Territorial Oms Insurance Program. The territorial compulsory health insurance program, which determines the standards and cost of providing medical care, is provided for by the current compulsory health insurance system The territorial compulsory health insurance program is

Updated 01.13.

Types of quality and terms of provision medical care determined by the Territorial program of state guarantees of free provision of medical care to citizens in the city of Moscow for 2020 and for the planning period of 2021 and 2022

Territorial compulsory medical program

insurance of the city of Moscow

(Extract from the Decree of the Moscow Government dated 24.12.2019 No. 1822-PP)

4.1. Development of the mandatory health insurance in the city of Moscow is carried out by the Moscow City Fund of Compulsory Medical Insurance as part of the implementation of the legislation Russian Federation on compulsory health insurance, which provides for the implementation of a set of measures aimed at increasing the socio-economic efficiency of the compulsory health insurance system, ensuring the targeted and rational use of compulsory health insurance funds, modernizing, developing and ensuring smooth functioning information system compulsory health insurance through the use of modern information technologies, hardware, software and telecommunications by ensuring personalized accounting of information about the medical care provided and the protection of personal data.

4.2. In order to create organizational measures aimed at ensuring, in the event of an insured event, guarantees of free provision of medical care to citizens at the expense of compulsory medical insurance, including the timeliness of the provision of this medical care, in the city of Moscow:

4.2.1. Acceptance of relevant applications on paper and issuance of compulsory health insurance policies for such applications, in addition to insurance medical organizationscarrying out activities in the field of compulsory health insurance in the city of Moscow is also carried out by the State budgetary institution of the city of Moscow "Multifunctional centers for the provision of public services of the city of Moscow" on the basis of an appropriate agreement between the specified
institution and the Moscow City Fund of Compulsory Medical Insurance and taking into account the agreements concluded by this institution with medical insurance organizations operating in the field of compulsory medical insurance in the city of Moscow.

4.2.2. Submission of relevant applications in electronic form is possible using the subsystem " personal Area"State information system" Portal of state and municipal services (functions) of the city
Moscow "or through the personal account of a person insured under compulsory health insurance, on the official website of the Moscow City Fund for Compulsory Health Insurance, with the subsequent issuance of compulsory health insurance policies for such applications by the State Budgetary Institution of the city of Moscow" Multifunctional Centers
the provision of public services of the city of Moscow "on the basis of the agreement specified in clause 4.2.1 of the Territorial Program, or by an insurance medical organization, depending on the place of obtaining a compulsory health insurance policy chosen by a person insured under compulsory health insurance, upon submitting an application.

4.3. The territorial compulsory health insurance program, as an integral part of the territorial program, creates a unified mechanism for citizens from among the persons insured under compulsory health insurance (hereinafter also referred to as insured persons under compulsory health insurance) of the rights to receive free medical care at the expense of compulsory health insurance.

4.4. The purpose of the implementation of the Territorial MHI Program is to provide, within the framework of the basic program of compulsory medical insurance of insured persons, Free compulsory health insurance medical care of guaranteed volume and proper quality in medical organizations included in the Register of medical organizations operating in the field of compulsory health insurance.

4.5. Within the framework of the Territorial CHI program, insured persons under CHI:

4.5.1. It is rendered in medical organizations participating in the implementation of the Territorial CHI program, primary health care, including preventive care, ambulance, including specialized emergency, medical care and medical evacuation (except for airborne evacuation), specialized, including high-tech medical care , the species of which are included in Section I of Appendix 12 to the Territorial Program, for diseases and conditions specified in Section 3 of the Territorial Program (except for sexually transmitted diseases caused by the human immunodeficiency virus, acquired immunodeficiency syndrome, tuberculosis, mental disorders and behavioral disorders) ...

4.5.2. Preventive measures are carried out, including medical examination, dispensary observation for diseases and conditions specified in Section 3 of the Territorial Program (except for sexually transmitted diseases caused by the human immunodeficiency virus, acquired immunodeficiency syndrome, tuberculosis, mental and behavioral disorders), and preventive medical examinations of certain categories of citizens specified in Section 3 of the Territorial Program, as well as measures for medical rehabilitation carried out in medical organizations in outpatient and inpatient conditions and in a day hospital, measures for carrying out renal replacement therapy, measures for using assisted reproductive technologies (including including in vitro fertilization), including the provision of medicines in accordance with the legislation of the Russian Federation.

4.5.3. Preventive medical examinations (examinations) of minors are carried out in order to obtain permits for physical culture and sports, including recreational activities, drawn up in the form of certificates of the absence (presence) of medical contraindications for such activities.

4.5.4. The registration and issuance of certificates on the absence (presence) of medical contraindications for physical education, including recreational activities, to certain categories of citizens specified in section 3 of the Territorial Program, based on the results of medical examination and preventive medical examinations.

4.5.5. The audiological screening of newborns and children of the first year of life is carried out.

4.6. Within the framework of the Territorial MHI program, infertility treatment is carried out for medical reasons using assisted reproductive technologies, including in vitro fertilization, as well as renal replacement therapy:

4.6.1. Persons insured under compulsory health insurance in the city of Moscow, according to the directions of the relevant commissions for the selection of patients created by the Moscow Department of Health, within the scope of medical care established by the Commission for the development of a territorial compulsory health insurance program for the city of Moscow.

4.6.2. Persons insured under compulsory health insurance in other constituent entities of the Russian Federation, according to the directions of the relevant commissions created by the executive authorities in the field of healthcare of the constituent entities of the Russian Federation, or applications (petitions) of the executive authorities or territorial compulsory medical insurance funds of the constituent entities of the Russian Federation with subsequent settlements between The Moscow City Compulsory Medical Insurance Fund and the territorial compulsory medical insurance funds of the constituent entities of the Russian Federation, in which the specified persons were issued compulsory medical insurance policies.

4.7. Within the framework of the Territorial MHI program to persons insured under compulsory health insurance in the city of Moscow:

4.7.1. In case of malignant neoplasms, high-tech medical care is provided in addition to the basic compulsory medical insurance program (Appendix 13 to the Territorial Program) in medical organizations specified in section 1 of Appendix 14 to the Territorial Program.

4.7.2. Prenatal (prenatal) diagnostics of child developmental disorders not established by the basic compulsory health insurance program are carried out to pregnant women in the medical organizations specified in section 2 of Appendix 14 to the Territorial Program, according to the list of services of such diagnostics approved by Tariff agreement to pay for medical care provided under the Territorial MHI Program.

4.7.3. Treatment of oncological diseases prevailing in the morbidity structure in the city of Moscow is carried out in a day hospital and in inpatient conditions, with the provision of drugs, provided for by the treatment regimen, determined in accordance with the clinical recommendation (medical methodology) for the treatment of cancer.

4.7.4. It is carried out with the involvement of medical organizations of the state health care system of the city of Moscow, providing primary health care, as part of the basic program of compulsory medical insurance, medical examination of persons in inpatient social service organizations, and in the presence of chronic diseases, dispensary observation of these persons is carried out.

4.7.5. Hospitalization of persons in inpatient social service organizations is carried out in medical organizations of the state health care system of the city of Moscow, providing specialized medical care in inpatient conditions, in order to provide specialized, including high-tech, medical care in case of detection of such persons in the framework of clinical examination or in the implementation of dispensary observation of diseases and conditions that are indications for the provision of specialized, including high-tech, medical care in stationary conditions.

1. The territorial program of compulsory medical insurance is an integral part of the territorial program of state guarantees for the provision of free medical care to citizens, approved in the manner established by the legislation of the subject of the Russian Federation. The territorial compulsory health insurance program is formed in accordance with the requirements established by the basic compulsory health insurance program.

2. The territorial compulsory health insurance program includes the types and conditions for the provision of medical care (including a list of types of high-tech medical care, which includes, among other things, methods of treatment), the list of insured events established by the basic compulsory health insurance program, and determines, taking into account the morbidity structure in the constituent entity of the Russian Federation the values \u200b\u200bof the standards for the volume of medical care per one insured person, the standards for financial costs per unit of the volume of medical care per one insured person and the standard financial security territorial compulsory health insurance program per one insured person. The values \u200b\u200bof the standards of financial costs per unit of the volume of medical care provided per one insured person specified in this part are also established according to the list of types of high-tech medical care, which includes, among other things, methods of treatment.

3. The standard of financial support of the territorial compulsory health insurance program may exceed the standard of financial support of the basic compulsory health insurance program established by the basic program of compulsory health insurance in the event of an additional amount insurance coverage for insured events established by the basic compulsory health insurance program, as well as in the case of establishing a list of insured events, types and conditions for the provision of medical care in addition to those established by the basic compulsory health insurance program.

4. Financial support of the territorial compulsory health insurance program in the cases specified in part 3 of this article is carried out at the expense of payments of the constituent entities of the Russian Federation, paid to the budget of the territorial fund, in the amount of the difference between the standard of financial support of the territorial compulsory medical insurance program and the standard of financial support of the basic compulsory medical insurance programs taking into account the number of insured persons in the territory of the constituent entity of the Russian Federation.

5. In case of establishing an additional volume of insurance coverage for insured events established by the basic program of compulsory health insurance, the territorial program of compulsory health insurance must provide for a list of areas for the use of compulsory health insurance.

6. The territorial program of compulsory health insurance within the framework of the implementation of the basic program of compulsory health insurance determines on the territory of a constituent entity of the Russian Federation methods of payment for medical care provided to insured persons under compulsory health insurance, the structure of the tariff for paying for medical care, contains a register of medical organizations participating in the implementation of territorial compulsory health insurance programs, determines the conditions for the provision of medical care in them, as well as the target values \u200b\u200bof the criteria for the availability and quality of medical care.

7. The territorial compulsory health insurance program may include a list of insured events, types and conditions of medical care in addition to those established by the basic compulsory health insurance program, provided that the requirements established by the basic compulsory health insurance program are met.

8. When the territorial compulsory health insurance program establishes the list of insured events, types and conditions for the provision of medical care, in addition to those established by the basic compulsory health insurance program, the territorial compulsory health insurance program must also include the values \u200b\u200bof the standards for the volume of medical care per one insured person , standards of financial costs per unit of volume of medical care per one insured person, the value of the standard of financial security per one insured person, methods of payment for medical care provided under compulsory health insurance to insured persons, tariff structure for payment of medical care, register of medical organizations participating in the implementation of the territorial compulsory health insurance program, the conditions for the provision of medical care in such medical organizations.

9. To develop a draft territorial compulsory health insurance program in a constituent entity of the Russian Federation, a commission is created to develop a territorial compulsory health insurance program, which includes representatives of the executive body of the constituent entity of the Russian Federation, authorized by the supreme executive body of state power of the constituent entity of the Russian Federation, territorial fund, medical organizations and medical organizations, representatives of medical professional non-profit organizations or their associations (unions) and professional unions of medical workers or their associations (associations) operating on the territory of the subject of the Russian Federation on an equal footing. The commission for the development of the territorial program of compulsory health insurance is formed and operates in accordance with the regulation, which is an appendix to the rules of compulsory health insurance.

(see text in previous edition)

10. The volumes of medical care provided by the territorial compulsory health insurance program are distributed by the decision of the commission specified in part 9 of this article between medical insurance organizations and between medical organizations based on the number, sex and age of insured persons, the number of insured persons attached to medical organizations providing outpatient care, as well as the needs of insured persons in medical care. The volumes of medical care provided by the territorial program of compulsory medical insurance of the constituent entity of the Russian Federation, in which the policy of compulsory medical insurance was issued to the insured persons, includes the volumes of medical care provided to these insured persons outside the territory of this constituent entity of the Russian Federation.

The ability of citizens to receive medical care free of charge depends on the content of the basic and territorial system compulsory medical insurance... It is in them that a list of specific types of assistance, services and procedures that insured persons can count on is recorded. In this article, we will consider what differences exist between the specified CHI programs, what are the features of the territorial program, as well as by whom and why it is being developed.

The difference between the territorial program and the basic

The basic package of compulsory medical insurance contains a detailed list of diseases and ailments related to the number of insured events, a classification of types and standards for the volume of assistance provided, the principle of calculating the tariff, payment methods, etc. It operates throughout the territory of the Russian Federation. This means that if, for example, a resident of Moscow, during his trip to Novosibirsk, felt unwell and turned to a local clinic, then he will receive medical assistance in accordance with the basic plan.

The territorial program, in turn, applies only to a specific region and provides an opportunity to use the services included in it only for residents of this region. The document contains the following points:

• The list of insured events and the procedure for the provision of medical care (in it in mandatory the entire list from the basic program will be included, but additional provisions may be contained);
• Financial calculations of the cost of the services provided in proportion to one insured person;
• Indicators of the availability and quality of medical care in the region.

Thus, the main difference between these health insurance systems is based on a territorial basis and a list of types of medical services. Nevertheless, the territorial part of the MLA must comply with general principles and the conditions of the basic system and contain all the rights guaranteed to citizens.

The basic purpose of regional programs is to form an expanded list of areas of medical assistance available to residents of a particular constituent entity of the Russian Federation, as well as tariff indicators and the procedure for its provision. Therefore, the content of regional lists of medical care can vary significantly depending on different regions.

What functions does it perform?

The main purpose of the territorial program is the development of the health care system in a particular region, taking into account its specificity and characteristics. The thing is that the Russian Federation is a very large state with a different standard of living, climate, nature, and the number of medical workers in each region. Therefore, for the full functioning of the healthcare sector insurance services must be adapted to the characteristics of the subject of the Russian Federation. For example, a certain disease may practically not occur in most of the state, and therefore is not included in the general policy. However, in one certain region, the epidemics of the disease are constant, and as a result, the corresponding insured event will be included in the territorial program.

The same applies to the sphere of financing health insurance - in different regions, the gender and age composition of the insured differs, the number medical institutions and tariffication of the services provided. Moreover, if according to the identical (compared to the basic program) insured event financial support is greatly overestimated, then the document should contain a detailed list of areas for which additional funds are planned to be allocated.

The procedure for the development and approval of the territorial CHI program

Reimbursement to medical institutions for the cost of medical care provided is carried out according to the rules and tariffs regulated in the territorial part of the CHI program. Funding is provided by budget funds The territorial CHI fund, which is formed in the following ways:

• From contributions paid by employers for employees;
• At the expense of contributions paid by the constituent entity of the Russian Federation for non-working persons;
• At the expense of subsidies from the federal and regional budgets, aimed at equalizing the conditions for financing the TFOMI of various constituent entities of the Russian Federation.

The design development of the territorial part of the CHI program is carried out independently in each constituent entity of the Russian Federation by creating a special commission. Its composition without fail includes:

• Officials of the regional authorities;
• TFOMS representatives;
• Medical officials;
• Insurance companies.

The preparation of the regional program is carried out on the basis of information from the annual monitoring of the volume and quality of medical care, which is carried out by the authorities of the constituent entities of the Russian Federation to ensure the protection of public health. The authority to approve the territorial compulsory medical insurance program falls within the competence of the regional executive bodies, and its change is allowed in cases of need to amend one or several criteria.

The territorial compulsory health insurance program operates within one region of the Russian Federation, and when it is drawn up, all the provisions laid down in the federal program of state guarantees are observed.

We will tell you how the territorial compulsory medical insurance programs are formed, how it is regulated and what features must be taken into account when compiling them.

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The main thing in the article

Territorial program

The territorial compulsory health insurance program is formed by each region of the Russian Federation based on the procedure that is determined by this region independently and is enshrined in the corresponding law.

The programs of state guarantees of the regions must be published on the Internet within 14 days from the date of signing.

Funds within the Territorial Program

The territorial compulsory health insurance program, which determines the standards and the cost of providing medical care, is provided for by the current CHI system.

In accordance with this system, medical institutions receive cashspent on medical care from insurance companies. At the same time, the territorial program spelled out the criteria that medical care must meet, which must be observed.

The basis for interaction with an insurance company is an agreement for payment and provision of medical services. The standard form of such an agreement was approved by order of the Ministry of Health of the Russian Federation No. 1355n dated 12.24.2012.

For a year, the volumes of medical care are approved, which are guided by medical institutions. These volumes are broken down on a quarterly basis and can subsequently be adjusted.

If the approved procedure is followed, can the training of health workers be paid for from the MHIF funds? What is the order and what needs to be done - we will tell you in a video note.

Types of financing

The program is based on the principle of per capita financing of medical care. When insurance companies pay for the already provided medical care, they take into account how many insured persons are attached to each medical facility.

In addition, it takes into account how much money was spent on various types of medical services, based on the lists of expenses that are included in the territorial compulsory medical insurance program.

How to make calculations of financial security is described in detail in the guidelines - letter of the Ministry of Health of the Russian Federation No. 11-8 / 10 / 2-8266 and FFOMS No. 12578/26 / and dated December 22, 2016.

The rules approved by the order of the Ministry of Health and Social Development of the Russian Federation No. 158n of 28/02/2011 tell which indicators are taken into account by insurance companies when determining the amounts of provision for outpatient medical institutions:

1. The number of people who are attached to the medical facility.
2. Indicators of tariffs that are applied when paying for medical care.

Information to the territorial funds of the CHI

Medical institutions must adhere to the territorial program. Also, organizations must send the following information to insurance companies:

• data on the number of insured patients who have chosen a medical facility to receive outpatient medical services;
• list of patients assigned to the outpatient medical facility. This is necessary for the further conclusion of an agreement on the provision of payment for medical care in the compulsory medical insurance system. In addition, in the future, these lists are changed on the basis of reconciliation acts.

Also, these data are provided to the territorial fund within the time frame established by the commission for the formation of the territorial program. This is stated in more detail in the letter of the Ministry of Health of the Russian Federation No. 11-9 / 10 / 2-5718 dated 25.12.2012.

In order to receive the necessary funds, the medical institution must submit an application for an advance payment to the insurance company on a monthly basis, by the 10th day, indicating the amount of the advance and the period for which it is provided.

The form of such an application is approved Methodical recommendations FFOMS letter No. 9161 / 30-1 / and dated 30.12.2011.

The amount of advance payment is limited - no more than 50% of the amount of funds that are provided monthly to medical institutions as payment for medical care provided.

There are two exceptions to this rule:

1. It is possible to increase the advance by 20% from the initial one in the 2nd and 3rd quarters.
2. It is possible to increase the advance payment up to 95% of the monthly volume of funds in December.

The program provides for sending the following documents to the insurance company to pay for medical care:

• bills for payment of medical care;
• registers of accounts in the approved form.

If these documents are not provided, or are provided, but do not correspond to reality, various sanctions will be applied to the medical facility. Therefore, without this documentation, medical care cannot be paid.

Invoices for payment and account registers

As mentioned above, registers of accounts and invoices for payment are the most important documents that allow medical institutions to receive funds as payment for medical care provided.

They indicate the total volume of medical services provided by type, as well as the approved tariffs for these units.

The provided account registers are the main reason for inspections of medical insurance organizations in relation to medical institutions.

The control is carried out by insurance companies in accordance with the Federal Law "On OMI". If during the control errors are revealed in these documents, financial sanctions may be applied to the medical facility.

So, if any services were not supposed to be paid for by a medical institution, or were provided in excess of the norm, the amount for their provision will be deducted from the total amount of funds.

The size of the sanctions is calculated according to uniform methods and formulas, which are approved by the Ministry of Health and Social Development and the FFOMS.

However, the compulsory medical insurance program allows medical institutions to also finalize rejected invoices and submit them to insurance organization again. A period of 25 working days is given for this from the date of receipt of the act from the medical institution.

If the actual volumes of medical care turn out to be more than indicated in the invoices for payment, in next month the advance payment for the medical facility from the insurance company will be reduced by the excess amount.

There are exceptions to this situation:

• high patient morbidity;
• an increase in tariffs for paying for medical care;
• change in the number of insured persons;
• change in the gender, age and structural composition of the insured.

The territorial compulsory medical insurance program allows medical institutions to spend funds received from insurance organizations only on those items that are directly related to the process of providing medical care. This follows from numerous explanations of the FFOMS and the federal program of state guarantees.

Are all consumables included in the territorial programs

Does the territorial compulsory health insurance program include all those consumables that are indicated in the basic part of the program? For example, composite for fillings - will it be included in the regional program?

The current program of state guarantees, approved for the period until 2019, determines the list of those medical services that patients can receive free of charge.

The program is compiled taking into account the current medical standards and procedures, morbidity and mortality rates, as well as the characteristics of the gender and age of patients, etc. are also taken into account.

The basic program includes:

1. The volume of medical care calculated for one patient.
2. The cost of providing one medical service.
3. Medical standards for one insured person.
4. Criteria for the quality and availability of medical care at the expense of compulsory medical insurance.
5. Requirements to be met by regional programs.

Based on this, the basic part of the compulsory medical insurance program does not contain restrictions on the use of consumables that are used in the provision of various free medical services for patients.

The compulsory health insurance policy provides access to free health care services. But does everyone know what opportunities the compulsory medical insurance policy provides, what is included in free servicewhat types of examinations and operations can be carried out?

Legislative acts regulating the CHI system

Free health care services are provided under compulsory health insurance. The CHI system guarantees citizens equal rights to receive medical services. It is regulated by a number of normative legal acts:

• law No. 326-FZ "On Compulsory Medical Insurance in the Russian Federation";
• government decree No. 1403 "On the program of state guarantees for free provision of medical care to citizens for 2017 and for the planning period of 2018 and 2019", which contains the basic compulsory medical insurance program. This document, in particular, explains what is included in the MLA in 2017;
• a number of other acts that allow citizens to receive the minimum guaranteed volume of services.

Who is eligible for free health care?

Both Russians (indefinitely) and stateless persons (with a limited period of validity) can get a compulsory medical insurance policy. The presence of this document means that the patient is under the protection of the insurance company with which he entered into a contract.

Medical care is carried out by the healthcare organization (both public and private institutions participate in the CHI system) to which the patient is attached. At the same time, he has the right to change the clinic and the attending physician once a year and an unlimited number of times - when moving to another place of residence. Once a year, it is allowed to change the insurer, this must be done no later than November 1.

The list of services under the compulsory medical insurance policy

What types of medical care are available under the policy, does it include high-tech diagnostic methods, is MRI included in the list of free compulsory medical insurance services?
The legislation provides for the following forms of medical care:

• emergency (ambulance);
• outpatient, including examinations (the basic list includes MRI, ultrasound and endoscopic methods (gastroscopy, colonoscopy, etc.);
• stationary:

- in cases of exacerbation of diseases;
- in the direction of treatment and operations (among available services - chemotherapy, removal of prostate adenoma, treatment of diseases in gynecology, etc.);
— medical services for pregnant women, as well as childbirth, recovery after them, abortion;
- when intensive therapy is required (in case of poisoning, severe injuries);

• high-tech;
• palliative.

The last item concerning serious illnesses was added in 2017. In total, the basic list includes about 20 cases for which free medical care is available.

Is it allowed to carry out therapeutic massage, remove papillomas, warts - are such procedures provided by the compulsory medical insurance policy, which is included in the program? Taking a massage course at no cost will allow the availability of indications for the procedure. As for skin defects, the operation will be performed free of charge if the growth is bleeding or damaged, that is, there is a danger to the patient's life and health.

Within the framework of the CHI system, there are basic and territorial programs: the first is applied throughout the country, the rest - within a specific constituent entity of the Russian Federation. The list of services for regional programs is wider. Some of them provide free tests for chlamydia and spermogram, some allergy tests (such types of examinations, for example, are carried out on compulsory medical insurance policy in Moscow, in the Moscow region and in St. Petersburg).

From time to time, the media report on public initiatives to add or delete a particular service from the list. Thus, earlier proposals were discussed to exclude abortion from the compulsory medical insurance system and to include the work of a nutritionist in it, but they did not find reflection in the legislative acts.

Dental services under the compulsory medical insurance policy

Is available free dentistry under the compulsory medical insurance policy? This question is of interest to many, since the services of dentists, as you know, are not cheap. So, what opportunities does dentistry provide under the compulsory medical insurance policy, what is included in the free service?
A visitor to a clinic participating in the CHI system can expect:

• for an appointment, examination and consultation;
• for the prevention and treatment of inflammation of the oral cavity;
• for filling teeth;
• for surgical intervention (tooth extraction, abscess opening, etc.);
• for an x-ray examination.

Please be aware that there are also restrictions on dental services. For example, filling will not require payment if cement is used during treatment. But the light seal will not be delivered free of charge.

Certain services are possible if there is a referral, for example, the surgeon will cut the frenum of the tongue upon presentation of a certificate from the orthodontist.

How to find out if a service is included in the CHI program?

Information on services provided free of charge is contained in the regulatory documents adopted in a particular subject. A detailed list is also provided by health care institutions and insurance companies operating in the CHI system.
The list of compulsory medical insurance services on the official health care website in 2018 is absent, but from the resource of the Ministry of Health you can go to the MHIF website, where all the regulations concerning the compulsory health insurance system are posted.