer. HMOs receive financial resources for the implementation of compulsory medical insurance from the TFOMS according to per capita standards, depending on the size and age and sex structure of the population insured by them, and make insurance payments in the form of payment for medical services provided to insured citizens.

HMOs have the right to simultaneously conduct compulsory and voluntary medical insurance of citizens, but are not entitled to carry out other types of insurance activities. At the same time, financial resources for compulsory and voluntary insurance are accounted for by HMOs separately. HMOs do not have the right to use the funds transferred to them for the implementation of MHI for commercial purposes.

HMOs act as an intermediary between citizens, medical institutions (HCIs) and funding organizations - territorial CHI funds.

The activities of the CMO represent the final stage in the implementation of the provisions of the MLA. Insurance medical organizations are an important link in the system of compulsory medical insurance. The purpose of an insurance medical organization is to ensure payment for medical care, monitor the completeness and quality of medical services provided and protect the rights of insured persons.

2. Legal regulation of compulsory health insurance

.1 Problems of implementation of social guarantees in the system of compulsory health insurance

Insurance mechanisms, being universal guarantors of security various kinds risks are actively used in most countries with a market economy and borrowed by Russian practice. The social sphere is no exception.

Minor history of insurance development in modern Russia shows, however, its significant growth in the early 1990s, which is explained by the introduction of insurance instruments to ensure the social obligations of the state, including the introduction of compulsory medical insurance.

The priority of the development of insurance in the social sphere is also perceived in the provisions of the Constitution of the Russian Federation, which proclaims the promotion of voluntary social insurance, and guarantees of free medical care are provided at the expense of the relevant budget, insurance premiums, and other revenues.

Over the long period of development of the system of compulsory health insurance, a very significant number of regulations have been adopted, the main, basic of which is the Law of the Russian Federation of June 28, 1991 No. 1499-1 "On health insurance of citizens in the Russian Federation" (hereinafter - Law No. 1499- 1), which fixed in its norms the foundations of health insurance. This normative act was largely associated with the transition period of the healthcare system, and at a certain stage it had already ceased to fulfill the tasks assigned to it. The main problems of the law can be reduced to certain critical remarks that do not pretend to be exhaustive and absolute. At least for today, the problems faced by the field of compulsory health insurance are more than obvious.

As an initial (and main) remark, one can note the inconsistency of Law No. 1499-1 in its content with modern requirements for the organization of compulsory state social insurance: it did not spell out effective mechanisms for ensuring the rights of citizens to free medical care, from which all related problems arise .

A significant, if not the main, problem was the inadequate definition of the priorities of the law, the shift of which went far away from the health insurance system itself. The central element of the system is the insured person - a citizen endowed with a certain set of rights and obligations in the area under consideration. The provision of medical care to citizens within the framework of CHI often depended on the utilitarian interests of insurers, who had the opportunity to choose insurance medical organizations involved in the provision of medical services. Thus, the citizen was actually eliminated from participating in the choice of an insurance medical organization. The legislator, perhaps, seriously miscalculated, giving the right of choice, along with the insured person, to the insured, who, for objective reasons, uses his right in a preferential manner.

The financial instruments of the legislation also turned out to be insufficient. There was no requirement to pay for medical services in the field of CHI at the full rate, apparently in order to save financial resources.

The lack of financial leverage hindered the formation of market principles in medical activity, which determine the presence of organizations of various forms of ownership in this area. This situation inevitably artificially limited the right of a citizen to freely choose a medical organization, and ultimately undermined the competitive principles in health insurance and the organization of medical care.

Another related problem of financial standards can be called the lack of requirements for the amount of insurance premiums for non-working citizens on the part of state authorities of the constituent entities of the Federation.

Given the wide geography of Russian regions and heterogeneous economic opportunities, the financial provision of medical care acquires significant differences. For these reasons, the quality and volume of medical care often depend on the level of economic well-being of the subject of the Federation, which reduces the guarantees of equal access for citizens of the relevant categories to medical services.

The problems of subjects of the CHI system are not limited to the status of insured citizens and also concern the Federal Compulsory Medical Insurance Fund (FFOMS) and its territorial divisions.
The legislation did not have a clear definition of the legal status of the Federal Fund. In particular, the lack of a clear definition of the powers within the framework of the fund's functions, which are generated primarily by the problems of its organizational and legal form, can be considered as a negative point. Among other things, problems in the field of accounting for insured persons can be noted.

A separate flaw is the imperfection of the management structure of the compulsory health insurance system.

2.2 The modern concept of compulsory health insurance in the mechanism of ensuring the rights of citizens to medical care

The concept of the long-term socio-economic development of the Russian Federation for the period up to 2020, approved by the Decree of the Government of the Russian Federation dated November 17, 2008 No. 1662-r, states: the healthcare system does not yet ensure the sufficiency of state guarantees of medical care, its availability and high quality . The main goal of the state policy in the field of healthcare for this period is to form a system that ensures the availability of medical care and increase its effectiveness. As the most important task, the Concept provides for the modernization of the system of compulsory medical insurance and the development of a system of voluntary medical insurance, including:

implementation of the transition to a single-channel model of financing medical care in the system of compulsory medical insurance, including the legislative consolidation of revenue sources and expenditure obligations;

introduction of insurance premiums for compulsory health insurance at a single rate for all employers and individual entrepreneurs;

introduction size limit annual earnings, on which insurance premiums are calculated;

the establishment of uniform requirements for determining the amount of contributions of the constituent entities of the Federation for compulsory medical insurance of the non-working population;

creation of an effective system for equalizing the financial support of territorial programs of state guarantees for the provision of free medical care to citizens on the basis of the minimum per capita standard of the territorial program of state guarantees;

increasing the responsibility of insurance medical organizations with the introduction of a single-channel financing model for healthcare organizations participating in compulsory medical insurance;

a phased transition to effective methods of paying for medical care based on reasonable tariffs, depending on the quality of its provision and volume;

creation of a quality management system for medical care;

formation of a competitive model of compulsory health insurance with the creation of conditions for the insured to choose an insurer and a medical organization, as well as providing the population with accessible information about the activities of insurers and medical organizations;

creation of conditions for the participation of medical organizations of various organizational and legal forms in compulsory medical insurance.
The development of conceptual ideas within the framework of the formation of a targeted state policy in health care, which determine the implementation of the relevant norms of the Constitution of the Russian Federation, required the development of a normative act that adequately perceives the elements of the modernization of compulsory health insurance. Full regulation of the issues of compulsory health insurance is possible only within the framework of rethinking the problems of practice and building on its basis a qualitatively new legal mechanism, which is reflected in the Federal Law of November 29, 2010 No. 326-ФЗ “On Compulsory Medical Insurance in the Russian Federation” (hereinafter - Law on CHI, Law No. 326-FZ). In its provisions, Law No. 326-FZ contains key tools for achieving long-term goals and objectives.

In general, the CHI Law is aimed at strengthening the guarantees of the rights of insured persons to free medical care, the main provisions of which correspond to the Federal Law of July 16, 1999 No. 165-FZ “On the Basics of Compulsory Social Insurance”.

First of all, it is necessary to pay attention to the principles of legislation in the field of social insurance, which are fully perceived in the fundamental ideas of the Law on CHI:

the universal nature of compulsory health insurance;

state guarantee of protection of insured persons from social risks;

autonomy financial system compulsory health insurance.

First of all, positive novelties are associated with a clearer perception of the rights of insured persons.

The basic rights of citizens, reflecting, in fact, the principles in the field of healthcare and compulsory medical insurance, are enshrined in the Fundamentals of Legislation on the Protection of Citizens' Health. The rights of citizens in the health insurance system are directly established by Article 16 of the Law on CHI, which determines that citizens of the Russian Federation have the right to:

compulsory 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;

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 policyholder, medical insurance organization, medical institution, including for material compensation for damage caused through their fault, regardless of whether it is provided for in the health insurance contract or not;

repayment of a part of insurance premiums for voluntary medical insurance, if this is determined by the terms of the contract.

These fundamental postulates determine the content of the compulsory health insurance system within the healthcare system.

Formation modern system health care following the introduction of the so-called new economic mechanism, since 1992, is based on social (compulsory health) insurance, organically combining the features of public and private health care.

With this, first of all, one of the main goals of the Law on CHI is associated - ensuring market principles in the healthcare sector, which can be ensured by the development of competition.

In order to improve the quality of medical care for insured citizens, the Law ensures the creation of a competitive environment between medical organizations. Fulfillment of competitive conditions implies activity on an equal footing in the system of compulsory medical insurance of medical organizations and those with property in any form of ownership provided for by the legislation of the Russian Federation. In addition to organizations of any form of ownership, medical organizations in the field of CHI include individual entrepreneurs engaged in private medical practice. At the same time, organizations and individual entrepreneurs should have the right to carry out medical activities and be included in the register of medical organizations operating in the field of CHI.

The main problem solved by the legislator is the elimination of administrative barriers for the admission of subjects to the market of medical insurance services. In particular, a declarative procedure for the entry of specialized organizations is provided, which excludes any permitting actions of the competent authorities. Medical organizations will not require the decision of the state authorities of the constituent entities of the Federation on their participation in the system of compulsory medical insurance.

In order to increase the availability of medical care to insured citizens by including private medical organizations in the system of compulsory medical insurance, the Law provides for the possibility of switching to predominantly single-channel financing of healthcare organizations through the system of compulsory medical insurance in connection with the establishment of payment for medical care at a tariff that includes all items of expenditure.

Moreover, new law to a greater extent specifies and quite clearly defines the legal status of all subjects of compulsory health insurance and the mechanism of their interaction.

Based on the principle of universal provision of social insurance, the corresponding risks are extended to all categories of the population, i.e. the insured persons include working and non-working citizens of the Russian Federation. The scope of health insurance covers the foreign element, which actually enjoys the national legal regime applicable to residents. Permanently or temporarily residing on the territory of the Russian Federation Foreign citizens and stateless persons have the same rights and obligations in the compulsory health insurance system as Russian citizens.

Insurance of children from birth to state registration of birth is carried out by an insurance medical organization in which their mothers or other legal representatives are insured; other legal representatives.

The law is more focused on ensuring the realization by citizens - insured persons of their rights. The legislator excluded the right of the employer and state authorities of the constituent entities of the Federation to choose insurance medical organizations, and leaves such a right only to insured persons. Here it should be said that the opinions of specialists in the framework of considering the problems of the previous law were more cautious, and were reduced to the exercise by the insured of the right to choose an insurance company only with the consent of the person in respect of whom the contract of compulsory medical insurance is concluded. Today, the role of the employer in the compulsory health insurance system is reduced to a technical function, since by concluding an agreement, the insured implements the rights of employees.

At the same time, rules were formulated on the possibility of insured persons not only to choose, but also to replace the insurance medical organization chosen by them with another one, while insurance medical organizations have no right to refuse such a choice. The insured person can replace the insurance medical organization once during the calendar year no later than November 1, or more often in case of a change of residence.

The right to choose a health insurance organization is closely related to the choice of organizations providing medical care. In the field of healthcare, the identity of the subject providing the medical service really matters. This circumstance determines the quality of the services provided, along with their specific property. As F. Kotler rightly believes, “a service is inseparable from its source, be it a person or a machine, while a commodity exists in material form regardless of the presence or absence of its source.”

It is the different qualitative composition of essentially homogeneous services that should ensure the choice of the most acceptable of them in order to best meet the interests of a person in health care, taking into account his natural physical properties and characteristics of the body. It is no coincidence that in the literature, some specialists associate the quality of insurance for a citizen in the medical field with providing the opportunity to receive medical care in the best medical and preventive institutions.

Therefore, the full implementation in practice of the principle of freedom of choice and the quality of medical services is possible only with simultaneous observance of the choice of the insurer and the medical organization, up to the definition of a specific specialist (doctor). The only condition is the presence of a medical organization in the system of compulsory medical insurance.

An accompanying tool in ensuring the right to choose is the information support of the insured population in choosing the market for insurance and medical services in the region. Territorial compulsory health insurance funds post information about medical organizations and insurance medical organizations operating in the system of compulsory health insurance on Internet sites and provide free access to such information.

Positive changes, dictated rather by the peculiarities of the exercise by insured persons of their right to choose, relate to the simplification of the mechanism for replacing insurance and medical organizations, and, first of all, technical design. We are talking about a compulsory health insurance policy, which had to be reissued every time the insurer was changed. Now the legislator has established a rule on issuing to insured persons a medical insurance policy of a single sample that does not require replacement when changing an insurance medical organization and is valid throughout the Russian Federation.

An important role in the implementation of state policy in healthcare is to be played by systems of economic incentives that motivate medical insurance organizations to control the quality of medical care and ensure the realization of the rights of insured persons.

Firstly, it is possible to establish incentives for insurance medical organizations depending on the health indicators of the insured persons, which will encourage insurance medical organizations to promote the implementation of preventive measures in medical organizations, the introduction of the most effective methods of treatment, and the conclusion of contracts with the most successfully operating medical organizations.

Secondly, the possibility of applying civil liability measures to insurance medical organizations and medical organizations is also an incentive tool. The insured person has the right to compensation for damage in connection with the non-fulfillment or improper fulfillment by the insurance medical organization and the medical organization of the obligations for organizing medical care under compulsory medical insurance.

In this regard, the issues of the mechanism of compensation for the damage caused to the victims come to the fore. According to scientific studies, not only the legal status of a medical organization, the procedure for its financing, the rights and obligations of a medical worker, etc., but the insurance of the risks of poor-quality medical care, a clear delineation of civil and professional liability in medicine deserve attention.

The previously effective Law on Health Insurance contained negative points, and not least criticism of its norms, including the judicial one, concerned the protection of the rights of insured persons, since this is the most important guarantee of the realization of the rights of citizens in the field of healthcare.

In particular, Article 6 of the Law determined the right of a citizen to bring claims against an insurer, an insurance medical organization, a medical institution. This created additional difficulties in obtaining the necessary reimbursement, as noted in the literature. As can be seen from the fixed normative structure, the receipt of the compensation itself was made dependent on the citizen's appeal to the court with the corresponding claim, in the absence of any guarantees of its satisfaction.

Attention should also be paid to the general mechanism of proof, since when filing such claims, the patient encounters difficulties arising from the essence of the service itself and the elements that form a harmful result. Speech to a certain extent in accordance with paragraph 1 of Art. 1085 of the Civil Code of the Russian Federation is about compensation for property damage (actual damage and lost profits), which is confirmed by the generalizations of the highest judicial instances regarding moral damage. However, such harm is compensated in cash, despite its non-property nature (Article 151 of the Civil Code of the Russian Federation). Actually, the similar nature of the harmful result makes it possible to reflect the claims of both property and non-property nature in the content of the insurer's claim for material compensation for harm.

Legislation on the protection of consumer rights (Law of the Russian Federation of February 7, 1992 No. 2300-1 "On Protection of Consumer Rights"), as well as arbitrage practice fully applies to the provision of medical services, free of charge for the patient (consumer), but paid at the expense of compulsory medical insurance. At the same time, Law No. 2300-1 provides maximum legal protection to the victim of poor-quality provision of services in private medical organizations.

However, as some experts note, the courts do not always take the side of the injured patient when providing them with medical care within the CHI system, which leads to serious distortions, and in fact the introduction of "double standards" in regulating issues of paid and free medicine.

In addition, according to A. Samoshkin, it requires the definition and differentiation of the categories of the insured population - consumers of health care services and drug provision.

The very quality of medical services is defined in different ways. There are also characteristics of causing harm to the patient's health, when, for example, poor-quality medical care is associated with a deterioration in the patient's health compared to what it was before it was provided (medical intervention).

In departmental regulations, in particular the documents of the FFOMS, the concept of "medical care of proper quality" is given. In the Guidelines, approved. By order of the Federal Compulsory Medical Insurance Fund dated September 6, 2000 No. 73, medical care of inadequate quality (poor-quality medical care) is understood as medical care provided by a medical worker, excluding negative consequences:

making it difficult to stabilize or increase the risk of progression of the patient's disease, increasing the risk of a new pathological process;

leading to suboptimal use of the resources of a medical institution;

causing dissatisfaction of the patient from his interaction with the medical institution.

It is quite reasonable to assume that the quality of medical services depends on the skill and professionalism of the executing doctor, medical personnel, on their conscientiousness and skill, on the availability of appropriate modern medical and technical means. According to Yu. Andreev, the degree of consolidation of quality issues, legislative and contractual regulation of responsibility for its non-compliance is of great importance.

However, the need to develop regulatory framework governing the issues of effective protection of the rights of affected patients is a very relevant topic. Actually, the definition of sources Money when imposing fines on organizations and individual medical workers, it will help improve the quality of medical care.
The legislator does not always carry out consistent work, and specific areas of public relations (interests) are left without proper protection, and adjustments are episodic. In fairness, it should be noted that changes have been made to the current legislation on administrative responsibility, and the Code of the Russian Federation on administrative offenses supplemented by articles 15.32 “Violation of the registration period established by the legislation of the Russian Federation on compulsory social insurance” and 15.33 “Violation of the procedure and deadlines for submitting documents and (or) other information to state authorities established by the legislation of the Russian Federation on compulsory social insurance off-budget funds”, which highlight the responsibility of officials directly to the off-budget fund. However, such adjustments generally do not eliminate problems in regulating all issues of fulfillment of accounting and financial obligations and protecting the rights of patients and encouraging employees of medical organizations to properly perform their professional duties in the established area.

In this regard, it should be stated that medical institutions, regardless of their form of ownership, within the framework of a unified healthcare system are given equal legal status, which will contribute to the formation of a general idea of ​​the status and patients of such organizations, the possibility of disseminating the provisions of legislation on the protection of the rights of consumers of their services.

It seems that this will also be facilitated by control and supervisory measures. In order to ensure the realization of the rights of insured persons, the law provides for control over the volume, timing and quality of medical care provided to insured persons by medical organizations. Medical assistance must comply with the volumes and conditions corresponding to the territorial program of compulsory medical insurance and the contract for the provision of medical assistance under compulsory medical insurance through medical and economic control, medical and economic examination, examination of the quality of medical care. The procedure and mechanism for their implementation is determined. Control functions are provided by the mandatory health insurance funds in order to ensure the protection of the interests of the insured persons.

Of particular importance in the system of compulsory health insurance is protection against financial risks which is reflected in the provisions of the new Law. For these purposes, it is envisaged to establish reserves in insurance medical organizations. The reserve can be used to pay for medical care, in case of insufficient funds from the medical insurance organization to pay for medical care provided to insured persons.

The functions of the reinsurer in the system of compulsory medical insurance are performed by the Federal Compulsory Medical Insurance Fund, which forms a normalized insurance reserve and a reserve for financing preventive measures. The reserve of financial support for preventive measures is a tool for reducing the costs of providing medical care and stimulating medical institutions that achieve the best results in the treatment process.

The system for organizing personalized (individual) accounting in the system of compulsory medical insurance has been significantly modernized by introducing a single information space within the CHI system

.3 Regulatory regulators of the compulsory health insurance system

The legal foundations of compulsory health insurance are formed by regulations of various levels, and traditionally they include the Constitution of the Russian Federation, federal laws, laws of the constituent entities of the Federation, norms of international treaties, and explanatory documents. In the latter case, this refers to the publication of clarifications by the authorized executive authorities for the purpose of uniform application of the norms of the legislation on compulsory medical insurance.

Regional rule-making is designed to reflect the territorial features in the field of compulsory health insurance. However, this process is often plagued by general problems in the formation of legal acts that do not always take into account the system of legislation. The use of a systematic approach in the development of regional laws is increasingly supported by specialists, since it allows to overcome the inevitable conflicts in relation to the norms. federal law, strengthen legal discipline.

Important elements of the legal regulation of CHI are territorial programs of compulsory medical insurance. The Territorial Program of Compulsory Medical Insurance (CMI) is an integral part of the Territorial Program of State Guarantees for the Provision of Free Medical Care to Citizens, developed and approved in the constituent entity of the Federation in accordance with the procedure established by the Government of the Russian Federation. The territorial CHI program defines the rights of insured persons to free medical care on the territory of a constituent entity of the Federation and meets the uniform requirements of the basic program of compulsory medical insurance.

However, the creation of such documents often goes beyond the scope of regional rule-making. Subjects of the Federation, and after them municipalities take an active position in the development and implementation of compulsory medical insurance programs for citizens, which in the latter case allows us to talk about the "lawmaking" of local governments in this area.

The designated legal instruments form the basis of the legal regulation of compulsory health insurance. However, in order to implement the norms of the Law on Compulsory Medical Insurance, a significant amount of subordinate regulatory framework is required, which makes it possible to ensure in practice the mechanism of compulsory medical insurance. About 40 such acts are required, and some of them have already been adopted or are being prepared for adoption.

In particular, in the area under consideration, they have already been published: for example, Decrees of the Government of the Russian Federation dated February 15, 2011 No. 74 “On the rules of compulsory medical insurance”, dated December 31, 2010 No. 1225 “On the placement of temporarily free funds of the Federal Compulsory Medical Fund insurance and territorial funds of compulsory medical insurance”, dated December 31, 2010 No. 1227 “On the specifics of licensing the activities of insurance medical organizations in the field of compulsory medical insurance and the invalidation of certain acts of the Government of the Russian Federation”, dated February 7, 2011 No. 60 “ On the procedure for implementing measures to increase the availability of outpatient medical care, carried out within the framework of regional programs modernization of healthcare in the constituent entities of the Russian Federation”, Orders of the Ministry of Health and Social Development of Russia dated December 23, 2010 No. 1168n “On Approval of the Procedure for Registration and Deregistration of Insurers for Non-Working Citizens by Territorial Compulsory Medical Insurance Funds”, dated December 23, 2010 No. 1169n “On Approval forms of calculation for accrued and paid insurance premiums for compulsory medical insurance of the non-working population", dated December 30, 2010 No. 1229n "On approval of the procedure for using the funds of the normalized insurance reserve of the Federal Compulsory Medical Insurance Fund", dated January 21, 2011 No. 15n "On approval of the model regulation on the territorial fund of compulsory medical insurance”, dated January 25, 2011 No. 29n “On approval of the procedure for maintaining personalized records in the field of compulsory medical insurance”, etc.

medical insurance financing

2.4 Obligations in the compulsory health insurance system: legal nature and design

Structural policy in the insurance services market is currently on the path of finding the optimal ratio of proportions in voluntary and compulsory types of insurance. Compulsory health insurance is a type of compulsory social insurance. For this type of insurance, the insurers are, along with insurance medical organizations, compulsory medical insurance funds.

According to V.S. Belykh, “legal relations established within the framework of any type of compulsory insurance are characterized by a public character. At the same time, compulsory medical insurance is quite naturally included in this area.

However, according to M.D. Suvorov, compulsory insurance, based on its legal and technical placement in the norms of civil law, is only a sphere of regulation of civil law. At the same time, the author does not take into account the sign of "obligation" as not having a decisive significance for determining the nature (private or public) of legal regulation. The main purpose of compulsory insurance, in his opinion, is to protect private interests.

However, in the periodical literature they talk about the need for a clear correlation between public and private principles in the field of compulsory health insurance. According to V.Yu. Stetsenko, state intervention should be determined by the laws of the market, which determine the predetermined boundaries of public interests. The fairness of this remark can hardly be denied against the background of the demonopolization of the sphere social security.

However, it is unnecessary to transfer compulsory insurance to the area of ​​private law relations in advance, since here voluntary principles, the discretion of the subjects, and the discretion of the parties are mainly used. Such a legal background, being an accompaniment of insurance obligations, will inevitably give rise to problems in the implementation of the insurance mechanism, thereby preventing the insured citizens from exercising their rights.

Carrying out the correlation of the properties of the contractual regulation of CHI, it seems quite logical to distinguish between public and private elements in the obligations provided for by law.

It is necessary to take into account the nature of the contract in the field of compulsory medical insurance, which, based on the analysis of its content, has a heterogeneous, rather, multi-sectoral character. Actually, it is impossible to reduce contractual relations in the field of CHI only to the norms of public law and order, which is embodied in an administrative contract.

Its features are very clearly identified by scientists in the middle of the last century. The main satellites of the administrative contract are the inequality of the parties to its participants, the regulation of relations by acts of public administration, administrative responsibility for non-fulfillment of contractual terms.

The contract reflects the coordinated actions of the participants, expressing their mutual expression of will. V.R. Idelson characterized insurance as a bilateral transaction, with mutual rights and obligations for each party, which is also perceived in modern literature. The contract reflects the coordinated actions of the participants, expressing their mutual expression of will.

When providing medical services, payment for a patient is usually made through the system of compulsory health insurance, and therefore the remuneration of the provision of such medical services is not as obvious as, for example, in the field of ordinary household services, where the citizen himself deposits money into the contractor's cash desk.

According to G.R. Kolokolov and N.I. Makhonko, the object of medical insurance is the insured risk associated with the costs of providing medical and diagnostic services in the event of an insured event.

Actually, health insurance itself, being a kind of social insurance, is organically included in the number of institutions of social security law.

However, we should not forget: relations in this area are built mainly with the help of civil law regulators, in particular, general provisions and norms on insurance. At the same time, the public nature of compulsory health insurance is not diminished even by the significant presence of the civil law element and the norms of insurance law, despite the significant predominance of private principles in this dichotomy. A clear example of public interest in this area is the management of social funds exclusively by the state.

The implementation of the right of the insured person to free medical care in the system of compulsory medical insurance is established on the basis of agreements concluded between subjects of compulsory medical insurance.

The design of the compulsory health insurance contract involves its conclusion and execution in favor of a third party. Therefore, the parties to the contract are the insured and the insurance medical organization. In this case, by analogy with the norm of the Civil Code of the Russian Federation, the beneficiary is not the party under the contract, but the person in whose favor the contract is concluded - the insured person.

The Law on Compulsory Medical Insurance distinguishes two independent types of contract in the field of compulsory medical insurance. The right of the insured person to free medical care under compulsory health insurance is exercised on the basis of the following concluded in his favor between the participants of compulsory health insurance:

agreements on financial provision of compulsory medical insurance;

contracts for the provision and payment of medical care under compulsory medical insurance.

It is necessary to highlight the features of the agreement on financial security, which come into force on January 1, 2012.

Under the contract for the provision and payment of medical care under compulsory medical insurance, the medical organization undertakes to provide medical assistance to the insured person within the framework of the territorial compulsory medical insurance program, and the insurance medical organization undertakes to pay for medical care provided in accordance with the territorial compulsory medical insurance program.

An insurance medical policy of compulsory medical insurance is a document certifying the conclusion of an agreement on compulsory medical insurance of citizens, valid throughout the Russian Federation, as well as in the territories of other states with which the Russian Federation has agreements on compulsory medical insurance of citizens.

The contract for the provision and payment of medical care under compulsory medical insurance is concluded between a medical organization included in the register of medical organizations that participate in the implementation of the territorial compulsory medical insurance program and which, by decision of the commission for the development of the territorial compulsory medical insurance program, establishes the amount of medical care to be paid at the expense of compulsory medical insurance, and an insurance medical organization participating in the implementation of the territorial CHI program. The provisions governing contractual relations within the framework of Article 39 of the Law are effective from January 1, 2011.

5 Status of elements of the compulsory health insurance system: new legal regime fund of obligatory medical insurance

The need to create an effective financial instrument that provides constitutional guarantees for the protection of the health of citizens of the Russian Federation is long overdue. Previously, experts noted the need for regulatory regulation of the activities of territorial compulsory medical insurance funds, as well as financing of measures to protect the health of citizens on regional level.

The financial component of medical care in itself is an important issue, the timely and proper solution of which determines the fate of the compulsory medical insurance mechanism. It is no coincidence that scholars-specialists make the very content of rights exclusively dependent on the amount of funding. Moreover, the problems in the organization of the healthcare system have already been addressed in the literature, and in particular, the problems of insufficient legal regulation of this system, including the legal status (powers) of the Federal Compulsory Medical Insurance Fund.

In doctrinal studies, the Foundations, including the Compulsory Health Insurance Fund, are classified as so-called public authorities that are not state executive bodies, but have part of their competence in relation to a certain circle of persons. In a certain sense, we are talking about the independent legal personality of such organizations, which does not allow them to be classified as bodies of a single public legal entity. The state in such cases, for certain purposes, limits its powers of authority, giving them to independent organizations. A distinctive feature of such legal entities is the predominantly public nature of the functions they perform and the tasks assigned to them, the successful implementation of which forms the material and legal basis for the effective life of society and the state.

K.A. Grave and L.A. Luntz at one time considered the economic nature of insurance. Under insurance in the broad sense of the word, scientists understood, first of all, a set of measures to create resources of material and (or) monetary funds, at the expense of which harm is corrected, losses in the public economy in case of natural disasters or accidents are restored.

A separate and very significant sign of the allocation of such institutions is their property isolation, relative autonomy in matters of organizing activities. This circumstance, as shown above, excludes such organizations from the system of executive authorities.

O.V. Gutnikov offers a description of funds with the features inherent in such an organizational and legal form of a legal entity:

funds belong to non-profit organizations, i.e. cannot pursue as the main goal of their activities the extraction of profit and its distribution among the founders;

foundations are not affiliated organizations;

funds can be established by both individuals and (or) legal entities, as well as public entities;

the property of the fund, necessary for the implementation of the statutory goals of the fund, is formed at the expense of voluntary property contributions;

foundations must carry out social, charitable, cultural and other socially useful purposes;

the foundation is required to conduct its affairs publicly;

the fund may be liquidated, and the charter of the fund may be amended in a special manner.

The fund, in fact, is a collection of property, by analogy with funds of funds (state non-budgetary funds), which from this point of view does not allow such forms of performance of public duties to be considered within the framework of the activities of the executive authority.

According to H.V. Peshkov, "The Federal Compulsory Medical Insurance Fund (FFOMS) and its territorial counterparts, or rather, their budgets, are an integral part of the budget structure of the modern Russian state."

In general, legislation, using the term "fund", often refers to the fund, understanding it as a way of accumulating monetary resources for use for predetermined purposes. The legal personality in such a mechanism fades into the background or is completely lost against the background of a significant number of rules governing the formation of funds. social purpose. In this regard, it was not accidental and quite logical to develop an independent federal law “On State Social Funds”, which was adopted and put into effect in 2012.

However, according to the current founding documents The Compulsory Medical Insurance Fund of the Russian Federation is classified by the legislator as a specialized financial and credit institution. It should be noted that the Fund has acquired powers that are not reflected in the main documents that define its activities and which are characteristic of a state body, and not an institution.

The CHI Law also assigned similar powers to the Fund. The Fund accumulates and manages compulsory medical insurance funds, forms and uses reserves to ensure the financial stability of compulsory medical insurance in the manner prescribed by the authorized federal executive body.

Such conclusions are confirmed in general by the analysis of normative acts that determine the list of their public authorities, including the Compulsory Medical Insurance Fund and its territorial funds.

In particular, the Fund establishes the forms of reporting and determines the procedure for keeping records and the procedure for keeping records of the provided medical care under compulsory medical insurance; exercises control over observance by the subjects of compulsory medical insurance and participants in compulsory medical insurance of the legislation on compulsory medical insurance and the use of compulsory medical insurance funds by them, including conducts inspections and audits; performs accounting functions (maintains a register of insurance medical and medical organizations, experts in the quality of medical care, a register of insured persons).

The legal nature of the funds that are created by the state determine the nature of the funds that are recognized as the property of the state. Indirectly, this conclusion confirms the legal status of the property of the territorial CHI fund. The property of such a fund, acquired at the expense of compulsory medical insurance, is the state property of the corresponding subject of the Federation and is used by the territorial fund on the basis of the right of operational management.

In the literature, the attribution of the funds' monetary resources to the property of the state is explained by the private law model of relations from compulsory insurance, which makes it possible to attract a subsidiary debtor for the obligations of the fund represented by the state. Among other things, the Federal Fund performs the functions of a single insurer in the system of compulsory health insurance. At the same time, territorial funds of compulsory medical insurance and insurance medical organizations can exercise certain powers.

In conclusion, it should be said that a single organizational and financial model of CHI in all territories contributes to the efficiency of the functioning of the entire system and its elements. Given the importance of compulsory health insurance, it seems reasonable to address the issue of including insurance medical organizations in the system of social protection of the population.

3. Prospects for improving compulsory health insurance

.1 Prospects for the development of the health insurance system

In modern conditions, a fundamentally new approach to the organization of healthcare is needed, which guarantees the right of every citizen to receive medical care corresponding to the level of development of both the country as a whole and its individual regions. The implementation of such an approach can be provided by the system of insurance medicine.

As world experience shows, the transition to insurance medicine is necessary in conditions market economy and the development of the medical services market, since it provides, firstly, the guarantee, accessibility and high quality of medical services (even with the inevitable increase in prices for them) for the general population; secondly, it helps to solve the problem of attracting additional financial resources to the healthcare sector.

Supplementary (voluntary) health insurance systems, if properly organized, will not only improve the quality of care for those insured under these systems, but will also contribute to the development of medical services for the rest of the population by accumulating additional financial resources in the health care system.

An important argument in favor of health insurance is its wide distribution in developed countries ah of the world, providing a high level of medical services to different categories of citizens.

The introduction of the principles of health insurance involves the transfer of the industry to market relations, under which there are strict economic laws. Therefore, a prerequisite for this translation is the introduction economic methods management in the practice of medical institutions.

Socially responsible competitive medicine is possible only with the parallel existence and development of various forms of ownership, forms and methods of organization economic activity, management, sources of financing mechanisms for medical institutions, as well as various methods (planned and market) for regulating processes occurring in the healthcare sector. As world experience shows, the existence of alternative sectors in the national health care system serves as the basis and guarantee of freedom of choice of place and working conditions for medical workers, and also, of course, expands the patient's right to free, independent choice of a doctor, medical institution, type of medical services, to the greatest extent possible. as appropriate to his interests.

The formation of a medical services market involves the creation of conditions and prerequisites for the implementation of a system of market freedoms and consumer rights.

The most important problem in the functioning of the medical services market is the problem of creating a pricing mechanism for services provided by healthcare institutions. The main requirement of the market pricing mechanism is the free formation of prices on the basis of an agreement between the manufacturer of medical services (seller) and the buyer. Under these conditions, it is necessary to form a well-thought-out state and regional pricing policy, taking into account that artificial containment, “freezing” of prices for health care services can lead to a decrease in the quality and efficiency of medical care for the population.

Economic transformation carried out in our country, the transfer of the entire economy to market relations, will gradually create the necessary prerequisites and conditions for the implementation of the main provisions of the industry reform. Thus, the depth and scale of the forthcoming changes dictates the expediency of gradual introduction into healthcare practice of the provisions of the new financial model of growth and their phased development.

.2 Prospects for improving legislation on compulsory insurance

The main goal of state regulation of the insurance market in Russia, first of all, is to protect the interests of policyholders and the state, which can be expressed not only in controlling the financial stability and solvency of insurers, but also in ensuring constant tax and other revenues from the insurance industry.

Insurers, as a subject of regulation, expect, first of all, not so much supervisory, as developing the insurance market, actions. The Ministry of Finance of the Russian Federation supervises the insurance market. The functions of the long-term development of most industries, including the insurance industry, are handled by the Ministry of Economic Development and Trade.

The state and legislative bodies plan to stimulate the insurance market only if this is part of the main goal - to protect the interests of the insured and the state interests. In addition, the disunity of supervisory and developmental quality has a bad effect, despite the fact that supervisory mechanisms clearly prevail over incentive ones. Nevertheless, the stimulating effect of state regulation should be expected.

What mechanisms do the authorities in Russia have to carry out this process? The mechanisms of the stimulating influence of the state on the insurance market include:

legislative development of compulsory types of insurance;

provision of special tax regimes policyholders.

The legislative development of compulsory types of insurance as a mechanism for increasing the indicators of insurance activity was among the first noted in the Concept for the development of the insurance market in Russia in the medium term. Moreover, its effect is associated not so much with a mechanical increase in the industry's turnover due to coercion to insurance, but with the access of insurers to the client base and the additional sale of voluntary insurance policies. A typical example is compulsory insurance civil liability vehicle owners.

True, many insurers have recently been wondering whether they will be able to survive the “critical” 2-3 year period of payments for this type of compulsory insurance and whether this is compensated by additional sales of policies for voluntary types with low loss (property and accident insurance) .

The provision of special tax regimes to policyholders so far provides for the attribution of contributions for certain types of insurance to the cost (in full for property insurance, in the established, obviously insufficient, amounts for personal insurance, and not provided for liability insurance).

The mechanisms for providing tax deduction for individuals in case of purchasing policies for long-term (pension) life insurance, voluntary medical and other socially significant types of insurance. There is no opportunity to choose between compulsory (public) and voluntary systems of medical and pension provision. It is in this direction that legislators are currently working.

Undoubtedly, the process of creating a more independent body of insurance supervision as part of the administrative reform will also have a positive impact on state regulation. Thus, it is possible that the rule-making (law-setting) and supervisory (law-enforcement) functions of ministries and departments, including the Ministry of Finance of the Russian Federation, will be separated. It is planned that the Insurance Supervision Department will be transformed into an independent structure and, probably, into the Ministry of Finance.

In accordance with the same administrative reform, a draft law “On self-regulatory organizations” is being developed, including in the insurance market. The All-Russian Union of Insurers is accordingly ready to be transformed into a self-regulatory organization with the possibility of mandatory membership and expansion of functions.

It was supposed that this law would be introduced by the Government of the Russian Federation, but it turned out to be not ready to delegate part of the functions to self-regulatory organizations. In this regard, on the last day of the work of the State Duma, more than fifty deputies from different factions signed this law and introduced it.

The All-Russian Union of Insurers believes that the only alternative to "inhibited" mechanisms state regulation insurance market in Russia is the introduction of self-regulation mechanisms.

The main advantage of self-regulation mechanisms lies in the possibility of developing professional quality standards for the provision of insurance services and increasing confidence on the part of policyholders. In addition, self-regulation allows more flexibility in responding to the needs of insurers for better insurance services.

We emphasize two new areas of application of this method of regulation:

Firstly, in Russia there are more than 40 types of compulsory insurance. At the same time, the implementation of the main directions for the development of compulsory insurance, laid down in the Concept, which include strengthening control over the conduct of compulsory insurance; the introduction of new types of compulsory insurance, the creation of centralized guarantee funds, seems to be very problematic.

This is due, first of all, to the fact that the draft law "On the implementation of compulsory insurance on the territory of the Russian Federation", which was assigned the main role in the regulation of compulsory types of insurance, was rejected by the Government of the Russian Federation, and in the draft law "On amendments and additions to the law" On the organization of insurance business in the Russian Federation” only a small article is devoted to this issue. All this causes changes in the approach to the regulation of the compulsory insurance system.

The relevance of the issue of regulating the system of compulsory types of insurance is also determined by the fact that the Civil Code of the Russian Federation states that "objects subject to compulsory insurance, the risks against which they must be insured, and the minimum amount of insurance amounts are determined by law."

And here the insurance community, including the insurance supervisory authority, falls into a legal conflict. On the one hand, a type of insurance can be called compulsory if there is a federal law about it, at the moment there are only 3 such types: compulsory medical insurance, compulsory insurance of civil liability of vehicle owners and compulsory insurance of military personnel.

On the other hand, more than 40 types of insurance, which are introduced by "non-insurance" legislative acts, also need to define provisions that provide equal conditions for the implementation and guarantees for the performance of insurance services.

However, a way out of this impasse can be found through self-regulatory mechanisms. The regulation of the compulsory insurance system should be based on the principle of mandatory membership in a professional association of insurers in compliance with the standards of professional activity for a particular type of insurance.

The All-Russian Union of Insurers has already proposed to the Ministry of Finance to introduce a self-regulation system to create a working group consisting of representatives of the insurance community and the supervisory authority to determine the list of mandatory types of insurance that need regulation.

After that, at the level of the Ministry of Finance will be accepted normative document who, in order to comply with the principles of compulsory insurance, could issue instructions to insurers in the implementation of this type of compulsory insurance, it is mandatory to be a member of an association of insurers that has a package of documents agreed with the Ministry of Finance on this type of compulsory insurance.

Based on this, the introduction of elements of self-regulation in the sector of compulsory insurance makes it possible to systematize the mechanism for regulating more than forty varieties of compulsory insurance and to protect the interests of the subject of the insurance business in the widest possible way.

Secondly, without the creation of a professional association of insurers with compulsory membership, reforming compulsory medical insurance is indispensable. Due to the specifics of this type of insurance, insurers are the only ones who protect the interests of patients (insureds) and the development of uniform standards for determining the quality of an insurer is simply necessary.

Conclusion

Health insurance is a form of social protection of the population's interests in health protection. Medical insurance in the territory of the Russian Federation is carried out in two forms: compulsory 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.

The health insurance system is based on the Federal Law of the Russian Federation "On Compulsory Medical Insurance of Citizens in the Russian Federation". It spells out the subjects, objects, medical insurance contract, the rights of citizens of the Russian Federation in the health insurance system and the insured, contribution rates, etc.

Compulsory health insurance is an integral part of the state system of social protection. The compulsory medical insurance program is implemented by compulsory medical insurance funds and medical insurance organizations.

The main problems in the development of health insurance are insufficient funding and organization of the distribution of financial resources, as well as an inaccurate regulatory framework. The solution of problems is possible only by precise purposeful actions of the Government of the Russian Federation, the creation of a well-thought-out reform in the field of social protection of the population.

Under the current conditions, there are two ways of further development:

The first is the abandonment of attempts to create a social insurance mechanism and the transition to the model of state social security. The advantages of this path are that responsibility is concretized - it is only executive power, the number of intermediaries in the financing chain is reduced and the path for the passage of funds is shortened. Based on the experience of other countries, it is obvious that public health care is the cheapest form of ensuring the availability of medical services for the population.

The second is the formation of a mechanism (not a form) of insurance, which initially implies a clear separation of insurance and non-insurance obligations, sources of financing for these obligations, organizational structures and responsibilities between the executive power and insurance institutions, and the creation of a system of insurance statistics. And a prerequisite is the withdrawal of insurers from the jurisdiction of the government.

The first way, it seems, will not be accepted due to political considerations - the alleged loss of the status of a state of a liberal democratic type.

The second way will not be implemented because of the economic interests of all participants in the current scheme of redistribution of funds. The reason is financial resources. To implement the insurance mechanism, significant funds are needed: first, for payments for the unemployed, if we do not abandon the idea of ​​insuring them; secondly, to finance the maintenance and technical equipment of the entire state and municipal network of healthcare facilities.

In addition, a serious, concretized, regular economic justification for the tariff rate for insurance is needed. According to the former head of the FFOMS V.V. Grishina, it should be at least 8%.

Why hasn't it been done yet? Because the result of such work is known. They will not raise the tariff, especially since they will not establish it differentiated by regions. It is clearly impossible to reduce the Basic Program under the existing tariff, except to remove completely stationary services from it. In addition, a conscientious justification will show the obvious - for the unemployed (pensioners and children), the contribution should be 20-30% higher than for employees. And as already noted, a third of the regions do not fully contribute even a significantly lower tariff.

In conclusion, let's return to the problem of choice - which way to move in order to realize the guaranteed right to accessibility and at a lower cost. I am becoming more and more convinced that the preferred option is state support.

The fact is that compulsory health insurance, in my opinion, is a dead end in the development of medicine. At the first stage, its application, of course, gives impetus to the development of medical technology, but has serious negative aspects that manifest themselves in the long-term development. The medical services market will not only stimulate the development of new technologies, but also the demand for them, and not always justified. Health care costs will continue to rise.

The specifics of the “medical services market” do not meet the standard of a free competitive market which is characterized by the following features:

a) the problem of information asymmetry between the producer and the consumer. There is a natural monopoly of the "seller" (doctor) both on knowledge of the patient's health status and on treatment methods, i.e. to the list of medical services required by the patient. The patient can be treated indefinitely, and the problem of "excessive" medical services is already seriously worrying specialists in those countries where insurance has existed for a long time.

b) the problem of ethical order is that the Hippocratic oath already seems to be a "burden" for the medical corps, and there is a need to abandon it. The fact that, in fact, the insurance model requires an assessment of the value of human life has an ethical character.

List of used literature

1.The Constitution of the Russian Federation of December 12, 1993 (subject to amendments introduced by the Laws of the Russian Federation on amendments to the Constitution of the Russian Federation of December 30, 2008 No. 6-FKZ, of December 30, 2008 No. 7-FKZ) // Consultant Plus, 1992-2014.

2.Budget Code of the Russian Federation No. 145-FZ dated July 31, 1998 (as amended on December 28, 2013) (as amended and supplemented, effective from January 1, 2014) // Consultant Plus, 1992-2014.

.Civil Code of the Russian Federation (part one) dated November 30, 1994 No. 51-FZ (as amended on November 2, 2013) // Consultant Plus, 1992-2014.

.Federal Law of November 29, 2010 No. 326-FZ (as amended on December 28, 2013) “On Compulsory Medical Insurance in the Russian Federation” // ConsultantPlus, 1992-2014.

.Federal Law of November 29, 2010 No. 326-FZ (as amended on December 28, 2013) “On Compulsory Medical Insurance in the Russian Federation” // ConsultantPlus, 1992-2014.

.Federal Law of November 29, 2010 No. 326-FZ (as amended on December 28, 2013) “On Compulsory Medical Insurance in the Russian Federation” // ConsultantPlus, 1992-2014.

.Federal Law of November 29, 2010 No. 326-FZ (as amended on December 28, 2013) “On Compulsory Medical Insurance in the Russian Federation” // ConsultantPlus, 1992-2014.

.Federal Law of November 29, 2010 No. 326-FZ (as amended on December 28, 2013) “On Compulsory Medical Insurance in the Russian Federation” // ConsultantPlus, 1992-2014.

.Federal Law of November 29, 2010 No. 326-FZ (as amended on December 28, 2013) “On Compulsory Medical Insurance in the Russian Federation” // ConsultantPlus, 1992-2014.

.Federal Law No. 165-FZ of July 16, 1999 (as amended on December 28, 2013) “On the Basics of Compulsory Social Insurance” // ConsultantPlus, 1992-2014.

.Decree of the Government of the Russian Federation of July 29, 1998 N No. 857 (as amended on February 4, 2013) “On Approval of the Charter of the Federal Compulsory Medical Insurance Fund” // ConsultantPlus, 1992-2014.

.Decree of the Government of the Russian Federation of February 15, 2011 No. 74 “On the rules of compulsory medical insurance” (repealed) // Consultant Plus, 1992-2014.

.Decree of the Government of the Russian Federation of December 31, 2010 No. 1227 (as amended on August 26, 2013) "On the specifics of licensing the activities of insurance medical organizations in the field of compulsory medical insurance and the recognition of certain acts of the Government of the Russian Federation as invalid" (as amended and supplemented by in force from 21.01.2014) // ConsultantPlus, 1992-2014.

.Order of the Ministry of Health and Social Development of Russia dated January 21, 2011 No. 15n (as amended on October 7, 2013) “On Approval of the Model Regulations on the Territorial Compulsory Medical Insurance Fund” (Registered in the Ministry of Justice of Russia on February 2, 2011 No. 19661) // ConsultantPlus, 1992-2014.

.Decree of the Government of the Russian Federation dated November 17, 2008 No. 1662-r (as amended on August 08, 2009) “On the Concept of the Long-Term Socio-Economic Development of the Russian Federation for the period up to 2020” (together with the “Concept of the Long-term Socio-Economic Development of the Russian Federation for the period until 2020”) // Consultant Plus, 1992-2014.

.Kolokolov G.R., Makhonko N.I. Medical Law: Proc. allowance. Moscow: Dashkov i Ko, 2011.

.Gerasimenko L.V. Some prerequisites for the legal status of an insurer for medical insurance // Society and Law. 2011. №3. S. 12.

.Kotler F. Fundamentals of marketing. M.: Progress, 2012. S. 638.

.Kapranova S.Yu. Insurance of civil liability of the performer of medical services: Abstract of the thesis. dis…. cand. legal Sciences. SPb., 2014.

.Kameneva Z.V. On the legal nature of the relationship of patients with medical organizations // Lawyer. 2013. No. 12. pp. 38 - 41.

.Belov V.A. "Sick" issue: civil legal relations with medical organizations // Legislation. 2013. No. 11. pp. 6 - 12.

.Andreev Yu. Paid medical services. Legal regulation and judicial practice. M., 2012. S. 127.

.Vronskaya M.V. Institute of the right to health protection in the system of social protection of citizens of the Russian Federation // Social and pension law. 2011. №2.

.Sergeev Yu.D., Grigoriev Yu.I., Grigoriev I.Yu. System analysis in the field of medical law // Medical Law. 2012. No. 4.

.Putilo N.V. Legislation of the constituent entities of the Russian Federation on healthcare // Journal of Russian law. 2012. №2.

.Belykh V.S., Krivosheev I.V. Insurance law. M., 2013.

.Suvorov M.D. On the private law nature of the insurance institute // Jurisprudence. 2013. No. 4. S. 135.

.Stetsenko V.Yu. Public Law Basis for Healthcare Regulation in Modern Ukraine // Administrative Law and Process. 2013. №3.

.Yampolskaya Ts.A. On the theory of the administrative contract (instead of a review) // Soviet state and law. 2012. No. 10. S. 134.

.Samoshkin A. Obligatory medical insurance. Ways of modernization [ Electronic resource] // URL: http://www.kreml.org.

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Siberian State Medical University

TEST

Topic: "Legal bases of obligatory and voluntary medical insurance"

Completed by: Kulikov A.V.

Tomsk, 2007

Health insurance, in a broad sense, is new economic relations in healthcare in market conditions, that is, the creation of such a system of health care and social security that would actually guarantee all residents of the Russian Federation freely accessible qualified medical care, regardless of their social status and income level .

Currently, there are several options for public health insurance:

- the health care system of economically developed countries, where health care is financed from 3 main sources - deductions from the income of entrepreneurs, deductions from the state budget and insurance premiums of the population;

- medical care for the insured as part of the social insurance system, when all contributions to this system go to the state budget and then are distributed among institutions (such a system exists in Russia and the UK);

-- system voluntary insurance health, which provides payment for medical care by commercial (receiving profit for this work), non-profit and charitable organizations (such a system operates, for example, in the USA);

- the insurance system (or, as it was called earlier in Russia, the "insurance work system") - the financing of medical care for workers, employees and members of their families exclusively at the expense of entrepreneurs.

The following options for voluntary medical insurance are of greatest interest in Russia:

1. Types of voluntary medical insurance providing for payments not related to the cost of treatment:

- insurance in cases of diagnosis of the disease;

- insurance in case of illness due to injury;

- insurance against loss of income due to illness;

- insurance of daily (daily) payments for the period of hospitalization.

2. Types of voluntary medical insurance that provide payments in the form of compensation for treatment costs:

- insurance of expenses for outpatient treatment;

- insurance of expenses for inpatient treatment;

- insurance of surgical expenses;

- insurance of expenses for postoperative care;

- Comprehensive medical expenses insurance.

Lack of an effective mechanism for management and management in healthcare, lack of budgetary funds and stable extrabudgetary sources of financing, insufficient equipment of healthcare institutions with medical equipment, shortage of medicines, low salaries of medical and pharmaceutical workers do not provide the proper level of medical care to the population, lead to disinterest of medical workers in improving the efficiency and quality of work. Despite the annual increase in budget funds allocated for the development of health care, their share in the gross national product over the past decade has not exceeded 3-4% (2-2.5 times less than is spent on health care in developed countries).

The current procedure for financing health care requires new forms and approaches based on a combination of interest and responsibility for the health of not only the state, but also ministries, departments, enterprises, institutions, organizations, and every citizen. Such a form is medical insurance, which provides for a set of measures for the accumulation by insurance organizations of financial resources coming from budgetary and non-budgetary sources to pay for medical care to insured citizens, provided that the insurance organization pays for medical services to the insured person in cases specified by the contract. One of the main conditions of health insurance is the free choice of the insured doctor and medical institution, which predetermines the emergence of competition and contributes to improving the quality of medical care and increasing attention to each citizen, since the source of the material well-being of health care workers will be the funds received for the provision of medical care.

A fundamentally new approach to health care financing is defined by the Law “On Health Insurance of Citizens in the Russian Federation” (1991). In the field of health care financing, a transition to a mixed budget-insurance model is expected. Health insurance may be compulsory or voluntary.

Compulsory health insurance, according to this law, is universal for the population of Russia and is implemented in accordance with programs that guarantee the volume and conditions for the provision of medical and drug assistance to citizens. The size of the insurance premium for enterprises was established by the Government of the Russian Federation and approved by the Supreme Council. The amount of mandatory insurance premiums is included in the cost of production.

For the non-working population, compulsory medical insurance is carried out by the executive authorities, the local administration at the expense of the funds provided for in the budgets. Insurance premiums for employees budget institutions and organizations are also paid from the funds of the respective budgets.

Thus, the CHI system is based on the following organizational principles:

1. Universality - all citizens regardless of gender, age, state of health, place of residence, level personal income have the right to receive free medical services included in the CHI program. The norms of compulsory medical insurance apply to working citizens from the moment an agreement is concluded with them.

2. Statehood - CHI funds are state-owned by the Russian Federation. The state is the direct insurer for the non-working part of the population (students, students, pensioners). The state exercises control over the collection, redistribution and use of CHI funds. The state ensures the financial stability of the CHI system, guarantees the fulfillment of obligations to the insured.

3. Non-commercial nature - CHI funds cannot become income or profit of legal entities and individuals who are founders of medical insurance companies. Compulsory medical insurance is unprofitable and not one insurance company is engaged only in health insurance. As a rule, insurance companies are engaged in voluntary medical insurance, they can also be engaged in non-medical insurance.

4. Public solidarity and social justice - all citizens have equal rights to receive medical care at the expense of compulsory medical insurance. CHI insurance payments are paid for all citizens, but the demand for financial resources is carried out only when applying for medical care. The principle works - the healthy pays for the sick. The range and volume of services provided does not depend on the size of the compulsory medical insurance payment, and citizens with different income levels have the same rights to receive medical services. The principle works - the rich pay for the poor.

Voluntary medical insurance is carried out on the basis of voluntary insurance programs and provides citizens with additional medical and other services in excess of those established by compulsory medical insurance programs. It can be collective and individual. This type of insurance is carried out at the expense of profits (income) of enterprises and personal funds of citizens by concluding an agreement. The object of medical insurance is the insured risk associated with the cost of medical care in the event of an insured event. The subjects of health insurance are a citizen, an insured, an insurance medical organization, a medical institution. The insurers of non-working citizens are local administrative bodies, working - enterprises or employers.

At the head of the entire CHI service is the federal background of CHI (FFOMS). Financing at the expense of enterprises, organizations and other economic entities and at the expense of the state budget. From business entities, the fund receives money in the amount of 0.2% of the fund wages from the state budget.

Territorial background of compulsory medical insurance (TFOMS) is a fund where money flows to finance medical institutions. Money from the enterprise and the state budget. 3.6% of the payroll comes from enterprises (total 3.8%). These deductions go to the working part of the population. The state budget pays for the non-working part of the population (now this amount is less than 1% for all health care, and not just for the territorial fund).

The insured is a legal or capable natural person who has entered into an insurance contract with the insurer, and who is also the insured by virtue of law. With voluntary medical insurance, the insurers are the citizens themselves or enterprises representing the interests of citizens.

An insurer is a legal entity created to carry out insurance activities, which has received in statutory procedure for a license to carry out insurance activities on the territory of the Russian Federation. In the case of health insurance, it is the insurance medical organization. The latter is understood as a legal entity that provides medical insurance and has a state license, which is issued by the Russian Federal Service for Supervision of Insurance Activities for each type of insurance. Insurers must clearly separate the money for medical institutions in accordance with the MHI agreement.

Insurance medical organizations are legal entities that provide medical insurance and have a state permit (license) for the right to engage in this activity. The license is issued by the Ministry of Economy and Finance of the Russian Federation or its bodies.

The insurance company has such departments as the department of voluntary medical insurance, the medical department, which analyzes the activities of health facilities, financial and economic, legal, engineering and commercial departments.

Insurance medical organizations are not allowed to engage in production, trade and intermediary and banking. In addition, it is necessary to comply with a number of conditions for health insurance organizations that have a license for compulsory health insurance. A medical insurance organization must have an authorized capital of at least 1200 minimum dimensions wages. The ratio of own and financial resources cannot be more than 1:20. This organization is not allowed for the purposes commercial activities use of funds intended for the implementation of compulsory health insurance programs (except for the purchase of reserve fund securities and bank deposits).

Health authorities and medical institutions do not have the right to be founders of insurance medical organizations, however, they can own their shares (no more than 10% of the total block of shares). Insurance medical organizations are not part of the healthcare system. The main task of the insurance medical organization is the implementation of compulsory health insurance by paying for medical care provided in accordance with the territorial program of compulsory medical insurance, monitoring the quality of medical services.

Insurance medical organizations can: freely choose medical institutions for the provision of medical care and services under medical insurance contracts; participate in the accreditation of medical institutions; establish the amount of insurance premiums for voluntary medical insurance; take part in determining tariffs for medical services; file a claim in court against a medical institution or a medical worker for material compensation for physical or moral damage caused to the insured through their fault. In accordance with the Law of the Russian Federation "On the health insurance of citizens" and the Regulations on insurance medical organizations that carry out compulsory medical insurance, insurance medical organizations are obliged to carry out activities on compulsory medical insurance on a non-commercial basis, to conclude contracts with medical institutions for the provision of medical care to insured persons under compulsory medical insurance. insurance, conscientiously fulfill all the conditions of the concluded contracts, create insurance reserves in the prescribed manner, protect the interests of the insured. These organizations do not have the right to refuse the insured to conclude a contract of compulsory medical insurance.

Below in the chain from insurers are outpatient-type institutions and inpatient-type institutions. Outpatient clinics create an outpatient fund (AF) and are financed according to the norm per inhabitant (the figure changes every month, in the spring of 1996, 8400 rubles per month.). Stationary institutions create a hospital fund (GF). Financing is spent on one treated patient. Medical institutions are medical institutions, research and medical institutes, collectives and persons licensed to engage in certain types of activities and provide services under compulsory and voluntary medical insurance programs. All medical institutions are subject to licensing, regardless of ownership. Licensing is carried out by licensing commissions established under government bodies from representatives of territorial health committees, professional medical associations, medical institutions, public organizations (associations). Accreditation of a medical institution is also carried out, that is, its compliance with established professional standards is determined. A certificate is issued to an accredited medical institution.

The main document of health insurance is a contract (agreement) between the insured and the insurance medical organization, which includes: names of the parties; the duration of the contract; number of insured persons; the amount, terms and procedure for making insurance premiums; a list of medical services corresponding to programs of compulsory or voluntary medical insurance. Each insured citizen receives an insurance medical policy.

In accordance with the law “On the health insurance of citizens in the Russian Federation”, every citizen can choose a medical insurance organization, a medical institution and a doctor, receive medical care throughout Russia (the principle of extraterritoriality) and medical services that comply with the terms of the contract in terms of volume and quality, regardless of the amount of the insurance premium paid, sue the insured and the medical institution for damage caused, etc. The law provides the creation of two funds - a health care fund (for the implementation of prevention programs, the rehabilitation of special contingents of patients, low-income citizens) and an insurance fund (for the implementation of insurance programs). V government programs of mandatory health insurance, target preventive programs (improvement of the external environment, family planning, prevention of infectious diseases, overcoming risk factors, promoting a healthy lifestyle, etc.) still rank first. To implement the comprehensive Russian and regional programs “Health”, to ensure the medical, social, sanitary and epidemic well-being of the population, funding from the state budget and local budgets is necessary.

Within the framework of compulsory medical insurance, the insured person is provided with the following scope of medical care:

1. Provision of primary medical care, including: ambulance for sudden life-threatening diseases, injuries, poisoning, childbirth.

2. Outpatient treatment of acute and exacerbations of chronic diseases, injuries and accidents.

3. Home treatment of persons unable to visit the clinic.

4. Preventive measures for children, adolescents, disabled people and participants in the Great Patriotic War, pregnant women and puerperas, as well as patients with tuberculosis, cancer, mental disorders and after heart attacks and strokes.

5. Dental care in full for persons under 18 years of age, as well as pupils, students, participants in the Second World War, pregnant women, and women with children under the age of 3 years.

6. Drug assistance in accordance with the list of diseases with preferential treatment.

Inpatient care: for patients with acute illnesses, injuries, infectious diseases, cancer patients, during pregnancy and childbirth, abortions and for medical reasons.

Medical insurance provides for the creation of a special “Health Fund” for guaranteed medical and social provision of the population with the necessary range of medical services. A network of religious, charitable, philanthropic and public organizations and foundations is being created to help expand the range of medical and social services.

To implement the law, regulations have been developed and approved on medical insurance organizations, on the procedure for issuing licenses for the right to engage in medical insurance, the basic program of compulsory medical insurance (CHI) and other regulatory documents.

The law defines the legal, economic and organizational foundations of public health insurance. It is aimed at strengthening the responsibility and interest of the population and the state, enterprises and organizations in protecting the health of citizens in the new economic conditions and ensures the constitutional right of citizens to medical care. The law consists of 5 sections and 28 articles.

In chapter " General provisions”It is noted that health insurance is a form of social protection of the interests of the population in protecting health.

The purpose of health insurance is to guarantee, in the event of an insured event, the receipt of medical care at the expense of accumulated funds and to finance preventive measures.

The second section “Health insurance system” presents the objects of health insurance (insurance risk), the structure of the health insurance contract is given, insurance policy, the rights of citizens, the rights and obligations of the insured, health and insurance funds, etc.

The third section contains articles on the tasks, rights and obligations of medical insurance organizations, on the procedure for issuing licenses for the right to engage in medical insurance, etc. The activities of medical institutions in the health insurance system are reflected in the fourth section, which analyzes in detail the rights and obligations of medical institutions, issues of organizing work on licensing and accreditation of medical institutions, the program of compulsory medical insurance. The agreement on the provision of medical and preventive care and tariffs for medical services is aimed at ensuring the profitability of their activities.

The fifth section “Regulation of relations between the parties in the system of health insurance” coordinates the responsibility of the parties, the right of the insurance medical organization to reimburse expenses, etc. A regulation has been developed on the procedure for issuing licenses for the right to engage in health insurance. Insurance companies and medical institutions (laboratories) are required to have a license (document) for the right to engage in medical activities to serve the insured. These institutions must comply with sanitary and hygienic standards, have diagnostic equipment, medical complexes with modern methods prevention, diagnosis and treatment.

In the order of the Ministry of Health of the Russian Federation No. 93 dated March 20, 1992 “On Measures to Implement the Law “On Health Insurance of Citizens in the Russian Federation””, it is noted that at the first stage, licensing commissions are created under the health committees of local administrations, which study the submitted documents, acts, equipment, methods, etc.; groups of experts are appointed to analyze the data, determine the scope and duration of the license.

The above law defines the basic rights and obligations of health insurance participants. A citizen of the Russian Federation has the right: to compulsory and voluntary medical insurance; to the free choice of an insurance medical organization and a doctor in accordance with the contract; to receive medical care throughout Russia, including outside the permanent place of residence; to receive medical services corresponding in volume and quality to the terms of the contract, regardless of the amount of the actually paid insurance premium; to file a claim against the policyholder, insurance medical organization, medical institution, including material compensation for damage caused through their fault; for the return of a part of insurance premiums for voluntary medical insurance, if this is determined by the terms of the contract.

A medical insurance organization (HIO) has the right to: freely choose medical institutions for the provision of medical care and services under medical insurance contracts; participate in the accreditation of medical institutions; establish the amount of insurance premiums, tariffs for medical services; file a lawsuit against a medical institution or a medical worker for material compensation for physical or moral damage caused to the insured through their fault. An insurance medical organization is obliged to: conclude an agreement with medical institutions for the provision of medical care to insured persons under compulsory and voluntary medical insurance; issue medical insurance policies to the insured or the insured; return part of the insurance premiums to the insured, if this is provided for by the medical insurance contract; control the volume, timing and quality of medical care; protect the interests of the insured.

Goals and objectives of health insurance

The purpose of health insurance is to improve the quality and expand the volume of medical care through: a radical increase in health care spending; decentralization of the health fund management system; material interest of medical workers in the final results; economic interest of enterprises in maintaining the health of workers; the economic interest of each person in maintaining their health. This is how the purpose is broadly defined in the health insurance law. Naturally, the transition to health insurance gives rise to a significant number of problems, the solution of which becomes extremely relevant. Thus, in particular, an important problem is the development of methods for the feasibility study of the relevant services. Such methods are necessary, on the one hand, for medical insurance companies to predict their development in order to ensure the profitability of their activities, and on the other hand, for health authorities and the State Insurance Supervision Service of the Russian Federation to develop adequate measures to regulate the insurance medical services market.

In order to create conditions for the development of the health insurance system in our country, as many experts note, it is necessary to first solve the following legal, organizational and financial tasks:

"fit" the health insurance system into the basic principles, structure and management of the existing public health system;

establish the legal status of the insured person, insured organizations and institutions providing medical services;

develop principles and single system pricing applied in the health insurance system;

develop a fundamentally new information system, which allows to determine the efficiency and quality of medical services provided in the health insurance system;

propose schemes and set the size of the formation of financial resources for health insurance, bearing in mind the participation of the state, enterprises, local authorities, and the population;

organize an arbitration system at all levels of healthcare management.

The insurance mechanism itself objectively reflects the property of uncertainty inherent in market relations and the emergence of a situation that generates large unforeseen losses. Insurance is one of the main ways that people and various businesses resort to to reduce losses from risky situations. The main purpose of insurance is to reduce the risk (losses from risk) that various entities must bear, in shifting the risk to those who are more willing (or in a better position) to bear it. The mechanism of insurance includes the pooling of risks and their redistribution.

At the same time, a kind of contradiction arises. On the one hand, insurance reflects the nature of market relations, and on the other hand, it distorts the demand and supply of medical services to a certain extent. In particular, there is a serious consequence of insurance - it encourages a person to spend more on medical services than under other conditions. If a person knows that the insurance company will pay 80% of the cost of a hospital stay for each additional day, he can stay further in it, although in fact he no longer needs it. And he won't mind too much if, say, the hospital charges 10,000 rubles for one day instead of 9,000 rubles, knowing that the price increase will only cost him 200 rubles. It can be assumed that doctors, knowing that the patient will not have to pay the full bill, prescribing even a very expensive drug with dubious effectiveness, will hesitate less.

The greater the price elasticity of demand for medical services, the more this pattern will manifest itself. To an even greater extent, this contradiction will manifest itself when patients do not participate at all in the costs of providing medical services.

It is also necessary to pay attention to the fact that the insurance contract affects the behavior of people, which is called moral hazard. Even with the possibility of risk pooling and sharing, insurance companies may find themselves unable to cover certain types of risks. This is due to the following reason. For example, if a person is insured against car theft and, in the event of this event, should receive enough funds to purchase a new one, his interest in locking the car doors with a key may drop sharply. However, if most cars are stolen for this very reason, then the cost of anti-theft insurance for the insurance company will be close to the price of a new car, and it will hardly be possible to find someone who wants to get an insurance policy at such a high price. One of the ways to solve this problem can be partial compensation for damage, that is, if the car is stolen, then only part of the cost of the car will be reimbursed to its owner. Thus, the owner will still have an incentive to lock the door, with the car owner taking on some of the risk that he can eliminate without insurance.

Thus, insurance affects only the quantity of medical services, that is, the demand, but also the activity of a person to "maintain his health." There is a certain alternative between insurance and stimulation of various subjects of the medical services market. The better developed insurance, the less market incentives to increase the efficiency of the use of available resources; the worse insurance is developed, the stronger the market incentives. It is easy to upset the balance between these parties. The balance can be maintained by introducing various restrictions in insurance. People should not be insured for 100% of the cost of treatment, otherwise this completely eliminates market incentives. But they must be sure that for all major risks they will have to pay only a fraction of the price.

Some of the problems associated with moral hazard can be reduced by expanding controls to ensure that unnecessary spending is not made. However, improved control can increase costs. For example, to ensure that funds are provided only for truly necessary surgeries, some insurance companies in the United States only pay for surgeries performed in a hospital. The consequence of this is an increase in the number of operations in hospitals that could be performed at lower cost in the offices of private practitioners.

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. Such social protection can be implemented through the creation of a specialized monetary fund in a unified manner, in the formation of which, in the final analysis, every citizen would take part.

In this case, health insurance takes the form of compulsory. The social nature of compulsory health insurance, which allows each citizen to receive the same medical care, is achieved by the unequal contribution of everyone to the creation of a monetary fund to pay for this care. In other words, the rich pay for the poor. It is in this that the principle of social solidarity is manifested, on which the system of compulsory medical insurance is built in many countries. European countries Oh. According to A.V. Telyukov, in democratic states, the issue of universal access to medical care is based on free individual choice, that is, it is the result of civil consent and has a solid economic, social and political basis. Under the economic basis, he understands a fairly high level of personal income: the willingness to redistribute part of the funds in favor of less fortunate fellow citizens organically follows from a high level of one's own well-being. The social foundation means that the decisions made by people in the public sphere are shaped by their own beliefs, attitudes, concepts, beliefs. The political basis of the social contract is the institutions of the legislative and executive power, which give the social contract the form of a law and implement it in government policy. At the same time, both legislative and executive power are under the control of voters.

Social insurance, including compulsory health insurance, is by its nature non-profit. Insurance activity is carried out on the basis of self-sufficiency and the return of the resulting profit to the development funds of the insurance system. In most countries, the state exempts such systems from paying taxes, provides other benefits, provides insurance against ruin, and issues targeted grants for development. In this regard, attention should be paid to the fact that of the 300 billion rubles additionally received by the compulsory medical insurance system in 1993-1994, 110 billion rubles were given to the state in the form of taxes.

At the same time, insurance, including medical insurance, belongs to the field of market activity. And market behavior is characterized primarily by the production of goods and services (and insurance services are a commodity).

Insurance, as a commercial activity, always seeks to equalize individual risks between members of the group and prevent the inclusion of insurance objects in the group that can significantly deviate the group risk towards exceeding the average level. In social terms, such behavior is called discriminatory. The essence of insurance in this case can be expressed in words: always group - never universal. This is reflected in the limitations of commercial insurance, which can be a mechanism for financing a universal public good, so commercial health insurance can be carried out exclusively in a voluntary form.

With voluntary medical insurance, we can talk about guaranteed insurance material protection only for those citizens who are insured under an individual or collective voluntary insurance contract at the expense of contributions paid from their personal income or profits of enterprises. At the same time, the volume and cost of medical services provided under such an agreement depends on the amount of the paid contribution, the amount of which, in turn, is set by the insurer depending on the state of health of each insured person or group of insured persons. In addition, the amount of the insurance premium depends on the tariffs for those medical services that are necessary for a given contingent and are provided under a specific contract by a specific medical institution.

Let us give a comparative description of social and commercial types of health insurance.

Comparative features	Social insurance	Commercial insurance
Legal basis	Mandatory	Voluntary
	Mass	Group, with a relatively narrow coverage of the population and individual
Reimbursement conditions	Guaranteed mechanism and unified set of social payments and benefits	A variety of "packages" of compensation and services, formed at the discretion of each insurer
The status of the manager of insurance funds	State or quasi-state organization	Private insurance companies
Principles of organization of insurance compensation	Current financing of social benefits for others	Deferred financing of special benefits for self
Performance criteria	The redistribution of funds has the character of social transfers, that is, it is subject to target efficiency (in particular, universal coverage).	The redistribution is limited to the groups and is subject to the cost effectiveness of the insurer and the insured.

Thus, the need for compulsory health insurance arises when the state recognizes that the need of its citizens for health is of public importance for the whole way of life and the further development of society. However, since there are no funds in the state budget to protect a certain level of satisfaction of this need, compulsory insurance is used for this purpose, that is, on the basis of compulsory health insurance, those health protection measures that are considered important for the whole society are financed.

Market relations express a certain economic isolation of producers and consumers of products and services, the compensation of their interaction. According to their content, they will include a wide range of different elements. The scope of market relations of certain aspects of the life of society is not a constant value. The market mechanism is the process by which sellers and buyers interact to determine the price and quantity of goods produced, whereby demand, supply and price are its main elements.

The key concept expressing the essence of market relations is the concept of competition. In the general case, competition can be defined as a type of relationship between producers regarding the establishment of prices and volumes of supply of goods and services, as well as between consumers regarding the formation of prices and the volume of demand in the market. From the standpoint of the structural organization of the market, the number of producers (sellers) and the number of consumers (buyers) participating in the exchange process are of decisive importance.

Analyzing from these positions the healthcare sector in many developed countries, it should be noted the presence of such restrictions, which appear in a variety of forms. For example, the American Medical Association, which unites about half of all private practitioners, plays an important role in artificially curbing the supply of medical services in the United States. It limits enrollment in medical faculties, increases tuition fees, controls the influx of migrant doctors and their access to medical practice. Without the knowledge of the association, no significant initiatives regarding health care can be approved.

It should be noted that there are additional artificial barriers for medical service providers when they enter the market: frequent attestations, the need to obtain a new license when a doctor moves from state to state, etc. This is due to the fact that in purely economic terms, it is relatively easy for an already established specialist to enter the medical services market and leave it, since the provision of many types of medical care is not associated with large initial costs, significant start-up capital (unlike activities in industry, trade, and most other areas). On the other hand, dynamic demand, the emergence of new needs and "niches" in the market of medical services and related products actively attract new specialists and pseudo-specialists to this area. Therefore, the desire of the already established contingent of manufacturers by all possible, and not only economic, means to minimize the likelihood of potential competitors appearing on the market, limit supply, and maximize prices and incomes is quite understandable.

Under the conditions of widespread use of medical insurance, the market for services can be represented by the following types: the insurance market, the market for medical services under the insurance system, and the free market for medical services. As for the resource market, it can also be classified in a certain way. This is the market for medical equipment, the market for medicines, the labor market.

The first medical cooperatives and small businesses that appeared in these conditions were largely successful due to access to modern equipment, scarce medicines, and the involvement of the most qualified specialists. This led to an even greater differentiation in the quality of medical care and increased social tension in society. Therefore, the state was forced to increase state control in the production of medicines and medical equipment. In particular, this was expressed in the reorganization of the Ministry of Health of Russia, which became the Ministry of Health and Medical Industry of the Russian Federation, as well as in the publication in the summer of 1994 of the Decree of the Government of the Russian Federation "On State Support for the Development of the Medical Industry and Improving the Provision of the Population and Healthcare Institutions with Medicines and medical products".

In any case, most of these problems can be successfully solved only with the expansion of the financial base of the entire health care system in the country. The development of market relations today makes this possibility real. Along with the traditional source of funds, which is the state budget, new ones are emerging. As defined in the law "On health insurance of citizens in the Russian Federation", they can be funds from state and public organizations, enterprises, income from securities, loans from banks and other creditors.

In order for these listed sources to actually function, conditions are necessary that make financial investment in public health protection an attractive enough direction. To this end, in our opinion, it is necessary to differentiate financial market instruments and provide them with appropriate state support. And although public and private insurance organizations will play the main role in these processes, nevertheless, medical institutions and relevant health authorities can attract additional free funds. This can be achieved in various ways:

1. Issue of own debt obligations;

2. Participation in the capital and profit of a medical institution, by issuing shares;

3. Obtaining loans from a commercial bank.

Thus, the specific structure of the market is formed under the influence of various factors that reflect the state of the country's economy as a whole, regional features, the level of development of the relevant infrastructure. And the more accurate the legislative and executive powers will be these factors, the more efficient and civilized they will be used market mechanisms in protecting public health.

Legal form of organization

voluntary health insurance right

Medical care in the health insurance system is provided by medical institutions accredited in accordance with the procedure established by law. Accreditation of medical institutions is the determination of their compliance with established professional standards by accreditation commissions.

An insurance medical organization and medical institutions conclude a contract for the provision of medical and preventive care, according to which the medical institution undertakes to provide the insured contingent with medical care of a certain volume and quality within a specific timeframe within the framework of the medical insurance program. The parties to this agreement are an insurance medical organization and a medical institution. The volume and conditions of medical care should not be lower than the basic program of compulsory medical insurance.

According to the legislation of the Russian Federation, a medical insurance contract is an agreement between the insured and the insurance medical organization, under which the insurer undertakes to organize and finance the provision of medical care of a certain amount and quality or other services to the insured contingent under compulsory and voluntary medical insurance programs.

When concluding a medical insurance contract, each citizen receives an insurance policy that is valid on the territory of the Russian Federation and on the territory of those states that have agreements on medical insurance with the Russian Federation.

Voluntary medical insurance implies the obligations of the insurer to the enterprise representing the interests of citizens, or directly to the citizen, to organize and pay for medical and social services in excess of the established compulsory medical insurance programs.

In case of violation of contractual obligations, for example, failure to provide the insured citizen with the service stipulated by the contract, incomplete or poor-quality medical care, the insurance company pays a fine.

State regulation under this agreement allows for the deprivation of a license for the right to engage in health insurance by a court decision.

By decision of the Board of Rosstrakhnadzor, the license of an insurance organization may be suspended if a violation by the latter of the legislation of the Russian Federation is revealed until the violations are eliminated.

Federal and territorial funds of tactile medical insurance are empowered tax authorities of the Russian Federation when collecting fines and penalties in an indisputable manner from economic entities paying insurance premiums for relevant financial violations.

According to insurance companies, doctors are protected from unintentional errors related to their professional activities. Such protection guarantees the payment of compensation to a patient who has suffered as a result of professional errors of a doctor without involving funds from the latter. The subject of professional liability insurance may be a medical institution, doctors and nurses. The risks associated with compensation for damages due to the necessary re-treatment after an unsuccessful treatment, as well as economic risks associated with compensation of earnings for the time the patient was unable to work due to the fault of the doctor, and moral damages for causing pain, suffering to the patient are insured.

The contract provides for penalties for poor-quality medical care, for refusing to provide medical care, etc. The basis for payment should be a court decision to recover a certain amount of money from a medical institution or doctor to account for possible damage caused to the health of patients. Basically, errors and shortcomings that have arisen by chance, in an unforeseen way are subject to insurance. In case of criminal negligence, the insurance company does not pay insurance compensation.

Bibliography

1. Akopov V. I., Bova A. A. Legal foundations of the doctor’s activity.- M .: Expert Bureau, 2000.

2. Gromov A. P. Rights, duties and responsibilities of medical workers. - M., 2001.

3. Dragonets Ya., Hollender VP. Modern medicine and law. - M .: Legal literature, 1991.

4. Legislative foundations for the professional activities of medical workers: a collection of official documents. - M., 1995.

5. Popov V. L., Popova N. P. Legal foundations of medical activity. - M., 2002.

6. Rykov A. V. Legal foundations of medical law in Russia: textbook.- M., 2000.

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Chapter 7. The program of state guarantees for the provision of free medical care to citizens of the Russian Federation

Chapter 8. Medical personnel with secondary vocational education

Chapter 9

Chapter 10

Chapter 11

Chapter 12

Chapter 14

Chapter 15

Chapter 16

Chapter 17

Chapter 5. Fundamentals of medical insurance of citizens

Chapter 5. Fundamentals of medical insurance of citizens

5.1. GENERAL PROVISIONS

The first normative act that marked the beginning of medical insurance in modern Russia was the Law “On Medical Insurance of Citizens in the RSFSR”, which was adopted in 1991. Later, the legislator made a number of significant changes to it, and from that moment on, the legal basis for the development of medical insurance in our country State became the Law of the Russian Federation "On health insurance of citizens in the Russian Federation". According to the law health insurance is a form of social protection of the interests of the population in the protection of health, the purpose of which is to guarantee citizens, in the event of an insured event, the receipt of medical care at the expense of accumulated funds and to finance preventive measures. In a broad sense, health insurance is a new form of economic relations in the healthcare sector, which ensures the restoration of public health in a market economy.

Medical insurance of citizens in the Russian Federation is carried out in two types:

Mandatory;

Voluntary.

5.2. COMPULSORY MEDICAL

INSURANCE

In the system of compulsory medical insurance, the object of insurance is the insured risk associated with the costs of providing medical care in the event of an insured event. Wherein insurance risk- this is supposed possible event, a insurance case- an event that has already taken place, provided for by the insurance contract (illness, injury, pregnancy, childbirth).

Participants (subjects) of compulsory health insurance are: a citizen, an insurer, a medical insurance organization (HIO), a healthcare organization (medical institution), compulsory medical insurance funds (FOMS) (Fig. 5.1). Compulsory health insurance is carried out on the basis of contracts concluded between the subjects of health insurance.

Rice. 5.1. Subjects of compulsory health insurance

Policyholders with compulsory medical insurance for the non-working population - executive authorities of the constituent entities of the Russian Federation; for the working population - enterprises, institutions, organizations, that is, employers. Persons engaged in self-employment, as well as persons of free professions (persons of creative professions not united in creative unions) are themselves insured.

Each citizen in respect of whom a contract of compulsory medical insurance has been concluded or who has independently concluded such an agreement shall receive an insurance medical policy that is equally valid throughout the territory of the Russian Federation.

Citizens of the Russian Federation in the system of compulsory medical insurance have the right to:

Choice of insurance medical organization, medical institution and doctor;

Obtaining guaranteed (free) 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 an insured, an insurance medical organization, a medical institution, including for material compensation for damage caused through their fault.

Along with citizens of the Russian Federation, the same rights in the system of compulsory medical insurance are granted to stateless persons in the territory of Russia and foreign citizens permanently residing in Russia.

The functions of insurers in compulsory health insurance are performed by insurance medical organizations and territorial funds of compulsory medical insurance (TFOMS).

Compulsory medical insurance of citizens can be covered by insurance medical organizations with any form of ownership that have a state permit (license) for the right to engage in medical insurance. The main task of the insurance medical organization is the implementation of compulsory medical insurance by paying for medical care provided to citizens in accordance with territorial program of obligatory medical insurance. Insurance medical organizations control the volume and quality of medical services, as well as ensure the protection of the rights of the insured, up to the filing of legal claims against a medical institution or a medical worker for material compensation for physical or moral damage caused to the insured through their fault.

The financial resources of the system of compulsory medical insurance (CMI) are formed from the deductions of insurers for all working and non-working citizens. The amount of the insurance premium for the working population is established by the Federal Law as a percentage of the accrued wages of each employee in

part of the unified social tax. In 2008, the amount of contribution to compulsory medical insurance of the working population was 3.1%. The amount of the insurance premium for non-working citizens is annually established by the state authorities of the constituent entity of the Russian Federation when approving the territorial program of state guarantees for the provision of free medical care to citizens of the Russian Federation at the expense of funds provided for these purposes in the budget of the constituent entity of the Russian Federation. These contributions are accumulated in the Federal and territorial CHI funds.

Financing of insurance medical organizations is carried out by territorial compulsory medical insurance funds on the basis of differentiated per capita standards and the number of insured citizens. Financial relations between insurance medical organizations and the territorial CHI fund are regulated by the contract on financing compulsory medical insurance and the territorial rules of the CHI, which are approved by the relevant state authorities of the constituent entity of the Russian Federation.

An important role in protecting the interests of citizens when receiving medical care is performed by experts from insurance medical organizations who control the volume, timing and quality of medical care (medical services) in the event of an insured event.

The federal and territorial compulsory health insurance funds are independent state non-profit financial and credit institutions that implement the state policy in the field of compulsory medical insurance. The Federal Compulsory Medical Insurance Fund is created by the supreme legislative body of Russia and the Government of the Russian Federation. Territorial CHI funds are created by the relevant legislative and executive authorities of the constituent entities of the Russian Federation. CHI funds are legal entities and their funds are separate from the state budget. CHI funds are intended to accumulate financial resources, ensure the financial stability of the state CHI system and equalize financial resources for its implementation.

Medical care in the CHI system is provided by healthcare organizations with any form of ownership, licensed in the prescribed manner. In recent years, it has become a practice to allow healthcare organizations of private forms of ownership to participate in the implementation of territorial CHI programs for competition.

basis. This contributes to the creation of a competitive environment and serves as a factor in improving the quality and reducing the cost of providing medical care to the insured.

Medical institutions are financed by insurance medical organizations on the basis of presented invoices. Payment of bills is carried out according to tariffs in accordance with the volume of medical care provided by the institution. For outpatient clinics, the unit of care is medical visit, for stationary - completed case of hospitalization.

Medical insurance, which is constituent part state social insurance, has a pronounced social character. Its main principles:

universal and binding: all citizens of the Russian Federation, regardless of gender, age, state of health, place of residence, level of personal income, are entitled to free medical services included in the basic and territorial CHI programs;

state nature of compulsory health insurance: implementation of the state financial policy in the field of protecting the health of citizens, they are provided by the Federal and territorial CHI funds as independent non-profit financial and credit organizations. All CHI funds are state-owned;

social solidarity and social justice: insurance premiums and payments are transferred for all citizens, but these funds are spent only when applying for medical care (the principle of "healthy pays for the sick"); citizens with different income levels have the same rights to receive free medical care (the “rich pays for the poor” principle). Despite the fact that the cost of providing medical care to citizens at an older age is greater than at a young age, insurance premiums and payments are transferred in the same amount for all citizens, regardless of age (the principle “the young pays for the old”).

In general, despite the mistakes and difficulties of the initial period, the introduction of compulsory health insurance ensured not only the survival, but also the development of the health care system in the extremely unstable political and economic situation of the 90s of the last century. The compulsory medical insurance system provided

setting a minimum of guaranteed (free) medical care, made it possible to introduce non-departmental quality control of medical care, start restructuring health care in accordance with the real need of the population for basic types of medical care and move to a more rational use of the resources available in health care.

The created financing mechanisms ensured greater “transparency” of the flow of financial flows in healthcare. It is especially important to note that the introduction of compulsory health insurance contributed to the creation of organizational and legal mechanisms for protecting the rights of the patient as a consumer of medical services.

5.3. VOLUNTARY MEDICAL

INSURANCE

Unlike compulsory health insurance, as part of the social insurance system, voluntary health insurance (VMI) is a part of personal insurance and a type of financial and commercial activity, which is regulated by the Law of the Russian Federation "On the organization of insurance business in the Russian Federation".

Voluntary health insurance is designed to provide a higher level of provision of certain medical services in addition to the compulsory health insurance program. It is implemented at the expense of own funds received directly from citizens or funds of the employer, who additionally insures his employees.

The amount of insurance premiums for voluntary medical insurance is set by insurance medical organizations independently and depends on the type of risks, insurance rules adopted by a particular insurer, the cost of medical and other services, the number of insured, etc.

Voluntary insurance is carried out on the basis of an agreement between the insured (employer), insurer and healthcare organization. The rules of voluntary insurance, which determine the general conditions and procedure for its implementation, are established by the insurer independently, but in accordance with the Law of the Russian Federation "On the organization of insurance business in the Russian Federation".

The development of health insurance involves cooperation between the state health care system and the voluntary health insurance system. The determining conditions for such interaction are, first of all, the expansion of the market for paid medical services and, in connection with this, the activation of the activities of companies working under VMI programs, as well as the desire of insurance companies to participate in the financing of regional targeted medical and social programs. In this case, the interests of all health insurance participants are realized. For healthcare organizations, this means obtaining additional funding for targeted medical and social programs, the possibility of improving the quality of medical care and developing services. For territorial CHI funds - the possibility of joint implementation of CHI and VHI programs and thereby eliminating the practice of "double payment" for the same medical service in healthcare institutions. For insurance companies, this is an opportunity to increase the number of policyholders and insured persons. For enterprises - obtaining additional high-quality medical services provided to employees under collective labor agreements.

The main differences between compulsory and voluntary medical insurance are listed below (Table 5.1)*.

Table 5.1. The main differences between compulsory and voluntary health insurance

* Based on the materials of Yu.P. Lisitsyna, A.I. Vyalkova, V.I. Starodubova, Yu.V. Mikhailova

The end of the table. 5.1

Health insurance, in a broad sense, is new economic relations in healthcare in market conditions, that is, the creation of such a system of health care and social security that would actually guarantee all residents of the Russian Federation freely accessible qualified medical care, regardless of their social status and income level .

Currently, there are several options for public health insurance:

• - the health care system of economically developed countries, where health care is financed from 3 main sources - deductions from the income of entrepreneurs, deductions from the state budget and insurance premiums of the population;
• - medical care for the insured as part of the social insurance system, when all contributions to this system go to the state budget and then are distributed among institutions (such a system exists in Russia and the UK);
• - a system of voluntary health insurance, which provides payment for medical care by commercial (receiving profit for this work), non-profit and charitable organizations (such a system operates, for example, in the USA);
• - the insurance system (or, as it was called earlier in Russia, the "insurance work system") - the financing of medical care for workers, employees and members of their families exclusively at the expense of entrepreneurs.

The following options for voluntary medical insurance are of greatest interest in Russia:

• 1. Types of voluntary medical insurance providing for payments not related to the cost of treatment:
  • - insurance in cases of diagnosis of the disease;
  • - insurance in case of illness due to injury;
  • - insurance against loss of income due to illness;
  • - insurance of daily (daily) payments for the period of hospitalization.
• 2. Types of voluntary medical insurance that provide payments in the form of compensation for treatment costs:
  • - insurance of expenses for outpatient treatment;
  • - insurance of expenses for inpatient treatment;
  • - insurance of surgical expenses;
  • - insurance of expenses for postoperative care;
  • - Comprehensive medical expenses insurance.

Lack of an effective management and management mechanism in healthcare, lack of budgetary funds and stable non-budgetary sources of financing, insufficient equipment of healthcare institutions with medical equipment, shortage of medicines, low salaries of medical and pharmaceutical workers do not provide an adequate level of medical care to the population, lead to disinterest of medical workers in improving the efficiency and quality of work. Despite the annual increase in budget funds allocated for the development of health care, their share in the gross national product over the past decade has not exceeded 3-4% (2-2.5 times less than is spent on health care in developed countries).

The current procedure for financing health care requires new forms and approaches based on a combination of interest and responsibility for the health of not only the state, but also ministries, departments, enterprises, institutions, organizations, and every citizen. Such a form is medical insurance, which provides for a set of measures for the accumulation by insurance organizations of financial resources coming from budgetary and non-budgetary sources to pay for medical care to insured citizens, provided that the insurance organization pays for medical services to the insured person in cases specified by the contract. One of the main conditions of health insurance is the free choice of the insured doctor and medical institution, which predetermines the emergence of competition and contributes to improving the quality of medical care and increasing attention to each citizen, since the source of the material well-being of health care workers will be the funds received for the provision of medical care.

A fundamentally new approach to health care financing is defined by the Law “On Health Insurance of Citizens in the Russian Federation” (1991). In the field of health care financing, a transition to a mixed budget-insurance model is expected. Health insurance may be compulsory or voluntary.

Compulsory health insurance, according to this law, is universal for the population of Russia and is implemented in accordance with programs that guarantee the volume and conditions for the provision of medical and drug assistance to citizens. The size of the insurance premium for enterprises was established by the Government of the Russian Federation and approved by the Supreme Council. The amount of mandatory insurance premiums is included in the cost of production.

For the non-working population, compulsory medical insurance is carried out by the executive authorities, the local administration at the expense of the funds provided for in the budgets. Insurance premiums for those working in budgetary institutions and organizations are also paid from the funds of the relevant budgets.

Thus, the CHI system is based on the following organizational principles:

• 1. Universality - all citizens, regardless of gender, age, state of health, place of residence, level of personal income, have the right to receive free medical services included in the CHI program. The norms of compulsory medical insurance apply to working citizens from the moment an agreement is concluded with them.
• 2. Statehood - CHI funds are state-owned by the Russian Federation. The state is the direct insurer for the non-working part of the population (students, students, pensioners). The state exercises control over the collection, redistribution and use of CHI funds. The state ensures the financial stability of the CHI system, guarantees the fulfillment of obligations to the insured.
• 3. Non-commercial nature - CHI funds cannot become income or profit of legal entities and individuals who are founders of medical insurance companies. Compulsory medical insurance is unprofitable and not one insurance company is engaged only in health insurance. As a rule, insurance companies are engaged in voluntary medical insurance, they can also be engaged in non-medical insurance.
• 4. Public solidarity and social justice - all citizens have equal rights to receive medical care at the expense of compulsory medical insurance. CHI insurance payments are paid for all citizens, but the demand for financial resources is carried out only when applying for medical care. The principle works - the healthy pays for the sick. The range and volume of services provided does not depend on the size of the compulsory medical insurance payment, and citizens with different income levels have the same rights to receive medical services. The principle works - the rich pay for the poor.

Voluntary medical insurance is carried out on the basis of voluntary insurance programs and provides citizens with additional medical and other services in excess of those established by compulsory medical insurance programs. It can be collective and individual. This type of insurance is carried out at the expense of profits (income) of enterprises and personal funds of citizens by concluding an agreement. The object of medical insurance is the insured risk associated with the cost of medical care in the event of an insured event. The subjects of health insurance are a citizen, an insured, an insurance medical organization, a medical institution. The insurers of non-working citizens are local administrative bodies, working - enterprises or employers.

At the head of the entire CHI service is the federal background of CHI (FFOMS). Financing at the expense of enterprises, organizations and other economic entities and at the expense of the state budget. From business entities, the fund receives money in the amount of 0.2% of the payroll fund, from the state budget.

Territorial background of compulsory medical insurance (TFOMS) is a fund where money flows to finance medical institutions. Money from the enterprise and the state budget. 3.6% of the payroll comes from enterprises (total 3.8%). These deductions go to the working part of the population. The state budget pays for the non-working part of the population (now this amount is less than 1% for all health care, and not just for the territorial fund).

The insured is a legal or capable natural person who has entered into an insurance contract with the insurer, and who is also the insured by virtue of law. With voluntary medical insurance, the insurers are the citizens themselves or enterprises representing the interests of citizens.

An insurer is a legal entity created to carry out insurance activities that has received, in accordance with the procedure established by law, a license to carry out insurance activities in the territory of the Russian Federation. In the case of health insurance, it is the insurance medical organization. The latter is understood as a legal entity that provides medical insurance and has a state license, which is issued by the Russian Federal Service for Supervision of Insurance Activities for each type of insurance. Insurers must clearly separate the money for medical institutions in accordance with the MHI agreement.

Insurance medical organizations are legal entities that provide medical insurance and have a state permit (license) for the right to engage in this activity. The license is issued by the Ministry of Economy and Finance of the Russian Federation or its bodies.

The insurance company has such departments as the department of voluntary medical insurance, the medical department, which analyzes the activities of health facilities, financial and economic, legal, engineering and commercial departments.

Insurance medical organizations are not allowed to engage in production, trade, intermediary and banking activities. In addition, it is necessary to comply with a number of conditions for health insurance organizations that have a license for compulsory health insurance. A medical insurance organization must have an authorized capital of at least 1,200 minimum wages. The ratio of own and financial resources cannot be more than 1:20. This organization is not allowed to use funds intended for the implementation of compulsory medical insurance programs for the purposes of commercial activities (except for the acquisition of securities and bank deposits with the funds of the reserve fund).

Health authorities and medical institutions do not have the right to be founders of insurance medical organizations, however, they can own their shares (no more than 10% of the total block of shares). Insurance medical organizations are not part of the healthcare system. The main task of the insurance medical organization is the implementation of compulsory health insurance by paying for medical care provided in accordance with the territorial program of compulsory medical insurance, monitoring the quality of medical services.

Insurance medical organizations can: freely choose medical institutions for the provision of medical care and services under medical insurance contracts; participate in the accreditation of medical institutions; establish the amount of insurance premiums for voluntary medical insurance; take part in determining tariffs for medical services; file a claim in court against a medical institution or a medical worker for material compensation for physical or moral damage caused to the insured through their fault. In accordance with the Law of the Russian Federation "On the health insurance of citizens" and the Regulations on insurance medical organizations that carry out compulsory medical insurance, insurance medical organizations are obliged to carry out activities on compulsory medical insurance on a non-commercial basis, to conclude contracts with medical institutions for the provision of medical care to insured persons under compulsory medical insurance. insurance, conscientiously fulfill all the conditions of the concluded contracts, create insurance reserves in the prescribed manner, protect the interests of the insured. These organizations do not have the right to refuse the insured to conclude a contract of compulsory medical insurance.

Below in the chain from insurers are outpatient-type institutions and inpatient-type institutions. Outpatient clinics create an outpatient fund (AF) and are financed according to the norm per inhabitant (the figure changes every month, in the spring of 1996, 8400 rubles per month.). Stationary institutions create a hospital fund (GF). Financing is spent on one treated patient. Medical institutions are medical institutions, research and medical institutes, collectives and persons licensed to engage in certain types of activities and provide services under compulsory and voluntary medical insurance programs. All medical institutions are subject to licensing, regardless of ownership. Licensing is carried out by licensing commissions established under government bodies from representatives of territorial health committees, professional medical associations, medical institutions, public organizations (associations). Accreditation of a medical institution is also carried out, that is, its compliance with established professional standards is determined. A certificate is issued to an accredited medical institution.

The main document of health insurance is a contract (agreement) between the insured and the insurance medical organization, which includes: names of the parties; the duration of the contract; number of insured persons; the amount, terms and procedure for making insurance premiums; a list of medical services corresponding to programs of compulsory or voluntary medical insurance. Each insured citizen receives an insurance medical policy.

In accordance with the law “On Health Insurance of Citizens in the Russian Federation”, every citizen can choose a health insurance organization, a medical institution and a doctor, receive medical care throughout Russia (the principle of extraterritoriality) and medical services that correspond in volume and quality to the terms of the contract, regardless from the amount of the paid insurance premium, to sue the insured and the medical institution for the damage caused, etc. The law provides for the creation of two funds - the health fund (for the implementation of prevention programs, the rehabilitation of special contingents of patients, low-income citizens) and the insurance fund (for the implementation of insurance programs) . Targeted preventive programs (improvement of the external environment, family planning, prevention of infectious diseases, overcoming risk factors, promoting a healthy lifestyle, etc.) are still in the first place in state programs of compulsory health insurance. To implement the comprehensive Russian and regional programs “Health”, to ensure the medical, social, sanitary and epidemic well-being of the population, funding from the state budget and local budgets is necessary.

Within the framework of compulsory medical insurance, the insured person is provided with the following scope of medical care:

• 1. Provision of primary medical care, including: ambulance for sudden life-threatening diseases, injuries, poisoning, childbirth.
• 2. Outpatient treatment of acute and exacerbations of chronic diseases, injuries and accidents.
• 3. Home treatment of persons unable to visit the clinic.
• 4. Preventive measures for children, adolescents, disabled people and participants in the Great Patriotic War, pregnant women and puerperas, as well as patients with tuberculosis, cancer, mental disorders and after heart attacks and strokes.
• 5. Dental care in full for persons under 18 years of age, as well as pupils, students, participants in the Second World War, pregnant women, and women with children under the age of 3 years.
• 6. Drug assistance in accordance with the list of diseases with preferential treatment.

Inpatient care: for patients with acute illnesses, injuries, infectious diseases, cancer patients, during pregnancy and childbirth, abortions and for medical reasons.

Medical insurance provides for the creation of a special “Health Fund” for guaranteed medical and social provision of the population with the necessary range of medical services. A network of religious, charitable, philanthropic and public organizations and foundations is being created to help expand the range of medical and social services.

To implement the law, regulations have been developed and approved on medical insurance organizations, on the procedure for issuing licenses for the right to engage in medical insurance, the basic program of compulsory medical insurance (CHI) and other regulatory documents.

The law defines the legal, economic and organizational foundations of public health insurance. It is aimed at strengthening the responsibility and interest of the population and the state, enterprises and organizations in protecting the health of citizens in the new economic conditions and ensures the constitutional right of citizens to medical care. The law consists of 5 sections and 28 articles.

In the section "General Provisions" it is noted that health insurance is a form of social protection of the interests of the population in the protection of health.

The purpose of health insurance is to guarantee, in the event of an insured event, the receipt of medical care at the expense of accumulated funds and to finance preventive measures.

The second section “Health insurance system” presents the objects of health insurance (insurance risk), gives the structure of a health insurance contract, insurance policy, discloses the rights of citizens, the rights and obligations of the insured, health and insurance funds, etc.

The third section contains articles on the tasks, rights and obligations of medical insurance organizations, on the procedure for issuing licenses for the right to engage in medical insurance, etc. The activities of medical institutions in the health insurance system are reflected in the fourth section, which analyzes in detail the rights and obligations of medical institutions, issues of organizing work on licensing and accreditation of medical institutions, the program of compulsory medical insurance. The agreement on the provision of medical and preventive care and tariffs for medical services is aimed at ensuring the profitability of their activities.

The fifth section “Regulation of relations between the parties in the system of health insurance” coordinates the responsibility of the parties, the right of the insurance medical organization to reimburse expenses, etc. A regulation has been developed on the procedure for issuing licenses for the right to engage in health insurance. Insurance companies and medical institutions (laboratories) are required to have a license (document) for the right to engage in medical activities to serve the insured. These institutions must comply with sanitary and hygienic standards, have diagnostic equipment, medical complexes with modern methods of prevention, diagnosis and treatment.

In the order of the Ministry of Health of the Russian Federation No. 93 dated March 20, 1992 “On Measures to Implement the Law “On Health Insurance of Citizens in the Russian Federation””, it is noted that at the first stage, licensing commissions are created under the health committees of local administrations, which study the submitted documents, acts, equipment, methods, etc.; groups of experts are appointed to analyze the data, determine the scope and duration of the license.

The above law defines the basic rights and obligations of health insurance participants. A citizen of the Russian Federation has the right: to compulsory and voluntary medical insurance; to the free choice of an insurance medical organization and a doctor in accordance with the contract; to receive medical care throughout Russia, including outside the permanent place of residence; to receive medical services corresponding in volume and quality to the terms of the contract, regardless of the amount of the actually paid insurance premium; to file a claim against the policyholder, insurance medical organization, medical institution, including material compensation for damage caused through their fault; for the return of a part of insurance premiums for voluntary medical insurance, if this is determined by the terms of the contract.

A medical insurance organization (HIO) has the right to: freely choose medical institutions for the provision of medical care and services under medical insurance contracts; participate in the accreditation of medical institutions; establish the amount of insurance premiums, tariffs for medical services; file a lawsuit against a medical institution or a medical worker for material compensation for physical or moral damage caused to the insured through their fault. An insurance medical organization is obliged to: conclude an agreement with medical institutions for the provision of medical care to insured persons under compulsory and voluntary medical insurance; issue medical insurance policies to the insured or the insured; return part of the insurance premiums to the insured, if this is provided for by the medical insurance contract; control the volume, timing and quality of medical care; protect the interests of the insured.