What is the difference between basic and territorial OMS programs?
For insured citizens, the right to receive the right to receive medical care free throughout the Russian Federation only in the volume of the Basic program of the OMS, and on the territory of the subject of the Russian Federation, where polis Oms - in the amount of territorial program of the mandatory medical insurance. What are the differences?
The basic compulsory medical insurance program is currently approved by the Resolution of the Government of Russia under the Program of State Guarantees of Free Medical Citizens. It lists the types and volumes of medical care that each insured has the right to get free throughout the country.
In the subjects (regions) of Russia on the basis of the OMS base program, territorial programs of compulsory medical insurance are developed and approved. Territorial programs for the provided types and amounts of medical care cannot be less than the Basic MSM program approved by the Government of Russia. But may be greater - due to additional volumes and types of medical care provided to residents of this particular region for free. Thus, in its region, the insured by OMS can receive medical care in an extended volume (if it is provided for by the territorial program of the OMS), and in another region of the Russian Federation, where he found himself for any reason and fell ill, in the amount provided for by the basic medical program Insurance.
If there was a "bad" on the street and the policy with you?
Emergency medical care is due to the presence or absence of your OMS policy.
Emergency help will have to have in that hospital, which turned out to be closest and where there is an opportunity for this.
In the clinic, they said that I need to make a computer tomography, but it is not included in the OMS and is not free. It is legal?
Program of state guarantees for citizens Russian Federation Free medical care for 2011, approved by Decree of the Government of the Russian Federation dated October 4, 2010 No. 782, it was determined that primary health care is provided for citizens for free, incl. Sanitary and aircraft, medical care, specialized, including high-tech, medical care. Any restrictions on the free provision of such a study as a computer tomography, the state guarantees program does not contain. Consequently, it should be paid for this study from OMS.
At the same time, it must be said that the conditions for the provision of medical care, including the timing of the expectation of medical care provided in a planned manner, are established by the territorial program of state guarantees, which is approved by the executive body of the state authority of the subject of the Russian Federation. Thus, in the Moscow Regional Program of State Guarantees for the provision of free medical care for 2010, it is indicated that in the ambulatory and polyclinic institutions it is possible to receive planned patients, holding appointed diagnostic research and therapeutic measures. At the same time, according to emergency testimony, medical care in an outpatient polyclinic facility is since the appeal of a citizen.
I recommend in all cases when you have questions about the payability or free medical care you need, contact insurance companywhich is obliged to protect your rights to receive free medical care.
All the time they said that in the hospital the medicine is free, but recently a neighbor in the hospital had to buy medicines. Is it correct?
According to part 1 of Article 41 of the Constitution of the Russian Federation, "Medical assistance in state and municipal health institutions is provided by citizens for free at the expense of the relevant budget, insurance premiums, other revenues." In addition, according to the program of state guarantees to citizens of the Russian Federation of free medical care, medical care tariffs provided within the framework of the territorial compulsory medical insurance program include including the costs of acquiring medicines. Thus, the cost of drug treatment in a hospital providing medical care for compulsory health insurance should be paid at the expense of OMS.
At the same time, in the program of state guarantees to provide citizens of the Russian Federation of free medical care for 2011, it is indicated that the territorial program of state guarantees should include "lists of vital and most important drugs and medical products needed to provide stationary medical care, as well as Emergency and emergency medical care (in the event of the creation of emergency medical care). " These lists contain substantially less than the names of drugs than the number of drugs allowed for use in the Russian Federation. A situation may arise when a patient who is in inpatient treatment will be prescribed a medicine that is not included in the list of vital and most important drugs, and will offer to buy it. In this case, we recommend to apply for clarification into your insurance medical Company, and in case you have already acquired a medicine for your own account, save the recipe and cash check. This will solve the issue of compensation to the wrong costs you.
1. Territorial Mandatory Medical Insurance Program - component territorial program of state guarantees free provision Citizens of medical care, approved in the manner prescribed by the legislation of the subject of the Russian Federation. The territorial compulsory medical insurance program is formed in accordance with the requirements established by the basic compulsory health insurance program.
2. The territorial compulsory medical insurance program includes the types and conditions for the provision of medical care (including a list of types of high-tech medical care, which contains including treatment methods), a list of insurance cases established by the basic program of compulsory health insurance, and determines with regard to the structure of morbidity In the subject's constituent of the Russian Federation, the values \u200b\u200bof the provision of medical assistance in the amount of the insured person, the financial costs per unit of the amount of medical assistance in the calculation of one insured person and the status of financial support for the territorial program of compulsory medical insurance in the calculation of one insured person. The value of the financial cost standards specified in this part per unit of volume of medical care in the calculation of one insured person is also established on the list of types of high-tech medical care, which contains the treatment methods.
3. The standard of financial support for the territorial program of compulsory medical insurance may exceed the compulsory medical insurance standard established by the basic program of compulsory medical insurance in the event of an additional amount of insurance coverage on insurance claims established by the basic health insurance program, as well as in the event of a list establishment Insurance cases, species and conditions for the provision of medical care in addition to the established basic health insurance program.
4. Financial support for the territorial certificate of compulsory medical insurance in cases specified in paragraph 3 of this article is carried out by payments of the constituent entities of the Russian Federation paid to the territorial fund's budget, in the amount of the difference between the statutory of financial support for the territorial compulsory medical insurance program and the standard of financial support for the Base Compulsory medical insurance programs, taking into account the number of insured persons on the territory of the constituency of the Russian Federation.
5. In the event of an additional amount of insurance coverage for insured cases established by the basic health insurance program, the territorial compulsory medical insurance program should include a list of areas of use of compulsory health insurance.
6. The Territorial Mandatory Medical Insurance Program in the framework of the Base Program of Compulsory Medical Insurance Determines on the territory of the subject of the Russian Federation, the methods of payment for medical assistance provided to the insured persons on compulsory health insurance, the facilities of the tariff for medical care, contains the register of medical organizations involved in the implementation of territorial Mandatory Medical Insurance Programs, determines the conditions for the provision of medical care in them, as well as target values \u200b\u200bof the accuracy and quality of medical care.
7. The territorial compulsory medical insurance program may include a list of insurance claims, species and conditions for medical care in addition to the established basic health insurance program, subject to the fulfillment of the requirements established by the basic health insurance program.
8. When establishing a territorial program of compulsory medical insurance, the list of insurance claims, species and conditions for the provision of medical care In addition to the required basic medical insurance program, the territorial program of compulsory medical insurance should also include the values \u200b\u200bof the provision of medical assistance in the calculation of one insured person. , financial cost standards per unit of provision of medical care based on one insured person, the value of the financial support standards based on one insured person, the methods of payment for medical care provided for compulsory medical insurance to the insured persons, the facilities of the tariff for medical care, the register of medical organizations involved in the implementation of the Territorial Mandatory Medical Insurance Program, the conditions for the provision of medical care in such medical organizations.
9. To develop a project for the territorial program of compulsory medical insurance in the constituent entity of the Russian Federation, a commission of the development of the territorial certificate of compulsory medical insurance is created, which includes representatives of the executive authority of the subject of the Russian Federation authorized by the Supreme Executive Body of the State of the Statute of the Russian Federation, the Territorial Fund, Insurance medical organizations and medical organizations, representatives of medical professional non-Profit Organizations or their associations (unions) and trade unions medical workers Or their associations (associations) operating on the territory of the constituent entity of the Russian Federation on the parity principles. The Commission on the Development of the Territorial Program of Mandatory Medical Insurance is formed and operates in accordance with the provision that is an annex to the Rules of Mandatory Medical Insurance.
(see text in the previous edition)
10. The provision of medical care established by the territorial program of compulsory medical insurance is distributed to the decision of the Commission specified in Part 9 of this article, between insurance medical organizations and between medical organizations based on the number, gender and age of insured persons, the number of attached insured persons to medical organizations providing outpatient polyclinic care, as well as the needs of insured persons in medical care. The volume of medical care, established by the territorial program of compulsory medical insurance of the constituent entity of the Russian Federation, in which the insured persons issued a policy of compulsory health insurance, include the volume of medical care to drugs from these insured persons outside the territory of this subject of the Russian Federation.
The territorial program includes:
The approved cost of the territorial program of state guarantees of free provision of medical care to citizens in Moscow for 2019 and on the planning period 2020 and 2021 on the sources of financial support (Appendix 1 to this territorial program).
The approved cost of the territorial program of state guarantees of free provision of medical care to citizens in Moscow for 2019 and on the planning period 2020 and 2021 under the terms of its provision (Appendix 2 to this territorial program).
The procedure for providing citizens with drugs, medical products, medical nutrition, including specialized food products, to the appointment of a doctor, as well as donor blood and (or) its components for medical testimony in accordance with the standards of medical care, taking into account species, forms and conditions providing medical care (Appendix 3 to this territorial program).
The list of vital and most important drugs to provide primary health care in day hospital and emergency form, specialized, including high-tech, medical care, emergency, including emergency specialized medical care, palliative care in stationary conditions ( Appendix 4 to this territorial program).
The list of drugs released by the population in accordance with the list of population groups and categories of diseases, with the outpatient treatment of which drugs and medical products are released on the appointment of doctors for free, as well as in accordance with the list of population groups, with the outpatient treatment of which drugs are released for free or With a fifty percent discount on the appointment of doctors (Appendix 5 to this territorial program).
The list of measures for the prevention of diseases and the formation of a healthy lifestyle, carried out within the framework of the territorial program of state guarantees of free provision of medical care to citizens in Moscow for 2019 and on the planning period 2020 and 2021 (Appendix 6 to this territorial program).
Conditions and terms for the dispensary of the population for certain categories of citizens (Appendix 7 to this territorial program).
The procedure for implementing the right of extraordinary medical care established by the legislation of the Russian Federation special categories Citizens in medical organizations involved in the implementation of the territorial program of state guarantees of free provision of medical care to citizens in Moscow for 2019 and on the planning period 2020 and 2021 (Appendix 8 to this territorial program).
The procedure for recovery of expenses related to the provision of medical care citizens in emergency form, medical organizations that are not involved in the implementation of the territorial program of state guarantees of free provision of medical care in Moscow for 2019 for the planning period 2020 and 2021 (Annex 9 to this territorial territorial program).
The list of medical organizations of the State Health System of Moscow, participating in the implementation of the territorial program of state guarantees of free provision of medical care in Moscow for 2019 and on the planning period 2020 and 2021 (Appendix 10 to this territorial program).
The list of medical organizations not included in state system Health of the city of Moscow and participating in the implementation of the territorial program of state guarantees of free provision of medical care to citizens in the city of Moscow for 2019 and on the planning period 2020 and 2021 (Appendix 11 to this territorial program).
The list of types of high-tech medical care, including treatment methods and sources of financial support for high-tech medical care, for 2019 and on the planning period 2020 and 2021 (Appendix 12 to this territorial program).
The territorial program is formed taking into account the procedures for the provision of medical care and on the basis of medical care standards, as well as the peculiarities of the age of age, the level and structure of the incidence of residents of the city of Moscow, based on data from medical statistics. In the formation of the territorial program, the balance of medical care and its financial support is taken into account
- Application. Plan of measures to eliminate comments on the results of monitoring the formation, economic substantiation of the territorial program of state guarantees of free provision of medical care citizens
Agreement of July 10, 2017
Ministry of Health of the Russian Federation, the Federal Fund for Compulsory Medical Insurance and the Government of the Moscow Region on the implementation of the territorial program of state guarantees of free provision of medical care to citizens, including the territorial program of compulsory medical insurance, the Moscow Region for 2017 and the planning period 2018 and 2019
The Ministry of Health of the Russian Federation (hereinafter - the Ministry) represented by the Minister of Health of the Russian Federation of Skvortz Veronika Igorevna, existing on the basis of the Regulation on the Ministry of Health of the Russian Federation, approved by the Decree of the Government of the Russian Federation of June 19, 2012, N 608, the Federal Fund for Mandatory Medical Insurance (hereinafter - Foundation) Stadchenko Natalia Nikolayevna, chairman of the Federal Medical Insurance Foundation, which is valid on the basis of the Charter of the Federal Mandatory Medical Insurance Fund, approved by Decree of the Government of the Russian Federation of July 29, 1998, N 857, and the Government of the Moscow Region (hereinafter - the highest executive body ), represented by the First Deputy Chairman of the Government of the Moscow Region, Olga Sergeyevna, operating on the basis of the order of the Government of the Moscow Region dated June 30, 2017 N 357-RP, hereinafter referred to "Parties", in accordance with Article 81 of the Federal Law of November 21, 2011 N 323-FZ "On the Fundamentals of the Health of Citizens in the Russian Federation", concluded this agreement on the following:
I. Subject of the Agreement
The subject matter of this Agreement is the conditions for the implementation of the territorial program of state guarantees of free provision of medical care to citizens (hereinafter referred to as the territorial program), including the territorial program of compulsory medical insurance, the Moscow region for 2017 and the planning period of 2018 and 2019.
II. Rights and obligations of the parties to implement the territorial program, including the territorial program of compulsory medical insurance
1. Ministry:
1.1. Provides organizational and methodological guidance, submission of the necessary explanations on the implementation of the territorial program.
1.2. Implements the implementation of the implementation of the territorial program for the next fiscal year and on the planning period, including in terms of the execution of the action plan to eliminate the comments contained in the conclusion of the Ministry on the results of monitoring the formation and economic substantiation of the territorial program (hereinafter - conclusion), according to Annex to this Agreement .
1.3. Informs the highest executive body on cases of non-compliance with the conditions of this Agreement, as well as in the presence of an action plan to eliminate the comments contained in the conclusion, on the non-fulfillment of these events.
2.1. Provides the necessary clarification on the implementation of the territorial program of compulsory medical insurance.
2.2. It is evaluating the implementation of the territorial program for the next fiscal year and for the planning period, including in terms of the execution of the action plan to eliminate the comments contained in the conclusion.
2.3. Informs the Ministry on cases of non-compliance with the conditions of this Agreement, as well as if there are an action plan to eliminate the comments contained in the conclusion, on the non-fulfillment of these events.
2.4. Provides subventions by the budget of the territorial fund of compulsory medical insurance of the Moscow Region in the manner and on the conditions established by Article 27 of the Federal Law of November 29, 2010 N 326-FZ "On compulsory medical insurance in the Russian Federation" (hereinafter - the federal law N 326-FZ).
3. Supreme body executive power:
3.1. It implements the territorial program in accordance with the legislation in the field of health protection and the program of state guarantees of free provision of medical care for the next fiscal year and on a planned period (hereinafter referred to as a program) approved by the Government of the Russian Federation.
3.2. Implements the plan of measures to eliminate the comments contained in the conclusion.
3.3. Makes changes to the territorial program in accordance with the conclusion and presents it to the Ministry and Fund.
3.4. Establishes in the territorial program the values \u200b\u200bof the amount of medical care provisions, including adjusted taking into account the conclusion:
number of hospitalization cases: due to the budget allocations of the budget of the Moscow region - 0.005 cases of hospitalization per 1 inhabitant; As part of the basic compulsory medical insurance program - 0.17233 per 1 insured person; at the expense of the budget of the Moscow region transmitted by the inter-budget transfers to the territorial fund of compulsory medical insurance of the Moscow region, - 0.009 cases of hospitalization on 1 insured person;
number of cases of treatment under day hospitals: in the framework of the basic compulsory medical insurance program - 0.06 cases of treatment at 1 insured person; at the expense of the budget of the Moscow region transmitted by the inter-budget transfers to the territorial fund of compulsory medical insurance of the Moscow region - 0.001 per 1 insured person;
number of emergency care visits - 0.56 visits to 1 insured person in the framework of the territorial program of compulsory medical insurance;
the number of beds-days for medical rehabilitation in stationary conditions is 0.039 Koiko-day by 1 insured person within the framework of the territorial program of compulsory medical insurance.
3.5. Carries out financial support for medical care within the territorial program, including the territorial program of compulsory medical insurance, in accordance with the legislation of the Russian Federation.
3.6. Implements financial support for the additional amount of insurance coverage on insurance cases established by the basic health insurance program, in the amount of 6,852,177.0 thousand rubles by transferring payments from the budget of the Moscow region to the budget of the territorial fund of compulsory medical insurance of the Moscow Region monthly in January - April The amount of 2,284,059.0 thousand rubles, and in May - December 4,568,118.0 thousand rubles, indicating in the territorial program, the list of areas of use of compulsory health insurance.
3.7. Implements financial support for the list of insurance cases, species and conditions for the provision of medical care in addition to the established basic health insurance program in the amount of 9,425,448.0 thousand rubles by transferring payments from the Moscow Region budget to the budget of the territorial fund of compulsory medical insurance of the Moscow region monthly in In January - April in the amount of 314,7083.2 thousand rubles, and in May - December 6,778,64.8 thousand rubles, subject to the following conditions:
fulfillment of the requirements established by the basic program of compulsory medical insurance;
indication in the Territorial Program of the List of Insurance Cases, species and conditions for the provision of medical care in addition to the established basic health insurance program; values \u200b\u200bof the values \u200b\u200bof the provision of medical care in the calculation of 1 insured person; values \u200b\u200bof financial cost standards per unit volume of medical care per 1 insured person not lower than the program approved; values \u200b\u200bof the financial support standard per 1 insured person; methods of payment for medical care provided for compulsory health insurance to the insured persons; facilities of the tariff for the payment of medical care; registry of medical organizations involved in the implementation of the territorial compulsory medical insurance program; The conditions for the provision of medical care in such medical organizations.
3.8. Establishes within the framework of the activities of the Commission for the Development of the Territorial Program of Mandatory Medical Insurance Differentiated terms of the provision of medical care and their cost for medical organizations submitted by the Federal Medical and Biological Agency, providing medical assistance to residents of closed administrative-territorial entities, in accordance with average regulations approved by the Program, In proportion to the number of attached population, taking into account the power of a karea fund for profiles, medical specialties, profiles of the rendered medical care.
III. Agreement
This Agreement enters into force from the date of its signing and is valid until December 31, 2017.
IV. Final provisions
4.1. The parties have the right to make changes to the present agreement or terminate its effect in the manner prescribed by the legislation of the Russian Federation.
4.2. All disputes arising from this Agreement or arising about this Agreement are authorized by negotiation.
4.3. The relationships of the parties not settled by this Agreement are governed by the legislation of the Russian Federation.
V. Requisites of Party
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Ministry of Health of the Russian Federation |
Government of the Moscow region |
Federal Compulsory Medical Insurance Fund |
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Address: Rahmanovsky per., D. 3, Moscow, 127994 |
Address: Builders Boulevard D.1, Krasnogorsk, Moscow region, 143407 |
Address: ul. Novoslobodskaya, d. 37, Moscow, 101481 |
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The possibility of obtaining medical care citizens freely depends on the content of the basic and territorial system mandatory Medustration. It is in them that a list of specific types of assistance, services and procedures, which may be calculated by the insured persons. In this article, we will look at what differences exist between the specified OMS programs, which are the features of the territorial program, and also for which it is being developed. The difference between the territorial program from the basicThe basic package of the OMS contains a detailed list of diseases and diseases related to the number of insurance claims, classification of species and standards of the volume of assistance provided, the principle of calculating the tariff, payment methods, etc. It operates throughout the Russian Federation. This means that if, for example, a resident of Moscow during his trip to Novosibirsk felt bad and appealed to the local clinic, then he will be provided for medical assistance in accordance with the basic plan. The territorial program in turn applies only to a specific region and provides the opportunity to take advantage of the services included in it only in the residents of this region. The document contains the following items:
Thus, the main difference between the specified media systems is held by territorial sign and the list of types of medical services. Nevertheless, the territorial part of the OMS is obliged to general principles and the conditions of the basic system and contain all rights guaranteed to citizens. The basic appointment of regional programs is the formation of an extended list of directions of medical care, affordable to residents of a particular subject of the Russian Federation, as well as tariff indicators and the procedure for its provision. Therefore, the content of regional medical device lists can vary significantly depending on different regions. What functions do?The main purpose of the territorial program is the development of a health care system in a particular region, taking into account its specifics and features. The thing is that the Russian Federation is a very large state with a different standard of living, climate, nature, the number of health workers in each region. Therefore, for the full functioning of the health sector insurance services must be adapted to the specifics of the subject of the Russian Federation. For example, some disease can practically do not meet in most of the state, and therefore is not included in the total policy. However, in one particular region of the epidemic of the disease is constant, and as a result, the appropriate insurance case will be included in the territorial program. The same applies to the field of funding for medical insurance - in different regions is the sexual agent of insured persons, the number medical institutions and the tariffing of the services provided. At the same time, if it is identical (compared to the basic program) insurance case Financial support is greatly overestimated, then the list of directions on which additional funds are planned to be distinguished in detail in the document. The procedure for the development and approval of the territorial program of the OMSReimbursement of medical institutions of the value of the assistance of a medical nature is carried out according to the rules and tariffs regulated in the territorial part of the OMS program. Financing is carried out at the expense of budgetary funds of the OMS Territorial Fund, which is formed in the following ways:
The project development of the territorial part of the OMS program is carried out independently in each subject of the Russian Federation by creating a special commission. It includes:
The preparation of the regional program is carried out on the basis of information for annual monitoring of the volume and quality of medical care, which is carried out by the authorities of the constituent entities of the Russian Federation to ensure the health of the population. The authority to approve the territorial program of the OMS is within the competence of the executive bodies of the region, and its change is allowed in cases of need to make amendments to one or more criteria.
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