Protection of the rights of the insured in the health insurance system. CHI policy: what is included in the free service? What types of services are guaranteed by the state

According to the adopted legislation, practically every person registered and residing in the territory of the Russian Federation has the right assigned to him to apply to any medical institution for appropriate treatment if such a need arises. However, there is one important nuance - services of this kind, as well as the right to receive medicines free of charge, that is, free of charge, are provided only if the citizen has such a document as a compulsory medical insurance policy.

Who can receive free medical services?

Any citizen who is the owner of:

• Employed citizens. That is, the category of persons who regularly pays taxes to the state budget. That is, in fact, he pays for his treatment in advance.
• unemployed citizens. In this case, the payment of funds for the treatment of these persons also occurs at the expense of the federal budget.
• Children, teenagers, and who have not reached the age of eighteen and are not taxpayers.

In the event that a person is officially employed, he has the right to issue, as well as . If he is not employed, works unofficially, or has not reached the age of majority, you can apply for this document at any company that provides insurance services.

In the event that any citizen needs to contact a specialist who conducts an appointment outside the locality where the specified individual lives, an additional referral from the attending physician is also required.

There is a certain list of medical services, the provision of which is free of charge. These include the following:

1. Help of an emergency nature, that is, the departure of an ambulance on a call from a patient. This service is provided free of charge not only to persons who have, but also do not have this document. In the recent past, there were unreliable rumors that if a person does not have a compulsory medical insurance policy, he will have to pay about one and a half to two thousand rubles for calling an emergency. This is not true. This service is provided in any case absolutely free of charge.
2. Ambulatory treatment in the medical institution that is included in the insurance system and includes a number of many different manipulations: examining and diagnosing the patient's disease, performing the necessary procedures and prescribing adequate treatment. However, when a patient is on the terms of the so-called outpatient, day or home treatment, all necessary drugs must be purchased by him at his own expense, since there are no benefits in this case.
3. Work with the public to raise awareness of sanitary and hygienic issues. I.e, holding various lectures, seminars and so on.
4. Diagnosis and treatment of the population using expensive innovative drugs and methods. For example, in some regions of the Russian Federation, in vitro fertilization is carried out free of charge.
5. Diagnosis of the disease with subsequent hospitalization.
6. in dental clinics and offices with state status.

Free services under the MHI policy

For example, while being treated in a state-type hospital, a citizen has the right to receive free services for the treatment of diseases of the following kind: pregnancy support in case of a complicated course, as well as in the presence of pathologies of any kind, medical abortion, the presence of chronic diseases, or in case of exacerbation of the disease, poisoning , bodily harm and so on. In this case, the provision of medicines necessary for adequate treatment is free of charge.

The diseases, the treatment of which, according to the list, is free of charge, include the following:

1. Diseases of an infectious nature, with the exception of those categories that are classified as sexually transmitted infections.
2. Various diseases of the blood, vascular system, heart.
3. Diseases of the stomach, as well as the gastrointestinal tract in general.
4. Any disease caused by a nervous breakdown.
5. Diseases of the joints, bones, muscles and so on.
6. All kinds of defects in vision, hearing, speech.
7. Tumors, both benign and malignant.
8. Diseases of tissues and skin.
9. Diseases of the urinary tract.
10. Diseases of the respiratory system.

What to do if you are denied treatment if you have a policy?

At present, not every citizen is fully aware of the rights that are granted to him in accordance with, which is often used by unscrupulous workers in this field of activity, demanding a certain fee for providing the necessary assistance.

What to do if your rights are violated

Every citizen of the Russian Federation who has insurance has the right to seek help from any medical institution located on the territory of the state. In the indicated institution, he is obliged to accept and carry out appropriate diagnostics, treatment, as well as other manipulations that are necessary. However, it often happens that doctors, as well as hospital staff, refuse to admit a patient in such cases. This is not legal and violates human rights. It's important to produce.

In order to restore the violated right, a person who was denied the provision of medical services must file a complaint with, whose employees will take appropriate measures. If such a case is detected, administrative penalties may be applied to employees of the medical services sector.

What can you expect with a CHI policy?

In order to know the right to use which services the compulsory medical insurance policy gives, you need to carefully familiarize yourself with the list of services provided to the population free of charge.

It should be remembered that, in essence, these services are not at all free of charge due to the fact that a certain amount is deducted from the salary of each employed citizen every month, intended specifically for this purpose. Therefore, in this way, each individual pays in advance for his treatment in a state-type institution. In our other articles you can read and .

Free medical care in medical organizations in the event of an insured event (illness, injury, etc.) throughout Russia in the amount established by the basic CHI program and in the territory where the policy is issued - in the amount of the territorial CHI program (in each region its).

The choice of an insurance medical organization in the manner prescribed by the rules of compulsory medical insurance by submitting an application

Replacement of the insurance medical organization in which the citizen was previously insured, once during the calendar year, but no later than November 1 (or more often in the event of a change of residence or termination of the agreement on the financial provision of CHI in relation to your insurance medical organization) by submitting an application to newly selected health insurance organization

Selection of a medical organization from those participating in the implementation of the territorial CHI program

Choosing a doctor by submitting an application addressed to the head of a medical organization personally or through his representative

Obtaining reliable information from the territorial fund, insurance medical organization and medical organizations about the types, quality and conditions for the provision of medical care under compulsory medical insurance

Protection of personal data collected for personalized accounting in the MHI

Compensation by the insurance medical organization for damage caused in connection with the non-fulfillment or improper fulfillment by the insurance medical organization of its obligations to organize the provision of medical care in accordance with the legislation of the Russian Federation

Compensation by a medical organization for damage caused due to non-fulfillment or improper fulfillment by a medical organization of its obligations to organize and provide medical care, in accordance with the legislation of the Russian Federation

Protection of rights and legitimate interests in the field of CHI

What are the obligations of the Insured Citizens under CHI?

Present the compulsory medical insurance policy when applying for medical care, except in cases of emergency medical care.

Submit an application for the choice of an insurance medical organization to an insurance medical organization in person or through your representative in accordance with the rules of compulsory medical insurance.

Notify the medical insurance organization of the change in last name, first name, patronymic, place of residence within one month from the day these changes occurred.

To carry out the choice of an insurance medical organization at a new place of residence within one month in case of a change in the place of residence and the absence of an insurance medical organization in which the citizen was previously insured.

What is the procedure for choosing an insurance medical organization?

the insured person has the right to choose or replace an insurance medical organization (HIO) from among the HIOs, the list of which is posted by the territorial MHI fund on its official website on the Internet and may additionally be published in other ways

in order to select or replace a medical insurance company, the insured person personally or through his representative applies to the insurance medical organization of his choice with an application for the choice (replacement) of the medical insurance company. To apply for a compulsory medical insurance policy, you must contact any office of the branch convenient for you. Familiarize yourself with the application form and the list of required documents for issuing an MHI policy.

The choice or replacement of the CMO is carried out by the insured person who has reached the age of majority or who has acquired legal capacity in full before reaching the age of majority. Compulsory medical insurance of children from the date of birth until the expiration of thirty days from the date of state registration of birth is carried out by HMOs in which their mothers or other legal representatives are insured. After thirty days from the date of state registration of the child's birth and until he reaches the age of majority or until he acquires legal capacity in full, compulsory medical insurance is provided by HMOs chosen by one of his parents or another legal representative.

The insured person has the right to replace the HMO once during the calendar year no later than November 1, or more often in the event of a change of residence or termination of the activity of the HMO in which the citizen was insured earlier. If the place of residence changes and there is no health insurance in which the citizen was previously insured, the insured person chooses the health insurance for the new place of residence within one month. HMO notifies the insured persons of its intention to terminate its activities ahead of schedule three months before the date of termination of activities. In case of early termination of the activity of the HMO, the insured person, within two months, submits an application for the choice (replacement) of the HMO to another HMO.

If the insured person does not submit an application for the choice (replacement) of an insurance medical organization, then such a person is considered insured by the insurance medical organization in which he was previously insured.

Who will protect your rights?

An insurance medical organization issues policies, keeps records of insured citizens and the medical care provided to them, is obliged to inform its insured about the types, quality and conditions for providing them with medical care, to protect their rights and interests. Remember, the medical insurance organization is your assistant in solving problems and contentious issues related to obtaining medical care under the compulsory medical insurance program. If you are insured by one of our companies, you can contact our representative offices for advice, legal support, professional assistance, to resolve a conflict with a medical institution or a doctor.

Polis ( CHI) are given to a child shortly after birth, and to adults on. It is required to be presented when contacting any clinic or hospital, when children enter kindergarten and school. It would seem that why we need a medical policy and what rights obligatory health insurance gives us should be well known to all of us for a long time, but in fact, many people still have a lot of questions and not everyone clearly knows how to use CHI correctly?

The constitution guarantees us the opportunity to be treated for free However, in practice this is very difficult to do. Even with treatment in state clinics, we increasingly have to fork out, although experts say that it is real to get free treatment, and each of us can contribute to improving the quality of medical care received if we behave correctly.

Policy compulsory health insurance (CHI) is a document that gives us the right to receive free medical care throughout the Russian Federation. They issue a policy not only to adults, but also to children, and even newborns. Today, policies of the 2011 model are valid, and policies issued before December 31, 2010 are considered obsolete and are subject to replacement with policies of a new model. No one canceled the action of the "old" policies, they can be used, but they are gradually being replaced with new ones.

By law, each of us has the right to choose health insurance company. To do this, you need to find out which insurance organizations are available in the region where you live, compare the conditions for their services, opt for the best one, come to their office and write an application. The insurance organization must issue a temporary certificate immediately, on the day of application. The temporary policy is valid until the receipt of the permanent policy, which is usually issued within 30 days of receipt of the application.

Compulsory health insurance policy gives us the right to use free healthcare under the basic program of state guarantees. More specifically, OMS provides us with the opportunity to:
1. Upon the occurrence of an insured event, receive free medical care in full and of proper quality.
2. In case of harm to health during the provision of medical care, compensate for all damages.
3. Protect our rights and interests.
4. To gain a foothold in the medical organization that we choose ourselves.
5. Select a general practitioner, gynecologist, dentist and other medical specialists, subject to their consent.

If you have a policy CHI you can get medical care at the place of residence or temporary residence in those clinics and hospitals that operate under the compulsory health insurance program. The list of such medical organizations is posted on the official website of the territorial branch of the Compulsory Medical Insurance Fund. A CHI policy issued in one region is valid throughout Russia.

If you received compulsory medical insurance policy at work and did not write an application, then attachment to the clinic occurs automatically at the place of registration, or at the address that you named when you received the policy. In the event that you have chosen another polyclinic and written an application, you will be provided with medical care in this polyclinic, but you will no longer be able to call a doctor home. At the same time, it is important to know: anyone can call an ambulance, you do not need a CHI policy for this! Emergency medical care in our country should be provided regardless of the availability of a compulsory medical insurance policy and other documents.

Insurance medical organization, which issued the CHI policy, guarantees not only the provision of free medical care, but is also obliged to help in cases where there are difficulties in obtaining medical care. For example, when they do not give a coupon for a free examination; it is difficult to get to a specialist for an appointment; there are complaints about the quality of treatment; do not start treatment without payment.

If in public medical institution will offer to pay for treatment or examination, do not rush to go to the cashier. First, call your insurance company and ask if the service offered to you is among the free ones. Even if you have already paid for the treatment, keep the documents and receipt confirming the payment. Show them to the employees of your insurance company and perhaps they will help you get the money spent on treatment back.

By compulsory health insurance provides for the provision of medical care according to programs established by the state, while each subject has its own list. It is not comprehensive and high-tech operations cannot be carried out on it, since they are expensive and are not included in the program under such a policy.

A) throughout the Russian Federation in the amount established by the basic program

b) in the territory of the subject of the Russian Federation in which the compulsory medical insurance policy was issued, in the amount established by the territorial program of compulsory medical insurance;

3) replacement of the insurance medical organization in which the citizen was previously insured, once during the calendar year no later than November 1, or more often in the event of a change of residence or termination of the agreement on the financial provision of compulsory medical insurance in the manner established by the rules of compulsory medical insurance, by submitting an application to a newly selected medical insurance organization;

4) selection of a medical organization from medical organizations participating in the implementation of the territorial program of compulsory medical insurance in accordance with the legislation in the field of health protection;

5) choosing a doctor by submitting an application personally or through his representative addressed to the head of the medical organization in accordance with the legislation in the field of health protection;

(see text in previous edition)

6) receiving from the territorial fund, insurance medical organization and medical organizations reliable information about the types, quality and conditions for the provision of medical care;

7) protection of personal data necessary for maintaining personalized records in the field of compulsory health insurance;

8) compensation by the insurance medical organization for damage caused in connection with its failure to perform or improper performance of its obligations to organize the provision of medical care, in accordance with the legislation of the Russian Federation;

9) compensation by a medical organization for damage caused in connection with its failure to perform or improper performance of its obligations to organize and provide medical care, in accordance with the legislation of the Russian Federation;

10) protection of rights and legitimate interests in the field of compulsory medical insurance.

2. The insured persons are obliged to:

1) present a compulsory medical insurance policy when applying for medical care, except in cases of emergency medical care;

2) submit to the insurance medical organization personally or through his representative an application for the choice of an insurance medical organization in accordance with the rules of compulsory medical insurance;

3) notify the medical insurance company about the change in the last name, first name, patronymic, data of the identity document, place of residence within one month from the day when these changes occurred;

(see text in previous edition)

4) to select an insurance medical organization at a new place of residence within one month in case of a change in the place of residence and the absence of an insurance medical organization in which the citizen was previously insured.

3. Compulsory medical insurance of children from the date of birth and until the expiration of thirty days from the date of state registration of birth is carried out by an insurance medical organization in which their mothers or other legal representatives are insured. After thirty days from the date of state registration of the birth of a child and until he reaches the age of majority or until he acquires legal capacity in full, compulsory medical insurance is carried out by an insurance medical organization chosen by one of his parents or another legal representative.

(see text in previous edition)

4. The choice or replacement of an insurance medical organization is carried out by the insured person who has reached the age of majority or has acquired legal capacity in full (for a child until he reaches the age of majority or until he acquires legal capacity in full - by his parents or other legal representatives), by submitting an application to the insurance medical an organization from among those included in the register of insurance medical organizations, which is placed on a mandatory basis by the territorial fund on its official website on the Internet and may be additionally published in other ways.

(see text in previous edition)

5. In order to select or replace a medical insurance organization, the insured person personally or through his representative applies for the choice (replacement) of a medical insurance organization directly to the medical insurance organization or other organizations chosen by him in accordance with the rules of compulsory medical insurance. On the basis of this application, the insured person or his representative is issued a policy of compulsory medical insurance in the manner prescribed by the rules of compulsory medical insurance. If the insured person did not submit an application for the choice (replacement) of an insurance medical organization, such a person is considered insured by the insurance medical organization with which he was insured earlier, except for the cases provided for in clause 4 of part 2 of this article.

(see text in previous edition)

6. Information about citizens who did not apply to the insurance medical organization for the issuance of compulsory medical insurance policies, as well as those who did not replace the insurance medical organization in the event of termination of the agreement on the financial provision of compulsory medical insurance in connection with the suspension, revocation or termination of the license of the insurance medical organizations, monthly until the 10th day, are sent by the territorial fund to insurance medical organizations operating in the field of compulsory medical insurance in a constituent entity of the Russian Federation, in proportion to the number of insured persons in each of them for concluding agreements on financial support for compulsory medical insurance. The ratio of working citizens and non-working citizens who did not apply to the insurance medical organization, as well as those who did not replace the insurance medical organization in the event of termination of the agreement on the financial provision of compulsory medical insurance in connection with the suspension, revocation or termination of the license of the insurance medical organization, which is reflected in the information sent to insurance medical organizations should be equal.

The rights and obligations of patients in the compulsory health insurance system are what the patient and the doctor should be guided by when concluding an agreement for the provision of medical care and service for patients in the framework of inpatient and outpatient treatment. To ensure that the basic human rights of independence of expression, decision and action, concern for human dignity and human relationships are preserved for all patients, and to define the responsibilities of the patient, it is necessary to follow the policy of the health system within the MHI. The work of the health sector is to respect the individual rights of all persons arriving at this “site” to provide assistance. Patients' rights include the ability to decide whether or not to receive health care.

The patient may formulate advance directives (written instructions such as a living will or durable health care power of attorney recognized by law). Patient responsibilities include those actions on the part of patients that are necessary to enable healthcare professionals to provide appropriate care, make accurate and responsible care decisions, and meet the needs of patients.

Individuals are provided with impartial access to treatment that is medically accessible, regardless of race, creed, gender, national origin, religion, sexual orientation, citizenship, disability or social class and source of funds. The patient has the right to a constant and attentive attitude towards himself under any circumstances, recognizing his personal dignity and worth.

He also has the right, in accordance with the law, to personal confidentiality and confidentiality of information, which is manifested in the right:

1. Refuse to speak to anyone not officially associated with the hospital, including visitors, persons officially employed there but who are not directly related to the institution.
2. Wear appropriate personal clothing and religious or other symbolic items unless they compromise safety or interfere with diagnostic procedures or treatment.
3. Have your own medical record accessible only to persons directly involved in treatment or quality monitoring, and to other citizens only with the written permission of the patient or his legally authorized representative.
4. Expect information provided to interested family members or other legally qualified person to be kept confidential.
5. Request a transfer to another room if another patient or visitors in that room are unreasonably disturbing the patient.

The rights of citizens in the health insurance system are also regulated by the legislative framework of the Russian Federation, in particular, Article 42 of the Constitution of the Russian Federation. It also provides for car insurance for persons who are officially employed citizens on the basis of the Compulsory Health Insurance Fund.

The patient has the right to expect a safe relationship, which excludes medical errors and negligence. Other security measures include limited access to the patient through the use of electronic access cards and readers at external entrances, video monitoring in many areas of federal facilities, and the use of employee identification marks, which must be clearly displayed. This applies to those cases when a prisoner or a particularly dangerous criminal who is in danger or who is dangerous to society is in the hospital. In private hospitals there are special wards that provide for the maintenance of such patients with the assignment of a security system increased in severity.

The patient has the right to know by sight and the professional status of the doctors providing services, or those who are primarily responsible for his care. This includes the patient's right to know that there are any professional relationships between people who treat him, as well as relationships with any medical or educational institutions involved in his care.

Patient participation in research programs or in the collection of data for research purposes must be voluntary with signed informed consent.

The patient has the right to receive from the practitioner responsible for coordinating his care full and up-to-date information about his diagnosis (to a certain extent), treatment and known prognosis. This information should be communicated in terms that can be explained to the patient. If medical assistance is not necessary or possible to provide such information to the patient, it is provided to a legally authorized person.

In addition to all the rights mentioned, in addition to them, patients can expect from hospital staff and other measures aimed at the urgent recovery of patients. If the situation requires it, the person admitted to the emergency room must be provided with all the conditions and urgent assistance, which is equivalent to salvation. He has the right to communicate with people outside the hospital, as well as through oral and written communication. The patient may request that he or she not be included in the patient's register. Enabling means that the patient's name, room number, and general status report can be provided to people who ask about the patient by name. Such situations are possible if a person is in danger and he really needs the help of the police or guardianship authorities.

A prisoner has the right to receive visitors only if they are approved by the head of the prison of the penitentiary institution where the citizen is under arrest. It is lawful to keep confidential all information about the patient's health if he gave the order and consent to the safety of information. Otherwise, if the disclosure of data has led to an "information leak", this has affected the image or reputation, then this act is severely punished. Also, it is impossible to distribute false data about persons, no matter what crimes they have committed. Doctors of a medical institution are obliged to provide full treatment, even if there is a criminal in the hospital.

When the patient does not speak or understand the state language or the one in which he is addressed, he has the right to invite his representative or interpreter. This is especially true when language barriers are an ongoing problem for complex treatment appointments. Since it is not possible to make a diagnosis without a complaint survey, or it would be considered an incomplete picture, it is worth considering such a human right.

Also, the rights of patients under compulsory medical insurance policies are reflected in the following:

1. A person has the right to reasonably informed participation in decisions related to their health care.
2. To the greatest extent possible, this should be based on a clear, concise explanation of his condition and any proposed technical procedures, including the possibility of any risk of mortality or serious side effects, problems associated with recovery or complication, and the likelihood of success.
3. A person should not be subjected to any procedure without his voluntary, competent consent or legal representative. Where medical alternatives exist for treatment, the patient should be informed of them.
4. A person can refuse treatment to the extent permitted by law. When refusal of treatment interferes with the provision of appropriate medical care in accordance with ethical and professional standards, the relationship with the patient may be terminated with a notice of discharge.
5. If the patient is unconscious or considered mentally incompetent and consent cannot be obtained from the relevant family member, urgent action may be taken to obtain a court order for diagnostic and therapeutic procedures. In life-threatening emergencies where the person is incompetent or unconscious, appropriate treatment may be provided without consent.

Also, even refusing a specific method of treatment, a citizen cannot be transferred to another institution if he has not received a full explanation of the need for transfer and alternatives to such a situation. Regardless of the source of payment, the patient has the right to request and receive a detailed explanation of his payment for services provided in the hospital.

The citizen has the right to file a complaint about the services. He also has the right to receive data on the mechanism of the hospital's work in order to understand how and within what time limits complaints are considered.

If the competent authorities of the Russian Federation do not accept written statements about the violation of human rights in the field of medical insurance, the citizen will be able to demand that his complaints be considered in the presence of the commission. In the case when the board of doctors cannot come to a consensus regarding treatment, indicate the rights of citizens of the Russian Federation in the health insurance system, and a list of measures will be quickly compiled in your presence. However, remember that reporting on the activities of doctors is also prohibited. This is discussed in Patient Responsibilities, and more on that later.

Responsibilities of patients in the course of treatment

Every citizen also has obligations and responsibilities that come with health protection when they enter a medical facility. These data are reflected in the law FZ-323, as well as the Constitution of the Russian Federation. A Russian, as a person living and working in Russia, is obliged to respect and know the laws and constitutional provisions.

The main responsibilities are presented as follows:

1. Follow the rules of the hospital and use its prescriptions properly.
2. Treat all staff (medical or non-medical) as well as other patients and their families with respect.
3. Observe general health regulations as well as certain behavioral patterns set by the health authorities.
4. In the event of a denial of the proposed treatment, sign a document stating your denial after receiving sufficient information.

The rules also apply to all citizens of the country who are registered with family doctors. All able-bodied persons, as well as schoolchildren and university students, must provide certificates for admission to the registration of educational institutions. This is legal and provides for the protection of all persons who may come into contact with a sick person. Before the start of the school year, parents and children undergo a medical examination to prevent the epidemic from starting en masse.

This applies to children and adults:

1. Annual examination and preventive measures to establish the level of health. This is a mandatory measure, since "neglect" can cause complications.
2. Early diagnosis is the key to successful and short-term treatment. In order to avoid negative consequences, not to come to complex methods of diagnosing a disease based on several symptoms, people are required to notify family doctors about their condition.
3. Moms and dads are required to undergo a monthly medical examination with the child. If a family wishes to have IVF, they must obtain a referral for this procedure in order to receive benefits. This is provided for by law.

Benefits in the field of healthcare also apply to the disabled, orphans and residents of boarding schools. Pensioners receive mandatory discounts during the start of insurance. The health insurance policy must be kept and renewed by filing an application, as well as by submitting a tax return at enterprises. That is, the policy is automatically paid, and its validity period is extended by a legal entity. Since there is no liability for non-fulfillment of obligations in the field of medical insurance, all measures are considered formal, but mandatory for citizens.

Persons who hold positions in the field of catering, work with people are required to undergo an annual medical examination to confirm the status of a healthy person. If a disease such as tuberculosis is acquired during this period, the management of the organization cannot allow the employee to carry out activities, as this can harm customers and visitors. In other cases, when it comes to working with other objects where contact with people is limited (production, driving a car, remote work), a legal entity is obliged to employ a citizen in accordance with the Labor Code of the Russian Federation or on the basis of an agreement, deducting interest to the social and pension fund.