Subjects and objects of OMS. Who are the participants in compulsory health insurance? Definition of participants in social health insurance

Policyholder

The insured is the party that insures its own health or the health of its employees. The policyholders for compulsory health insurance are:
executive authorities of the constituent entities of the Russian Federation and local governments - for the non-working population;
organizations, individuals registered as individual entrepreneurs, private notaries, lawyers, individuals who have entered into employment contracts with employees, as well as pay remuneration under civil law contracts, on which taxes are charged in full accordance with the legislation of the Russian Federation in the part subject to enrollment in compulsory health insurance funds - for the working population.
Decree of the Government of the Russian Federation of September 15, 2005 N 570 "On approval of the Rules for registering policyholders in TFOMI under CHI and the form of a certificate of registration of the policyholder in TFOMI under CHI" approved the corresponding Rules for registering policyholders in TFOMI under CHI.
Organizations, individuals registered as individual entrepreneurs, private notaries, lawyers, individuals who have entered into employment contracts with employees, as well as pay remuneration under civil law contracts, on which taxes are charged in full accordance with the legislation of the Russian Federation, subject to enrollment in the compulsory health insurance funds, are subject to registration with the territorial compulsory health insurance fund as policyholders for the working population.
The executive authorities of the constituent entities of the Russian Federation act as insurers for the non-working population.
Organizations are subject to registration as policyholders in the territorial fund at the place of their location, and the registration of organizations as policyholders is carried out by the territorial fund within 5 days from the date of submission in the manner established by Decree of the Government of the Russian Federation of June 19, 2002 N 438 "On the Unified State register of legal entities ", the federal executive body that carries out state registration of legal entities and individual entrepreneurs, to the territorial fund of information contained in the Unified State Register of Legal Entities.
The said Resolution provides that information on the date of registration of a legal entity as a policyholder, its registration number, the name of the body that carried out the specified registration, or the date of the deregistration of the legal entity as the policyholder, are provided by the relevant state authorities extrabudgetary funds no later than 5 days from the date of registration of a legal entity as a policyholder or deregistration as an policyholder.
The specified information is submitted to in electronic format using electronic digital signatures through communication channels on the terms established by agreement of the parties. The format of the transmitted information is established by the Federal Tax Service, and if it is impossible to transfer the information in this form, the bodies of state extra-budgetary funds send them by mail with a receipt acknowledgment.
The rules for registering insurers in the TFOMS under CHI determine that an organization that has separate subdivisions is obliged to register as an insured in the territorial fund at the location of each separate subdivision with compulsory medical insurance on the basis of an application in the established form.
The application is submitted to the territorial fund no later than 30 days from the date of the creation of a separate subdivision with the submission of copies of documents confirming the creation of a separate subdivision (constituent documents containing information on the creation of a separate subdivision, or an order (order) on the creation of a separate subdivision and a provision on a separate subdivision); documents confirming the fulfillment by the organization of the obligation to pay tax credited to the compulsory health insurance funds; certificates of registration of the organization as an insured in the territorial fund at the place of its location. These copies of documents must be notarized.
The rules for registering policyholders with the TFOMI under the CHI provide that individual entrepreneurs, private notaries, lawyers and individuals are subject to registration as policyholders in the territorial fund at their place of residence.
In the event that private notaries carry out their activities in another place, they are subject to registration as policyholders in the territorial fund at the place of implementation of these activities.
TFOMS registers an individual entrepreneur as an insured within 5 days from the date of submission by the federal executive body carrying out state registration of legal entities and individual entrepreneurs to the territorial fund of information contained in the Unified State Register of Individual Entrepreneurs, in accordance with the procedure established by the Decree of the Government of the Russian Federation dated October 16, 2003 N 630.
Information on the date of registration of an individual entrepreneur as an insured, its registration number, the name of the body that carried out the specified registration, or information on the date of deregistration of an individual entrepreneur as an insured, shall be submitted by the bodies of state extra-budgetary funds no later than 5 days from the date of registration of an individual entrepreneur as the policyholder or deregistered as the policyholder.
Registration of a private notary as an insurant, in accordance with the Rules for the registration of policyholders in the TFOMS under OMI, is carried out on the basis of an application in the established form.
The application is submitted no later than 30 days from the date of publication of the order on the appointment of a person to the office of a notary. The application must be accompanied by notarized copies of the certificate of registration of an individual in tax authority and (or) notification of registration of an individual with the tax authority at the place of residence (at the place of business); licenses for the right to notarial activity; an order on the appointment of a notary; documents proving the identity of the policyholder and confirming his registration at the place of residence.
The rules for registering policyholders with the TFOMS under the CHI also provide for the registration of a lawyer as an policyholder on the basis of an application in the established form. The application is submitted no later than 30 days from the date of issue of the lawyer's certificate with the attachment of notarized copies of the lawyer's certificate; documents proving the identity of the policyholder and confirming his registration at the place of residence.
Registration of an individual as a policyholder is carried out on the basis of an application in the established form.
The application is submitted no later than 30 days from the date of the conclusion of employment contracts with employees, as well as contracts of a civil nature, on remuneration for which, in full accordance with the legislation of the Russian Federation, taxes are charged in the part subject to enrollment in compulsory medical insurance funds. The application shall be accompanied by notarized copies of the employment contract with the employee or of a civil law contract, on remuneration for which, in full accordance with the legislation of the Russian Federation, taxes are charged in the part subject to enrollment in the compulsory medical insurance funds; documents proving the identity of the policyholder and confirming his registration at the place of residence.
The executive authorities of the constituent entities of the Russian Federation act as policyholders for the non-working population. Their registration as an insured is carried out in the territorial fund with compulsory medical insurance.
These bodies are registered on the basis of an application in the established form, which is submitted no later than 30 days from the date of their establishment.
TFOMS keeps a register of policyholders who are registered with the territorial fund. The form of the journal is established by the Federal Mandatory Health Insurance Fund. Among other things, for each registered policyholder, the territorial fund opens an policyholder's file, which stores documents related to the registration of the policyholder.
When registering with a territorial fund, each policyholder is assigned a registration number, the structure of which is approved by the Federal Fund for Compulsory Medical Insurance. This registration number cannot be reassigned to another policyholder, including after the policyholder is deregistered in the territorial fund, as well as in the event of the death of an individual.
The certificate of registration of the policyholder in the territorial fund in case of compulsory medical insurance, the territorial fund within 5 days from the date of entering the account in the register of the policyholders shall deliver (send by post by registered mail with acknowledgment of receipt) to the policyholder.
When transferring funds to be credited to the income of compulsory health insurance funds, in payment orders, as well as in other cases stipulated by regulatory legal acts of the Russian Federation, the policyholder indicates his registration number of the policyholder in the territorial fund.
Making changes to the affairs of policyholders - organizations registered in the territorial fund, and deregistering them during their reorganization, liquidation, as well as when changing the location or excluding a legal entity that has ceased its activities from the Unified State Register of Legal Entities by decision of the registering body is carried out by the territorial fund on the basis of information provided by the federal executive body that carries out state registration of legal entities and individual entrepreneurs.
The insured - private notaries, lawyers and individuals shall notify the territorial fund in writing about the change in the place of residence and other information specified during registration with the territorial fund within 10 days from the date of making such changes to the Unified State Register of Taxpayers.
Deregistration in the territorial fund of policyholders - private notaries and lawyers - is carried out in the event that they cease their activities in this capacity or change their place of residence to a place of residence in another constituent entity of the Russian Federation.
Deregistration in the territorial fund of policyholders - individuals is carried out in the event of expiration (termination) of the employment contracts concluded with employees, as well as contracts of a civil nature or change of place of residence to place of residence in another constituent entity of the Russian Federation.
Territorial funds ensure the safety of documents and information submitted for registration of policyholders in territorial funds, in full compliance with the legislation of the Russian Federation.

MHIF

Payments for the working and non-working population are transferred to specialized financial and credit institutions - the Federal and territorial compulsory health insurance funds. These institutions were created on the basis of Resolution of the Supreme Soviet of the Russian Federation N 4543-1 of February 24, 1993, within the framework of which the Regulation on the Federal Fund for Compulsory Medical Insurance (FFOMS) and the Model Regulation on the Territorial Fund for Compulsory Medical Insurance (TFOMS) were approved.
Compulsory health insurance funds - ϶ҭᴏ independent state non-profit financial and credit institutions implementing the RF Law "On Health Insurance" and implementing the state policy in the field of compulsory health insurance of citizens.
For implementation public policy in the field of compulsory health insurance, federal and territorial compulsory health insurance funds are created as independent non-commercial financial institutions. Compulsory health insurance funds are intended to accumulate funds for compulsory health insurance, to ensure the financial stability of the state system of compulsory health insurance and equalization financial resources for its implementation (RF Law of June 28, 1991 N 1499-1 "On health insurance of citizens in the Russian Federation").
The main tasks of the Federal Fund are:
ensuring the financial stability of the compulsory health insurance system and creating conditions for leveling the volume and quality of medical care provided to citizens throughout the Russian Federation within the framework of the basic compulsory health insurance program;
accumulation of financial resources from the budget of the Federal Fund for Compulsory Health Insurance to ensure the financial stability of the compulsory health insurance system.
FFOMS performs the following main functions:
aligns financial conditions the activities of territorial compulsory health insurance funds within the framework of the basic compulsory health insurance program;
develops and in the prescribed manner submits proposals on the amount of contributions for compulsory health insurance;
carries out, in full accordance with the established procedure, the accumulation of financial resources from the budget of the Federal Fund for Compulsory Medical Insurance;
allocates funds in accordance with the established procedure to territorial compulsory health insurance funds, including on a non-refundable and repayable basis, for the implementation of territorial compulsory health insurance programs;
together with the territorial compulsory health insurance funds, exercise control over the rational use of financial resources in the compulsory health insurance system, including through appropriate audits and targeted inspections;
carries out, within its competence, organizational and methodological activities to ensure the functioning of the compulsory health insurance system;
submits, in the prescribed manner, proposals for improving legislative and other regulatory legal acts on compulsory health insurance;
participates in the development of the basic program of compulsory health insurance for citizens;
collects and analyzes information, including on the financial resources of the compulsory health insurance system, and submits relevant materials to the Ministry of Health and social development Russian Federation;
organizes in the prescribed manner the training of specialists for the compulsory health insurance system;
studies and summarizes the practice of applying regulatory legal acts on compulsory health insurance;
ensures, in the prescribed manner, the organization of research work in the field of compulsory health insurance;
participates in the prescribed manner in international cooperation on compulsory health insurance;
annually submits to the Ministry of Health and Social Development of the Russian Federation draft federal laws on the budget of the Federal Compulsory Medical Insurance Fund for the next financial year and planning period and on its implementation for the reporting financial year.
Formation and execution of the budget of the Federal Mandatory Medical Insurance Fund is carried out in full accordance with the budgetary legislation of the Russian Federation. The procedure for spending funds in the course of compulsory health insurance, the principles of financial interaction of executive authorities, the Federal and territorial CHI funds, and other subjects of medical insurance are determined by the Temporary Procedure for Financial Interaction and Spending of Funds in the System of Compulsory Health Insurance of Citizens (approved by FFOMS on April 5, 2001 N 1518 / 21-1).
In accordance with it, from the funds received on the main accounts of the territorial fund, a part of the unified social tax, a part of the unified tax on imputed income to be credited to the territorial fund, insurance contributions for compulsory medical insurance of the unemployed population, as well as other receipts provided for by the legislation of the Russian Federation, the territorial fund carries out:
financing of medical insurance organizations according to differentiated per capita standards for paying for medical care within the territorial compulsory medical insurance program;
payment for medical services provided to citizens insured by the territorial fund (in the case of compulsory medical insurance by the territorial fund);
financing of health care activities within the framework of regional target programs, approved in accordance with the established procedure, for medical institutions operating in the CHI system;
formation of a standardized insurance stock intended to ensure the financial stability of the compulsory health insurance system in the territory of a constituent entity of the Russian Federation;
the formation of funds intended to provide them with management functions according to the standard established by the executive director in agreement with the board of the territorial fund as a percentage of the amount of all funds received, excluding the balance of funds at the beginning of the year.
The value of the standardized insurance stock of the MHIF is determined at least 15 percent of the total amount of subsidies allocated to territorial compulsory health insurance funds for the implementation of territorial compulsory health insurance programs within the framework of the basic compulsory health insurance program.
Funds reserved in case of critical situations with the financing of compulsory health insurance as a result of natural disasters, catastrophes, terrorist acts and other emergencies, in case of non-use during the year, are directed at the end of the year to equalize the financial conditions for the activities of territorial funds for financing territorial compulsory programs medical insurance of the constituent entities of the Russian Federation (decision of the board of the Federal CHI Fund dated September 19, 2007 N 13A / 01).
The funds of the standardized insurance stock of the MHIF are directed to the territorial fund to equalize the financial conditions for the activities of territorial funds for financing territorial programs of compulsory medical insurance of the constituent entity of the Russian Federation for the implementation of the territorial compulsory medical insurance program on the basis of the application of the territorial fund.
Funds reserved in case of critical situations with the financing of compulsory health insurance as a result of natural disasters, catastrophes, terrorist acts and other emergencies, in case of non-use during the year, are directed at the end of the year to equalize the financial conditions for the activities of territorial funds for financing territorial compulsory programs medical insurance of the constituent entities of the Russian Federation.
To ensure the financial stability of the compulsory health insurance system, the funds of the normalized insurance stock in the amount of up to 10% of the funds provided for under this article are reserved in case of critical situations with the financing of compulsory health insurance as a result of natural disasters, catastrophes, terrorist acts and other emergencies during of the year.
These funds, if they are not used during the year, are directed at the end of the year to equalize the financial conditions for the activities of territorial funds to finance territorial compulsory medical insurance programs of the constituent entities of the Russian Federation.
The composition of the tariff for medical and other services provided under the territorial CHI program is determined in full accordance with the current regulatory documents by the decision of the conciliation commission, which on an equal footing includes the interested parties, namely: representatives of the territorial CHI fund and its branches, government bodies, insurance medical organizations, professional medical associations (in the absence of the latter, the interests of medical institutions can be represented by trade unions of medical workers). In this case, a territorial tariff agreement is concluded (general agreement on prices and tariffs).
Payment for the provided medical care is carried out by the insurer on the basis of bills presented by medical institutions. The procedure for paying for medical care is regulated by the Regulation on the procedure for paying for medical services in the CHI system, which defines the types and methods of payment for medical services in the territory.
Medical institutions of any form of ownership, licensed to provide certain types of medical care, use the funds received in full accordance with the concluded agreements for payment of medical care (medical services) for compulsory medical insurance, for payment of medical care within the framework of the territorial compulsory medical insurance program, at tariffs adopted under tariff agreement for compulsory medical insurance in the territory of the subject of the Russian Federation.
Funds received from the territorial fund for certain health care activities are used by medical institutions operating in the compulsory medical insurance system, within the framework of approved target health programs.
Payment for medical care is made on the basis of an agreement for the provision of medical and preventive care (medical services) under compulsory medical insurance, concluded by a medical institution and an insurer, and can be carried out in two versions:
1. Direct payment by the territorial fund Compulsory medical insurance services provided by medical institutions (in in this case the fund or its branch acts as an insurer - performs the functions of a medical insurance organization).
2. TFOMI transfers the funds of compulsory health insurance based on information about concluded insurance contracts and in full compliance with the differentiated average per capita standard financing of CHI medical insurance organizations that settle accounts with medical institutions. The interaction of the compulsory health insurance fund and the medical insurance organization, as well as their mutual responsibility, are regulated by the agreement on financing compulsory health insurance and the regulation on the implementation of compulsory health insurance by branches of the territorial compulsory health insurance fund.
The document certifying the right of the insured to receive medical services included in the territorial compulsory health insurance program is a uniform insurance policy for the entire territory of the region. In the event of an insured event with an insured under compulsory health insurance outside the territory of insurance, medical services provided in the scope of the basic compulsory health insurance program are paid by the territorial cHI funds at the place of medical care.
So, thanks to the inclusion of compulsory (social) health insurance in various organizational and economic models of health care, a high degree of social protection of the population is achieved in terms of ensuring a guaranteed volume of free medical care (compulsory health insurance program). An effective system of financing medical institutions and remuneration of doctors is being formed.
By compulsory medical insurance agreement the maximum amount of the insurer's liabilities for individual risk (the cost of medical care provided to a specific person during the validity period of the compulsory medical insurance agreement for non-working citizens and the insurance period for working citizens) is not determined.
This provision means that the duration of treatment, the number of requests for medical care, the provision of medicines during the provision of medical care to a specific person who applied for it, within cHI systems are not legally limited.
In accordance with Article 6 of the Law "On Health Insurance of Citizens in the Russian Federation", relations on compulsory health insurance of working citizens arise from the moment a citizen concludes an employment contract with an employer registered in the prescribed manner as a taxpayer in a territorial tax authority and paying a unified social tax (contribution ) or other tax in the part calculated and paid to the compulsory health insurance funds in full accordance with the legislation of the Russian Federation on taxes and fees.
So, the employment of a citizen automatically means that he entered into an OMS relationship, provided that the organization where he settled is registered in the prescribed manner as a taxpayer in the territorial tax authority.
In voluntary health insurance, the insured are individual citizens with civil legal capacity, and / or enterprises representing the interests of citizens.

Medical insurance organizations

Medical insurance organizations are legal entities that carry out health insurance and have a state permit (license) for the right to engage in health insurance. In accordance with Article 14 of the Law of the Russian Federation "On Medical Insurance of Citizens in the Russian Federation", the Regulation on insurance medical organizations providing compulsory medical insurance, approved by the Resolution of the Council of Ministers - the Government of the Russian Federation of October 11, 1993 N 1018, by medical insurance organizations that carry out compulsory medical insurance, legal entities that are independent economic entities with all forms of ownership provided for by the legislation of the Russian Federation, possessing the necessary for the implementation of medical insurance authorized capitalstipulated by the Law of the Russian Federation of November 27, 1992 N 4015-1 "On the organization of insurance business in the Russian Federation", and carrying out their activities on compulsory health insurance on a non-commercial basis in full compliance with the legislation of the Russian Federation.
Insurance medical organizations carry out their activities on the basis of a license obtained in the manner prescribed by the legislation of the Russian Federation, which regulates relations on compulsory health insurance.
So, those organizations that insure the health of citizens act as insurers or insurance medical organizations.
The relationship between the policyholder and the medical insurance organization for compulsory and voluntary health insurance is carried out on the basis of a standard form insurance contract (Appendices 1, 2, 3).
The functions of an insurance medical organization are not limited to concluding an agreement with a medical institution for the provision of medical and preventive care to the insured. The insurer is also obliged to control the volume, timing and quality of medical services in full compliance with the terms of the contract. In turn, the contract for the provision of medical and preventive care must provide for the procedure for such control.
According to D.P. Savinov, the structure of insurance medical relations is fundamentally different from insurance relations of another type by the presence of an agreement with a medical institution. Until the insurer has such a contract, he is not entitled to enter into an insurance medical relationship.
One of the essential conditions of the said agreement is "the procedure for monitoring the quality of medical care and the use of insurance funds." Since the ϶ҭᴏ condition is declared by law as material, failure to reach an agreement on it may lead to the fact that the contract will not be recognized as concluded. It is extremely difficult to reach an agreement here. Medical institutions categorically do not want to be controlled, and, taking advantage of their monopoly position, they simply refuse to conclude contracts in which such a condition exists.
As a result, the insurer is forced to conclude an agreement with a medical institution even when there are no control conditions or the control procedure is not specified, which is equivalent to the absence of such conditions. Because of this, the right of the insurer to conduct health insurance becomes doubtful, and therefore, there is a threat of sanctions (Savinov D.P., 2000).
An insurance medical organization bears material (property) liability to the insured party or the policyholder for failure to comply with the terms of the health insurance contract, including for improper quality control of medical care provided in a particular medical institution.

Medical institutions

Medical care in the compulsory health insurance system can be provided by medical institutions of any form of ownership, which have the appropriate licenses.
Treatment-and-prophylactic institutions, research and medical institutes, other institutions providing medical care, as well as persons engaged in medical activities, both individually and collectively and having licenses for given view activities are medical institutions in the health insurance system.
The relationship between a medical institution and an insurance medical organization is built on the basis of an agreement for the provision of medical and preventive care (medical services).
Medical institutions, together with insurers, are responsible for the volume and quality of medical services provided, for refusing to provide medical assistance to the insured party. In case of violation by a medical institution of the terms of the contract, an insurance medical organization has the right to partially or fully reimburse the costs of providing medical services.
The health insurance contract, which is concluded between the policyholder and the insurer, must necessarily indicate:
names of the parties;
terms of the agreement;
number of insured persons;
the size, timing and procedure for making insurance premiums;
list of medical services corresponding to compulsory or voluntary medical insurance programs;
rights, obligations, responsibilities of the parties and other conditions not contrary to the legislation of the Russian Federation.
The form model contracts compulsory and voluntary medical insurance, the procedure and conditions for their conclusion are established by the Council of Ministers of the Russian Federation.
The health insurance contract is considered concluded from the moment of payment of the first insurance premiumunless otherwise provided by the terms of the contract.