Basic provisions of compulsory health insurance. Historical aspects of the formation and development of health insurance Development of compulsory health insurance in the Russian Federation

Health insurance is a form of protection for the population, which consists of guaranteeing payment for doctors’ care from accumulated funds. It guarantees the citizen the provision of a certain amount of services free of charge in case of health problems. Next, let's talk about what it is like in Russia. We will try to consider its features in as much detail as possible.

Concepts

Implemented in accordance with the state program. It is universal for the citizens of the country. in Russia allows you to receive additional services not provided for by compulsory medical insurance. This could be a certain number of visits to specialists, inpatient treatment, etc. By participating in a voluntary program, a person independently chooses the types and volume of services and the institutions in which he wants to be served. When concluding a contract, the client pays a fee, which allows him to receive services according to the chosen program for a certain period of time without additional payment. Let's understand some terms.

The policyholder is the person who pays the premiums. This could be a person or an organization.

Insurer is a legal entity that provides health insurance.

Establishments that provide a range of medical services to people with various diseases. These include: therapeutic, surgical, psychiatric, neurological, pediatric medical institutions, maternity hospitals and rehabilitation centers.

A policy is a document confirming a person’s participation in the program.

A legal entity with an authorized capital that is engaged exclusively in voluntary or compulsory health insurance. Activities are carried out in two directions:

accumulation of funds to provide assistance to the population;
examination after receiving services.

Development of health insurance in Russia

Stage 1 (1861-1903)

An act was adopted that introduced the basics of compulsory medical insurance in Russia. Partnerships and auxiliary cash offices were established at state-owned factories, through which payments were made to members of the society, and deposits were accepted. In 1866, hospitals with a certain number of beds appeared at the factories. In general, workers did not like this kind of medical care.

Stage 2 (1903-1912)

Medical insurance in Russia experienced its first turning point in 1903, when a law was passed that made the employer liable for damage caused to the health of employees in accidents.

In 1912, the Law on Compulsory Medical Insurance in Case of Accidents and Sickness was adopted. Health insurance funds have appeared on the territory of the Russian Federation. Employees, at the expense of entrepreneurs, were provided with assistance in four areas: initial, outpatient and in-bed treatment, and obstetrics.

Compulsory health insurance in Russia was greatly transformed by the Provisional Government:

requirements for health insurance funds have appeared;
the circle of insured persons has expanded;
sickness funds were merged without the consent of entrepreneurs.

The Declaration introduced full social health insurance in Russia, which applied to all hired workers, regardless of the reasons for loss of ability to work. There was a merger of the People's Commissar of Health and insurance medicine. The medical business was transferred to the management of the People's Commissariat of Health. Cash medicine was abolished.

Stage 6 (November 1921 - 1929)

The new economic policy reintroduced social insurance in case of disability. Contribution rates were calculated based on the number of employees in the enterprise. Two funds were organized using the transferred funds. One was at the disposal of social insurance authorities, the second - health care.

Stage 7 (1929–present)

Over the next 60 years, the principles of financing the system were formed. This is how the development of health insurance in Russia took place.

Modern system

Medical insurance in Russia currently exists in three forms. The state one is fully financed from the budget. Insurance is formed by accumulating contributions from enterprises of all forms of ownership and contributions from individual entrepreneurs. The amount of funds that go to private medicine is calculated by the patient himself.

The state program does not provide high-quality medical care due to a lack of funding. Private medicine is expensive. Therefore, health insurance is considered the most optimal option for receiving assistance. Ideally, all individuals should receive quality services. After all, the frequency of payments does not correspond to requests to health authorities. This is the principle of accumulation. And since the rate of contributions to the Russian Medical Insurance Fund is set the same for all categories of citizens, the volume of payments should be equal.

Compulsory medical insurance

Compulsory health insurance in Russia is part of the state social program. Within its framework, all citizens are given equal opportunities to receive medicinal and medical care in a pre-agreed volume and conditions.

In the Russian Federation there are basic and territorial programs. They determine what kind of assistance and in what institutions is provided to citizens living in one or another part of the region. The first is developed by the Ministry of Health, the second is approved by government bodies.

Scheme of work

Enterprises monthly transfer 3.6% of their personal income to compulsory medical insurance. Of these, 3.4% are paid to the territorial and 0.2% to the federal Compulsory Medical Insurance Fund. For the non-working population, contributions are paid by the state. Both funds are independent institutions that accumulate funds, ensure the stability of the system and equalize financial resources. The accumulated money is used to pay for the established volume of medical services.

Insurance companies enter into agreements with health care facilities to provide assistance to owners of compulsory medical insurance policies, protect the interests of clients, controlling the timing, volume and quality of services provided. Participants in the program can be both citizens of the Russian Federation and non-residents. True, as for the latter, the list of services available to them is limited.

Territorial compulsory medical insurance program

This document defines the scope of providing free medical care to citizens. It includes:

emergency;
outpatient, polyclinic;
inpatient care for acute diseases and exacerbations of chronic diseases, injuries, pregnancy pathologies, abortions; planned hospitalization for treatment.

Exceptions:

tuberculosis and other socially significant diseases;
emergency medical care;
preferential drug provision;
expensive types of care: from open heart surgery to chemotherapy and neonatal intensive care.

Paid services

The health insurance system in Russia is structured in such a way that even within the framework of the state program, a person will have to pay for some types of services on the spot. These services include:

Citizen-initiated surveys.
Anonymous diagnostic and preventive measures.
Procedures carried out at home.
Preventive vaccinations at the request of citizens.
Spa treatment.
Cosmetology services.
Dental prosthetics.
Teaching nursing skills.
Additional services.

Compulsory medical insurance policy

This document can be issued by all Russian citizens, including non-residents who temporarily reside in the country. The validity period of the policy coincides with the time of stay in the state. Citizens of the Russian Federation are issued a policy once for life.

The document must be prepared by the employer or the CMO. In this case, the insured person has the right to choose the company in which he will be served. Unemployed citizens receive insurance policies at distribution points serving their area.

Changing data

The peculiarities of health insurance in Russia are such that after changing your place of residence or passport data, you need to hand over your old policy to the insurance company, and after registering in a new area, you need to get a new one. When changing jobs, the document must be returned to the employer. The entrepreneur is obliged to notify the insurance company about this within 10 days.

In case of loss of the policy, you must notify the insurer as soon as possible. Company employees will exclude the document data from the compulsory medical insurance database and begin the procedure for registering a new policy. In this case, a fee of 0.1 minimum wage is charged for issuing the form.

Voluntary health insurance in Russia (VHI)

This service allows citizens to receive additional services beyond compulsory medical insurance. Subjects of the program can be:

individuals;
organizations that represent the interests of citizens or medical institutions;
enterprises.

A person can receive expensive, complex (in the field of dentistry, plastic surgery, ophthalmology, etc.) services of improved quality, undergo additional tests, etc. Medical insurance in Russia under this program is regulated by contract. According to this document, the company is obliged to pay for services provided to citizens who are included in the corresponding list, to issue each insured person within a certain period of time a policy with a service program and a list of institutions through which assistance will be provided.

The contract also states that the insured person is obliged to pay contributions within a certain period of time, specifies the validity period of the document, the conditions for its extension, the rules for receiving compensation, as well as the transfer of the right to contribution after the death of the insured.

According to the latest data, in 2015, 62% of Russian employers do not pay for voluntary health insurance services to their employees. Most companies refused to participate in the program due to the difficult economic situation. The costs of employers who entered into contracts before 08/01/2014 for 12 months remained unchanged. This is only 14% of the 1000 companies surveyed. But there are also exceptions. 2% of surveyed employers reduced costs for voluntary health insurance by optimizing staffing levels. A few managed to conclude more profitable contracts. Some entrepreneurs have reduced costs by removing dentistry from insurance. For another 5% of companies surveyed, costs increased by 5% due to rising prices for medical services.

Problems of health insurance in Russia

At this stage of development, there are the following difficulties in the functioning of the system:

Reduced budget funding. The existing tariff of 3.6% does not provide coverage for medical care even for working citizens. The elderly, disabled people and children are in greatest need of medical care. Contributions for non-working citizens are transferred from the state budget. As a result, there is a reduction in funding, which affects the ambulance service the most.
The non-working population is financed from the funds of anti-tuberculosis, psychiatric and drug treatment services. There is a real risk of a gap between treatment and prevention.
There is no single insurance model.
Lack of reliable information regarding revenues and expenditures for health insurance in Russia.
Availability of arrears in payment of contributions.

These are the serious problems with health insurance in Russia that exist at the moment.

Conclusion

One of the forms of social protection of the country's population is health insurance. In Russia, its features are that services are provided in three areas. Compulsory medical insurance is financed by the state, but within the framework of this program a person does not receive all types of services. Private medicine is not available to everyone. Therefore, Russians are offered services under a voluntary insurance program. By paying an additional fee, a person can choose the intermediary insurance company, the scope of services, their types and the institutions in which he will receive medical care.

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Compulsory medical insurance is designed to provide all Russian citizens with equal opportunities to receive medical and medicinal care provided at the expense of compulsory medical insurance funds in the amount and on conditions corresponding to compulsory medical insurance programs, as an integral part of the Program of State Guarantees for the provision of free medical care to citizens of the Russian Federation.

In the compulsory medical insurance system, the object of insurance is the insurance risk associated with the costs of providing medical care in the event of an insured event. In this case, an insurance risk is an expected, possible event, and an insured event is an already accomplished event provided for by the insurance contract (illness, injury, pregnancy, childbirth).

Participants (subjects) of compulsory health insurance are a citizen, policyholder, medical insurance organization (IMO), medical institution, compulsory health insurance funds (MHIF) (Fig. 8.1). Compulsory health insurance is carried out on the basis of contracts concluded between health insurance entities.

Rice. 8.1. Subjects of compulsory health insurance

Insured for compulsory health insurance are: for the non-working population - executive authorities of the constituent entities of the Russian Federation and local governments; for the working population - organizations, individual entrepreneurs, private notaries, lawyers, individuals who have entered into employment contracts with employees, as well as paying remuneration under civil contracts, on which taxes are charged in the part subject to credit to compulsory health insurance funds.

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

Citizens of the Russian Federation in the compulsory medical insurance system have the right to:
. choosing a medical insurance organization, medical institution and doctor;
. receiving guaranteed (free) medical care throughout the Russian Federation, including outside your permanent place of residence;
. receipt of medical services that correspond in volume and quality to the terms of the contract, regardless of the amount of the insurance premium actually paid;
. filing a claim against the insured, medical insurance organization, medical institution, including for material compensation for damage caused through their fault.

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

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

Medical insurance organizations with any form of ownership that have a state permit (license) for the right to engage in medical insurance can participate in compulsory health insurance of citizens. The main task of a medical insurance organization is to implement compulsory medical insurance by paying for medical care provided to citizens in accordance with the territorial compulsory health insurance program. CMOs monitor the volume and quality of medical services, and also ensure the protection of the rights of the insured, up to the point of filing lawsuits against a medical institution or medical worker for material compensation for material or moral damage caused to the insured through their fault.

The financial resources of the compulsory medical insurance system are generated through contributions from policyholders for all working and non-working citizens. The amount of the insurance contribution for the working population is established by federal law as a percentage of the accrued wages of each employee as part of the unified social tax. In 2008, the amount of the contribution to the compulsory medical insurance of the working population was 3.1%, the amount of the insurance premium for non-working citizens is annually established by the state authorities of the constituent entity of the Russian Federation when approving the territorial program of state guarantees for the provision of free medical care to citizens of the Russian Federation at the expense of funds provided for these payments in budget of a constituent entity of the Russian Federation. These contributions are accumulated in the Federal and territorial compulsory medical insurance funds.

Financing of medical insurance organizations is carried out by TFOMS on the basis of differentiated per capita standards and the number of insured citizens. Financial relations between medical insurance organizations and TFOMS are regulated by the agreement on the financing of compulsory medical insurance and the territorial rules of compulsory medical insurance, which are approved by the relevant government bodies of the constituent entity of the Russian Federation.

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

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

Medical care in the compulsory medical insurance system is provided by healthcare organizations of any form of ownership that have received the appropriate license in the prescribed manner.

In the context of decentralization of management of state and municipal medical institutions by state health authorities, the licensing mechanism allows solving issues of optimizing the structure of medical care and increasing the level of technical equipment of medical institutions, bringing the volumes and conditions of providing medical care to the insured population in accordance with compulsory medical insurance programs.

In recent years, it has become a practice to allow private health care organizations to participate in the implementation of territorial compulsory medical insurance programs on a competitive basis. This helps create a competitive environment and is a factor in improving the quality and reducing the costs of providing medical care to the insured.

Medical institutions are financed by medical insurance organizations based on their invoices. Payment of bills is carried out at tariffs in accordance with the volume of medical care provided by the institution. For outpatient clinics, such a unit of care is a medical visit, for inpatient facilities - a completed case of hospitalization.

An analysis of the implementation of compulsory medical insurance in individual constituent entities of the Russian Federation shows that today it is possible to distinguish four models of organizing compulsory medical insurance in various constituent entities of the Russian Federation.

The first model mainly corresponds to the legislative framework and most fully takes into account the basic principles of implementation of state policy in the field of compulsory medical insurance. Funds from policyholders (enterprises and executive authorities) are transferred to the TFOMS account. The fund accumulates financial resources and, under agreements with health care organizations, transfers them to finance the activities of healthcare organizations; health care organizations enter into agreements directly with medical organizations and with insurers.

The second model represents a combined compulsory medical insurance system. This means that insurance of citizens (issuance of policies and financing of medical institutions) is carried out not only by health insurance organizations, but also by branches of TFOMS.

The third model is characterized by the absence of medical insurance organizations in the compulsory medical insurance system. These functions are performed by TFOMS and their branches.

The fourth model is characterized by the absence of a compulsory medical insurance system as such in the regions. In these constituent entities of the Russian Federation, the Law of the Russian Federation “On Compulsory Medical Insurance of Citizens in the Russian Federation” is implemented only in terms of collecting insurance premiums for the working population. These funds are managed by local health authorities, directly financing medical institutions.

An analysis of many years of experience in the development of the compulsory health insurance system in the Russian Federation has shown that to ensure efficient spending of financial resources and provision of high-quality medical care to the population, the first model of organizing compulsory health insurance is most suitable.

Thus, being an integral part of state social insurance, compulsory medical insurance has a pronounced social character. Its main principles are:
. universal and mandatory: all citizens of the Russian Federation, regardless of gender, age, state of health, place of residence, level of personal income, have the right to free medical services included in the basic and territorial compulsory medical insurance programs;

The state nature of compulsory health insurance: the implementation of state financial policy in the field of protecting the health of citizens is ensured by the Federal and territorial compulsory medical insurance funds as independent non-profit financial and credit organizations. All compulsory medical insurance funds are state property;

Social solidarity and social justice: insurance premiums and payments are transferred for all citizens, but these funds are spent only when seeking medical help (the “healthy person pays for the sick” principle); citizens with different income levels have the same rights to receive free medical care (the “rich pays for the poor” principle); despite the fact that the costs of providing medical care to older citizens are higher than to younger ones, insurance premiums and payments are transferred in the same amount for all citizens, regardless of age (the “young pays for the old” principle).

The main direction for further improvement of the compulsory medical insurance system is the creation of conditions for sustainable financing of medical organizations to provide the population with guaranteed (free) medical care within the framework of basic and territorial compulsory medical insurance programs.

To do this, it is necessary to consistently solve a number of problems:
. ensure a balance between the income of the compulsory medical insurance system and the state’s obligations to provide guaranteed (free) medical care to insured citizens;
. develop legal mechanisms for the responsibility of the executive authorities of the constituent entities of the Russian Federation for the fulfillment of the obligations of the insurer of the non-working population living in a given territory;
. develop new approaches to the formation of basic and territorial compulsory medical insurance programs within the framework of the Program of State Guarantees for the provision of free medical care to citizens of the Russian Federation.

The most important task remains the search for mechanisms to increase funding for the compulsory medical insurance system.

An additional source of funding may be funds from the Pension Fund of the Russian Federation to finance costs associated with providing targeted medical care to non-working pensioners.

As the compulsory health insurance reform develops, tasks related to expanding the participation of the population in the compulsory health insurance system must be solved. At the same time, an increase in the share of financial participation of the population should be accompanied by an increase in the quality and expansion of the list of medical services. A prerequisite for the civilized development of the compulsory medical insurance system should be the development of legal and financial mechanisms to eliminate informal payments from patients to medical workers.

One of the forms of citizen participation in health insurance may be the provision of the opportunity to voluntarily refuse to participate in the compulsory medical insurance system and resolve the issue of payment for medical care through the voluntary health insurance system.

And finally, the main direction of the compulsory health insurance reform is the creation in the future of a unified system of medical and social insurance that could provide the population with the necessary set of social guarantees, including the provision of guaranteed (free) medical care.

A prerequisite for this should be the transition to single-channel financing of the healthcare system.

O.P. Shchepin, V.A. Medic

Page 1

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

In 1861, the first legislative act was adopted, introducing elements of compulsory insurance in Russia. In accordance with this law, partnerships were established at state-owned mining plants, and at partnerships - auxiliary cash offices, the tasks of which included: issuing benefits for temporary disability, as well as pensions to participants of the partnership and their families, accepting deposits and issuing loans. Participants in the auxiliary cash fund at mining plants were workers who paid established contributions to the cash fund (within 2-3 percent of wages). In 1866, a law was passed providing for the creation of hospitals in factories. According to this Law, employers, owners of factories and factories were required to have hospitals, the number of beds in which was calculated according to the number of workers in the enterprise: 1 bed per 100 workers.

Opened in the 70-80s of the 19th century. In large factories, hospitals were few in number and could not provide for everyone in need of medical care. In general, medical care for factory workers was extremely unsatisfactory.

Stage 2. From June 1903 to June 1912:

Of particular importance in the development of compulsory health insurance in Russia was the Law “On remuneration of citizens who suffered as a result of an accident, workers and employees, as well as members of their families at enterprises of the factory, mining and mining industries,” adopted in 1903. According to this Law, the employer was responsible for damage caused to health in industrial accidents, and the obligation of the entrepreneur and the treasury to pay compensation to victims or members of their families in the form of benefits and pensions was provided.

In 1912, the III State Duma did a lot for the social renewal of the country, including on June 23, 1912, the Law on Insurance of Workers in Case of Sickness and Accidents was adopted.

In December 1912, the Insurance Council was established. In January 1913, Insurance Presences opened in Moscow and St. Petersburg. From June-July 1913, sickness funds were created in many territories of the Russian Empire. In January 1914, insurance partnerships began to appear to provide workers with accidents.

According to the Law of 1912, medical care at the expense of the entrepreneur was provided to the participant of the health insurance fund in four types:

1) Initial assistance in case of sudden illnesses and accidents.

2) Outpatient treatment.

3) Obstetrics.

4) Hospital (bed) treatment with full care of the patient.

After the February Revolution of 1917, the Provisional Government came to power, which, from the first steps of its activities, began reforms in the field of compulsory health insurance (Novella dated July 25, 1917), including the following basic conceptual provisions:

Expanding the circle of insured, but not to all categories of workers (since it was technically impossible to do this at once, categories of insured were separated).

Granting the right to health insurance funds to merge, if necessary, into general funds without the consent of entrepreneurs and the Insurance Presence (district, citywide health insurance funds).

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

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

The Soviet government began its activities on social insurance reform with the Declaration of the People's Commissar of Labor of October 30 (November 12), 1917 on the introduction of “full social insurance” in Russia. The main provisions of the Declaration were as follows:

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Public health and healthcare: textbook / O. P. Shchepin, V. A. Medic. - 2011. - 592 p.: ill. - (Postgraduate education).

Chapter 8. Development of health insurance in the Russian Federation

8.1. GENERAL PROVISIONS

Health insurance- one of the forms of social insurance, which, in turn, is part of the insurance system as a whole. Let's look at this in more detail.

Insurance is a system of legal and economic relations to protect the interests of individuals and legal entities upon the occurrence of certain events (insured events) at the expense of funds formed from the insurance premiums (insurance contributions) they pay, as well as other funds of insurers.

The peculiarity of insurance as a type of business activity is that it has a certain risk associated with the insurer’s obligation to compensate for damages agreed upon in advance. Insurance is carried out in cases where the probability of the occurrence of risks can be assessed, and there are certain financial guarantees from the insurer for compensation for damage.

Insurance can be classified as follows:

by insurance object: personal, property, liability insurance;

according to the form: mandatory, voluntary;

by the method of formation and use of insurance reserves: risky, accumulative;

by the number of insured (in one contract): individual, collective.

The main function of insurance in a market economy is compensation for financial and material losses of a citizen or legal entity resulting from illnesses, accidents, natural disasters, man-made disasters, failure to fulfill obligations by counterparties (partners), etc.

Social insurance in a broad sense is understood as a system that ensures citizens the right to work and earnings

and fair distribution of the social product, as well as legally guaranteed social protection, compensation for losses, provision of social assistance and services. Thus, social insurance is a system that protects citizens from social risk factors, which include: illness, accident, disability, unemployment, old age, loss of a breadwinner, death, etc. In addition, social insurance provides financing for preventive and health measures, provides social guarantees for case of pregnancy and childbirth, birth of a child.

Health insurance is a form of social insurance. The first regulatory act that laid the foundation for medical insurance in Russia is the Law “On Medical Insurance of Citizens in the RSFSR,” which was adopted in 1991. Later, in 1993, the legislator made a number of significant changes to it, and from that moment on, the legal basis the development of health insurance in the state was the Law of the Russian Federation “On health insurance of citizens in the Russian Federation”.

According to the law, health insurance is a form of social protection of the population’s interests in health care, the purpose of which is to guarantee that citizens, in the event of an insured event, receive medical care from accumulated funds and finance preventive measures.

The Law “On Medical Insurance of Citizens in the Russian Federation” defines the legal, economic and organizational foundations of medical insurance in the Russian Federation. The law is aimed at strengthening the interest and responsibility of government bodies, enterprises, institutions, organizations in protecting the health of citizens in a market economy and ensures the constitutional right of citizens of the Russian Federation to guaranteed (free) medical care.

In a broad sense, health insurance is a new form of legal and economic relations in the field of healthcare, ensuring the preservation and restoration of public health in a market economy.

In the Russian Federation, health insurance is provided in two types: mandatory And voluntary. Let us consider the organizational, legal and financial basis of each of these types separately.

8.2. MANDATORY MEDICAL

INSURANCE

8.2.1. Problems of establishing compulsory health insurance in Russia

The adoption in 1993 of a new version of the Law of the Russian Federation “On Medical Insurance of Citizens in the Russian Federation” could not immediately change the situation in one of the most difficult areas of society - healthcare.

The introduction of compulsory health insurance in Russia was carried out in a difficult political and socio-economic situation. The goals initially set in the law and the mechanism for their implementation became outdated, unable to keep up with the ongoing changes in legislation and economics, so medical workers and the population in the first years of implementation of the law did not see the expected changes in the healthcare system, improvement in the organization and quality of medical care. Moreover, at that time, social expectations so far exceeded the achieved results that they raised doubts about the correctness of the choice made - the transition to the principles of health insurance.

One of the reasons for the lack of expected results with the introduction of the law was the sharp reduction in budget funding for the healthcare system. Another reason is the inability of medical insurance organizations to fulfill the functions assigned to them by law as an additional source of financing and protection of patients' rights. This was primarily due to a pronounced funding deficit (insurance organizations could not increase financial resources by placing free financial resources on bank deposits and in securities), as well as to the imperfections of the current legislation, therefore, subsequently the legislator introduced new insurance entities into the legal field , - Federal and territorial compulsory health insurance funds,- as independent state non-profit financial and credit institutions implementing state policy in the field of compulsory health insurance.

At the same time, the financial situation in the compulsory medical insurance system did not improve due to the preservation of the insurance tariff at the initially low level.

contribution to the working population. The situation was aggravated by the fact that the planned volume of funding in the compulsory health insurance system was decreasing due to a pronounced shortfall in payments from local budgets for the non-working population, as well as direct withdrawals by executive authorities of financial funds from the compulsory medical insurance system for purposes not related to the protection of the health of citizens. In addition, financial authorities, from the moment additional funds were received from compulsory medical insurance funds, reduced, in proportion to them, the budget share of healthcare costs, thereby negating the increase in funding for the healthcare system.

The situation was aggravated by a number of circumstances. The shift in the emphasis of financing from the budget to compulsory medical insurance funds has led in a number of constituent entities of the Russian Federation to a shift in the center of control from healthcare management bodies to the Federal Compulsory Medical Insurance Fund, which, in turn, has caused conflict situations.

An ambiguous attitude was caused by the provision provided by law that allows compulsory medical insurance funds to increase financial resources by placing them in securities and bank deposits. At that time, this legislative norm in itself was so revolutionary that, in conditions of severe financial deficit, it naturally could not help but cause a negative reaction from the medical community.

The introduction of compulsory health insurance took place in the context of an aggravation of the economic crisis in the country, delays in the payment of wages, and a decline in the standard of living of the population. Against this background, the formation of new organizational structures (funds, medical insurance organizations), which had financial resources other than healthcare organizations for their development, gave rise to a feeling of social injustice among healthcare workers and, as a consequence, rejection of the compulsory medical insurance system itself.

The compulsory medical insurance system was planned as an effective form of social protection for citizens in the upcoming market reforms. Compulsory medical insurance was supposed to protect citizens who received medical care under the Soviet health care system from the accidents of the market and preserve the guarantee of free medicine for them. In the future, we will create an effective system for managing the quality of medical care, increase the legal responsibility of medical workers when carrying out their professional activities, and ensure the patient’s rights to receive guaranteed (free) medical care.

Qing care, freedom of choice of doctor and medical institutions. Not everything that was planned was successful.

Another significant problem with the implementation of compulsory medical insurance was the excessively large obligations of the state to provide citizens with free medical care in the scope of the State Guarantees Program.

The persistence of an imbalance between government obligations in the compulsory medical insurance system and their actual financial support turned out to be a serious obstacle to the development of compulsory medical insurance. At the same time, two ways to solve the problem are realistic: the first is a revision of the state’s obligations towards their reduction, the second is the redistribution of consumption funds in favor of healthcare.

During the formation of compulsory medical insurance, there were other negative aspects: rising prices for medicines, medical products, medical nutrition products, medical services, which, of course, placed a heavy burden on patients and the healthcare system as a whole. The process of providing paid medical services has become unmanageable, which has led to the formation of a shadow sector in healthcare. The state began to allocate less and less funds for general health activities, prevention, and sanatorium and resort treatment, which ultimately had a negative impact on the health of the nation.

These and other problems, of course, did not contribute to the popularization of compulsory health insurance and slowed down the improvement and development of its legal, organizational and financial mechanisms.

In general, despite the mistakes and difficulties of the initial period, the introduction of compulsory medical insurance ensured not only the survival, but also the development of the healthcare system in the conditions of the extremely unstable political and economic situation of the 90s of the last century. The compulsory medical insurance system ensured the provision of a minimum of guaranteed (free) medical care, made it possible to introduce non-departmental control over its quality, begin the structural restructuring of healthcare in accordance with the real need of the population for basic types of medical care and move to a more rational use of available healthcare resources.

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

8.2.2. Organization of compulsory health insurance at the present stage of healthcare development

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

Participants (subjects) of compulsory medical insurance are a citizen, policyholder, medical insurance organization (IMO), medical institution, compulsory health insurance funds (MHIF) (Fig. 8.1). Compulsory health insurance is carried out on the basis of contracts concluded between health insurance entities.

Rice. 8.1. Subjects of compulsory health insurance

Policyholders with compulsory health insurance are: for the non-working population - executive bodies

authorities of the constituent entities of the Russian Federation and local governments; for the working population - organizations, individual entrepreneurs, private notaries, lawyers, individuals who have entered into employment contracts with employees, as well as paying remuneration under civil contracts, on which taxes are charged in the part subject to credit to compulsory health insurance funds.

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

Choosing a medical insurance organization, medical institution and doctor;

Receiving guaranteed (free) medical care throughout the Russian Federation, including outside your permanent place of residence;

Receipt of medical services that correspond in volume and quality to the terms of the contract, regardless of the amount of the insurance premium actually paid;

Filing a claim against the insured, medical insurance organization, medical institution, including for material compensation for damage caused through their fault.

The functions of insurers in compulsory health insurance are performed by medical insurance organizations And territorial compulsory health insurance funds.

Medical insurance organizations with any form of ownership that have a state permit (license) for the right to engage in medical insurance can participate in compulsory health insurance of citizens. The main task of a medical insurance organization is to implement compulsory medical insurance by paying for medical care provided to citizens in accordance with territorial compulsory health insurance program. CMOs monitor the volume and quality of medical services, and also ensure the protection of the rights of the insured, up to the point of filing lawsuits against the medical institution or medical

to the employee for material compensation for material or moral damage caused to the insured through their fault.

The financial resources of the compulsory medical insurance system are generated through contributions from policyholders for all working and non-working citizens. The amount of the insurance contribution for the working population is established by federal law as a percentage of the accrued wages of each employee as part of the unified social tax. In 2008, the compulsory medical insurance contribution for the working population was 3.1%. The amount of the insurance premium for non-working citizens is annually established by the state authorities of the constituent entity of the Russian Federation when approving the territorial program of state guarantees for the provision of free medical care to citizens of the Russian Federation at the expense of funds allocated for these purposes in the budget of the constituent entity of the Russian Federation. These contributions are accumulated in the Federal and territorial compulsory medical insurance funds.

Medical care in the compulsory medical insurance system is provided by healthcare organizations of any form of ownership that have received the appropriate license in the prescribed manner (for more details, see Chapter 9).

First model basically complies with the legislative framework and most fully takes into account the basic principles of implementation of state policy in the field of compulsory medical insurance. Funds from policyholders (enterprises and executive authorities) are transferred to the TFOMS account. The Fund accumulates financial resources and, under agreements with health insurance organizations, transfers them to finance the activities of healthcare organizations. CMOs enter into contracts directly with medical organizations and insurers.

Second model represents a combined compulsory medical insurance system. This means that insurance of citizens (issuance of policies and financing of medical institutions) is carried out not only by health insurance organizations, but also by branches of TFOMS.

Third model characterized by the absence of medical insurance organizations in the compulsory medical insurance system. These functions are performed by TFOMS and their branches.

Fourth model characterized by the absence of a compulsory medical insurance system as such in the regions. In these constituent entities of the Russian Federation, the Law of the Russian Federation “On Compulsory Medical Insurance of Citizens in the Russian Federation” is implemented only in terms of collecting insurance premiums for the working population. These funds are managed by local health authorities, directly financing medical institutions.

Thus, being an integral part of state social insurance, compulsory medical insurance has a pronounced social character. Its main principles are:

universal and mandatory: all citizens of the Russian Federation, regardless of gender, age, state of health, place of residence, level of personal income, have the right to free medical services included in the basic and territorial compulsory medical insurance programs;

state nature of compulsory health insurance: The implementation of the state financial policy in the field of protecting the health of citizens is ensured by the Federal and territorial compulsory medical insurance funds as independent non-profit financial and credit organizations. All compulsory medical insurance funds are state property;

social solidarity and social justice: insurance premiums and payments are transferred for all citizens, but these funds are spent only when seeking medical help (the “healthy person pays for the sick” principle); citizens with different income levels have the same rights to receive free medical care (the “rich pays for the poor” principle); despite the fact that the costs of providing medical care to older citizens are higher than to younger ones, insurance premiums and payments are transferred in the same amount for all citizens, regardless of age (the “young pays for the old” principle).

To do this, it is necessary to consistently solve a number of problems:

Ensure a balance between the income of the compulsory medical insurance system and the state’s obligations to provide guaranteed (free) medical care to insured citizens;

Develop legal mechanisms for the responsibility of the executive authorities of the constituent entities of the Russian Federation for fulfilling the obligations of the insurer of the non-working population living in a given territory;

Develop new approaches to the formation of basic and territorial compulsory medical insurance programs within the framework of the Program of State Guarantees for the provision of free medical care to citizens of the Russian Federation.

The most important task remains the search for mechanisms to increase funding for the compulsory medical insurance system.

An additional source of funding may be funds from the Pension Fund of the Russian Federation to finance costs associated with providing targeted medical care to non-working pensioners.

A prerequisite for this should be the transition to single-channel financing of the healthcare system.

8.3. VOLUNTARY HEALTH INSURANCE

Unlike compulsory medical insurance as part of the social insurance system, voluntary medical insurance is part of personal insurance and a type of financial and commercial activity, which is regulated by the Law of the Russian Federation “On the organization of insurance business in the Russian Federation.”

VHI is carried out on the basis of voluntary health insurance programs and provides citizens with additional medical and other services in addition to those established by compulsory health insurance programs.

In the history of the formation of VHI in modern Russia, four main stages can be distinguished.

The first stage - 1991-1993.

At this time, a campaign was carried out to conclude contracts providing for the payment by the insured of an insurance premium, which included the cost of guaranteed payment for treatment, as well as the costs of maintaining an insurance business. The insured contingent was also assigned to medical institutions chosen by the policyholder.

The second stage - 1993-1994.

During this period, voluntary health insurance contracts established a limit on the insurer's liability for paying the insured for medical services in the amount of the insured amount exceeding the amount of the insurance premium. However, no refund of the insurance premium was provided.

The third stage - 1995-1998.

It was characterized by a ban on carrying out VHI operations under contracts providing for the return to the policyholder of the portion of the premium not spent on treatment at the end of the insurance period. From this moment on, the question of the need for medical insurance as one of the classical types of insurance, which allows the insurance company to bear liability within the limits of the insured amount, which is determined by the health status of the insured and the financial capabilities of the insured, has become relevant.

Fourth stage - from 1998 to present

After the August crisis of 1998, a qualitatively new stage in the development of VHI began.

Since then, one of the main tasks of VHI has been to ensure a high level of provision of certain medical services in addition to the compulsory medical insurance program. It is implemented at the expense of own funds received directly from citizens or funds from the employer, who additionally insures its employees.

The amounts of VHI insurance premiums are set by medical insurance organizations independently and depend on the type of risks, insurance rules adopted by a particular insurer, the cost of medical and other services, the number of insured, etc.

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

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

Health insurance.

Main stages of MS development.

(Instead of introduction).

Providing social assistance to citizens in case of illness has a fairly long tradition. Even in Ancient Greece and the Roman Empire, there were mutual aid organizations within professional colleges that collected and paid funds in the event of an accident, injury, or loss of ability to work due to long-term illness or injury. In the Middle Ages, the protection of the population in case of illness or disability was carried out by guilds or craft guilds (unions) and the church.

However, social assistance in case of illness acquired the form of health insurance only in the second half of the 19th century. It was at this time that the trade union labor movement began to actively manifest itself, one of the most important results of which was the creation of health insurance funds in many European countries. England and Germany were pioneers in the field of hospital insurance. It was in Germany in 1883 that the first state law on compulsory sickness insurance for workers was issued.

In Russia, the establishment of a system of assistance to the population in case of illness is associated, first of all, with the development of zemstvo medicine at the end of the 19th century, subsidized by the treasury and allocations from provincial and district authorities. However, health insurance in pre-revolutionary Russia was not as widespread as in Europe. Medical insurance developed mainly only at large enterprises in Moscow and St. Petersburg.

In 1912, the State Duma adopted a law introducing compulsory health insurance for working citizens.

After the revolution, insurance through sickness funds became irrelevant due to the introduction of a state monopoly in insurance.

In 1991, Russia adopted a law introducing health insurance for citizens in two forms: mandatory and voluntary. From that time on, new rules and procedures began to be established in the MS. This is precisely what will be the subject of my consideration in this work.

Compulsory health insurance (CHI).

Compulsory medical insurance system in Russia.

Compulsory health insurance (CHI) is one of the most important elements of the social protection system for the population in terms of protecting health and obtaining necessary medical care in case of illness. In Russia, compulsory medical insurance is state and universal for the population. This means that the state, represented by its legislative and executive bodies, sets the basic principles for organizing compulsory health insurance, sets contribution rates, the range of insurers and creates special state funds for the accumulation of contributions for compulsory health insurance. The universality of compulsory medical insurance is to provide all citizens with equal guaranteed opportunities to receive medical, medicinal and preventive care in the amounts established by state compulsory medical insurance programs.

The main goal of compulsory health insurance is to collect and capitalize insurance premiums and provide medical care to all categories of citizens using the collected funds on legally established conditions and in guaranteed amounts. Compulsory medical insurance is part of the state social protection system along with pension, social insurance and unemployment insurance. Also, thanks to the compulsory medical insurance system, additional funding for health care and payment for medical services is provided in addition to budgetary allocations. It should be noted that compensation for earnings lost during illness is carried out within the framework of another state system - social insurance and is not the subject of compulsory medical insurance.

Medical care within the framework of compulsory medical insurance is provided in accordance with the basic and territorial compulsory health insurance programs developed at the level of the Federation as a whole and in the constituent entities of the Federation. The basic compulsory medical insurance program for Russian citizens contains the basic guarantees provided under compulsory medical insurance. These include outpatient and inpatient care provided in health care institutions, regardless of their organizational and legal form, for any diseases, with the exception of those whose treatment should be financed from the federal budget (expensive types of medical care and treatment in federal medical institutions) or budgets of the constituent entities of the Russian Federation and municipalities (treatment in specialized dispensaries and hospitals, preferential drug provision, prevention, emergency medical care, etc.).

The main indicators of the program are the standards for the volume of medical care provided by healthcare institutions:

1) standard for visits to outpatient clinics - 8173 visits per 1000 people;

2) the standard for the number of days of treatment in day hospitals is 538 days per 1000 people;

3) standard volume of inpatient care - 2006.6 bed days per 1000 people;

4) the average length of hospitalization is 11.4 days.

Financial resources of the state compulsory medical insurance system are generated through mandatory targeted payments of various categories of policyholders.

The collected funds are managed by independent state non-profit financial and credit institutions specially created for these purposes - federal and territorial (in the constituent entities of the Russian Federation) compulsory medical insurance funds.

The direct provision of insurance services within the framework of compulsory medical insurance is carried out by medical insurance organizations that have a license to provide compulsory medical insurance and have entered into appropriate agreements with territorial compulsory medical insurance funds. They are called upon to pay for the medical services provided to citizens at the expense of funds allocated to them for these purposes by territorial funds, and to monitor the correctness and amount of medical care provided.

Policyholders in the compulsory medical insurance system.

Compulsory medical insurance policyholders, i.e. Those entities that pay insurance premiums to provide all citizens with health insurance are employers and local executive authorities.

Employers are required to pay insurance premiums for the working population. The insurance premium rate is established by federal law and currently amounts to 3.6% of the wage fund. In accordance with the Instructions on the procedure for collecting and recording insurance premiums for compulsory medical insurance, all business entities are required to pay insurance premiums to compulsory medical insurance funds, regardless of their form of ownership and organizational and legal forms of activity.

Public organizations of people with disabilities and their owned enterprises and institutions created to implement the statutory goals of these organizations are exempt from paying insurance premiums for compulsory medical insurance.

Insurance premiums are calculated in relation to accrued wages on all bases in cash and in kind, including under civil contracts. There is no need to pay contributions on compensation payments, social benefits, one-time incentive payments, prize awards, dividends and some others.

The amounts of accrued contributions are paid to compulsory medical insurance funds monthly, no later than the 15th day of the following month. The amount of contributions in the amount of 3.4% of the wage fund is transferred to the account of the territorial MHIF, and 0.2% - to the account of the Federal MHIF. On a quarterly basis, policyholders are required to submit to the territorial Compulsory Medical Insurance Fund (at the place of registration) reporting statements on the accrual and payment of insurance premiums no later than the 30th day of the month following the reporting quarter.

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

1) for refusal to register as an insurer, a fine in the amount of 10% of the insurance premiums due for payment;

2) for failure to submit a payroll statement for insurance premiums within the specified time frame - a fine in the same amount from the amount of contributions accrued for the quarter;

3) in case of concealment or understatement of the amounts for which insurance premiums should be calculated - a fine in the amount of the insurance premium from the underestimated or hidden amount, levied in excess of the due payment of contributions, taking into account penalties;

4) for late payment of insurance premiums - penalties for each day of delay.

For the non-working population, insurance premiums for compulsory medical insurance are required to be paid by executive authorities, taking into account the volume of territorial compulsory medical insurance programs within the limits of funds provided for in the relevant health care budgets. The non-working population includes: children, students, disabled people, pensioners, and the unemployed.

Executive authorities are required to transfer funds for compulsory medical insurance of the non-working population on a monthly basis, no later than the 25th, in the amount of 1/3 of the quarterly amount of funds provided for these purposes.

Transfers of funds to territorial compulsory medical insurance funds must be carried out according to the standard, which is established based on the cost of the territorial compulsory medical insurance program. However, to date, the obligations of local administrations to pay insurance premiums are very uncertain. If for insurers - business entities the tariff is established by federal law, then for executive authorities only methodological recommendations prepared by the Compulsory Medical Insurance Fund itself are used.

Insurers in the compulsory medical insurance system.

According to the law “On Medical Insurance of Citizens in the Russian Federation,” there are three groups of subjects managing the organization and financing of compulsory medical insurance. These entities enter into contracts for the implementation of compulsory medical insurance, collect and accumulate insurance premiums, and allocate funds to pay for medical services. From an insurance point of view, they act as insurers, but they have significant differences and have strictly demarcated powers to carry out specific insurance operations.

The 1st level of insurance in the compulsory medical insurance system is represented by the Federal Fund Compulsory medical insurance (FFOMS), which carries out general regulatory and organizational management of the compulsory medical insurance system. He himself does not carry out insurance operations and does not finance the compulsory medical insurance system for citizens. The fund was created to implement state policy in the field of health insurance, and its role in compulsory medical insurance is reduced to general regulation of the system, which is achieved both through regulatory regulation of the main provisions of compulsory medical insurance on the territory of the Russian Federation, and through financial regulation of the implementation of medical insurance of citizens in the constituent entities of the Russian Federation .

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

The fund's financial assets are generated from:

parts of insurance premiums of enterprises, organizations and other economic entities (0.2% of the individual entrepreneur);

contributions from territorial compulsory health insurance funds for the implementation of joint programs;

allocations from the federal budget for the implementation of republican compulsory medical insurance programs;

income from the use of temporarily free funds of the fund by placing these funds on bank deposits and in highly liquid government securities.

The functions of the Federal Compulsory Medical Insurance Fund include:

financing of targeted programs within the framework of compulsory medical insurance;

approval of standard rules for compulsory medical insurance of citizens;

development of regulatory documents;

participation in the development of the basic compulsory medical insurance program for the entire territory of the Russian Federation;

participation in the organization of territorial compulsory medical insurance funds;

international cooperation in the field of MS;

carrying out financial and credit activities to fulfill the tasks of financing compulsory medical insurance;

conducting research work and training specialists for compulsory medical insurance.

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

2nd level of organization of compulsory health insurance represented by territorial MHIF funds and their branches. This level is the main one in the system, since it is the territorial funds that collect, accumulate and distribute compulsory medical insurance funds.

Territorial Compulsory Medical Insurance Funds are created in the territories of the constituent entities of the Russian Federation, are independent state non-profit financial and credit institutions and are accountable to the relevant bodies of representative and executive power.

TFOMS financial resources are state property, are not included in budgets or other funds and are not subject to withdrawal. They are formed due to:

parts of insurance premiums paid by enterprises, organizations and other economic entities for compulsory medical insurance of the working population;

funds provided in the budgets of the constituent entities of the Russian Federation for compulsory medical insurance of the working population (3.4% of the payroll);

income received from the use of temporarily available funds by investing them in bank deposits and government securities;

funds collected as a result of filing recourse claims against policyholders, medical institutions and other entities;

funds received from the application of financial sanctions to policyholders for violating the procedure for paying insurance premiums.

The main task of the TFOMS is to ensure the implementation of compulsory health insurance in each territory of the constituent entities of the Russian Federation on the principles of universality and social justice. The TFOMS is entrusted with the main work of ensuring the financial balance and sustainability of the compulsory health insurance system. TFOMS performs the following functions in the organization of compulsory medical insurance:

collect insurance premiums for compulsory medical insurance;

finance territorial compulsory medical insurance programs;

enter into agreements with medical insurance organizations (HMOs) to finance compulsory medical insurance programs conducted by HMOs according to differentiated per capita standards approved by the Federal Compulsory Compulsory Medical Insurance Fund;

carry out investment and other financial and credit activities, including providing loans to medical insurance organizations if they have a justified lack of financial resources;

form financial reserves to ensure the sustainability of the functioning of compulsory medical insurance, including a normalized safety stock in the amount of two months of funding for territorial programs (now the reserve has been reduced to ½ a month);

carry out equalization of conditions for financing compulsory medical insurance across the territories of cities and districts;

develop and approve rules for compulsory medical insurance of citizens in the relevant territory;

organize a data bank for all policyholders and monitor the procedure for calculating and timely payment of insurance premiums;

participate in the development of payment tariffs for medical services;

interact with federal and other territorial funds.

The management of the activities of the TFOMS is also carried out by the board and executive directorate. The chairman of the board is elected by the board, and the executive director is appointed by the local administration.

To perform its functions, TFOMS create branches in cities and regions. The branches carry out the tasks of the TFOMS in collecting insurance premiums and financing medical insurance organizations. If there are no medical insurance organizations in a given territory, branches are allowed to provide compulsory medical insurance to citizens themselves, i.e. and accumulate insurance premiums and make payments to medical institutions.

The 3rd level in the implementation of compulsory medical insurance is represented by medical insurance organizations. They are the ones who are assigned the direct role of insurer by law. HMOs receive funds for the implementation of compulsory medical insurance from the Federal Compulsory Medical Insurance Fund according to per capita standards, depending on the size of the gender and age structure of the population insured by them and make insurance payments in the form of payment for medical services provided to insured citizens.

According to the regulations on medical insurance organizations providing compulsory medical insurance, a legal entity of any form of ownership and organization provided for by Russian legislation, and having a license to conduct compulsory medical insurance issued by the department of insurance supervision, can act as a CMO.

The insurance company has the right to simultaneously conduct compulsory and voluntary insurance for citizens, but does not have the right to carry out other types of insurance activities. At the same time, financial resources for compulsory and voluntary insurance are taken into account by the insurance company separately. CMOs do not have the right to use the funds transferred to them for the implementation of compulsory medical insurance for commercial purposes.

CMOs build their insurance activities on a contractual basis, concluding four groups of contracts:

1. Insurance contracts with enterprises, organizations, other business entities and local administration. According to such contracts, the contingent of those insured in a given health insurance company is determined.

2. Agreements with the Federal Compulsory Medical Insurance Fund for the financing of compulsory medical insurance for the population in accordance with the number and categories of insured persons. Financing is carried out according to a differentiated average per capita standard, which reflects the cost of the territorial compulsory medical insurance program per resident and the gender and age structure of the insured population.

3. Agreements with medical institutions for payment of services provided to citizens insured by this health insurance company.

4. Individual compulsory medical insurance agreements with citizens, i.e. compulsory medical insurance policies, according to which free medical care is provided within the framework of the territorial compulsory medical insurance program.

All relationships within the compulsory medical insurance system are regulated on the basis of territorial compulsory medical insurance rules, which must comply with the standard compulsory medical insurance rules dated December 1, 1993, approved by the Federal Compulsory Medical Insurance Fund and agreed upon with Rosstrakhnadzor.

Thus, the activities of the CMO represent the final stage in the implementation of the provisions of the compulsory medical insurance. Its main task is to pay insurance claims. In this regard, the main functions of the QS are:

participation in the selection and accreditation of medical institutions;

payment for medical services provided to the insured;

exercising control over the volume and quality of medical services provided, including filing recourse claims and claims against medical institutions for violation of the terms of compulsory medical insurance or causing damage to the insured;

formation of insurance reserves: reserve for payment of medical services, reserve for financing preventive measures and reserve reserve;

investing temporarily free funds in bank deposits and government securities.

The composition and standard of expenses for conducting compulsory medical insurance, as well as the standards of insurance reserves as a percentage of financial resources transferred to insurance companies for compulsory medical insurance are determined by the Federal Compulsory Medical Insurance Fund. The amount of excess income over expenses is used to replenish reserves for compulsory medical insurance in the manner and amount determined by the Federal Compulsory Compulsory Medical Insurance Fund.

The volume of funds transferred monthly by the territorial fund of a medical insurance organization to pay for medical services to the insured is determined by the number of insured persons in this organization and the average per capita financing standard (NF), calculated in the manner approved by the Federal Compulsory Medical Insurance Fund and agreed upon with the Ministry of Health of the Russian Federation and the Ministry of Finance of the Russian Federation.

1) The average per capita funding standard for the NF is determined as the quotient of dividing the amount of funds collected by the fund per month, minus deductions for replenishing the normalized safety stock (its maximum value is double the cost of providing medical care for the previous month) and the cost of conducting business by the population size territories. If the fund has additional funds, Nf is multiplied by the indexation coefficient (Kin), agreed upon by the fund with executive authorities, associations of medical insurance organizations and professional medical associations.

2) The differentiated average per capita standard (Nfd) for the branches of the fund, used for the purpose of equalizing compulsory health insurance funds within the territory, is calculated as the product Kin * Nf * Kpz, where Kpz is the coefficient of previous costs, determined in relative units based on financial reports on the execution of health care budgets assigned to the branch over the past three years.

3) The differentiated average per capita standard (Nsd) for financing medical insurance organizations is calculated as the product Nfd * Kpv, where Kpv is the average coefficient of sex and age costs for the contingent insured by the organization, determined on the basis of the cost coefficient for each of the sex and age groups relative to the reference (usually insured at the age of 20 - 25 years) and the share of each age and sex group in the insured population.

Currently, several methods are used to pay for medical services. To pay for treatment in hospitals, the following is used:

payment according to cost estimates (11.2% of hospitals are financed at the beginning of 1996);

average cost of a treated patient (7.5%);

for the treated patient according to clinical-statistical groups (CSG) or medical-economic standards (MES) (50.4%);

number of bed days (29.4%);

combined payment method (1.5%).

Payment for treatment in outpatient clinics is made by:

according to cost estimates (20.3% of clinics);

according to the average per capita standard (16.6%);

for individual services (29.5%);

for the treated patient (27.6%);

combined payment method (6%)

Currently, there is no unified system of payment for medical services in the compulsory medical insurance system. This situation is typical for the transition period in the organization of compulsory medical insurance. Today, experts consider payment for the treated patient to be the most effective way to pay for medical services, i.e. completed treatment case.

The mechanism for the functioning of compulsory medical insurance presented above reflects the principles of organization and financing of the system that were laid down by the legislation on medical insurance of citizens.

However, the practice of introducing compulsory medical insurance in the constituent entities of the Russian Federation shows that at present, it is not yet possible to fully comply with the requirements of the legislation of the functioning territorial compulsory medical insurance systems. Today, we can name four options for organizing compulsory medical insurance in various regions of the Russian Federation.

The first option mainly corresponds to the legislative framework and most fully takes into account the principles of implementation of state policy in the field of MS. According to this option, all required entities work in the compulsory medical insurance system. Funds from policyholders (enterprises and executive authorities) are transferred to the TFOMS account. The Fund accumulates the collected funds and, upon concluding agreements with health insurance organizations, transfers to these organizations the shares due to them to finance compulsory medical insurance. CMOs work directly with medical institutions and the population. The greatest problems with such an organization of compulsory medical insurance arise when concluding contracts for insurance of the population. The legislation establishes two principles for concluding such agreements: either with the local administration or with employers. Unfortunately, at present, the conclusion of industrial insurance contracts directly between employers and HMOs has not become widespread. Basically, representatives of local administrations are involved in concluding insurance contracts, which removes the main payers of insurance premiums - employers from the sphere of control over the implementation of compulsory medical insurance and the choice of medical institutions for their employees. According to the first option, compulsory medical insurance systems operate in 19 constituent entities of the Russian Federation, covering more than 30% of the population: the cities of Moscow, St. Petersburg, Volgograd, Moscow, Kaliningrad, Novosibirsk, Kemerovo regions, Stavropol Territory and some others.

The second option represents a combined compulsory medical insurance system. This means that insurance of citizens (issuance of policies and financing of medical institutions) is carried out not only by health insurance organizations, but also by branches of TFOMS. This is the most common scheme for organizing compulsory health insurance, which covers 36 constituent entities of the Russian Federation, or 44.8% of the population.

The third option is characterized by the complete absence of SMO in the compulsory medical insurance system. Their functions were taken over by TFOMS and their branches. This type of compulsory medical insurance organization has developed in 17 constituent entities of the Russian Federation and covers 15% of the population. The implementation by the TFOMS of all functions within the framework of compulsory medical insurance is proposed by many experts as the main principle of possible reform of compulsory medical insurance. However, at present there are no significant improvements in medical care in these regions. Rather, on the contrary, such an organization of compulsory medical insurance is associated with the weak socio-economic development of the region.

The fourth option is characterized by the absence of compulsory health insurance as such in the regions in principle. In these constituent entities of the Russian Federation, compulsory medical insurance is carried out only in terms of collecting insurance premiums for the working population. Local health authorities manage the collected funds, directly financing medical institutions. This situation is typical for 17 regions and covers 9.2% of the country’s population: the republics of the North Caucasus, the East Siberian region, the Smolensk, Kirov, Nizhny Novgorod regions, etc.

Voluntary health insurance (VHI).

VHI is similar to compulsory and pursues the same social goal - providing citizens with a guarantee of receiving medical care through insurance financing. However, this common goal is achieved by the two systems through different means.

Firstly, VHI, unlike compulsory medical insurance, is not a branch of social, but commercial insurance. VHI, along with life insurance and accident insurance, belongs to the field of personal insurance.

Secondly, as a rule, this is an addition to the compulsory medical insurance system, providing citizens with the opportunity to receive medical services in excess of those established in compulsory medical insurance programs or guaranteed within the framework of state budgetary medicine.

Thirdly, despite the fact that both systems are insurance, compulsory medical insurance uses the principle of insurance solidarity, and VHI uses the principle of insurance equivalence. Under a VHI agreement, the insured receives those types of medical services and in the amounts for which the insurance premium was paid.

Fourthly, participation in voluntary health insurance programs is not regulated by the state and realizes the needs and capabilities of each individual citizen or professional team.

Voluntary private health insurance is present to a greater or lesser extent in almost all countries, occupying leading positions in national insurance markets. This is explained by the fact that state or mandatory insurance financial resources allocated for the development of medicine are currently insufficient to provide medical care to the population at the level of the most modern medical standards.

From an economic point of view, VHI is a mechanism for compensating citizens for expenses and losses associated with the onset of illness or accident.

According to general international standards, MS covers two groups of risks arising in connection with the disease:

costs of medical services for health restoration, rehabilitation and care;

loss of labor income caused by the inability to carry out professional activities, both during the illness and after it upon the onset of disability.

With insurance coverage of medical expenses, the insurer reimburses the actual costs associated with treatment and restoration of ability to work. Thus, medical expenses insurance is damage insurance and protects the client's condition from unexpected expenses.

With insurance coverage for loss of income, the insurer pays the insured a monetary compensation for the day of illness. The amount of compensation and the start date of its payment are agreed upon in the contract and depend on the labor income received by the insured and the day established by labor legislation or the current social insurance system until which the loss of labor income as a result of illness is covered either by the employer or by compulsory health insurance. Thus, insurance for loss of labor income is insurance for the amount. It serves to protect the personal income of the insured, similar to life insurance.

In Russia, VHI differs from that adopted abroad by the lack of insurance protection associated with loss of labor income as a result of illness.

The Law of the Russian Federation “On Medical Insurance of Citizens in the Russian Federation” defines “insurance risk associated with the costs of providing medical care in the event of an insured event” as an object of the International Insurance Policy. At the same time, the Law states that VHI “ensures citizens receive additional medical and other services in addition to those established by the compulsory medical insurance programs.”

In the conditions of licensing insurance activities on the territory of Russia, Rosstrakhnadzor of the Russian Federation specified the concept and defined MS only as “a set of types of insurance that provide for the insurer’s obligations to make insurance payments in the amount of partial or full compensation for additional expenses of the insured caused by the insured’s application to medical institutions for medical services included to the MS program."

The fact that the domestic MS does not have insurance for loss of income is explained by two factors. Firstly, in Russia, the loss of labor income during illness is compensated by social insurance, which until recently applied to the entire employed population. Secondly, at the time of the adoption of legislative acts regulating the organization of insurance policy, potential consumers did not have a need for such guarantees, and domestic insurers did not have a sufficient financial and actuarial basis for relevant proposals.

In modern conditions, the addition of VHI insurance for loss of income is becoming increasingly relevant, as the number of individual entrepreneurs and people in liberal professions who are not subject to compulsory social insurance and, in the event of illness, lose their personal income is growing. In addition, serious losses of labor income are observed among part-time workers, for whom the loss of income within the framework of social insurance is compensated only at the main place of work, leaving additional earnings without compensation.

The economic prerequisites for the emergence of VHI are the following facts:

firstly, VHI appears and successfully develops where and when the need to pay for medical services arises. If medical care is provided free of charge and fully financed by the state or the compulsory medical insurance system, then there is no need for additional medical insurance;

secondly, the periodicity of the onset of disease risk during a person’s life cycle makes it possible to classify this risk as insurable by leveling its consequences for large groups of the population. The risk of the disease actually affects every person, but a stable statistical pattern has been identified that allows us to divide a person’s life into four periods characterizing the frequency of the disease:

1) from birth to the 15th anniversary - a period of childhood diseases characterized by a fairly high incidence rate:

2) from 15 to 40 - a period of stability, characterized by the lowest incidence:

3) from 40 to 60 years - a period of gradual increase in risk;

4) after 60 years - the period of highest risk of morbidity.

This dynamics of risk made it possible to distribute it evenly in society through insurance using insurance premiums for different age groups.

Thirdly, the need for VHI directly depends on the extent to which the disease risk is covered by mandatory MS systems.

Fourthly, the demand for private health insurance is determined in many cases by the desire to receive a guarantee of not only treatment, but also a high level of service in a medical institution (private room, nurse, treatment by leading specialists and some other services).

Fifthly, the need for voluntary health insurance becomes very relevant when traveling abroad, especially to those countries where obtaining a visa is impossible without presenting medical insurance for the duration of the trip.

In the Law of the Russian Federation “On Medical Insurance of Citizens in the Russian Federation,” the main goal of medical insurance is formulated as follows: “..to guarantee citizens, in the event of an insured event, receiving medical care from accumulated funds and financing preventive measures.”

Based on general goals, several specific tasks can be identified.

Social objectives:

public health protection;

ensuring population reproduction;

development of the medical care sector.

Economic objectives:

financing of healthcare, improving its material base;

protection of incomes of citizens and their families;

redistribution of funds used to pay for medical services between different groups of the population.

The socio-economic significance of VHI lies in the fact that it complements the guarantees provided under social security and social insurance to the highest possible standards in modern conditions. This applies primarily to expensive treatments and diagnostics; application of the most modern medical technologies; ensuring comfortable treatment conditions; implementation of those types of treatment that are included in the scope of “medical care for life-saving indications”.

In the Russian Federation, collective forms of insurance at the expense of employers currently prevail in the VHI system. This is facilitated by fairly favorable economic and legal conditions for the financial resources of the enterprise to pay for health insurance for its employees.

Firstly, as for some other types of insurance, contributions for voluntary health insurance can be applied by an enterprise to the cost of production in the amount of 1% of gross turnover.

Secondly, the amounts of insurance payments paid by an enterprise in favor of employees under voluntary health insurance contracts concluded for a period of at least one year are not subject to contributions to extra-budgetary funds.

Thirdly, the amounts of insurance premiums for voluntary health insurance paid by employers in favor of their employees are not subject to income tax as part of the total annual income of employees.

Fourthly, the amount of payment for medical expenses of insured persons under voluntary health insurance contracts concluded by an enterprise in favor of its employees is not included in the total taxable income.

Main types of VHI. Types of VHI are distinguished depending on the consequences of the onset of the disease, both economic and medical and rehabilitation in nature; volume of insurance coverage; type of insurance rate; degree of addition to the compulsory medical insurance system.

Based on the economic consequences for a person, there are two types of insurance:

insurance of costs associated with treatment and health restoration;

insurance of income losses associated with the onset of disease.

Regarding medical and rehabilitation consequences, types of insurance are distinguished depending on the type and methods of treatment required. Typically, the following types of insurance for medical care expenses are distinguished:

for outpatient treatment and family doctor;

for inpatient treatment;

for dental care;

for specialized diagnosis of diseases;

for the purchase of medicines;

to visit specialist doctors;

for prosthetics;

for the purchase of glasses, contact lenses;

for costs associated with pregnancy and childbirth;

for service costs;

for patient care costs.

Naturally, the set of guarantees is expanded or narrowed by each individual insurance company, depending on which VHI programs it prefers to work with. Therefore, it is customary to distinguish between basic types of health insurance and additional types (options).

The first includes insurance of expenses for outpatient and inpatient medical care. These guarantees compensate for the costs of basic treatment necessary for life-saving reasons.

The second includes types of insurance that cover the costs of treatment-related services or specialized medical care (dentistry, obstetrics, prosthetics, spa treatment and some others).

Depending on the scope of insurance coverage, there are:

full insurance of medical expenses;

partial insurance of medical expenses;

insurance of expenses for only one risk.

Full medical insurance guarantees coverage of expenses for both outpatient and inpatient treatment. Unlike full, partial insurance covers the costs of either outpatient, inpatient, or specialized treatment at the choice of the policyholder.

According to the types of insurance rates applied, health insurance is classified as follows:

at a full (combined) rate;

at a rate with the insurer’s own participation;

at a tariff with a limit on the insurer's liability;

with dynamic tariffs.

Full-rate insurance involves payment by the policyholder of a premium to guarantee coverage of all costs of outpatient and/or inpatient treatment, including additional payment for selected options.

Insurance based on the principle of the policyholder's own participation involves a deductible, depending on which medical expenses are covered either starting from the amount agreed upon in the contract, or for each insured event the policyholder independently pays the part of the incurred treatment costs agreed with the insurer.

Limit-limit plans allow the insurer to limit its contribution to the policyholder's medical expenses to the amount for which the policyholder is able to pay a premium and that meets his needs. The limit of liability can be established in two ways:

1) the amount of insurance coverage for the year is agreed upon, within which the insurer pays for the insured’s medical expenses;

2) limits on coverage amounts are established for certain types of medical services;

3) the insurer’s share of participation in covering the insured’s medical expenses is determined.

Depending on whether there is an overlap of two types of health insurance - compulsory and voluntary for the same risk, we can distinguish:

additional private health insurance;

independent private health insurance.

Since one or another compulsory medical insurance system in many countries covers the majority of the population, insurers have developed types of VHI that would allow citizens participating in compulsory medical insurance to fully cover the costs of those medical services that are partially paid for by the compulsory medical insurance program with the help of private insurance, or improve conditions of your medical care under compulsory medical insurance. Additional VHI provides coverage for the costs of expensive operations, attracting leading specialist doctors, choosing a hospital and doctor, creating comfortable treatment conditions, providing care, and some others.

Independent medical insurance involves medical policies: for citizens who do not participate in compulsory medical insurance; certain groups of the population with particularities of treatment (children, women and some others); for treatment in private clinics and private practitioners; to provide medical insurance when traveling abroad.

Daily payment insurance, which covers loss of income due to illness, is offered by insurers in three options:

insurance of daily payments during a hospital stay;

insurance of daily payments for a day of illness;

insurance of daily payments for days in need of care.

In Russia, daily payments for health insurance are not covered.

VHI rules and programs.

The subject of VHI is the cost of medically necessary medical care for the insured person in case of illness or accident. Based on the capabilities of modern medicine and the needs of clients, insurance organizations develop insurance rules, and then specify them by drawing up various VHI programs.

VHI rules contain general insurance conditions:

determination of the insurance object, insured event, insured amount;

procedure for concluding and maintaining an insurance contract;

terms of payment of insurance compensation;

a list of standard exclusions from insurance coverage.

The object of VHI is usually the risk of costs for the insured's medical care.

In VHI, an insured event is understood as an insured person’s visit to a medical institution (to a doctor) for medical care. The insured event is considered settled when, for medical reasons, the need for further treatment disappears. The number of insurance cases according to VHI rules can be unlimited.

VHI insurance coverage is determined by:

1)or a firmly established insurance amount, within which the annual volume of specific medical expenses of the insured is paid;

2) or a list of cases in which full payment for treatment is guaranteed;

3) or a list of medical expenses with the insurer’s liability limit for each type.

Full VHI coverage guarantees payment of the following expenses.

Costs associated with outpatient treatment:

medical care (visiting a doctor, examinations, consultations with specialists, performing surgeries on an outpatient basis);

laboratory tests and diagnostics;

medicines;

therapeutic agents of a different nature (physiotherapy, massage, optics, prosthetic devices for analyzing cardiac stimulation, wheelchairs, etc.).

Costs associated with inpatient treatment:

medical care, including operations;

delivery to the clinic;

diagnostic costs;

medicines and other medicinal products.

Costs for dental services.

The definition of insurance coverage also includes the conditions for expanding the content of the contract by the insured. They usually include guarantees for additional types of medical expenses and conditions for the application of other tariff levels.

The VHI insurance rules, similar to other types of insurance, provide a standard set of exclusions from insurance coverage. Insurance payment is not made by the insurer if:

1) the disease was the result of an accident resulting from military action or military service;

2) the disease occurred as a result of the intentional actions of the insured;

3) the treatment was carried out using methods not recognized by official medicine or in clinics that do not have official accreditation or license.

If VHI rules contain the basic economic and legal aspects of the health insurance offered by the insurer, then VHI programs contain:

list of medical services included in insurance coverage;

scale of insurance amounts within which an insurance contract can be concluded;

insurer liability limits for certain types of medical services;

options indicating the amount of additional insurance premium;

a scale of insurance premiums corresponding to the scale of the proposed insurance amounts;

a list of medical institutions serving this program;

insurance period.

The procedure for concluding and maintaining a VHI agreement.

The procedure for concluding and maintaining a voluntary health insurance contract is general and special in comparison with other insurance contracts for damage and amount.

Like any insurance contract, it begins with the submission of an application for insurance by the policyholder. The application can be drawn up for the policyholder himself, for members of his family, or in case of collective insurance - for employees.

In the application, the policyholder provides the following information: age, gender, marital status, profession, place of residence, state of health at the time of filling out the application, presence of chronic diseases, injuries, physical indicators, list of previous diseases. In the case of concluding contracts with high guarantees, the insurer may ask in the application to indicate the presence of hereditary diseases, life expectancy of parents, data of basic laboratory tests, predisposition to certain diseases, and also require an additional medical examination or provide extracts from the medical history. When concluding collective insurance agreements, data on the health status of potential insured persons is not required. Since additional risk equalization occurs for a large group of people, this allows the insurer not to carry out an individual risk assessment and, saving on operational costs, conclude collective health insurance contracts at reduced rates.

Having received the application, the insurer can:

accept the risk for insurance under normal conditions for a given age and gender;

accept on special conditions, i.e. at an increased rate or with limited liability in the event of certain diseases;

refuse insurance.

When submitting an application, the validity period of the insurance contract is specified. A VHI agreement can be concluded:

for a certain period - as long as the policyholder has an interest in continuing the contract, subject to regular payment of the premium;

for a certain period - from one year to 10 years;

for a specific short-term period - during a trip abroad.

Calculation of premiums in health insurance, as well as in other types of commercial insurance, is based on the principle of equivalence.

The amount of insurance payment for VHI can be calculated using the following method.

1.The first (constant) component of the net payment:

C n1 = C n1p + C n1st + C n1sp, where C n1p, st, sp are the average costs per one insured person for seeking medical care, respectively, in an outpatient clinic, hospital and specialized medical institution under the VHI program in question during duration of the contract.

Each of the constant components of the net payment is calculated using the formula:

C n1 = sum (Q i * C p i), where i = (1; M), M - the number of types of insured events (diseases) provided for by the VHI program; Q i is the mathematical expectation of the number of visits to the relevant medical institutions per insured person for the i-th type of insured event during the term of the contract; C p i - the cost of providing medical and service services for the i-th type of insurance cases.

For a large (several thousand) contingent of insured people, the values of Q i can be taken from statistical reference books published annually in each region with the main performance indicators of health authorities and institutions, providing the corresponding data per 1000 people of the population. For small groups of insured people, it is advisable to evaluate the Qi values by expert means based on the data of a preliminary medical examination of the insured by a trusted doctor of the insurance organization.

The cost of providing medical and service services is accepted on the basis of tariff agreements (contracts) concluded with medical institutions.

2. The second (risk) component of the net payment, taking into account annual fluctuations in the number of people seeking medical care:

C n2 = r*C p *S (sum Q i), where i = (1;M); r is the coefficient of variation taken depending on the stability of the change in Q i over the previous period of 5-10 years. With sufficient accuracy for practice, it is recommended to take r =1...2; S (sum Q i) - the standard deviation of the total number of insurance cases within the framework of the VHI program under consideration for the previous period of 5-10 years; C p i - the cost of providing medical and service services, averaged by type of insurance cases:

С l = (sum(Q i *C p i))/sum(Q i), where i = (1;M).

3.Total cost of the policy (gross payment):

C b = (C n1 + C n2)*K load *K inf, where K load is the load factor, which includes the costs of the insurance organization for conducting business, including the creation of a reserve of preventive measures, if the latter is provided for by the VHI program (usually it is equal to 1.1 - 1.3); Profit - the profit ratio from health insurance operations planned by the insurance organization (usually it is 1.0 - 1.05).

The described methodology can also be used to calculate the real cost of a compulsory medical insurance policy, provided that the risk premium is adjusted in accordance with regulatory requirements for the amount of the reserve and the profit factor is excluded.

The progress of medicine, rising costs in healthcare, and rising morbidity make it necessary for insurers to annually review insurance rates and premiums in the direction of increasing them.

Unlike other insurance contracts, VHI has several stages of implementation of insurance guarantees:

1st stage - the formal beginning of the contract, which represents the signing of the contract by the policyholder and the insurer and is determined by the date the contract is completed. At this stage, the agreement on the volume, conditions and timing of the provision of insurance coverage is confirmed.

2nd stage - the material beginning of insurance protection, which is expressed in the payment of an insurance premium and the issuance of an insurance policy.

The 3rd stage is the technical beginning of insurance protection, which is expressed in the fact that, starting from this moment specified in the contract, the insurer bears full responsibility for the obligations assumed.

In health insurance, the material and technical principles of the insurance contract do not coincide. The insurer introduces a so-called pre-contractual period, the duration of which is specified in the contract. The essence of this period is, firstly, to avoid cases of concluding contracts with the deliberate purpose of paying for the treatment of an illness that the insured is already expecting, and secondly, to provide the insurer with a certain period of accumulation of funds under the contract for making subsequent payments.

Typically, a pre-contractual period is prescribed for all diseases, except for the consequences of an accident. It can range from one month to a year. The longest pre-contractual periods are established for childbirth, dentistry and orthopedics, psychiatry, chronic diseases and pathologies. The pre-contractual period may be waived upon payment of a higher premium or presentation of a medical certificate.

The policyholder has the right to make changes or additions to it during the contract. Insurers usually allow the policyholder to:

increase the amount of insurance coverage;

expand the list of insured medical services.

Naturally, the insurer provides both for an additional fee.

The settlement of an insured event in VHI also has significant features compared to other types of insurance.

Firstly, an insured event under VHI is extended over time and coincides with the period of incapacity for work of the insured.

Secondly, the duration of the insured event is determined by the treatment method and is established by a medical institution or a private practitioner.

Third, medical services must be provided by medical institutions or doctors accredited by the insurer, and drugs and other medications must be prescribed.

Payment for medical care can be made in different ways.

1. The simplest and most traditional method can be described as follows: the medical institution issues an invoice to the client, who in turn pays and submits it to the insurance company, which compensates him for the costs of treatment, or the client, having received the invoice, sends it to the insurer for payment.

Currently, insurers have begun to use deferred settlements with clients according to the following payment scheme for medical services. The insurer begins to accept invoices for payment only when the amount specified in the insurance contract is reached. This condition allows the insurer to save business costs and not divert reserves from the capitalization process.

2. A more common method of payment for medical services without the participation of the insured client is when the medical institution sends an invoice for payment for the services provided directly to the insurance company. Moreover, invoices can be issued for periods agreed upon by the insurer and the medical institution for entire groups of treated clients insured by this insurance company.

With this payment scheme, great importance is placed on calculating the cost of medical services. Typically, each country has tariff plans for medical services, which are used in calculations under social security and compulsory medical insurance. Private health insurance uses them as the basis of calculations, establishing payment systems at 100% social security (or SHI), 150% or even 300% tariff, depending on the specific insurance program chosen by the policyholder. In Russia, there are Rules for the provision of paid medical services to the population, approved by Government Decree of January 13, 1996. No. 27.

3. Recently, due to the emerging trend of a steady increase in the cost of medical services and the observed increase in unprofitability in the medical insurance system for direct insurance operations, completely new payment systems for medical services have begun to appear. The leader in this direction is the United States, where private medical insurance makes up the vast majority of the total national medical insurance. In the United States, health insurance with control over future use of insurance funds has become increasingly common.

4. Another way to reduce the unprofitability of VHI is the development of such a private type of insurance as payment by the insurer for all medical services necessary for the insured during the year with subsequent additional payment (at the end of the calendar year) for overexpenditure of accumulated funds from insurance premiums for certain types of treatment. The insurance contract under such conditions includes payment for dental care, services of medical specialists, and expensive diagnostic examinations.

5.Sometimes insurers, in order to increase the attractiveness of voluntary health insurance policies, include in them the conditions for making insurance payments to the client in advance, before the occurrence of the insured event. This opportunity is provided when the client is referred for treatment to an expensive private clinic or abroad.

Termination of the insurance contract. A voluntary health insurance contract can be terminated similarly to other insurance contracts at the initiative of both the client and the insurer.

The policyholder may terminate the insurance contract if the insurer violates its obligations - increasing the amount of insurance premiums.

The insurer may terminate the contract in case of failure to pay insurance premiums on time, in case of violation by the policyholder of the obligation to provide complete and honest information about himself in the application, in case of violation of medical regulations, or use of the medical policy by other persons.

In addition, the contract terminates: upon expiration of the contract; by agreement of the parties, in the event of the death of the insured; By the tribunal's decision; upon liquidation of the insurer.

The occurrence of an insured event is not a reason for termination of the contract before the end of the period established in the contract.

In case of early termination of the contract, the insurer returns to the policyholder part of the insurance premiums, in proportion to the unexpired term of the contract, minus the expenses incurred by the insurer.

Conclusion.

Despite the fact that medical insurance, like all other types of insurance in Russia over the past 10 years, has made a huge step forward, we still lag behind developed countries in this indicator. And therefore, like many other areas of the economy that came to us after perestroika, huge opportunities for development are opening up for insurance in Russia. Health insurance is also very important for the development of the domestic healthcare and medicine system.

In conclusion, I would also like to say that: unfortunately, I was not able to fit into this work everything that I wanted to describe in this work initially in the process of developing the plan for this work. Namely:

1) the question of what other insurance services (life insurance, accident insurance, disability insurance) is used in combination with MS;

2) also in this work almost not a word is said about such a specific type of insurance as insurance for citizens traveling abroad;

3) Reinsurance in MS.

4) Russian health insurance market.

List of used literature:

1. Fundamentals of insurance activities T.A. Fedorov

2. Insurance business B.Yu. Serbinovsky, V.N. Garkusha

3. Insurance: Practice and Principles compiled by David Bland

4. Actuarial calculations in non-state health insurance E.M. Chetyrkin.

Regulatory acts:

Civil Code of the Russian Federation, Chapter 48 “Insurance”.

Decree of the Government of the Russian Federation dated July 15, 1999 No. 805.

Decree of the Government of the Russian Federation of December 11, 1998 No. 1488.

Decree of the Government of the Russian Federation of May 31, 2000 No. 420.

Tax Code of the Russian Federation part 2.

Letter of the Ministry of the Russian Federation for Taxes and Duties dated 09.11.99 No. ДЧ-9-07/360.