What denotes OMS. Basic OMS program

As before, there are basic and territorial programs.
The basic program is part of the Program of State Guarantees for Citizens Russian Federation Free medical care.
It determines the types of medical care, a list of insurance claims, the facilities of the tariff for medical care, the methods of payment for medical assistance provided to the insured persons on compulsory health insurance in the Russian Federation at the expense of compulsory medical insurance, as well as the criteria for the availability and quality of medical care. The rights of the insured persons established by the basic program are united throughout the Russian Federation.
Within the framework of the basic program, primary health care is provided, including preventive care, ambulance (with the exception of specialized (sanitary) emergency medical care), specialized medical care. Part 6 of Article 35 lists cases (diseases) of free medical care.
The program of state guarantees for citizens of the Russian Federation of free medical care for 2011 approved by the Decree of the Government of the Russian Federation of 04.10.2010 N 782. In accordance with this regulatory legal act, the project of a similar program should be prepared until July 1, 2011.
In accordance with the requirements established by the basic program, a territorial program is approved. It determines, taking into account the structure of the incidence in the subject of the Russian Federation, the values \u200b\u200bof the provision of medical care issues, the financial costs of providing free medical care and the financial support of the territorial program of compulsory medical insurance in the calculation of one insured person. In accordance with the Government Decree, territorial programs for 2011 were to be adopted until December 25, 2010.

37. Name the legislative requirements for OMS

On May 27, 1993, the Order of the Government of the Russian Federation No. 927-p created a federal fund of compulsory medical insurance (FFOMS), and in the subjects of the Federation - territorial funds of compulsory medical insurance (TFOMS).

We list the main functions of the FFOMS and TFOMS:

 accumulation of financial resources of citizens collected for OMS;

 oMS financingconducted by licenses and

who concluded the relevant treaties, the insurers - the SMO;

 Alignment financial resourcesdirected to the CMI,

in territories;

 provision of CLOs;

 Creation of financial reserves;

 Implementation of control over timely and full admission

insurance premiums;

 development and coordination of tariff policy;

payers of insurance premiums.

Features of the contract and the rules of the DMS

The DMS rules contain general insurance conditions and regulate the relations of the parties in the conclusion and execution of DMS agreements. The DMS rules are not included with the consideration of medical services provided for by the basic and territorial OMS programs. Insurance rules are developed on the basis of the possibilities of modern medicine, customer needs and

economic benefits of the insurance organization itself.

TO general conditions Insurance reflected in the rules include:

 determining the object, subjects of insurance, the sum insured,

insurance premium, form and order of their payment;

 rights and obligations of the parties;

 relationships of the parties upon the occurrence of the insured event;

 The procedure for the conclusion, execution and termination of the insurance contract.

Insurance contract

The standard period for the insurance contract is 1 year, however, the terms of the contract may be provided for both greater and smaller period.

The insurance contract must be concluded in writing and comply with the civil law of the Russian Federation. The conditions of the DMS, contained in the insurance rules and not included in the text of the contract are mandatory for the insured or the insured person, but by mutual agreement of the parties the insurer and the policyholder can change or eliminate

separate rules. If there are several insured in the contract, the procedure for actions of the insured at the conclusion of the contract is particularly stipulated. Insurer

a list of insured persons is drawn up, which is attached to the insurance contract and is its integral part. The list of insured must contain the following information:

 surnames, names, patronymic;

 birth dates;

 home addresses and phone numbers;

 Passport details;

 posts.

If the policyholder is individual, then he fills in a medical questionnaire and is responsible for the accuracy and completeness of information reported. The insurer has the right to check the accuracy of the data. If it is established that the Insured reported itself or the insured face of false data that are essential for

estimates of the degree of insurance risk, the insurer or proposes to pay the insurance premium, or refuses to the insured in concluding a contract or terminates its action.

As a rule, the insurance contract comes into force at the time of payment of the insurance premium or its first insurance premium and is valid until the end of the insurance period established in the contract. After the expiration of the insurance contract, the insurance contract is terminated. But this

not the only case when insurance legal relations can end.

Other cases are:

 execution by the insurer of their obligations in full, that is, payment of the cost of medical services in the amount of the sum insured;

 The death of the insured or the insured person, if only one person was insured under the insurance contract;

 court decision on the recognition of an insurance contract invalid;

 Termination of an agreement on a mutual agreement of the parties, on the initiative of one of the parties, in case of non-payment by the insured of the insurance premium (insurance premium).

The insurance contract may provide for the return of the insurance premium (insurance premiums) for a non-sustained period in the event of early termination of the contract. Return is made on the basis of actually received under the insurance insurance premium amount (insurance

contributions) less expenses for the conduct of cases involving the actual amount of insurance premiums and the amount of insurance payments made by the approved DMS program.

What is an insured event in DMS and OMS?

Insurance case - The event stipulated by the insurance contract or law with the onset of which the obligation of the insurer arises to make insurance pays to the insured, the insured person, the beneficiary or other third parties

Insurance case at DMS- This is an appeal of the insured during the term of the insurance contract to the medical institution (from among those specified in the insurance contract) for obtaining medical care (in accordance with the terms of the contract). Insurance case in OMS - This is a disease.

Types of Insurance Cases in State Social Insurance

Insurance cases recognize the achievement of retirement age, offensive disability, loss of breadwinner, disease, injury, industrial accident or occupational disease, pregnancy and childbirth, childbirth (children), child care under the age of one and a half years and other cases established by federal laws On specific types of compulsory social insurance.

Upon the occurrence of several insurance cases at the same time, the procedure for payment of insurance coverage for each insurance case is determined in accordance with federal laws on specific types of compulsory social insurance.

Recently, a lot of bustle and conversations around the replacement of compulsory health insurance policies. They change whether it is necessary to make people a list of new sample? Do you need to receive their children? What is needed for this? Many do not understand what the CHI policy is and for what he is invented. We are trying to figure it out in this article.

OMS is compulsory medical insurance, which is part of the system of state guarantees of the Russian Federation and ensuring medical care free of charge. Since May 2011, in the Russian Federation, it was decided to introduce a single policy of compulsory health insurance (OMS). To do this, instead of the citizens of the citizens began to produce the policies of the new sample, made on a paper letterhead, some of them in the form of a plastic card. The policy on paper blank had a disadvantage, it could not be bended fourly, since he quickly came to disrepair and became unreadable.

From August 1, 2012, an improved form of paper policy of the OMS was introduced. The policy is issued to the policy, containing information about the rights of the insured and medical institutions to which he is attached. With a paper policy of OMS, you can make photocopies on both sides.

Part of the policies is issued as a plastic card. But it must be borne in mind that we do not have all the clinics have proper equipment to receive information in which insurance company is issued policy. Therefore, if you want to get a polis in the form of a plastic card, you must remember the name of the insurance company itself.

To obtain the OMS policy in the insurance medical company, it is necessary: \u200b\u200b1. Passport and 2. Insurance certificate of state pension insurance.

Insurance certificate of state pension insurance is such a plastic map of greenish color (all working people know). It has an insurance number of an individual personal account (SNILS).

Insurance certificate of state pension insurance Every citizen issues in the management of the Pension Fund at the place of residence, and since 2011, in compulsory parents, parents must arrange for each child, regardless of its age. If you have not received this testimony yet, make a useful and necessary case for your beloved child - visit the Pension Fund's Office at the place of residence with a testimony of the birth of a child or his passport.

Further. When you came with your passport and reduce the insurance medical company to apply for the policy of the OMS, everything is simple. The operator will fill out the application (in order to ensure that the errors have been as small as possible). You only have to verify the data and put your signature. The operator will give you a temporary testimony for a period of 30 days, confirming the execution of the policy. The operator will also assign a day when to get the Polis of the OMS. The policy is manufactured at the Gosnak factory and then sent later to the insurance medical company. He is permanent, permanent. Issued for free.

On children, the OMS policy make up parents from birth to 18 years. Before receiving the birth certificate, the child receives treatment at the MOMA policy. Falling the CHI policy on a child is one of the parents with his passport and the child's birth certificate. For children over 14 years old, a passport of a child is already needed to obtain the CHA policy. Take a child with you, let them take to adult life. In addition to these documents, children should have insurance testimonies of state pension insurance (SNILS).

In general, the policy need to issue all citizens of Russia - from birth to deep old age, regardless of employment, social status and health status. However, this is not at all necessary - without the policy you will not be sent out of the country and do not deprive citizenship, you just can't get free medical care. This is one of the main reasons why the policy of compulsory medical insurance should have, including for a child, receive free medical care. Do you need this or do you prefer expensive costly paid services? If the last one, then the Polis of the OMS can not be received at all.

If a person cannot attend the insurance medical company himself, then to obtain the OMS policy, he can do this through a trustee, making a power of attorney in writing without notarization.
Foreign citizens who have a residence permit document can also receive an OMS policy. If the passport of a foreign citizen is a special stamp "Permission for temporary residence", then the policy of the OMS is executed for a period of permission for temporary residence in the Russian Federation. There is also an article 13.5 Federal Law July 25, 2002 № 115-FZ "On Legal Regulations foreign citizens In the Russian Federation, "where the condition of obtaining the policy of the OMS is envisaged.

There is no section "Place of Work" in the Mandatory Medical Insurance Policy. He is not necessary to give to the employer or to the personnel department. This is your personal document for individual use.

Every citizen of the Russian Federation to obtain the CHA policy chooses the insurance medical company at its discretion. If in the future the chosen company did not suit for some reasons, it can be changed, but it can be done no more than once a year.

In the Policy of the OMS there is no information about the place of residence and registration of a citizen. Such information is entered into a single electronic registrar of insured citizens when designing. You can get the Polis of OMS in the insurance medical company located at the place of your actual stay, regardless of the place where you have a permanent or temporary registration.

Having an OMS policy on the hands, you can get medical care anywhere in the country (RF) for free, for example, if you are on a business trip. If the policy is not with you, then the services for you will be paid. Therefore, leaving to another region of Russia, do not forget to take a policy with you - life develops in every way and even healthy people sometimes happen to health problems.

In extreme cases, assistance turns out to be regardless of whether a person has a policy or it is not. This means that if your life is in danger, you must have a full range of medical services, even if you have no policy (forgotten or not at all). But only before the moment the threat to life will cease to exist. Further treatment services will be provided without a policy only on a fee.

Another question is in which medical assistance is provided if you have an OMS policy. It is very important. The fact is that the Ministry of Health is developing projects for two OMS programs every year: a basic program and a territorial program. Decisions of projects come to the Government of the Russian Federation. Currently, the Government approves decisions on basic and territorial programs for 2015, 2016, 2017.

The territorial program cannot be less basic. But if the region is "rich", then the territorial program of the OMS can be much more basic.

If you are in the region where your insured medical company has, then in its policy of the OMS you can receive medical care in the volume of the territorial program. If your region is also "rich", then for you it is very good - in rich regions it is easier to live.

If you are in a place where there is no insurance medical company, then the assistance is on the basic program. So think well what kind of insurance medical company choose. See the list of medical insurance companies in Russia, as well as the geography of their activities on the OMS website. The Tames, by the way, there are many other useful information about the OMS system.

If you changed the place of residence, then within a month you have to notify your insurance medical company about it. If there is no one in a new place, you will have to choose another. And do not forget to re-register for children!

If the policy is lost, nothing terrible, just need to appeal to your insurance for a duplicate.

Having an OMS policy you can choose a doctor and a medical institution in which you will be treated. It can be any clinic in the village where you live, with the exception of paid, naturally.

If you are not satisfied with those services that the doctor offers, you can contact the head of the clinic, the chief doctor of the hospital or to the insurance company for clarifications. Do not be afraid to do it - this is your legal right!

In addition to compulsory health insurance, which implies a free provision of services, there is still voluntary medical insurance (DMS), which is an addition to the OMS and is paid. It will be our next Council on the topic of medical insurance.

Be always healthy !!!

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Medical care in the OMS system is carried out in accordance with the basic and territorial programs of the OMS. The OMC basic program is valid throughout the Russian Federation, the territorial program of the OMS - on the territory of the relevant subject of the Russian Federation.

The Basic MMC Program is a document that determines the rights of insured persons for free provision of them at the expense of compulsory medical insurance throughout the territory of the Russian Federation of medical care and establishing uniform requirements for OMS territorial programs.

The basic OMS program determines:

Types of medical care provided at the expense of OMS;

List of insured cases;

The facilities of the tariff for the payment of medical care in the OMS system;

Methods of payment for medical assistance provided to the insured persons on the OMS in the Russian Federation at the expense of the CHI;

Criteria for the availability and quality of medical care;

Standards for providing medical care;

Statutors of financial costs per unit of medical care;

Changing financing standards;

Requirements for the provision of medical care;

Calculation of the coefficient of the appreciation of the program.

The basic OMS program is approved by the Government of the Russian Federation as part of the program of state guarantees of free provision of medical care to citizens, which determines the types and conditions for providing medical care to citizens funded by budget allocations All budgets budget system The Russian Federation, including the funds of the Budgets of State Funds OMS (Table 7.8).

The need for funds for medical insurance of citizens are determined on the basis of the regulations approved in the basic program of medical care and financial costs per unit of medical care.

The Law on Compulsory Medical Insurance in the Russian Federation identifies the right of government of the Russian Federation when approving the program to expand the list of insurance cases on OMS, as well as include additional elements in the tariff structure for paying for medical care. In 2011, the territories also provide for the possibility of inclusion within the framework of the OMS to the cost of medical institutions of other expenses in accordance with budget legislation, subject to the implementation of the established program: per capita statutors of financial support, including the OMS base program; Financial costs per unit of medical care. The formation of tariffs for medical assistance provided at the expense of OMS, is carried out by the executive authority of the subject of the Russian Federation.

Another indicator of the CHAM base program is a pillowing standard for funding, reflecting the amount of funds for compensation for the cost of providing guaranteed medical care per person per year. In 2011, this standard is an average of 7633.4 rubles. per year per person (without taking into account the costs of the federal budget), including 4102.9 rubles. at the expense of OMS; 3530.5 rub. at the expense of the relevant budgets.

Medical assistance provided in the OMS system must meet the criteria for the availability and quality of medical care, measured on the basis of the level and dynamics of the following indicators:

Population Satisfaction with medical care;

The number of persons suffering from socially significant diseases, with the diagnosis established for the first time in life;

The number of persons aged 18 and older, first recognized as disabled;

Mortality of the population;

Labor-bred population;

Mortality of the population from cardiovascular diseases;

Mortality of the population from cancer;

Population mortality from external reasons;

Mortality of the population as a result of road accidents;

Mortality of the population from tuberculosis;

Maternal mortality;

Infant mortality;

Coverage of the population with preventive inspections carried out in order to identify tuberculosis.

The level of accessibility of medical care is determined on the basis of assessing the implementation of standards for the volume of medical care by type.

The effectiveness of the use of health resources (personnel, material and technical, financial and other) is determined on the basis of the examination of medical care in accordance with the established medical and economic standards (the performance of the population by doctors, middle medical personnel and hospital beds).

When implementing medical care programs, it is possible to apply the following methods of payment for medical care, focused on the result of medical organizations: according to the completed case, based on the perverse standard of financial support for outpatient care, combined with payment for a unit of the volume of medical care produced by the average cost of inpatient treatment Patient taking into account the branch profile, according to the clinical and statistical group of diseases, as well as a unit of the amount of medical assistance.

In accordance with the requirements of the basic program of the OMS in the constituent entities of the Russian Federation, the territorial programs of the OMS (TP OMS) are being developed.

The OMS territorial program is a document that determines the rights of insured persons to be free to provide them with medical care in the territory of the Russian Federation and complying with the unified requirements of the basic health insurance program.

The territorial program of the OMS establishes on the territory of the subject of the Russian Federation:

Types and conditions for the provision of medical care;

The list of insurance claims established by the OMS base program;

Values \u200b\u200bof the provision of medical care provisions in the calculation of one insured person, taking into account the structure of morbidity in the subject of the Russian Federation;

Values \u200b\u200bof financial cost standards per unit volume of medical care in the calculation of one insured person;

The value of the financial support is the territorial program of the OMS in the calculation of one insured person;

Methods of payment for medical care provided to insured persons on OMS;

The facilities of the tariff for the payment of medical care;

A list of medical organizations involved in the implementation of TP OMS;

Medical assistance conditions;

Target values \u200b\u200bof the accuracy and quality of medical care.

The OMS Territorial Program may include a list of insurance claims, species and conditions for medical care in addition to the MED's established basic program, subject to the fulfillment of the requirements established by the basic OMS. In this case, the program must also establish the corresponding indicators.

During the transition period (from January 1, 2011 to December 31, 2012), the territorial programs of the OMS in the constituent entities of the Russian Federation may include the provision of medical care in individual diseases and states of health not included in the basic program of the OMS, without complying with the implementation of the standards established by the standards established by The OMS base program, while maintaining the volume of financial support of the OMC territorial program not lower than the level of 2010, including within the Base Program of the OMS.

The financial support for the OMS territorial program of the territorial program may exceed the MMC established by the basic program in two cases:

1) when establishing an additional amount of insurance coverage for insured cases established by the OMS base program (the territorial program of the OMS should include a list of areas of use of the CHA);

2) when establishing a list of insurance claims, species and conditions for medical care in addition to the OMS base program installed.

At the same time, the financial support of the territorial program of the OMS is carried out by payments to the subjects of the Russian Federation paid to the territorial fund's budget, in the amount of the difference between the financial support of the OMS territorial program and the financial support for the OMS base program, taking into account the number of insured persons on the territory of the subject of the Russian Federation.

The commission of the TP OMS project is being created in the subject of the Russian Federation, which includes representatives of the executive authority of the subject of the Russian Federation authorized by the Supreme Executive Body of Public Authority of the Directory of the Russian Federation, the Territorial Fund, Insurance Medical Organizations and Medical Organizations, representatives of trade unions or their associations (associations) operating on the territory of the subject of the Russian Federation on the parity principles. The provision of medical assistance established by TP OMS is distributed by the Commission's decision between insurance medical organizations and medical organizations based on the amount, gender and age of insured persons, the number of attached insured persons to medical organizations providing outpatient polyclinic assistance, as well as the needs of insured persons in medical Aid.

The provision of medical care established by the TP OMS subject of the Russian Federation, in which the insured persons were issued an OMS policy, including the provision of medical care to these insured persons outside the territory of this subject of the Russian Federation.

The basic program of compulsory medical insurance of citizens of the Russian Federation contains the main guarantees provided under the OMS. It is approved by the Government of the Russian Federation together with the program of state guarantees to ensure citizens of the Russian Federation free medical help. The first such program was adopted on September 11, 1998 and with some changes to the present.
At the expense of OMS, in the framework of the basic program, stationary and outpatient polyclinic assistance are provided in healthcare facilities, regardless of their organizational-right form with various kinds of diseases, injuries, pregnancy and childbirth, dental treatment, etc. Stationary assistance includes on a par with treatment, the provision of diagnostics services, the use of medical instruments and free provision of drugs. Ambulatory and polyclinic service implies assistance to both the clinic and home, diagnostics and prevention and dispensary monitoring activities.

Insurance on such polisses is carried out within the framework of the state program. Accordingly, the state acts as a kind of guarantee of the possibility of using its rights absolutely, those who applied for medical care. Working citizens make up a policy at the place of fulfillment of their labor function, unemployed and non-working citizens - in the body of the territorial unit. In the latter case, the presence of a passport with a registration stamp, workbook and a reduction.

Where can be treated free of charge?

Services included in OMS provide medical facilities included in the list of organizations medical type on the regional administrative level. These include municipal and state institutions, such as: hospitals, clinics, medical units, female consultations and maternity hospitals.

Each, having a policy, can attach to a medical facility. Usually, the attachment occurs on the district principle, that is, at the place of actual residence and / or registration of the patient.

Where can I find out the list of services for OMS?

The list of services for OMS is subject to annual approval of the Regional Health Program. Each medical institution, which is the link of the OMS system, must necessarily inform citizens about which medical services are included in the list of free services on OMS. If there are questions regarding the reasonable collection of funds as payment for the provision of services, it is necessary to contact the territorial fund of the obligatory, which is called the name in the form of a brief abbreviation of the FOMS.

How can you get the required service of medical professionals for free?

First of all, it is necessary go to the medical institutionincluded in the OMS system. Then sign up or take a coupon for a doctor. After the examination passed, the specialist will issue an official direction for the passage of a number of diagnostic manipulations (analyzes, ultrasound, etc.), and prescribes treatment.

If you need to obtain qualified assistance in the regions or in the area, for example, in the case of remote accommodation from them, it is also necessary get the appropriate direction from the doctor host in the local clinic, to which you belong to the policy.

List of services for OMS You can also look at official health care site.

Free Medical Services for OMS

1) Medical emergency help. Ambulance.
2) Outpatient assistance in the clinic, including a spectrum of medical measures to conduct diagnostic surveys and treatment of diseases under polyclinic conditions, at home or in a daytime hospital, as well as in the event that it has arisen for assistance that does not tolerate any deposits on holidays and weekends. It is worth noting that providing patients medicinal preparations At the time of finding on treatment, the status of an outpatient basis is not included in the list of free services.
3) Hospital assistance:

• pathology of pregnancy, abortions or childbirth;
• exacerbations of diseases of chronic flow or acute diseases, poisoning, injuries requiring the treatment of intensive nature, or observation by medical workers around the clock, as well as in case of hospitalization of a patient on a confirmed diagnosis or according to relevant indications;
• planned hospitalization in order to organize measures for the treatment and passage of rehabilitation requiring observation over full day, in hospitals, specialized departments and chambers for staying during the daytime.

4) Health carerequiring the use of high-level technologies, which includes a range of services for the treatment and diagnosis conducted in stationary conditions using the unique and most complex medical techniques and technologies.
5) Educational work with a population of sanitary and hygienic. Conducting measures for preventive and medical rehabilitation.

Free medical services for OMS are free completelyNo additional fees for them do not need. In addition to cases where medical events relating to payments are really needed in comprehensive treatment.

If, when contacting the clinic or hospital, there is a dispute with staff agencies for the payability or free of charge of a service, then it will be appropriate to require registry workers List of services provided by OMSAnd then, making sure the right thing and literacy, contact the Chief Doctor.