MHI - compulsory health insurance. Thanks to contributions to the compulsory medical insurance funds, we receive free medical care. In our country, this sphere is regulated by the Federal Law "On compulsory medical insurance" No. 326. The law was adopted in 2010. The latest (at present) changes to it were made in November 2018. In the framework of this article, we will figure out who are the subjects and participants of CHI. Consider their characteristics, rights, responsibilities.
Who will be the subjects?
The subjects of compulsory medical insurance under Federal Law No. 326 are:
- Insurers.
- Insured persons.
- Federal State Fund for MHI.
All subjects of CHI, in particular, are mentioned in Art. 9 chap. 3 Federal Law No. 326.
Who will be the participants?
We are interested in the subjects and participants of the compulsory medical insurance. The last, under Russian law, are:
- Medical insurance companies.
- Territorial offices of the MHI fund.
- Various medical facilities.
Now we will consider each of the presented categories of participants and subjects of CHI in more detail.
Who are insured persons?
Russian legislation in this context offers the following definition of insured persons. These are the following categories:
- Citizens of the Russian Federation.
- Foreign citizens who permanently or temporarily reside in the territory of the Russian Federation.
- Stateless Persons.
The exceptions here are only:
- Highly qualified specialists and members of their families.
- Foreign citizens who carry out labor activities in the spaces of the Russian Federation in accordance with Art. 13.5 of the Federal Law No. 115 (2002), devoted to the legal status of persons from other countries on the territory of Russia.
- Persons who are entitled to receive free medical care on the basis of the Federal Law "On Refugees".
Consider the main categories of data of compulsory medical insurance in the Russian Federation.
Categories of Insured
The following citizens are considered insured by domestic law:
- Employed under an employment contract.
- Company executives who are the sole participants or founders of their companies.
- Members of organizations, owners of their property.
- Collaborating on a civil law contract, the subject of which is the provision of a range of services or performance of work.
- Concluding the copyright agreement.
- Authors of works that receive remuneration under contracts on the alienation of exclusive rights to works, works of art, science, literature.
- Concluding a publishing license agreement.
- Working under licensing agreements to provide the right to use a work.
- Persons self-sufficient in their work. In particular, these are private entrepreneurs, as well as private lawyers, notaries, arbitration managers.
- Individual individuals applying a special tax regime called "Professional income tax".
- Members of various farms and peasant farms.
- Members of patrimonial, family communities of small indigenous peoples living in the Far North and the Far East, who permanently reside in the places of traditional stay of their people, and also conduct their traditional economic activities.
- Disabled citizens.
- Minors - children, adolescents under 18 years of age.
- Non-working pensioners (the reason for granting a pension to these persons is not taken into account in this context).
- Full-time citizens in educational institutions of higher or secondary vocational education.
- Unemployed citizens who have registered their social status in accordance with domestic legislation in the field of employment.
- A guardian or one of the parents who cares for a young child until the baby is 3 years old.
- Able-bodied citizens who have dedicated themselves to caring for a disabled child, a disabled person of the first group or an elderly citizen who have reached the age of 80.
- Other persons who do not work under an employment contract, with the exception of the category of military personnel and persons equated to them under Russian laws.
Insurers for employees
Subjects of CHI in this system are also policyholders. In relation to working citizens, these are the following persons and organizations:
- Payers transfer remuneration to working citizens. These are organizations, entrepreneurs, individuals-employers that do not have the status of "individual entrepreneur".
- Individual entrepreneurs, as well as arbitration managers, lawyers, notaries, individuals engaged in private practice, applying the special regime "Profit tax". As a rule, they will act as insurers only in relation to their personality.
Insured for the unemployed
These entities of the compulsory medical insurance system are insurers in relation to unemployed Russian citizens:
- The structure of executive bodies of the constituent entities of the Russian Federation.
- Authorized by the executive supreme authorities of Russian entities.
- Other organizations identified in this context by policyholders by the Government of the Russian Federation.
As for these subjects of the compulsory health insurance fund, they are payers of insurance premiums for compulsory medical insurance of a non-working share of the population.
Who is an insurer?
To trace the interaction of the subjects and participants of the compulsory medical insurance, it is necessary to clearly understand who the insurer is in this context. This is the federal compulsory health insurance fund within the framework of the implementation of basic compulsory health insurance programs.
But what is it? A federal fund is a non-profit institution created by the Russian Federation in the framework of the Federal Law No. 326 for the full implementation of state policy in the field of compulsory medical insurance.
About territorial funds
Speaking about the subjects and objects of the compulsory medical insurance, we also single out such a thing as territorial funds. These are non-profit institutions created by the constituent entities of the Russian Federation for the implementation of state policies in the field of compulsory medical insurance in their spaces.
Such funds carry out certain functions of the insurer in the implementation of regional mandatory medical insurance programs within the framework of the basic program defined by Federal Law No. 326.
In particular, they deal with issues of additional insurance coverage for insured events highlighted in the basic program, additional lists, reasons for insurance cases, lists of types and conditions for providing medical care in addition to those specified in the basic state program.
To exercise their own powers, such Territorial Funds may create their representative offices and branches.
Insurance company in the field of compulsory medical insurance
The legal status of the subjects of compulsory medical insurance will be determined further - respectively, in the subheading, where their powers are examined. Now we will provide a description of another participant in the compulsory medical insurance - a medical insurance company:
- This is an insurance company licensed in accordance with Russian law. The licensing features of such organizations are determined directly by the Government of the Russian Federation.
- The founders, participants, shareholders, management structures of such a company cannot include employees of the federal executive power of the Russian Federation, the executive power of the state’s regions in the field of health care, as well as representatives of the local government structure, which are authorized to conduct management in the field of health care. Also, participants, founders, managers and shareholders of such insurance companies cannot be employees of the Federal, Territorial Funds, medical organizations that provide assistance to the population through compulsory medical insurance.
- Such companies have the right to engage only in activities related to compulsory or voluntary medical insurance.
- The funds that are intended to pay for medical care, upon admission to the insurance company, are funds of targeted financing (or target). To carry out operations with them, it is necessary to have a separate r / s.
- Such companies carry out their activities in the field of compulsory medical insurance on the basis of agreements on financial support for compulsory medical insurance, contracts for payment and subsequent provision of medical assistance in compulsory medical insurance, which are concluded between this insurance company and the medical institution.
Medical organizations in the field of compulsory medical insurance
The interaction of the subjects of compulsory medical insurance is mainly aimed at providing full-fledged medical care to insured persons in medical institutions. In this context, they include organizations with the authority to carry out medical activities, included in the register of institutions operating in the field of compulsory medical insurance.
Here, organizations of various organizational and legal forms and individual entrepreneurs providing medical services will be considered medical institutions.
Rights of the insured
Now we proceed directly to the consideration of the rights and obligations of the subjects of compulsory medical insurance.
The rights of insured persons include the following:
- Free medical care in case of an insured event. This is possible throughout the Russian Federation as part of the basic compulsory medical insurance program. As for the space of the subject of the Russian Federation, in which the citizen was issued a compulsory medical insurance policy, he has the right to receive additional medical care free of charge. But to the extent that is established by the territorial compulsory health insurance programs.
- Choosing an insurance company. This is achieved by filing an application in the manner established by the rules of the MLA.
- Replacement of the insurance company whose services the citizen used earlier. This is possible no more than once per calendar year. A citizen must have time to submit an application before November 1 of this year. If a citizen has changed his place of residence, or his MHI agreement has expired, then he will also replace the policy any day by submitting an application to an insurance company providing the necessary service.
- Selection of an organization suitable at the request of a citizen from among all medical institutions providing their services within the framework of the territorial compulsory medical insurance program.
- The choice of a treating doctor by submitting an application in person or through his representative to the head of the selected medical institution (within the framework of Russian legislation in the niche of healthcare).
- Obtaining from the Territorial Funds, medical institutions reliable data on the quality, varieties and conditions for the provision of a particular medical care.
- Protection of the personal data of the insured citizen in the event that they are necessary for the personalized registration of patients.
- Compensation by the insurance company for damage that may be caused due to the failure to provide or improper presentation to the citizen of medical care from the medical institution participating in the compulsory medical insurance.
- Protection of the rights of the individual, the legitimate interests of a citizen in the field of compulsory medical insurance.
Obligations of the insured
We continue to analyze the rights and obligations of the subjects of compulsory medical insurance. With regard to responsibilities, the following is highlighted in Federal Law No. 326:
- A citizen is obliged to present his compulsory medical insurance policy at each appeal to the medical institution participating in the basic, territorial medical insurance program.
- Submit an application to the insurance medical company in person or through a legal representative on the choice of the insurer.
- Notify your insurer in the MHI system of the facts of a change in your own surname, name, patronymic, other information in the document proving his identity, change of place of residence. This information must be reported to the insurance company within one month from the date of amendment.
- Make the selection of the insurer company at the place of his new residence within one month from the date of move This obligation is valid if the previous insurance company in the field of compulsory medical insurance does not provide its services in a new place of residence.
Child insurance
In relation to their minor children, their parents or guardians draw up an application for the MHI policy. This can be done on the first day of a child’s life. The parent must have time to apply for a policy before the baby reaches one month of life.
Documents are submitted to the insurance company operating in the field of compulsory medical insurance, where the mother or other legal representative of the child is insured.
After 30 days from the date of state registration of the fact of the birth of the child and until he reaches the age of 18 (or until he has reached legal capacity at an earlier age in accordance with Russian law), this insurance company is obliged to carry out compulsory medical insurance for the young citizen.
Policy Replacement
The insured persons have the right to change the insurance company operating in the field of compulsory medical insurance. Both adult and minor citizens can use it. For the latter, an application for a change of policy is submitted by parents or other legal representatives.
Accordingly, you can apply for a change in the service insurance company only in the company listed in the compulsory medical insurance register. This list is presented on the official sites of the Territorial Funds. In addition, similar information is contained on the official Internet portal of the company itself.
A new insurance policy is issued only on the basis of an application submitted either by the citizen personally or by his legal representative.
Thus, the subjects of compulsory medical insurance in the Russian Federation are the insured and their insurers. The third subject is the Federal Fund for MHI. In addition, other participants are important in the compulsory medical insurance system - medical institutions, insurance companies, territorial compulsory health insurance funds. Each of them has its own rights and obligations, a special role in the national system of compulsory medical insurance.