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10.12.2023

Conditions for the provision of medical care under compulsory medical insurance. Types, forms and conditions of medical care. for persons insured in ___________________________________________________ (name of medical insurance organization)

Those insured through compulsory health insurance are provided with:

    primary health care, including primary pre-medical care, primary medical care and primary specialized care;

    specialized medical care, including high-tech;

    emergency medical care, including specialized ambulance;

    palliative care in medical organizations.

Primary health care is the basis of the medical care system and includes measures for the prevention, diagnosis, treatment of diseases and conditions, medical rehabilitation, monitoring the course of pregnancy, promoting a healthy lifestyle and sanitary and hygienic education of the population. Primary health care is provided free of charge on an outpatient basis and in a day hospital, in planned and emergency forms.

Primary pre-hospital health care turns out to be paramedics, midwives and other medical workers with secondary medical education.

Primary medical care turns out to be general practitioners, local physicians, pediatricians, local pediatricians and general practitioners (family doctors).

Primary specialized health care provided by medical specialists, including medical specialists from medical organizations providing specialized medical care, including high-tech care.

Specialized medical care is provided free of charge in inpatient conditions and in a day hospital by medical specialists and includes the prevention, diagnosis and treatment of diseases and conditions (including during pregnancy, childbirth and the postpartum period), which require the use of special methods and complex medical technologies, and also includes medical rehabilitation.

High-tech medical care is part of specialized medical care and includes the use of new complex and (or) unique treatment methods, as well as resource-intensive treatment methods with scientifically proven effectiveness, including cellular technologies, robotic technology, information technology and genetic engineering methods developed on the basis of advances medical science and related branches of science and technology. High-tech medical care is provided by medical organizations in accordance with the list of types of high-tech medical care defined in Appendix 10 to this Territorial Program.

Emergency, including specialized ambulance, is provided to citizens in an emergency or emergency form in case of diseases, accidents, injuries, poisoning and other conditions requiring urgent medical intervention outside a medical organization (at the place where the emergency medical team is called, including specialized ambulance, and also in a vehicle using medical equipment - during medical evacuation). Emergency medical care, including specialized emergency care, is also provided on an outpatient and inpatient basis by visiting emergency medical teams if it is impossible to provide this type of medical care in the appropriate medical organization. When providing emergency medical care, including specialized emergency care, if necessary, medical evacuation is carried out, which is the transportation of citizens in order to save lives and preserve health (including persons undergoing treatment in medical organizations that do not have the ability to provide the necessary medical care). assistance for life-threatening conditions, women during pregnancy, childbirth, the postpartum period and newborns, persons injured as a result of road accidents, emergencies and natural disasters). Emergency medical care, including specialized emergency care, is provided free of charge by medical organizations of the state health care system. Medical evacuation is carried out by mobile emergency medical teams, carrying out medical care measures during transportation, including the use of medical equipment.

Palliative care in outpatient and inpatient settings, it is provided by medical workers who have been trained to provide such care, and is a complex of medical interventions aimed at relieving pain and alleviating other severe manifestations of the disease, in order to improve the quality of life of terminally ill citizens. Palliative medical care is provided free of charge in medical organizations of the Moscow state health care system - hospices and in palliative treatment departments of medical organizations.

The Territorial Program provides medical care in the following forms:

    emergency - medical care provided for sudden acute diseases, exacerbation of chronic diseases, conditions that pose a threat to the patient’s life;

    emergency - medical care provided for sudden acute diseases, exacerbation of chronic diseases, conditions without obvious signs of a threat to the patient’s life;

    planned - medical care provided during preventive measures, for diseases and conditions that are not accompanied by a threat to the patient’s life, do not require emergency and emergency forms of medical care, the delay of which for a certain time will not entail a deterioration in the patient’s condition, a threat to his life and health .

Medical care may be provided in the following conditions:

    outside a medical organization (at the place where an emergency medical team is called, including a specialized ambulance, as well as in a vehicle during medical evacuation);

    on an outpatient basis, including at home when a medical professional is called (24-hour medical observation and treatment is not provided);

    in a day hospital (medical observation and treatment during the day are provided, but round-the-clock medical observation and treatment is not required);

    in an inpatient setting (24-hour medical supervision and treatment is provided).

Emergency medical care in a hospital setting
turns out to be immediate.

  • The waiting period for specialized medical care (with the exception of high-tech) in a hospital setting in a planned form (planned hospitalization), including for persons staying in inpatient social service organizations, is no more than 14 working days from the date the attending physician issues a referral for hospitalization of the patient, and for a patient with an oncological disease (a condition that has signs of an oncological disease), specialized medical care (with the exception of high-tech) in connection with the presence of the specified disease (condition) in a hospital setting in a planned form - no more than 7 working days from the date of the oncological consultation and determination treatment tactics.
  • Planned hospitalization is provided if there is a referral for hospitalization of the patient.
  • Medical care for emergency indications on an outpatient basis is provided by local therapists, general practitioners (family doctors), local pediatricians, obstetricians and gynecologists and is carried out on the day the patient contacts the medical organization.
  • The waiting period for emergency primary health care is no more than two hours from the moment the patient contacts the medical organization.
  • The provision of primary health care in a planned form is carried out by prior registration of patients, including in electronic form.
  • The waiting period for an appointment with local therapists, general practitioners (family doctors), and local pediatricians should not exceed 24 hours from the moment the patient contacts the medical organization.
  • The waiting period for an appointment (consultation) with medical specialists when providing primary specialized health care in a planned form (except for suspected cancer) is no more than 10 calendar days from the date the patient contacts the medical organization.
  • The waiting period for an appointment (consultation) with medical specialists in case of suspected cancer is no more than three working days from the date the patient contacts the medical organization.
  • The waiting period for diagnostic instrumental studies (x-ray studies, including mammography, functional diagnostics, ultrasound studies) and laboratory tests when providing primary health care in a planned form (except for studies for suspected cancer) is no more than 10 calendar days from the date of purpose of the study.
  • The waiting period for computed tomography (including single-photon emission computed tomography), magnetic resonance imaging and angiography when providing primary health care in a routine manner (with the exception of studies for suspected cancer) is no more than 14 working days from the date of appointment of the study.
  • The waiting period for diagnostic instrumental and laboratory tests in case of suspected cancer is no more than 7 working days from the date of appointment of the study.
  • The period for establishing dispensary observation by an oncologist for a patient with diagnosed cancer is no more than three working days from the date of his diagnosis of cancer.
  • The time it takes emergency medical services to reach a patient when providing emergency medical care should not exceed 20 minutes from the moment the emergency medical team is called to provide such medical care.
  • Waiting periods for the provision of high-tech medical care in a hospital setting in a planned form are established by the federal executive body that carries out the functions of developing and implementing state policy and legal regulation in the field of healthcare.
  • In medical organizations providing specialized, including high-tech, medical care in inpatient settings, a “waiting list” is maintained for the provision of specialized medical care in a planned form and citizens are informed in an accessible form, including using the information and telecommunications network Internet, about waiting periods for the provision of specialized, including high-tech, medical care, taking into account the requirements of the legislation of the Russian Federation on personal data.

In order to provide medical care to a patient undergoing treatment in an inpatient setting, if he needs diagnostic tests and it is not possible for them to be carried out by a medical organization providing medical care in an inpatient setting, free transport services are provided with simultaneous accompaniment of the patient by an employee of the medical organization.

One of the parents, another family member or other legal representative is given the right to free joint stay with the child in a medical organization when providing medical care in an inpatient setting during the entire period of treatment, regardless of the child’s age. When staying together in a medical organization of the state healthcare system of the city of Moscow or a medical organization participating in the implementation of the Territorial Compulsory Medical Insurance Program, in an inpatient setting with a child until he reaches the age of four years, and with a child older than this age - if there are medical indications, a fee for creating conditions of stay in stationary conditions, including for the provision of a bed and food, there is no charge from these persons.

When providing medical care in a hospital setting for medical and (or) epidemiological reasons, patients are accommodated in small wards (boxes) free of charge.

When providing medical care to citizens entitled to receive state social assistance, the organization of drug provision for which is provided for by the legislation of the Russian Federation, and to certain categories of citizens entitled to receive social support measures in accordance with the legal acts of the city of Moscow, provision of drugs and medical products is carried out , as well as specialized medical nutrition products for disabled children in the manner prescribed by the legislation of the Russian Federation and legal acts of the city of Moscow.

Within the framework of the Territorial program, dispensary observation is carried out, which is a dynamic observation, including the necessary examination, of the health status of persons suffering from chronic diseases, functional disorders, and other conditions, in order to timely identify, prevent complications, exacerbation of diseases, and other pathological conditions, their prevention and implementation of medical rehabilitation of these persons.

The procedure for conducting dispensary observation and the list of studies included in it are approved by the Moscow Department of Health in accordance with the procedure and list approved by the federal executive body exercising the functions of developing and implementing state policy and legal regulation in the field of healthcare.

Within the framework of the Territorial Program for the provision of primary specialized health care, patients who apply to medical organizations (structural units) participating in the implementation of the Territorial Program and do not provide relevant medical services are routed by referring them to other medical organizations (structural units) participating in implementation of the Territorial program to receive such medical services.

To receive medical care, citizens have the right to choose a doctor, including a general practitioner (family doctor) and an attending physician (subject to the doctor’s consent), as well as to choose a medical organization in accordance with the legislation of the Russian Federation.

In accordance with the Federal Law of November 29, 2010 N 326-FZ “On Compulsory Medical Insurance in the Russian Federation” (Collected Legislation of the Russian Federation, 2010, N 49, Art. 6422; 2011, N 25, Art. 3529; N 49 , Art. 7047, 7057; 2012, N 31, Art. 4322; N 49, Art. 6758) I order:

1. Approve the attached standard contract for the provision and payment of medical care under compulsory health insurance.

2. Recognize the order of the Ministry of Health and Social Development of the Russian Federation of December 24, 2010 N 1184n “On approval of the form of a standard agreement for the provision and payment of medical care under compulsory health insurance” (registered by the Ministry of Justice of the Russian Federation on February 4, 2011, as invalid) registration N 19714).

Minister V. Skvortsova

Registration No. 26421

Standard contract
for the provision and payment of medical care under compulsory health insurance

___________________________ “___” _______ 20__

(place of conclusion of the contract)

Medical insurance organization ________________________________________________

represented by _________________________________________________________________,

acting on the basis of the Charter, power of attorney ______, license No. _______

dated “__”_______20__, issued by __________________________________________

(name of the authority that issued the license)

in the manner established by the legislation of the Russian Federation, further

called a medical insurance organization, on the one hand, and

medical organization ________________________________________________,

(name of medical organization)

included in the register of medical organizations participating in the implementation

territorial compulsory health insurance program, and

acting on the basis of ________________________________________________

(information confirming the right to exercise

medical activities)

________________________________________________________________________,

(position, surname, first name, patronymic)

acting on the basis ______________________________________________,

(grounds for concluding an agreement)

insurance in the Russian Federation" (Collection of legislation of the Russian

Federation, 2010, No. 49, art. 6422; 2011, No. 25, art. 3529; No. 49, art. 7047,

Art. 7057; 2012, No. 31, art. 4322; No. 49, art. 6758) (hereinafter referred to as Federal

law) have entered into this agreement as follows:

I. Subject of the agreement

1. The organization undertakes to provide the necessary medical care to the insured person within the framework of the territorial compulsory health insurance program, and the medical insurance organization undertakes to pay for medical care provided in accordance with the territorial compulsory health insurance program.

II. Rights and obligations of the parties

2. A medical insurance organization has the right to:

2.1 receive from the Organization the information necessary to monitor compliance with the requirements for the provision of medical care to insured persons, information about the operating hours, types of medical care provided and other information in the amount and in the manner specified in this agreement, verify their accuracy, ensure their confidentiality and safety in accordance with the requirements of the legislation of the Russian Federation;

2.2 if violations of the obligations established by this agreement are detected, do not pay or do not fully pay the Organization’s costs for the provision of medical care, demand the return of funds to the medical insurance organization and (or) payment of fines by the Organization;

2.3 make claims and (or) claims against the Organization in order to reimburse the costs of paying for medical care provided to the insured person as a result of harm to his health in accordance with Article 31 of the Federal Law and apply sanctions in accordance with Article 41 of the Federal Law.

3. The organization has the right:

3.1 receive funds for medical care provided on the basis of this agreement in accordance with the established tariffs;

3.2 appeal the conclusion of the medical insurance organization if there are disagreements based on the results of medical and economic control, medical and economic examination and examination of the quality of medical care in the implementation of compulsory medical insurance in the manner established by the legislation of the Russian Federation.

3.3. increase the amount of funds indicated in the application for receiving targeted funds for advance payment for medical care (hereinafter referred to as the Application for Advance) in the 2nd and 3rd quarters of the year by no more than 20% of the amount specified in clause 5.5 of this agreement.

4. The medical insurance organization undertakes:

4.1 pay for medical care provided to insured persons within the scope of medical care under the territorial compulsory health insurance program, established by the decision of the commission for the development of the territorial compulsory health insurance program (Appendix No. 1 to this agreement), taking into account the results of monitoring the volumes, timing, quality and conditions provision of medical care, tariffs for payment of medical care under compulsory health insurance (hereinafter referred to as tariffs), within three working days after receipt of funds for compulsory medical insurance from the territorial fund of compulsory health insurance (hereinafter referred to as the territorial fund) by transferring these funds to the settlement account of the Organization on the basis of invoices and registers of accounts presented by the Organization, up to the ____ day of each month inclusive;

4.2 by the ____ day of each month inclusive, send an advance to the Organization in the amount of funds specified in the Application for advance received from the Organization;

4.3 carry out control of the volumes, timing, quality and conditions of providing medical care to insured persons in the Organization in accordance with the procedure for organizing and monitoring the volumes, timing, quality and conditions of providing medical care under compulsory health insurance (hereinafter referred to as the procedure for organizing control), established by the Federal Fund compulsory health insurance (hereinafter referred to as the Federal Fund) in accordance with paragraph 2 of part 3 of Article 39 of the Federal Law, and transfer acts of medical and economic control, medical and economic examination and examination of the quality of medical care, containing the results of control, to the Organization within the time limits determined by the procedure organization of control;

4.4 provide the Organization with information material (brochures, leaflets, memos) about the rights of citizens in the field of compulsory health insurance, information stands with posters and/or information about the types and volumes of medical care provided, the conditions for receiving it in accordance with the territorial compulsory health insurance program;

4.5 carry out monthly, on the 1st day of the month following the reporting month, as well as annually at the end of the financial year, reconciliation of settlements with the Organization, based on the results of which an act is drawn up on the acceptance for payment of invoices (registers of invoices) for medical care provided, confirming the amount of the final settlement between the parties and containing information provided for by the rules of compulsory health insurance;

4.6 carry out information exchange of information about insured persons and the medical care provided to them in accordance with the general principles of the construction and operation of information systems and the procedure for information interaction in the field of compulsory health insurance, approved by the Federal Fund in accordance with clause 8 of part 8 of Article 33 of the Federal Law;

4.7 fulfill other duties provided for by the Federal Law and this agreement.

5. The organization undertakes:

5.1 ensure that insured persons exercise the right to choose a medical organization and a doctor in accordance with the legislation of the Russian Federation;

5.2 provide free medical care to insured persons upon the occurrence of an insured event within the framework of the territorial compulsory health insurance program, the list of types of which is contained in the information provided in accordance with clause 5.15 of this agreement;

5.3 provide the insured persons with information about the operating hours, types of medical care provided, indicators of accessibility and quality of medical care and information received from the medical insurance organization in accordance with clause 4.4 of this agreement;

5.4 provide the insurance medical organization with information about the operating hours, types of medical care provided, changes in types, volumes, planned and actual terms of medical care within three working days from the date of change, about the insured person and the medical care provided to him, necessary for monitoring the volumes , terms, quality and conditions for the provision of medical care (medical, accounting and reporting documentation, results of internal and departmental quality control of medical care, if any), signed acts of medical and economic control, medical and economic examination and examination of the quality of medical care within the time limits determined by the procedure organization of control, as well as indicators of accessibility and quality of medical care, including information on waiting times for medical care in the Organization;

5.5 send to the medical insurance organization, before the tenth day of the current month, an application for an advance in the amount of up to ___ percent* of the average monthly amount of funds allocated to pay for medical care over the last 3 months, or from the beginning of this agreement (in the case of the validity period of the agreement less than three months);

5.6 submit to the medical insurance organization, within five working days of the month following the reporting month, a register of accounts and an invoice for payment of medical care provided to insured persons;

5.7 submit reports on the use of compulsory health insurance funds, on medical care provided to the insured person and other reports in the manner established by the Federal Fund in accordance with Article 33 of the Federal Law;

5.8 keep personalized records of medical care provided to insured persons in accordance with the Federal Law, and provide the insurance medical organization with the information necessary for the execution of this agreement;

5.9 provide the medical insurance organization with a place accessible to patients to post information materials about the rights of insured persons in the field of compulsory health insurance;

5.10 use compulsory health insurance funds received for medical care provided in accordance with the territorial compulsory health insurance program;

5.11 keep separate records of transactions with compulsory health insurance funds;

5.12 carry out monthly on the 1st day of the month following the reporting month, as well as annually at the end of the financial year, reconciliation of settlements with the medical insurance organization, based on the results of which an act of acceptance for payment of the medical care provided is drawn up, confirming the amount of the final settlement between the Parties and containing information provided for by the rules of compulsory health insurance;

5.13 carry out information exchange of information about insured persons and the medical care provided to them in accordance with the general principles of the construction and operation of information systems and

the procedure for information interaction in the field of compulsory health insurance, approved by the Federal Fund in accordance with clause 8 of part 8 of article 33 of the Federal Law;

5.14 submit, by the __ day of each month inclusive, in electronic form and (or) on paper, information to the medical insurance organization on the number of insured persons (Appendix No. 2 to this agreement) and lists of insured persons (indicating the last name, first name, patronymic (if any) ), date of birth, compulsory health insurance policy number), who chose the Organization to provide medical care on an outpatient basis, information about changes in previously submitted information, about circumstances that have arisen that may lead to a violation of the requirements of the standards of medical care;

5.15 provide the insurance medical organization, no later than 1 working day after the date of conclusion of this agreement, with information confirming the Organization’s right to carry out medical activities, certified in the prescribed manner, a list of types of medical care provided in accordance with the territorial compulsory health insurance program, information about the conditions provision of medical care to insured persons and the operating mode of the Organization, indicators of accessibility and quality of medical care established for the Organization, and other documents necessary for the implementation of this agreement;

5.16 provide the medical insurance organization with information about the provision of medical care to the insured person who suffered as a result of unlawful actions (inaction) of third parties, simultaneously with the provision of invoices for the medical care provided;

5.17 fulfill other duties provided for by the Federal Law and this agreement.

III. Responsibility of the parties

6. For failure to fulfill or improper fulfillment of obligations under this agreement, the Parties are liable in accordance with the legislation of the Russian Federation.

7. The medical insurance organization is responsible for:

7.1 non-payment, incomplete or untimely payment for medical care provided under this agreement, in the form of payment to the Organization at its own expense of a penalty in the amount of one three hundredth of the refinancing rate of the Central Bank of the Russian Federation, valid on the day of the violation of the deadline for the transfer of funds, from untransferred amounts for each day delays.

Payment of penalties does not relieve the medical insurance organization from paying for medical care in accordance with the terms of this agreement;

7.2. failure to ensure the safety and confidentiality of the information provided in accordance with the legislation of the Russian Federation;

8. The parties are released from liability for partial or complete failure to fulfill obligations under this agreement if this failure was a consequence of force majeure.

IV. Duration of the contract and procedure for its termination

9. This agreement comes into force on the day it is signed by the parties and is valid until December 31 of the year in which it was concluded.

10. This agreement is extended for the next calendar year unless either party declares its termination thirty days before its end.

11. The medical insurance organization and the Organization do not have the right to unilaterally refuse to fulfill this agreement.

12. This agreement may be terminated by agreement of the parties, made in writing.

13. This agreement is terminated unilaterally:

upon liquidation of one of the parties;

upon suspension, restriction, revocation or termination of the license of an insurance medical organization;

if the Organization loses the right to carry out medical activities;

upon exclusion of the Organization and (or) medical insurance organization from the registers of medical organizations, medical insurance organizations operating in the field of compulsory medical insurance.

14. The medical insurance organization notifies the Organization of its intention to terminate the contract early three months before the expected date of termination of the contract.

15. Upon termination of this agreement, the parties make a final payment within ten days after termination of the agreement, while liquidating mutual receivables and payables, about which they draw up a corresponding act, a copy of which is sent by the medical insurance organization to the territorial fund within one day.

V. Other conditions

16. This agreement is drawn up in two copies having equal legal force. One copy is kept by the medical insurance organization, the other by the Organization.

17. All notices and communications sent by the parties in connection with the execution of this agreement must be made in writing.

18. The parties undertake to immediately notify each other of changes in their addresses and details.

19. The parties undertake to take the necessary organizational and technical measures to protect personal data from unauthorized or accidental access, destruction, modification, blocking, copying, distribution of personal data, as well as from other unlawful actions. If one of the Parties entrusts the processing of personal data to third parties, it is obliged to ensure the said persons confidentiality of personal data and the security of personal data during their processing.

VI. Details of the parties:

INN/KPP_____/_____ INN/KPP ________/______

Address (location) of location Address (location) of location

legal entity:________________ legal entity:________

Bank details:______________ Bank details:______________

BIC __________________ BIC ___________________

VII. Signatures of the parties

Medical insurance organization: Organization:

____________________ ______________________

"__" _________ 20__ "__" __________ 20__

* The size of the application for advance payment is set: for 2013 - no more than 55%, for 2014 - no more than 40%, from 2015 - no more than 30% of the average monthly amount of funds allocated to pay for medical care

Appendix No. 1



dated December 24, 2012 No. 1355n

Volumes of medical care under the territorial compulsory health insurance program for ____ year*
___________________________________________________________________________
name of the medical organization)

for persons insured in ___________________________________________________
(name of medical insurance organization)

Types of medical care Line no. Unit just for ___year Scope of medical care: just for ___year Cost of the territorial program by sources of its financing, rub.
January March April June July - September October December January March April June July - September October December
A 1 2 4 5 6 7 8 9 10 11 12
Medical assistance within the framework of the territorial compulsory medical insurance program 1
- emergency medical care (sum of lines 7 + 12 + 17) 2 call
- outpatient care (sum of lines 8 + 13 + 18), including: 3 visit
3.1 visit
3.2 visit
3.3 appeal
- inpatient care (sum of lines 9 + 14 + 19) 4 k/day
- in day hospitals (sum of lines 10 + 15 + 20), including 5 patient-day
1. Medical care provided under the basic compulsory medical insurance program 6
- emergency 7 call
- outpatient care 8 visit
preventive visits 8.1 visit
emergency medical visits 8.2 visit
appeals due to illnesses 8.3 appeal
- inpatient care 9 k/day
- in day hospitals 10 patient-day
2. Additional costs included in the tariff above the basic program for medical care (expansion of cost items): 11 x x x x x
- emergency 12 call x x x x x
- outpatient care 13 visit x x x x x
preventive visits 13.1 visit x x x x x
emergency medical visits 13.2 visit x x x x x
appeals due to illnesses 13.3 appeal x x x x x
- inpatient care 14 k/day x x x x x
- in day hospitals 15 patient-day x x x x x
3. Medical care for diseases beyond the basic compulsory medical insurance program: 16
- emergency 17 call
- outpatient care 18 visit
preventive visits 18.1 visit
emergency medical visits 18.2 visit
appeals due to illnesses 18.3 appeal
- inpatient care 19 k/day
- in day hospitals** 20 patient-day

* - Within the limits established by the decision of the commission for the development of a territorial compulsory health insurance program in a constituent entity of the Russian Federation.

** - In the constituent entities of the Russian Federation, when establishing the volume of medical care in day hospitals, taking into account the place of provision of medical care (day hospital at home, day hospital at a clinic, day hospital at a hospital), additional lines can be entered reflecting these volumes (20.1, 20.2 , 20.3)"

Appendix No. 2
to a standard contract for the provision and payment of medical care
for compulsory health insurance,
approved by the Ministry of Health of the Russian Federation
dated December 24, 2012 No. 1355n

Intelligence
on the number of persons insured in ______________________,
(name of medical insurance organization)
who have chosen the Organization to provide outpatient medical care
on 01.__.20__

Document overview

The form of a standard contract for the provision and payment of medical care under compulsory medical insurance has been updated.

Let us recall that it is concluded between medical and insurance organizations implementing territorial compulsory medical insurance programs.

In general, the form has not changed.

As before, the contract indicates the names of the parties and the grounds for its conclusion.

The payment period for medical care provided has not changed either. Thus, the insurance organization transfers money within 3 working days from the moment it is received from the TFOMS.

An application for advance payment for medical care is still sent until the 10th of the month (monthly). It is stipulated that its size for 2013, 2014 and 2015. is, respectively, no more than 55%, 40% and 30% of the average monthly amount of funds allocated to pay for medical care. Previously, the application amount could be up to 70% of the average monthly volume of these funds.

Settlements with the insurer are reconciled monthly (as of the 1st day) and at the end of the year. Based on the results, an act of acceptance for payment of the medical care provided is drawn up, confirming the amount of the final settlement between the parties.

When an insured event occurs, the medical organization is obliged to provide free assistance included in the territorial compulsory medical insurance program. It should also provide insured persons with the opportunity to choose the doctor and the organization itself.

In accordance with the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Health Insurance in the Russian Federation" I order:

1. Approve the attached Procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance (hereinafter referred to as the Procedure).

2. The heads of territorial compulsory health insurance funds and medical insurance organizations should use the attached Procedure when organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance.

Chairman A. Yurin

The procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance

I. General provisions

1. This Procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance (hereinafter referred to as the Procedure) was developed in accordance with the Federal Law of November 29, 2010 N 326-FZ “On Compulsory Medical Insurance in the Russian Federation "(Collection of Legislation of the Russian Federation, 06.12.2010, N 49, Art. 6422) and determines the rules and procedure for organizing and conducting control over the volumes, timing, quality and conditions of medical care by medical organizations in the volume and on the terms established by the territorial compulsory health insurance program and the contract for the provision and payment of medical care under compulsory health insurance.

2. The purpose of this Procedure is to regulate measures aimed at realizing the rights of insured persons to receive free medical care in the volumes, terms and conditions of appropriate quality in medical organizations established by the territorial compulsory health insurance program and the agreement for the provision and payment of medical care under compulsory health insurance. participating in the implementation of compulsory health insurance programs.

II. Goals of controlling volumes, timing, quality and conditions of provision

medical assistance under compulsory health insurance

3. Control of the volume, timing, quality and conditions of the provision of medical care under compulsory health insurance (hereinafter referred to as control) includes measures to verify the compliance of the medical care provided to the insured person with the terms of the contract for the provision and payment of medical care under compulsory health insurance, implemented through medical economic control, medical and economic examination and examination of the quality of medical care.

4. The object of control is the organization and provision of medical care under compulsory health insurance. Subjects of control are territorial compulsory health insurance funds, medical insurance organizations, medical organizations that have the right to carry out medical activities and are included in the register of medical organizations operating in the field of compulsory health insurance.

5. Control objectives:

5.1. ensuring free provision of medical care to the insured person in the amount and under the conditions established by the territorial compulsory health insurance program;

5.2. protection of the rights of the insured person to receive free medical care in the amount and under the conditions established by the territorial compulsory health insurance program, of appropriate quality in medical organizations participating in the implementation of compulsory health insurance programs, in accordance with contracts for the provision and payment of medical care under compulsory health insurance ;

5.3. prevention of defects in medical care resulting from inconsistency of the provided medical care with the health status of the insured person; non-compliance and / or incorrect implementation of procedures for the provision of medical care and / or standards of medical care, medical technologies by analyzing the most common violations based on the results of control and taking measures by authorized bodies;

5.4. checking the fulfillment by insurance medical organizations and medical organizations of obligations to pay and provide free medical care to insured persons under compulsory health insurance programs;

5.5. checking the fulfillment of obligations by insurance medical organizations to study the satisfaction of insured persons with the volume, accessibility and quality of medical care;

5.6. optimizing the cost of paying for medical care in the event of an insured event and reducing insurance risks in compulsory medical insurance.

6. Control is carried out through medical and economic control, medical and economic examination, and examination of the quality of medical care.

III. Medical and economic control

7. Medical and economic control in accordance with Part 3 of Article 40 of the Federal Law of November 29, 2010 N 326-FZ “On Compulsory Medical Insurance in the Russian Federation” (hereinafter referred to as the Federal Law) - establishing the conformity of information on the volume of medical care provided to insured persons on the basis of the registers of accounts provided for payment by the medical organization, the terms of contracts for the provision and payment of medical care under compulsory health insurance, the territorial compulsory health insurance program, methods of payment for medical care and tariffs for payment of medical care.

8. Medical and economic control is carried out by specialists from medical insurance organizations and territorial compulsory health insurance funds.

9. During medical and economic control, all cases of medical care provided under compulsory health insurance are monitored in order to:

1) checking account registers for compliance with the established procedure for information exchange in the field of compulsory health insurance;

2) identification of a person insured by a specific medical insurance organization (payer);

3) checking the compliance of the medical care provided:

a) territorial compulsory health insurance program;

b) the terms of the contract for the provision and payment of medical care under compulsory health insurance;

c) a current license of a medical organization to carry out medical activities;

4) checking the validity of the application of tariffs for medical services, calculating their cost in accordance with the methodology for calculating tariffs for payment of medical care, approved by the authorized federal executive body, methods of payment for medical care and tariffs for payment of medical care and the agreement for the provision and payment of medical care for compulsory health insurance;

5) establishing that the medical organization does not exceed the volume of medical care established by the decision of the commission for the development of the territorial compulsory health insurance program, subject to payment from compulsory health insurance funds.

10. Violations identified in the registers of accounts are reflected in the act of medical and economic control (Appendix 1 to this Procedure) indicating the amount of reduction in the account for each register entry containing information about defects in medical care and / or violations in the provision of medical care.

In accordance with parts 9 and 10 of Article 40 of the Federal Law, the results of medical and economic control, drawn up by the relevant act in the form established by the Federal Compulsory Health Insurance Fund, are the basis for the application of measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care on compulsory health insurance and a list of grounds for refusing to pay for medical care (reducing payment for medical care) (Appendix 8 to this Procedure), and may also be the basis for conducting a medical and economic examination; organizing and conducting examination of the quality of medical care; carrying out repeated medical and economic control, repeated medical and economic examination and examination of the quality of medical care by the territorial compulsory medical insurance fund or medical insurance organization on the instructions of the territorial fund (except for control when making payments for medical care provided to insured persons outside the constituent entity of the Russian Federation, on territory of which the compulsory health insurance policy was issued).

IV. Medical and economic examination

11. Medical and economic examination in accordance with Part 4 of Article 40 of the Federal Law - establishing compliance of the actual terms of medical care, the volume of medical services presented for payment with the records in the primary medical documentation and the accounting and reporting documentation of the medical organization.

12. Medical and economic examination is carried out by a specialist expert (clause 78 of section XIII of this Procedure).

13. Medical and economic examination is carried out in the form of:

a) targeted medical and economic examination;

b) planned medical and economic examination.

14. Targeted medical and economic examination is carried out in the following cases:

a) repeated requests for the same disease: within 30 days - when providing outpatient care, within 90 days - when re-hospitalization;

b) diseases with an extended or shortened treatment period by more than 50 percent of the established standard of medical care or the average for all insured persons in the reporting period with a disease for which there is no approved standard of medical care;

c) receiving complaints from the insured person or his representative regarding the availability of medical care in a medical organization.

15. Based on the medical and economic control carried out, a planned medical and economic examination is carried out on invoices submitted for payment within a month after the provision of medical care to the insured person under compulsory health insurance, in other cases it can be carried out within a year after the presentation of invoices for payment.

16. When conducting a planned medical and economic examination, the following are assessed:

a) the nature, frequency and causes of violations of the rights of insured persons to receive medical care under compulsory health insurance in the volume, terms, quality and conditions established by the contract for the provision and payment of medical care under compulsory health insurance;

b) the volume of medical care provided by the medical organization and its compliance with the volume established by the decision of the commission for the development of the territorial compulsory health insurance program to be paid from compulsory health insurance funds;

c) the frequency and nature of violations by a medical organization of the procedure for creating account registers.

17. The scope of inspections during a routine medical and economic examination of the number of bills accepted for payment for cases of medical care provided under compulsory health insurance is determined by the contract for the provision and payment of medical care under compulsory health insurance and is no less than:

8% - inpatient medical care;

8% - medical care provided in a day hospital;

0.8% - outpatient medical care.

If during a month the number of defects in medical care and/or violations in the provision of medical care exceeds 30 percent of the number of cases of medical care for which a medical and economic examination was carried out, in the next month the volume of inspections from the number of bills accepted for payment in cases provision of medical care should be increased by at least 2 times compared to the previous month.

18. In relation to a certain set of cases of medical care, selected according to thematic criteria (for example, the frequency and types of postoperative complications, duration of treatment, cost of medical services) in a medical organization in accordance with the plan agreed upon by the territorial compulsory health insurance fund, a planned thematic medical and economic examination.

19. Based on the results of the medical and economic examination, a specialist expert draws up a medical and economic examination report (Appendix 2 to this Procedure) in two copies: one is transferred to the medical organization, one copy remains in the medical insurance organization / territorial compulsory health insurance fund.

In accordance with Part 9 of Article 40 of the Federal Law, the results of a medical and economic examination, drawn up by the relevant act in the form established by the Federal Compulsory Health Insurance Fund, are the basis for applying to a medical organization the measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care assistance for compulsory health insurance and a list of grounds for refusing to pay for medical care (reducing payment for medical care) (Appendix 8 to this Procedure), and may also be the basis for conducting an examination of the quality of medical care.

V. Quality examination

medical care

20. In accordance with Part 6 of Article 40 of the Federal Law, examination of the quality of medical care is the identification of violations in the provision of medical care, including assessment of the correct choice of medical technology, the degree of achievement of the planned result and the establishment of cause-and-effect relationships of identified defects in the provision of medical care.

21. An examination of the quality of medical care is carried out by checking the compliance of the medical care provided to the insured person with the contract for the provision and payment of medical care under compulsory health insurance, procedures for the provision of medical care and standards of medical care, and established clinical practice.

22. An examination of the quality of medical care is carried out by an expert on the quality of medical care included in the territorial register of experts on the quality of medical care (clause 81 of Section XIII of this Procedure) on behalf of the territorial compulsory health insurance fund or medical insurance organization.

23. Examination of the quality of medical care is carried out in the form of:

a) targeted examination of the quality of medical care;

b) planned examination of the quality of medical care.

24. A targeted examination of the quality of medical care is carried out within a month after the provision of an insured event (medical services) for payment, with the exception of cases determined by current legislation and the cases set out in subparagraph “e” of paragraph 25 of this section.

25. Targeted examination of the quality of medical care is carried out in the following cases:

a) receiving complaints from the insured person or his representative regarding the availability and quality of medical care in a medical organization;

b) the need to confirm the volume and quality of medical care for cases selected during medical and economic control and medical and economic examination;

c) deaths during the provision of medical care;

d) nosocomial infection and complications of the disease;

e) primary access to disability for persons of working age and children;

f) repeated justified appeal for the same disease: within 30 days - when providing outpatient care, within 90 days - when re-hospitalization;

g) diseases with an extended or shortened treatment period by more than 50 percent of the established standard of medical care or the average for all insured persons in the reporting period with a disease for which there is no approved standard of medical care.

26. When conducting a targeted examination of the quality of medical care in cases selected based on the results of a targeted medical and economic examination, the general time frame for conducting a targeted examination of the quality of medical care may increase to six months from the date of submission of the invoice for payment.

When conducting a targeted examination of the quality of medical care in cases of repeated treatment (hospitalization) for the same disease, the established deadlines are calculated from the moment the invoice containing information about the repeated treatment (hospitalization) is submitted for payment.

The time frame for conducting a targeted examination of the quality of medical care from the moment the invoice is submitted for payment is not limited in cases of complaints from insured persons or their representatives, deaths, nosocomial infections and complications of diseases, primary disability of persons of working age and children.

27. Conducting a targeted examination of the quality of medical care in the event of complaints from insured persons or their representatives does not depend on the time that has passed since the provision of medical care and is carried out in accordance with Federal Law of May 2, 2006 N 59-FZ "On the procedure for considering citizens' appeals Russian Federation" and other regulatory legal acts regulating work with citizens' appeals.

28. The number of targeted examinations of the quality of medical care is determined by the number of cases requiring its implementation on the grounds specified in this Procedure.

29. A planned examination of the quality of medical care is carried out with the aim of assessing the compliance of the volumes, timing, quality and conditions of providing medical care to groups of insured persons, divided by age, disease or group of diseases, stage of medical care and other characteristics, conditions stipulated by the contract for provision and payment medical care under compulsory health insurance.

30. The scope of the planned examination of the quality of medical care is determined by the contract for the provision and payment of medical care under compulsory health insurance and is no less than:

in hospital - 5% of the number of completed cases of treatment;

in a day hospital - 3% of the number of completed cases of treatment;

when providing outpatient care - 0.5% of the number of completed cases of treatment based on the results of medical and economic control.

31. A planned examination of the quality of medical care is carried out in cases of medical care provided under compulsory health insurance, selected:

a) random sampling method;

b) for a thematically homogeneous set of cases.

32. A planned examination of the quality of medical care using a random sampling method is carried out to assess the nature, frequency and causes of violations of the rights of insured persons to timely receipt of medical care of the volume and quality established by the territorial compulsory health insurance program, including those caused by improper implementation of medical technologies that led to a deterioration in health status the insured person, additional risk of adverse consequences for his health, suboptimal use of the resources of the medical organization, dissatisfaction with the medical care of the insured persons.

33. A planned thematic examination of the quality of medical care is carried out in relation to a certain set of cases of medical care provided under compulsory health insurance, selected according to thematic criteria in each medical organization or group of medical organizations providing medical care under compulsory health insurance of the same type or in the same conditions.

The choice of topics is carried out on the basis of performance indicators of medical organizations, their structural divisions and specialized areas of activity:

a) hospital mortality, frequency of postoperative complications, initial disability of people of working age and children, frequency of re-hospitalizations, average duration of treatment, cost of medical services and other indicators;

b) the results of internal and departmental quality control of medical care.

34. The planned thematic examination of the quality of medical care is aimed at solving the following tasks:

a) identification, establishment of the nature and causes of typical (repetitive, systematic) errors in the diagnostic and treatment process;

b) comparison of the quality of medical care provided to groups of insured persons divided by age, gender and other characteristics.

35. A planned examination of the quality of medical care is carried out in each medical organization that provides medical care under compulsory health insurance at least once during the calendar year within the time limits determined by the inspection plan (clause 51 of Section VII of this Procedure).

36. An examination of the quality of medical care may be carried out during the period of provision of medical care to the insured person (hereinafter referred to as an in-person examination of the quality of medical care), including at the request of the insured person or his representative. The main goal of an in-person examination of the quality of medical care is to prevent and/or minimize the negative impact of defects in medical care on the patient’s health.

An expert in the quality of medical care, with notification to the administration of a medical organization, can conduct a tour of the divisions of a medical organization in order to monitor the conditions for the provision of medical care, prepare materials for an expert opinion, and also advise the insured person.

During the consultation, the insured person who applies is informed about his state of health, the degree of compliance of the medical care provided with the procedures for the provision of medical care and standards of medical care, the contract for the provision and payment of medical care under compulsory health insurance with an explanation of his rights in accordance with the legislation of the Russian Federation.

37. The expert in the quality of medical care who carried out the examination of the quality of medical care draws up an expert report containing a description of the conduct and results of the examination of the quality of medical care, on the basis of which an act of examination of the quality of medical care is drawn up.

In accordance with parts 9 and 10 of Article 40 of the Federal Law, the results of the examination of the quality of medical care, drawn up by the relevant act in the form established by the Federal Compulsory Health Insurance Fund (Appendices 5, 6 to this Procedure), are the basis for applying to a medical organization the measures provided for in the article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care under compulsory health insurance and a list of grounds for refusing to pay for medical care (reducing payment for medical care) (Appendix 8 to this Procedure).

Based on certificates of examination of the quality of medical care, authorized bodies take measures to improve the quality of medical care.

VI. The procedure for implementation by the territorial fund

compulsory health insurance activity control

medical insurance organizations

38. The Territorial Compulsory Medical Insurance Fund, on the basis of Part 11 of Article 40 of the Federal Law, exercises control over the activities of medical insurance organizations by organizing control over the volumes, timing, quality and conditions of medical care, conducts medical and economic control, medical and economic examination, examination of the quality of medical care. help, including again.

39. Repeated medical-economic examination or examination of the quality of medical care (hereinafter referred to as re-examination) - a medical-economic examination carried out by another specialist expert or another expert on the quality of medical care, an examination of the quality of medical care in order to verify the validity and reliability of conclusions on previously accepted conclusions made a specialist expert or an expert on the quality of medical care who initially conducted a medical and economic examination or examination of the quality of medical care.

A repeated examination of the quality of medical care can be carried out in parallel or sequentially with the first using the same method, but by a different expert on the quality of medical care.

40. The objectives of re-examination are:

a) checking the validity and reliability of the conclusion of a specialist expert or expert on the quality of medical care who initially conducted the medical and economic examination or examination of the quality of medical care;

b) monitoring the activities of individual expert specialists / experts on the quality of medical care.

41. Re-examination is carried out in the following cases:

a) the territorial compulsory medical insurance fund conducts a documentary inspection of the organization of compulsory medical insurance by a medical insurance organization;

b) identifying violations in the organization of control on the part of the medical insurance organization;

c) the unfoundedness and/or unreliability of the conclusion of the expert on the quality of medical care who conducted the examination of the quality of medical care;

d) receipt of a claim from a medical organization that has not been settled with the medical insurance organization (clause 73 of section XI of this Procedure).

42. The Territorial Compulsory Medical Insurance Fund notifies the medical insurance organization and the medical organization about the re-examination no later than 5 working days before the start of work.

To conduct a re-examination to the territorial compulsory health insurance fund, within 5 working days after receiving the relevant request, the medical insurance organization and the medical organization are required to provide:

medical insurance organization - copies of medical and economic control, medical and economic examination and examination of the quality of medical care necessary for re-examination;

medical organization - medical, accounting and reporting and other documentation, if necessary, the results of internal and departmental quality control of medical care, including those carried out by the health care management body.

43. The number of cases subjected to re-examination is at least 20% of the number of all examinations for the corresponding period of time.

44. The territorial compulsory health insurance fund sends the results of the re-examination, drawn up in an act (Appendix 7 to this Procedure), to the medical insurance organization and medical organization no later than 20 working days after the end of the inspection. The medical insurance organization and the medical organization are obliged to review the specified acts within 20 working days from the date of their receipt.

45. The medical insurance organization and the medical organization, in the event of no agreement with the results of the re-examination, send a signed act with a protocol of disagreements to the territorial compulsory health insurance fund no later than 10 working days from the date of receipt of the act.

The Territorial Compulsory Health Insurance Fund, within 30 working days from the date of receipt, reviews the act with a protocol of disagreements with the involvement of interested parties.

46. ​​In accordance with Part 14 of Article 38 of the Federal Law, the territorial compulsory medical insurance fund, in the event of detection of violations of contractual obligations on the part of an insurance medical organization when reimbursing it for the costs of paying for medical care, reduces payments by the amount of identified violations or unfulfilled contractual obligations.

The list of sanctions for violations of contractual obligations is established by the agreement on financial support for compulsory health insurance, concluded between the territorial compulsory health insurance fund and the medical insurance organization.

In accordance with this agreement, if violations are detected in the activities of a medical insurance organization, the territorial compulsory medical insurance fund uses measures applied to the medical insurance organization in accordance with Part 13 of Article 38 of the Federal Law and the agreement on financial support of compulsory medical insurance or recognizes those applied by the medical insurance organization measures taken against a medical organization are unfounded.

47. The territorial compulsory medical insurance fund, when identifying violations in the organization and conduct of medical and economic examination and / or examination of the quality of medical care, sends a claim to the medical insurance organization, which contains information about the monitoring carried out over the activities of the medical insurance organization:

a) the name of the commission of the territorial compulsory health insurance fund;

b) date (period) of inspection of the medical insurance organization;

c) the composition of the commission of the territorial compulsory health insurance fund;

d) regulatory legal acts that are the basis for monitoring the activities of an insurance medical organization in organizing and conducting control and the reasons for conducting control;

e) facts of improper fulfillment by the medical insurance organization of contractual obligations to organize and conduct control, indicating re-examination reports;

f) the extent of responsibility of the medical insurance organization for identified violations;

g) attachments (copies of re-examination reports, etc.).

The claim is signed by the director of the territorial compulsory health insurance fund.

Fulfillment of the claim is carried out within 30 working days from the date of its receipt by the medical insurance organization, about which the territorial compulsory health insurance fund is informed.

48. If the territorial compulsory medical insurance fund identifies, during a re-examination, violations missed by the medical insurance organization during a medical-economic examination or examination of the quality of medical care, the medical insurance organization loses the right to use measures applied to the medical organization for a medical defect not detected in a timely manner. assistance and/or disruption in the provision of medical care.

49. The medical organization returns funds in the amount determined by the re-examination act to the budget of the territorial compulsory health insurance fund.

50. The Territorial Compulsory Health Insurance Fund analyzes requests from insured persons, their representatives and other subjects of compulsory health insurance based on the results of control carried out by the medical insurance organization.

VII. Interaction of subjects of control

51. The Territorial Compulsory Medical Insurance Fund coordinates the interaction of subjects of control on the territory of a constituent entity of the Russian Federation, carries out organizational and methodological work to ensure the functioning of control and protection of the rights of insured persons, coordinates the activity plans of medical insurance organizations in terms of organizing and conducting control, including plans inspections by medical insurance organizations of medical organizations providing medical care under contracts for the provision and payment of medical care under compulsory medical insurance.

52. When conducting a medical-economic examination and examination of the quality of medical care, the medical organization provides expert specialists and experts on the quality of medical care within 5 working days after receiving the relevant request with medical, accounting, reporting and other documentation, and, if necessary, the results of internal and departmental quality control medical care.

53. In accordance with Part 8 of Article 40 of the Federal Law, a medical organization does not have the right to interfere with the access of expert specialists and experts in the quality of medical care to the materials necessary for conducting a medical and economic examination, examination of the quality of medical care and is obliged to provide the requested information.

54. Employees involved in control are responsible for the disclosure of confidential information of limited access in accordance with the legislation of the Russian Federation.

55. Based on Article 42 of the Federal Law, the resolution of controversial and conflict issues arising during the control between a medical organization and a medical insurance organization is carried out by the territorial compulsory health insurance fund.

The commission informs interested parties and the executive authority of the constituent entity of the Russian Federation in the field of healthcare about the results of resolving controversial and conflict issues, about violations in the organization and conduct of control, in the provision of medical care in a medical organization.

VIII. Accounting and use

control results

56. Reports on the results of the control carried out are provided by medical insurance organizations to the territorial compulsory health insurance fund.

The medical insurance organization and the territorial compulsory medical insurance fund keep records of control acts.

Registration documents may be registers of acts of medical and economic control (Appendix 2 to this Procedure), medical and economic examination and examination of the quality of medical care.

The results of control in the form of reports are transferred to the medical organization within 5 working days.

It is possible to conduct electronic document flow between subjects of control using an electronic digital signature.

57. In the event that the act is delivered to the medical organization personally by a representative of the medical insurance organization / territorial compulsory health insurance fund, all copies of the act are marked with receipt indicating the date and signature of the recipient. When sending the act by mail, the specified document is sent by registered mail (with the preparation of an inventory) with notification.

The act can be sent to a medical organization in electronic form if there are guarantees of its reliability (authenticity), protection from unauthorized access and distortion.

58. The head of a medical organization or a person replacing him reviews the report within 15 working days from the date of its receipt.

If the medical organization agrees with the act and measures applied to the medical organization, all copies of the acts are signed by the head of the medical organization, certified with a seal, and one copy is sent to the medical insurance organization / territorial compulsory health insurance fund.

If the medical organization disagrees with the act, the signed act is returned to the medical insurance organization with a protocol of disagreements.

59. The territorial compulsory health insurance fund, based on an analysis of the activities of the subjects of control, develops proposals that help improve the quality of medical care and the efficiency of using compulsory health insurance resources and informs the executive body of the constituent entity of the Russian Federation in the field of healthcare and the territorial body of the Federal Service for Surveillance in Healthcare social development.

60. In accordance with Article 31 of the Federal Law, filing a claim or lawsuit against a person who caused harm to the health of the insured person in order to reimburse the costs of paying for medical care provided by an insurance medical organization is carried out on the basis of the results of an examination of the quality of medical care, documented in the relevant act.

IX. The procedure for informing insured persons about identified violations in the provision of medical care

under the territorial compulsory health insurance program

61. In order to ensure the rights to receive affordable and high-quality medical care, insured persons are informed by medical organizations, medical insurance organizations, territorial compulsory health insurance funds about identified violations in the provision of medical care under the territorial compulsory health insurance program, including the results of control.

62. Work with citizens’ appeals in the Federal Compulsory Medical Insurance Fund, territorial compulsory medical insurance funds and medical insurance organizations is carried out in accordance with the Federal Law of May 2, 2006 N 59-FZ “On the procedure for considering appeals from citizens of the Russian Federation” and other regulatory legal acts acts regulating work with citizens' appeals.

63. When a medical insurance organization or territorial compulsory medical insurance fund receives a complaint from the insured person or his representative regarding the provision of medical care of inadequate quality, the results of consideration of the complaint based on the results of the examination of the quality of medical care are sent to his address.

64. In medical insurance organizations that organize the service of representatives of medical insurance organizations to carry out work in medical organizations participating in the implementation of compulsory health insurance programs to protect the rights and legitimate interests of insured persons, representatives of medical insurance organizations take part in the preparation and placement of information materials on protection of the rights of insured persons and the results of control, and also provide insured persons receiving medical care in medical organizations with information and explanatory materials on their rights.

X. Procedure for applying sanctions

to a medical organization for violations identified during control

65. Based on Part 1 of Article 41 of the Federal Law, the amount not payable based on the results of medical and economic control, medical and economic examination, examination of the quality of medical care is withheld from the amount of funds provided for payment for medical care provided by medical organizations or is subject to return to a medical insurance organization in accordance with the contract for the provision and payment of medical care under compulsory health insurance, a list of grounds for refusal to pay for medical care or a reduction in payment for medical care in accordance with this Procedure.

66. The result of control in accordance with the contract for the provision and payment of medical care under compulsory health insurance and the list of grounds for refusal to pay for medical care (reduction in payment for medical care) are:

a) non-payment or reduction of payment for medical care in the form of:

exclusion of an item from the register of invoices subject to payment for volumes of medical care;

reducing the amounts presented for payment as a percentage of the cost of medical care provided for an insured event;

return of amounts not subject to payment to the medical insurance organization;

b) payment of fines by a medical organization for failure to provide, untimely provision or provision of medical care of inadequate quality (in the event of an insured event in which defects in medical care and / or violations in the provision of medical care were identified).

67. Non-payment or reduction of payment for medical care and payment of fines by a medical organization in accordance with subparagraph b) of paragraph 66 of this section, depending on the type of identified defects in medical care and / or violations in the provision of medical care, can be applied separately or simultaneously.

68. If violations of contractual obligations are identified in relation to the volume, timing, quality and conditions of providing medical care, the insurance medical organization does not partially or fully reimburse the costs of the medical organization for providing medical care, reducing subsequent payments on the medical organization’s bills by the amount of identified defects in medical care and / or violations in the provision of medical care or requires the return of amounts to the medical insurance organization.

The amount not subject to payment based on the results of control is withheld from the amount of funds provided for payment for medical care provided by a medical organization, or is subject to return to the medical insurance organization in accordance with the agreement for the provision and payment of medical care under compulsory medical insurance.

69. For failure to provide, untimely provision, or provision of medical care of inadequate quality under an agreement for the provision and payment of medical care under compulsory health insurance, the medical organization shall pay the medical insurance organization a fine in the amount established under the specified agreement and in accordance with the list of grounds for refusal (reduction ) payment for medical care (Appendix 8 to this Procedure).

70. If in one and the same case of medical care there are two or more grounds for refusal to pay for medical care or a reduction in payment for medical care, one more significant ground is applied to the medical organization, entailing a larger amount of non-payment or refusal to pay. The amount of incomplete payment for medical services for one insured event is not summed up.

71. Non-payment or incomplete payment for medical care, as well as payment by a medical organization of fines for failure to provide, untimely provision or provision of medical care of inadequate quality does not exempt the medical organization from compensating the insured person for harm caused through the fault of the medical organization, in the manner established by the legislation of the Russian Federation.

72. Funds received as a result of the application of sanctions to a medical organization for violations identified during control are spent in accordance with Federal Law.

XI. Appeal

medical organization, conclusion of an insurance medical organization

based on control results

73. In accordance with Article 42 of the Federal Law, a medical organization has the right to appeal the conclusion of a medical insurance organization based on the results of control within 15 working days from the date of receipt of the certificates of the medical insurance organization by sending a claim to the territorial compulsory health insurance fund according to the recommended sample (Appendix 9 to this in order).

The claim is made in writing and sent along with the necessary materials to the territorial compulsory health insurance fund. A medical organization is obliged to provide to the territorial compulsory health insurance fund:

a) justification for the claim;

b) a list of questions for each disputed case;

c) materials of internal and departmental quality control of medical care in a medical organization.

74. The Territorial Compulsory Medical Insurance Fund, within 30 working days from the date of receipt of the claim, reviews the documents received from the medical organization and organizes repeated medical and economic control, medical and economic examination and examination of the quality of medical care, which, in accordance with Part 4 of Article 42 of the Federal laws are formalized by a decision of the territorial fund.

75. The decision of the territorial compulsory medical insurance fund, recognizing the correctness of the medical organization, is the basis for canceling (changing) the decision on non-payment, incomplete payment of medical care and / or payment by the medical organization of a fine for failure to provide, untimely provision or provision of medical care of inadequate quality based on the results primary medical and economic examination and/or examination of the quality of medical care.

Changes in funding based on the results of consideration of controversial cases are carried out by the medical insurance organization no later than 30 working days (during the period of final settlement with the medical organization for the reporting period).

76. If a medical organization disagrees with the decision of the territorial fund, it has the right to appeal this decision in court.

XII. Organization of control by the territorial compulsory health insurance fund during settlements

for medical care provided to insured persons outside the constituent entity of the Russian Federation,

in the territory of which the compulsory health insurance policy was issued

77. The organization by the territorial compulsory medical insurance fund of control when making payments for medical care provided to insured persons outside the constituent entity of the Russian Federation on the territory of which the compulsory medical insurance policy was issued is carried out in accordance with sections III-V of this Procedure.

XIII. Workers,

carrying out medical and economic examination and examination of the quality of medical care

78. In accordance with Part 5 of Article 40 of the Federal Law, a medical and economic examination is carried out by a specialist expert who is a doctor who has worked in a medical specialty for at least five years and has undergone appropriate training in expert activities in the field of compulsory health insurance.

79. The main tasks of the specialist expert are:

a) monitoring the compliance of the medical care provided with the terms of the contract for the provision and payment of medical care under compulsory health insurance by establishing the compliance of the actual terms of medical care, the volumes of medical services provided for payment with the records in the primary medical and accounting and reporting documentation of the medical organization;

b) participation in organizing and conducting an examination of the quality of medical care and ensuring guarantees of the rights of insured persons to receive medical care of appropriate quality.

80. The main functions of a specialist expert are:

a) selective control of the volume of medical care for insured events by comparing actual data on medical services provided to the insured person with the procedures for providing medical care and standards of medical care;

b) selection of cases for examination of the quality of medical care and justification of the need for its implementation, preparation of documentation necessary for an expert of the quality of medical care to conduct an examination of the quality of medical care;

c) preparation of materials for the methodological framework used for the examination of the quality of medical care (procedures for the provision of medical care and standards of medical care, clinical protocols, methodological recommendations, etc.);

d) generalization, analysis of conclusions prepared by an expert on the quality of medical care, participation in the preparation of an act in the established form or preparation of an act in the established form;

e) preparation of proposals for filing claims or lawsuits against a medical organization for compensation for harm caused to insured persons and sanctions applied to the medical organization;

f) familiarization of the management of the medical organization with the results of medical and economic examination and examination of the quality of medical care;

g) generalization and analysis of control results, preparation of proposals for the implementation of targeted and thematic medical and economic examinations and examinations of the quality of medical care;

h) assessment of the satisfaction of insured persons with the organization, conditions and quality of medical care provided.

81. The examination of the quality of medical care in accordance with Part 7 of Article 40 of the Federal Law is carried out by a quality expert of medical care, who is a medical specialist with a higher professional education, a certificate of specialist accreditation or a specialist certificate, work experience in the relevant medical specialty of at least 10 years and trained in expert activities in the field of compulsory health insurance, included in the territorial register of experts in the quality of medical care (clause 84 of this section).

An expert in the quality of medical care conducts an examination of the quality of medical care in his/her main medical specialty, as determined by a diploma, a certificate of accreditation of a specialist, or a specialist certificate.

When conducting an examination of the quality of medical care, the quality of medical care expert has the right to maintain anonymity/confidentiality.

82. The main task of the quality of medical care expert is to conduct an examination of the quality of medical care in order to identify defects in medical care, including assessing the correctness of the choice of a medical organization, the degree of achievement of the planned result, establishing cause-and-effect relationships of identified defects in medical care, drawing up an expert opinion and recommendations for improvement quality of medical care in compulsory health insurance.

The quality of medical care expert is not involved in the examination of the quality of medical care in a medical organization with which he has an employment or other contractual relationship, and is obliged to refuse to conduct an examination of the quality of medical care in cases where the patient is (was) his relative or patient, in treatment in which a quality of care expert was involved.

83. An expert on the quality of medical care when conducting an examination of the quality of medical care:

a) uses medical documents containing a description of the diagnostic and treatment process, and, if necessary, examines patients;

b) provides information about the regulatory documents used (procedures for the provision of medical care and standards of medical care, clinical protocols, methodological recommendations) at the request of officials of the medical organization in which the examination of the quality of medical care is carried out;

c) complies with the rules of medical ethics and deontology, maintains medical confidentiality and ensures the safety of medical documents received for temporary use and their timely return to the organizer of the examination of the quality of medical care or to a medical organization;

d) discusses with the attending physician and the management of the medical organization the preliminary results of the examination of the quality of medical care.

84. The territorial register of medical care quality experts contains information about medical care quality experts who carry out examination of the quality of medical care as part of control in a constituent entity of the Russian Federation, and is a segment of the unified register of medical care quality experts.

The territorial register of medical care quality experts is maintained by territorial compulsory health insurance funds in accordance with clause 9 of part 7 of article 34 of the Federal Law on the basis of uniform organizational, methodological, software and technical principles.

Responsibility for violations in the maintenance of the territorial register of medical care quality experts lies with the director of the territorial compulsory health insurance fund.

In accordance with clause 11 of part 8 of Article 33 of the Federal Law, the Federal Compulsory Medical Insurance Fund maintains a unified register of medical care quality experts, which is a collection of electronic databases of territorial registers of medical care quality experts.

Russian citizens are guaranteed free medical care by the state. People are given a policy - a document that represents the support of the state healthcare system in the event of illness.

What does it really mean? What types of services are the clinic required to provide without additional payment, and which ones will you have to pay for yourself? Under what circumstances is a free medical examination carried out? Let's look at all the questions in detail.

About free medicine

Article 41 of the Constitution of the Russian Federation lists guarantees to citizens of the country from the state. In particular, it says:

“Everyone has the right to health care and medical care. Medical care in state and municipal health care institutions is provided to citizens free of charge at the expense of the corresponding budget, insurance premiums, and other revenues.”

Thus, the list of free medical services should be determined by the relevant government bodies, that is, the healthcare system. This happens on two levels:

  • federal;
  • regional

Important! The budget fund for the development of medical institutions is formed from several sources. One of them is tax revenues from citizens.

What types of services are guaranteed by the state?


By virtue of current legislation, patients are guaranteed the right to the following types of medical care:

  • emergency (ambulance), including special;
  • outpatient treatment, including examination;
  • hospital services:
    • gynecological, pregnancy and childbirth;
    • with exacerbation of ailments, ordinary and chronic;
    • in cases of acute poisoning, in case of injury, when intensive therapy associated with round-the-clock monitoring is necessary;
  • planned care in inpatient settings:
    • high-tech, including using complex, unique methods;
    • medical care for citizens with incurable illnesses.
Important! If the disease does not fall under one of the options, you will have to pay for medical services.

Medicines are provided at the expense of the budget to people suffering from the following types of diseases:

  • shortening lifespan;
  • rare;
  • leading to disability.
Attention! A complete and detailed list of drugs is approved by government decree.

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New in legislation since 2017

Government Decree No. 1403 dated December 19, 2016 provides a more detailed breakdown of medical services provided free of charge. In particular, primary health care stands for. It is divided into subspecies. Namely the primary one:

  • pre-medical (primary);
  • ambulance;
  • specialized;
  • palliative.
Attention! As part of the program, palliative medical care has been added to the list of services provided free of charge.

In addition, the text of the document contains a list of medical specialists who are subject to the obligation to treat patients without charging money.

These include:

  • paramedics;
  • obstetricians;
  • other health workers with secondary specialized education;
  • general practitioners of all profiles, including doctors of family medicine and pediatricians;
  • medical specialists from medical organizations providing specialized, including high-tech, medical care.
Attention! The document contains a list of diseases that doctors are obliged to treat free of charge.

Medical policy

A document guaranteeing the provision of care to patients is called a compulsory health insurance policy (CHI). This paper confirms that the bearer is insured by the state, that is, all the professionals listed above are obliged to provide services to him.

Important! Not only citizens of the Russian Federation have the right to take out a compulsory medical insurance policy. It is issued (for a small fee) to foreigners permanently residing in the country.

The compulsory medical insurance policy has the following semantic content:

  • the citizen is guaranteed medical support;
  • medical organizations perceive it as a client identifier (for it, funds from the Compulsory Medical Insurance Fund will be transferred to the hospital).
Important! The described document is issued only by licensed insurance companies. They are allowed to be changed, but not more than once a year (before November 1 of the current period).

How to get a compulsory medical insurance policy


The document is issued by the relevant companies operating within the framework of the legislation of the Russian Federation. Their ratings are regularly published on official websites, allowing citizens to make their choice.

To issue a compulsory medical insurance policy, you must provide a minimum number of documents.

Namely:

  • for children under 14 years old:
    • birth certificate;
    • passport of the parent (guardian);
    • SNILS (if any);
  • for citizens over 14 years old:
    • passport;
    • SNILS (if available).

Important! For citizens of the Russian Federation, the policy is valid for an indefinite period. Only foreigners are provided with a temporary document:

  • refugees;
  • temporarily residing in the country.

Rules for replacing a compulsory medical insurance policy


In some situations, the document must be replaced with a new one. These include the following:

  • when moving to a region where the insurer does not operate;
  • in case of filling out paper with errors or inaccuracies;
  • if a document is lost or damaged;
  • when it has become unusable (dilapidated) and it is impossible to make out the text;
  • in case of change of personal data (marriage, for example);
  • in case of planned updating of sample forms.
Attention! A new compulsory medical insurance policy is issued without paying a fee.

What is included in the free service under the compulsory medical insurance policy?


Clause 6 of Article 35 of Federal Law No. 326-FZ provides a complete list of free services under a medical policy provided to document holders. They are provided in:

  • clinic;
  • outpatient clinics;
  • hospital;
  • Ambulance.
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What can owners of a compulsory medical insurance policy expect?


In particular, patients have the right to free medical care and treatment in the following situations:


Dentists, like other professionals, are required to work with patients without pay.

They provide the following types of assistance:

  • treatment of caries, pulpitis and other diseases (enamel, inflammation of the body and roots of the tooth, gums, connective tissues);
  • surgical intervention;
  • jaw dislocations;
  • preventive actions;
  • research and diagnostics.

Important! The following services are provided to children without paying a fee:

  • to correct the bite;
  • strengthening enamel;
  • treatment of other lesions not related to caries.

How to apply the compulsory medical insurance policy


In order to organize treatment for patients, they are assigned to a clinic. The choice of medical institution is at the client's discretion.

It is defined:

  • ease of visiting;
  • location (near the house);
  • other factors.
Important! You are allowed to change medical facilities no more than once a year. The exception is a change of residence.

How to “attach” to the clinic


This can be done with the help of the insurer (select an institution when receiving the policy) or independently.

To be assigned to a clinic, you must go to the institution and write an application there. Copies of the following documents are attached to the paper:

  • ID cards:
    • passports for citizens over 14 years of age;
    • birth certificates of a child under 14 years of age and passports of the legal representative;
  • compulsory medical insurance policy (the original is also required);
  • SNILS.

Important! Citizens registered in another region can be legally denied access to a clinic if the institution is overcrowded (the maximum number of patients has been exceeded).

In case of refusal, it should be requested in writing. You can complain about a medical institution to the Ministry of Health of the Russian Federation or Roszdravnadzor.

Visit to the doctor


In order to get help from a specialist, you need to make an appointment with him through the reception desk. This department issues admission vouchers. The terms and rules for registration and patient services are established at the regional level. They can be found in the same registry.

In addition, the insurer is required to provide this information to clients (you need to call the number indicated on the policy form).

For example, in the capital the following rules apply for providing patients with medical services:

  • referral to an initial appointment with a therapist or pediatrician - on the day of treatment;
  • voucher for medical specialists - up to 7 working days;
  • carrying out laboratory and other types of examinations - also up to 7 days (in some cases up to 20).
Important! If the clinic is unable to meet the patient’s needs, he should be referred to the nearest institution that provides the necessary services under the compulsory medical insurance program.

Ambulance


All people in the country can use emergency medical services (compulsory medical insurance is not required).

There are regulations governing the activities of ambulance teams. They are:

  • The ambulance service responds to emergency calls within 20 minutes when there is a threat to people’s lives:
    • accidents;
    • wounds and injuries;
    • exacerbation of the disease;
    • poisoning, burns and so on.
  • emergency assistance arrives within two hours if there is no threat to life.
Important! The decision about which team will respond to a call is made by the dispatcher, based on the client’s information.

How to call an ambulance


There are several options for seeking emergency medical help. They are:

  1. From a landline phone, dial 03.
  2. By mobile connection:
    • 103;

Important! The last number is universal - 112. This is the coordination center for all emergency services: emergency services, fire, emergency and others. This number works on all devices if there is a network connection:

  • with zero balance;
  • with a missing or blocked SIM card.

Ambulance Response Rules


The service operator determines whether the call is justified. The ambulance will arrive if:

  • the patient has signs of an acute illness (regardless of its location);
  • there was a catastrophe, a mass disaster;
  • information has been received about an accident: injuries, burns, frostbite, and so on;
  • disruption of the functioning of the main body systems, life-threatening;
  • if labor or termination of pregnancy has begun;
  • the neuropsychiatric patient's disorder threatens the lives of other people.
Important! The service goes to children under one year of age for any reason.

Calls caused by the following factors are considered unreasonable:

  • patient's alcoholism;
  • non-critical deterioration in the condition of a clinic patient;
  • dental diseases;
  • carrying out procedures in the order of planned treatment (dressings, injections, etc.);
  • organization of document flow (issuing sick leave, certificates, drawing up a death certificate);
  • the need to transport the patient to another place (clinic, home).
Attention! The ambulance provides only emergency assistance. May transport patient to inpatient facility if necessary.

Where to file complaints against doctors


If conflict situations arise, rude treatment, or insufficient level of services provided, you can complain to the doctor:

  • chief physician (in writing);
  • to the insurance company (by telephone and in writing);
  • to the Ministry of Health (in writing, via the Internet);
  • The prosecutor's office (also).

Attention! The period for consideration of a complaint is 30 working days. Based on the results of the inspection, the patient is required to send a reasoned response in writing.

If necessary, the treating doctor can be changed to another specialist. To do this, you should write an application addressed to the head physician of the hospital. However, it is allowed to change specialists no more than once a year (except in cases of relocation).

Dear readers!

We describe typical ways to resolve legal issues, but each case is unique and requires individual legal assistance.

To quickly resolve your problem, we recommend contacting qualified lawyers of our site.

Last changes

On May 28, 2019, new compulsory medical insurance rules came into force, which provide for the introduction of uniform policies (paper or electronic format) in Russia. In this case, there is no need to replace a previously issued policy. In addition, if it is technically possible to unambiguously identify the insured person in the unified register of insured persons, then instead of a compulsory medical insurance policy, it is allowed to present a passport (Order of the Ministry of Health of Russia dated February 28, 2019 No. 108n “On approval of the Rules of Compulsory Medical Insurance”).

The new Rules provide for stricter control over compliance with the rights of the insured, as well as close electronic interaction between the territorial Compulsory Medical Insurance Fund, insurance organizations and medical organizations:

  • Every year, before January 31, clinics will have to report to the Federal Compulsory Compulsory Medical Insurance Fund (through a single portal) the number of those enrolled, the number of persons under dispensary observation, plans and schedules for medical examinations/dispensary examinations with a quarterly/monthly breakdown by therapeutic areas; work schedules);
  • clinics every weekday before 9 am must report (via the TFOMS portal) on insured persons who have undergone a medical examination, as well as on persons undergoing medical examination;
  • Medical organizations, medical insurance organizations (IMO) and TFOMS will exchange information every day in electronic form on the TFOMS portal: hospitals must update data on the implementation of volumes of medical care, free beds, accepted/rejected patients by 9 am; clinics update information about hospital referrals issued yesterday by 9 a.m.; medical organizations that provide specialized, including high-tech, medical care post information about patients who received a telemedicine consultation, and the CMO is obliged to monitor the implementation of recommendations received from doctors of the National Medical Research Center, and has the right to conduct a face-to-face examination within the next 2 working days ;
  • Regardless of the above-mentioned interaction, the health care provider every day no later than 10 am informs hospitals about patients sent to such hospitals the day before, and also every day no later than 10 am informs medical organizations about the number of free beds in the context of profiles/departments, about patients whose hospitalization did not take place;
  • The CMO, using data from the TFOMS portal, checks during the working day whether patients were correctly referred to specialized medical organizations. If the hospitalization was untimely and not according to the profile, the health care provider must file a complaint with the head physician of the offending medical organization and the regional Ministry of Health, and, if necessary, take action and transfer the patient;
  • insurance representatives of the health insurance company received a wide range of responsibilities - working with citizens’ complaints, organizing examinations of the quality of medical care, informing and accompanying them during the provision of medical care, inviting them to medical examination, monitoring its completion, creating lists of “persons for medical examination” and lists of citizens who fell under medical examination observation;
  • patients will be able to see when and what medical services were provided to them, and at what cost: in their personal account on the government services portal or through the Federal Compulsory Compulsory Compulsory Medical Insurance (TFOMS) - by authorization in the Unified Identification and Logistics Authority;
  • For cancer patients, the health insurance company undertakes to create (on the TFOMS portal) an individual history of insurance claims (based on registers and accounts) throughout all stages of medical care.

The updated Compulsory Medical Insurance Rules directly impose on the CMO the obligation to carry out pre-trial protection of the rights of insured persons. When they file complaints about poor-quality medical care or charging for services under the compulsory medical insurance program, the CMO registers written appeals, conducts a medical and economic examination and an examination of the quality of medical care.

Our experts monitor all changes in legislation to provide you with reliable information.

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The compulsory health insurance program was created to provide free medical care to citizens of the Russian Federation, to protect and prevent their health. Under this program, insured persons are entitled to receive a certain set of medical services. What is a medical service? Who has the right to provide medical services and by what regulatory act is this right regulated? What assistance can be provided under the compulsory medical insurance program? We will answer these questions in this article.

What is a medical service?

According to Article 2 of Federal Law No. 323 of November 21, 2011 “On the Fundamentals of Health Protection in the Russian Federation,” a medical service is a specific medical intervention or a set of such interventions that are aimed at diagnosis and treatment, medical rehabilitation and prevention. According to paragraph 1, article 5 of the same law, activities that are an integral part of medical services must be carried out on the basis of recognition, protection and respect for the rights of citizens, in accordance with regulations of international law and generally accepted principles.

In general, a medical service consists of certain medical actions - medical care. The object of civil rights is a medical service; accordingly, it has a commodity form with a certain value and can be the subject of purchase and sale. A special feature of the medical service is its professional variety, moreover, the performers are subject to high requirements in terms of qualifications, for example, only a certified doctor of the appropriate specialization is allowed to practice medicine.

Who is entitled to provide medical services under the compulsory medical insurance program?

As part of the state guarantee for the provision of free medical care, the Russian Federation has a compulsory medical insurance program, which is regulated by Federal Law No. 326 of November 29. 2011 “About compulsory medical insurance in the Russian Federation.” Within the framework of this law, two programs for the provision of medical services have been developed: basic and territorial. Medical organizations with any form of ownership have the right to participate in the implementation of the basic and territorial compulsory health insurance program, and they must meet certain criteria. Medical organizations that meet the following requirements are entitled to participate in the compulsory health insurance program:

  • Must be accredited and have appropriate documents to provide medical care;
  • Provide appropriate material, technical, personnel and drug resources to provide medical care of adequate quality;
  • Have technical and software tools for maintaining personalized records of medical care provided to the insured, protecting personal data and exchanging information in the information field;
  • Comply with the sanitary-epidemiological and medical-protective regime;
  • Be ready to provide medical assistance in response to emergency situations;
  • Be ready to carry out anti-epidemic measures and submit extraordinary reports in accordance with the regulatory documents of the federal and territorial Department of Health and Rospotrebnadzor;
  • Be prepared to provide emergency medical care;
  • Follow the procedure for hospitalization of planned and emergency patients in accordance with the requirements of the Department of Health;
  • Have information tools (including on the Internet) to inform insured persons about the operating hours of a medical organization, conditions and types of services provided, etc.

Requirements for medical organizations that have the right to provide medical services in the compulsory medical insurance system are regulated by Federal Law No. 323 of November 21, 2011 on health care in the Russian Federation and Federal Law No. 326 of November 29, 2010 on compulsory medical insurance in the Russian Federation. Control over compliance with these requirements by medical organizations, regardless of their form of ownership, is exercised by the territorial Department of Health and the Compulsory Medical Insurance Fund.

Medical services provided under the compulsory medical insurance policy

The implementation of medical care within the framework of compulsory medical insurance is carried out by medical institutions and licensed clinics included in a special register. Private clinics that are not included in a special register cannot provide free services as part of compulsory health insurance. Under compulsory medical insurance, patients can receive medical care within the framework of basic and territorial insurance programs. The list of diseases included in the compulsory medical insurance policy is enshrined in paragraph 6 of Article 35 of the Federal Law on Compulsory Medical Insurance.

The basic program is valid in all regions of the Russian Federation; the patient has the right to free medical care, regardless of the region in which the insured event occurred. As part of the basic compulsory medical insurance program, patients receive:

  • Primary health care;
  • Prevention of severe forms of diseases;
  • Providing health care at home;
  • Ambulance;
  • , including ;

In addition, the basic program implies the possibility of conducting,. However, these services will be provided free of charge only on the recommendation and direction of the attending (or duty) doctor; otherwise, you will have to pay for them according to the price list established by the medical institution. Rating: 2.6/5 (3 votes)

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