How to issue an electronic OMS policy. Electronic MHI - how to get a policy of compulsory health insurance Policy of compulsory health insurance how to use

Almost every Russian has a mandatory policy health insurance, but not everyone clearly understands where and what kind of medical care can be obtained through it. About what rights we are entitled to under the compulsory medical insurance policy and how to use it correctly, including in a foreign city, and when the policy may be useless, in an educational program from the expert of the Interregional Union of Health Insurers Tatyana Serebryakova.

What kind of treatment does the compulsory medical insurance policy give the right and do not need to insist on it?

The patient cannot apply for treatment under the compulsory medical insurance policy in the two most common situations.

Firstly, when contacting a medical institution that is not funded by the compulsory medical insurance for a specific profile. Each medical organization, both private and state, once a year declares to participate in the CHI system. Moreover, not "in general", but for specific profiles and types of treatment. And it's not a fact that the hospital or clinic you have chosen provides exactly the services you need under the compulsory medical insurance policy. That is, when contacting a medical institution, you need to find out two main parameters: whether it participates in the compulsory medical insurance system, and by what types and conditions (for all or some specific ones) in the context of profiles, specialist doctors, assistance to children or adults.

Secondly, if the treatment itself is not among those financed by the CHI. This applies, for example, to sexually transmitted diseases, HIV, AIDS, tuberculosis, mental and behavioral disorders, palliative care (both inpatient and outpatient). Such medical care is financed from other sources of the State Guarantee Program - federal, regional or local budget... The compulsory medical insurance policy does not pay for the treatment of citizens outside the Russian Federation, plastic aesthetic surgery (if there is no medical indication for this), preferential dental prosthetics, spa treatment, as well as the provision of medical care in conditions exceeding the level of comfort established by the program.

In addition, social benefits are not included in the number of services that are not financed by the compulsory medical insurance, which means that they are not provided under the policy. For example, related to preferential provision of drugs for outpatient treatment. That is, if in the hospital all medicines are provided free of charge, then the patient's prescription received at the clinic, who does not have the right to benefits, pays independently. They have nothing to do with the compulsory medical insurance policy and sick leave payments - this is a type of social benefit that is paid from funds social insurance.

Does it matter that a person gets sick while in a place where he does not have a permanent registration?

You can get treatment for free in any part of the country, the main thing is not to forget to take a policy on your trip compulsory medical insurance... But this applies to medical care under the basic compulsory medical insurance program, which is approved by the Government of the Russian Federation and is absolutely the same in all regions of Russia. That is, any acute condition or exacerbation of a chronic disease, toothache, bruises, poisoning, allergies or sunstroke - all these are reasons to seek free help from a polyclinic or a hospital operating in the compulsory medical insurance system.

If your condition worsens, you are also entitled to a free ambulance and an emergency ambulatory. Moreover, when providing emergency medical care in cases that threaten a person's life, the presentation of a compulsory medical insurance policy is not required. Such assistance is provided to everyone, without exception, free of charge and without delay.

However, in other cases, there is a difference between the permanent residence and the region of temporary residence. This difference applies to those medical services that are in excess of the basic compulsory health insurance program. For example, in a number of regions of the Russian Federation with a high level of socio-economic development, the territorial compulsory medical insurance program is much broader - due to certain types of high-tech medical care that are not included in the basic program. In addition, due to the "super-basic compulsory medical insurance program", the scope of preventive measures can be expanded. But the extended program is available only for residents of that particular region. A nonresident patient will not be provided services in excess of the basic compulsory medical insurance program free of charge under the compulsory medical insurance policy.

And if the disease is associated with some local peculiarities? For example, a Muscovite traveling across Transbaikalia was bitten by a tick.

It is obligatory to provide medical assistance under the compulsory medical insurance policy (including removing a tick) in any emergency room. If a disease associated with a bite develops, then it should also be treated free of charge - at the expense of compulsory medical insurance funds... This also applies to other similar situations, regardless of where the sick person is.

Is it possible to get sick on a trip sick leave?

A person has the right to receive a sick leave in any region of the country. It all depends on the medical indications that he is disabled. If you cannot go to the clinic, call the doctor at home. Medical assistance at home should also be provided under the compulsory medical insurance policy.

If the situation is not urgent, and a person on vacation simply has time to deal with his chronic illness, will he be provided with planned assistance?

The compulsory medical insurance policy allows you to apply for routine medical care anywhere in the country. The disease profiles for which such assistance is provided are listed in the basic compulsory medical insurance program. However planned treatment, for example, adjusting the insulin dose or selecting a hypertensive drug is a rather lengthy process that requires a lot of examinations, additional consultations, etc. Therefore, it is better to do this at home, in consultation with your doctor. If you plan to leave for another region for a long time and you know that at this time you may need routine medical care - attach to the clinic at the place of stay.

Or can they declare in another region that the compulsory medical insurance policy is invalid?

The current policy guarantees the provision of free medical care under the basic compulsory medical insurance program throughout Russia. Enter your insurance company's hotline in your address book mobile phone, and call it in any disputable case. If you have not used the policy for a long time, call the hotline of your insurance company (the phone number is indicated on the policy), check if there is information about it in the relevant register of insured persons. Best of all - replace it with new policy OMS uniform sample... To do this, it is enough to contact any insurance company, but it is better to plan a visit to it 1.5 months before the intended trip.

What if a patient is forced to pay for treatment?

Contact the head of the medical organization, call the Regional Compulsory Medical Insurance Fund of the region in which you are not at the place of insurance, and where you were denied medical care or demanded to pay for it. To date, each constituent entity of the Russian Federation has organized the work of Contact Centers in compulsory health insurance, the phone number of such a Contact Center should be posted on the stands in each medical institution, on the website of each Regional CHI Fund. This number and other details of the Contact Center will always prompt you if you call the hotline to your insurance company.

If you had to pay - save the receipt and warn that you will appeal this forced payment (write a complaint). If you are offered to sign a contract for the provision of paid services (and in another way, payment for medical care in the Russian Federation is not legal) - read it carefully and do not sign it if it states that you are aware that you can get medical care for free, but you voluntarily decided to pay.

According to OMC Rules within the territory of Russian Federation policies of a single sample are in effect. The document can be in the form of a paper or electronic policy (EPOMS). What electronic policy OMS? A single-sample policy in the form of a plastic card can only be issued by citizens of the Russian Federation. The document has a built-in chip, which contains information about its owner, the back side contains the signature and photo of the insured person, which excludes the use of your document by another person and guarantees the receipt of medical care throughout Russia.
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HOW TO USE
ELECTRONIC POLICY

HOW TO USE
ELECTRONIC POLICY

When an insured event occurs, many people ask themselves, how to use the electronic health insurance policy.

There are no differences in the use of the plastic analogue of the OMS and the document on paper. This document also gives the right to use the entire range of medical care free of charge anywhere in Russia, in accordance with the program of state guarantees.

Using an electronic policy, it is possible to make an appointment with a doctor through the terminal or online, without standing in line at the reception, while it is convenient to use.

Along with the policy, the insurance medical organization provides the insured person with information on the rights of insured persons in the field of compulsory health insurance, on the procedure information support at all stages of providing them with medical care in the form of a memo or a brochure.

The compulsory medical insurance policy guarantees a person the right to provide medical care in any corner of our country. However, the amount of this assistance can vary significantly. We understand the intricacies of obtaining and using the compulsory medical insurance policy.

The child was born, but there is no policy!

Newborn children receive medical care under the compulsory medical insurance policies of their mothers until they receive a birth certificate, that is, registration with the registry office.

After receiving a birth certificate, you need to contact the pension fund to obtain SNILS - a green laminated card ( since 16.05.2016 in mandatory, according to the order of the Ministry of Health of the Russian Federation No. 192n dated 03.25.16). It takes about a week to complete it. It is better to do this right away, since it is almost impossible to plan exactly when your baby will need medical attention.

Important! Emergency care for newborns is provided without a medical policy.

Having received SNILS, one of the parents goes to the insurance company to get the baby's compulsory medical insurance policy. For this you need:

• SNILS;
• passport of the parent who applied;
• child's birth certificate.

A temporary policy will be issued immediately (it is valid for 30 days), and a permanent one - after 2-4 weeks.

Note! You can also issue an OMI policy at the MFC (multifunctional center), where you can choose any insurance company from those operating in your region.

What does the new compulsory medical insurance policy look like?

Previously, each region and each insurance company had their own policies. Now they are all issued on Goznak paper and have a single look. Rather, they can be made in several formats:

1. a5 format - paper, with a barcode and number - issued by all insurance companies in all localities;
2. format of a plastic card with a photo - children under 14 years old are not done - they change quickly and do not know how to subscribe;
3. electronic attachment format (universal electronic card with a number) - not issued at all points, but it works in the same way as a paper policy;
4. virtual policy format - can be obtained only in St. Petersburg, it is convenient to use - the policy does not need to be taken with you, only a passport or a birth certificate.

However, our polyclinics, especially those located in small towns, do not have the appropriate equipment and health workers enter the policy data manually, and therefore paper ones are popular.

Advice: make a photocopy of the child's policy and put it in the birth certificate. This way you won't forget an important document in case of a rush.

How does the compulsory medical insurance policy work?

As in the story of bread, all medical services have their own cost. Therefore, they are not given out for free. The state pays for these services through insurance companies or budget resources... Therefore, by presenting a policy, you, in fact, pay for the work of doctors.

The doctor examines the child, the nurse gives the injection - they work. For work, the invoice is not issued to you, but to the insurance company, which pays for it within 25 working days.

Asking a doctor to see you without a compulsory medical insurance policy is similar to asking for bread in a store for free. They can give out of pity and pay out of their own pocket.

What if there is no compulsory medical insurance policy?

If you do not have an OMI policy with you, but it has been issued, you need to call your insurance company (or any one - now a single database of policies) and find out your number there. A medical institution can also make a request to the insurance company.

There are three types of medical care:

1. emergency, when the child's condition is so serious that he can die without medical care right now. No policy needed;
2. urgent, when the condition is serious, but there is no threat to life - in this case, a policy is needed;
3. planned - any other assistance is provided only upon presentation of the policy.

What is the scope of medical services included in the compulsory medical insurance policy?

The amount of medical care that a child can receive differs in different regions, depending on welfare and accepted traditions. Therefore, at the state level, the following terms are used:

• basic medical care is the amount that anyone can get anywhere:
• raceswide - what guarantees its residents a specific region.

It is clear that the volume of included medical care is different for Moscow and, for example, the regional center in the Rostov region.

Now mothers cannot schedule an examination for their child themselves (shouldn't they donate urine to us?) - only a pediatrician, if he sees fit. Therefore, it is necessary to find a common language with the pediatrician. If the doctor does not suit you at all, you can complain about him to the insurance company or the polyclinic administration, or you can simply attach to another doctor within the law, if, of course, another doctor agrees to take you.

Note. If, nevertheless, you really want to undergo some kind of research, but the pediatrician reasonably does not give a referral, you can take it for a fee, in accordance with the law of the Russian Federation "On the basics of protecting the health of citizens of the Russian Federation", article 84.

If the doctor prescribes an examination, then it should be carried out free of charge in the MLA, even if your clinic does not have the ability to do this. A request is made to another clinic, and then financial settlements will be made between them.

Advice: carefully read the documents to be signed, they may indicate that you yourself refuse free helpchoosing a paid service.

Do you use the compulsory medical insurance policy? Happy with the performance of your insurance company? Or have you already changed your doctor, clinic, insurance company? Tell us about your experience!

OMS policy - a document certifying the right to receive free medical care under the compulsory health insurance program throughout Russia. Compulsory health insurance (MHI) is a part of the state social insurance system that provides an opportunity to receive free medical and pharmaceutical care. A client who has a compulsory medical insurance policy applies to a medical organization participating in the compulsory medical insurance system and receives the necessary treatment. The medical organization issues an invoice for the assistance provided, which is paid by the insurance company.

To pay bills, money is transferred to the insurance company from the CHI funds, which, in turn, are financed from the federal and regional budgets, income from the placement of free funds and other sources. Including insurance premiums that your employer pays monthly. Each visit to a doctor, each prescribed study is paid by the insurance company at the rates established within the program.

All citizens of the Russian Federation can get a compulsory medical insurance policyforeign citizens permanently or temporarily residing on the territory of the Russian Federation, as well as persons entitled to medical assistance in accordance with federal law about refugees. Military personnel and persons equated to them in the organization of medical care were excluded from the CHI program. We will try to provide answers to the most frequent, but remaining topical issuesassociated with CHI.

How to get a compulsory medical insurance policy

Registration of a policy for a newborn child necessary after obtaining a birth certificate. Before receiving the certificate, the child is served by the mother's insurance company or another legal representative. The period of validity of the OMS policy is unlimited. During the validity period of the policy, if the last name, first name, patronymic, place of residence, the insured person changes, the insured must notify the insurance company within one month from the day these changes occurred in order to reissue the policy. In case of moving to a region where there is no representative office of the current insurance company, the insured must choose any other one represented in this region.

When applying for the choice (change) of the insurance company, the employee of the company issues a temporary certificate that provides the same rights as the policy. Within 30 days, the insurance company must prepare a policy and notify the client about it. If this does not happen, the client has the right to file a complaint with the territorial fund of compulsory medical insurance, since there are penalties for violation of the terms for the preparation of policies for insurance companies.

Do foreign citizens need a compulsory medical insurance policy

At the same time, from January 1, 2015, for foreign citizens planning to obtain a patent for the right to carry out labor activities, the conclusion of a VHI policy is mandatory. Foreign citizens who are not insured under the compulsory medical insurance and voluntary medical insurance programs are provided with medical assistance only in an emergency form.

How to choose an insurance medical organization

The main function of the insurance company is ensuring the protection of the rights and interests of the insured. As part of these obligations, the insurance company carries out registration, renewal, issuance of a policy, informing insured persons about the types, quality and conditions of providing them with medical care, control over the provision of medical care. Therefore, you should seriously think about choosing an insurance company.

The first thing to focus on is a list of insurance companies operating in your region. Information on them can be found on the website of the territorial compulsory health insurance fund. In some regions, there is only one medical insurance organization and there may be no choice. But in most regions there are several companies that are intensely competing with each other for the right to serve as many customers as possible. As a next step, you should familiarize yourself with the rating of medical insurance organizations posted on the website Federal Fund compulsory health insurance.

The main indicators characterizing the quality of the work of the insurance company: the number of insured, the availability of points of issue, specialist experts, the availability of information for the insured, the presence of justified complaints. Going to the sites of companies with the best indicators, study the completeness and relevance of the information, the possibility of obtaining round-the-clock advice from specialists both by phone and via the Internet, the number and availability of offices. The list of mandatory services provided by all companies is the same, but the quality of service can vary greatly.

What is included in the CHI program

On the basis of the basic program, each constituent entity of the Russian Federation has developed a territorial insurance program, which contains a wider list of medical care provided, financed by the constituent entity of the Federation. When a client applies for medical assistance in a region other than the region where the policy is issued, assistance is provided in the amount provided for by the Basic Program.

The list of types, forms and conditions for the provision of assistance under the territorial program can be found on the websites territorial funds compulsory health insurance, directly in medical organization and an insurance company. For a simple consumer, this information will not be particularly informative, since the description of the program does not contain a clear list of services provided. To inquire about the availability of a service in territorial programif such a question has arisen, as well as in order to avoid the imposition of paid services by a medical organization, it is easiest for the insured to contact his insurance company. She should provide initial consultation and, if necessary, conduct an examination of the quality of medical care.

Charging a fee for the provision of medical care included in the CHI program is one of the most common violations. Treatment prescribed by a doctor, and not recommended, should be provided free of charge if it is included in the CHI program. In the absence of the necessary doctor or equipment in the medical organization, the insured should be sent not to a paid clinic, but to issue a referral for the necessary free procedures to another medical organization working under the compulsory medical insurance program. If in a medical organization working under the CHI program you paid for the treatment, but found out that it should be carried out free of charge, you must keep all receipts and file a complaint with the insurance company. The insurer is obliged to organize an inspection and, if a violation is detected by a medical organization, return the money to you and impose a fine on the organization.

The policy is either a paper form or plastic card... It can also exist electronically.

To start using VHI, you need a printout of the policy and an identity document.

The maintenance of chronically ill people who need expensive treatment on an ongoing basis is not implied.

You can get the expensive procedure for free vHI policyand receive monetary compensation for the costs incurred to your account.

Medical assistance in in this case turns out to be the most highly qualified doctors of the department. The insurance may include the cost of transportation or repatriation of the patient.

What is an insured event?

The insured event for the company occurs in the event of an acute, as well as exacerbation of a chronic disease, injury and other suddenly occurring circumstances.

The treatment of conditions resulting from:

• illegal actions;
• suicidal actions;
• nuclear explosion and radiation effects;
• hostilities, riots, natural disasters, other force majeure circumstances.

Also, insurance companies do not pay for conditions that occurred outside the duration of the insurance.

The exceptions are situations when a person needs urgent hospitalization, the beginning of which refers to the period of validity of the insurance, and the end goes beyond this period.

Sometimes the question is whether an event belongs to insured event or not, requires expert approval.

At the first stage, such disputes are resolved by the company's specialists. In case of disagreement with their opinion, the issue can be resolved in court.