He alth insurance: essence, purpose and types of he alth insurance in the Russian Federation

2024 Author: Howard Calhoun | [email protected]. Last modified: 2023-12-17 10:16

The demographic situation, changing government priorities in the field of budget expenditures have led to an increase in the role of private sources of he alth financing. In all countries where medical insurance is intensively developing, individual products to protect the life and he alth of customers appear. Russia is no exception. Consider the main types of he alth insurance in the Russian Federation.

Essence

It is necessary to distinguish between the terms "insurance medicine" and "he alth insurance". In the first case, we are talking about the method of financing the he althcare sector, and in the second, about the type of activity. Let us consider in more detail the nature and types of he alth insurance.

This term refers to a form of social protection of the population in the field of he althcare. Its purpose is, in the event of an insured event, to provide citizens withthe opportunity to receive medical care at the expense of the accumulated money and to finance preventive procedures. Types of he alth insurance are compulsory and voluntary protection of the population.

The essence of this process is the transfer of risks associated with the loss of he alth (temporary or permanent) and compensation for the costs associated with its restoration. The deal with the insurer is formalized by the contract. The object is the risk of receiving expenses incurred in connection with the insured person applying to a medical institution for medical care. The amount of the contribution is calculated based on the probability of an insured event, the he alth status of the client, his age and other factors. The subjects are: citizens, insured, medical organization.

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

• participation of Russians in compulsory medical insurance programs (CHI);
• volume and conditions of providing assistance to the population within the framework of compulsory medical insurance;
• number of free services provided;
• participation of citizens of the Republic of Moldova in voluntary insurance (VHI), which covers services in excess of the CHI program;
• combination of VHI and CHI.

Legal side of the issue

The rights of citizens in the field of he althcare are enshrined in Art. 41 of the Constitution of the Russian Federation and the law "On medical insurance in the Russian Federation". These regulations state that all citizens have the right to medical care. In state and municipal institutions, it is provided free of charge, that is, at the expense of the budget,insurance premiums and other income. Residents and non-residents residing on the territory of the Russian Federation are subject to CHI. That is, he alth care should satisfy the need of people to maintain the level of he alth, regardless of their material capabilities.

He alth insurance: types, differences

On the territory of the Russian Federation, you can issue a policy of compulsory, voluntary and international medical insurance. All three types differ in cost, quality and quantity of services provided. The CHI policy is mandatory for all persons residing in the territory of the Russian Federation. Without it, only emergency medical care is provided free of charge. If the insurer wishes to receive the volume of services in a larger quantity or better quality, then he acquires a VHI policy. Tourists traveling outside the territory of the Russian Federation are required to take out international insurance.

CMI

Disability risk refers to risks that are beyond the control of the individual but result in significant costs. They concern not only individual citizens, but society as a whole. It is interested in maintaining the he alth of all members.

Compulsory he alth insurance is a type of social insurance. It guarantees protection in case of illness to all persons equally. Compulsory he alth insurance is a type of property protection that provides all citizens, regardless of gender, age and social status, with equal opportunities to receive medical care. It is implemented through a system of funds (Federal,territorial) and specialized organizations. The latter carry out MHI operations on a non-commercial basis. Insurers are intermediaries between funds and institutions that provide services to citizens. Organization and control over the entire system is carried out through foundations - non-profit institutions that operate in accordance with the legislation of the Russian Federation.

CHI is financed by insurance premiums (deductions from the single tax in the amount of 3.6%), payments from the budget. In this system, employers act as insurers, who must conclude contracts in favor of employees, individual entrepreneurs and government bodies at all levels.

CMI policy

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

You can issue a policy at any insurance company included in the CHI register. It operates throughout the territory of the Russian Federation. In the event of a change in full name, place of residence, document data or any inaccuracies, the policy must be reissued within one month. You must inform the insurance company in writing about the loss of the policy, and then proceed with the replacement procedure.

Service Programs

The volume and conditions for obtaining guaranteed assistance is fixed by a special document. The basic program is developed by the Ministry of He alth and approved by the government. On herterritorial programs are developed on the basis. They indicate the main types of he alth insurance, the quantity and quality of services provided, the tariff structure, methods of payment for assistance. The rights of insured persons to receive CHI are uniform throughout the Russian Federation.

The basic program provides primary sanitary, preventive, specialized medical care to people with the following diseases:

• infectious, parasitic (except for venereal diseases, tuberculosis and AIDS);
• cancer, skin, diseases of the endocrine system;
• malnutrition, work of the nervous, genitourinary system;
• diseases of the circulatory system;
• eye, ear and respiratory diseases;
• injuries;
• diseases of the musculoskeletal system;
• congenital anomalies in adults;
• impaired immune system;
• chromosomal abnormalities;
• pregnancy, childbirth and abortion.

Territorial program includes:

• list of diseases and types of assistance provided to citizens at the expense of budgetary appropriations and funds from the territorial compulsory medical insurance fund;
• the procedure for providing medical care to certain categories of the population;
• lists of vital medicines and medical products, without which it is impossible to provide medical care;
• list of drugs that are dispensed by prescription free of charge or with a 50% discount;
• list of organizations that participatein program implementation.

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

1. On conditions different from those provided by the program, including at the request of the client:

• establishment of an individual medical observation post for inpatient treatment;
• use of non-essential drugs.

2. Providing services anonymously.

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

4. When the insured person applies independently, with the exception of cases of emergency, specialized assistance.

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

Voluntary he alth insurance

To receive medical services in excess of the established minimum, you need to issue a VHI policy. An agreement is drawn up between the client and the insurance company, according to which, in exchange for the premium paid, the insurer undertakes to finance the costs of treating an illness or traumatic injury.

Depending on the form of payments, the following types of voluntary medical insurance are distinguished: primary and additional. In the first case, we are talking about paying for the costs of treatment (i.e., money in the hands of the insurerdo not get). Additionally, insurance provides for the payment of procedures that are not included in the CHI (experimental treatment, dental and prosthetic services, cancer treatment, etc.), and indirect costs (loss of earnings due to disability, parental leave, etc.).

VHI can be done individually or collectively. The second option is more popular all over the world. In this case, the insured is the enterprise (employer), and the insured person is its employees. In accordance with the agreement, citizens can receive medical assistance when certain circumstances occur. These types of he alth insurance in the Russian Federation operate on a voluntary basis. That is, the policy is purchased at the request of the client, and not without fail.

Payouts

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

Fares

He alth insurance, the purpose, the types of which wereconsidered earlier, are aimed at protecting the property interests of persons in case of disability. But VHI is subject to persons whose individual he alth characteristics differ from the average characteristics and the likelihood of the onset of the disease is higher.

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

• Group 1 - practically he althy individuals who do not have a burdened heredity. There are children's, colds, appendicitis, hernia; without bad habbits; not working in hazardous industries.
• Group 2 - persons with an increased risk of developing a disease, aggravated by heredity with diabetes, cardiovascular, renal and gallstone, mental diseases. There is a history of craniocerebral trauma; have bad habits; working with harmful production conditions.
• Group 3 - able-bodied persons with chronic diseases; abusing alcoholic beverages, taking tranquilizers; suffering from neurosis, hypertension, coronary artery disease without angina pectoris.

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

Infringements of rights

All considered types of he alth insurance operate on the same principles. If one of these facts is revealed, the rights of citizens to receive quality medical care are considered violated:

• illegalcollection by medical staff of funds for providing assistance in the amounts provided for by the state program;
• illegal collection of funds to the cash desk of medical institutions for providing assistance, issuing referrals, prescriptions for medicines;
• acquisition of drugs and medical products from the list approved by programs at the expense of patients;
• non-compliance with the terms of medical care;
• refusal to provide assistance under compulsory medical insurance.

Detailed information on what types of he alth insurance are available in a particular region can be obtained from the company, the Territorial CHI Fund, the He alth Committee.

International practice

Accessibility of he alth services is a key issue in any country. Priority types of he alth insurance largely depend on historical traditions. In the US, all types of he alth insurance are funded by voluntary contributions. Most countries do not have a public funding program. For them, VHI is an absolute necessity. Elderly and poor people participate in state programs. But for all employed persons, employers pay for the VMI policy. The UK has a National He alth Service. VHI policies are designed in such a way that clients can pay for unscheduled surgical treatment or improve the quality of medical services. In some countries, types of he alth insurance for citizens are being developed in the secondary market, aimed at additional payments that are not covered by a regular policy. Programs in Europestate support. But the most significant source of funding are compulsory insurance policies.