Often unforeseen for many people is the need to perform an operation, which can happen to the person himself or his close environment. Insurance makes the situation easier if the necessary intervention involves payment within the framework of its coverage. A free operation under the compulsory medical insurance policy includes payment for the manipulations themselves, examination, medication. Read about these and other important issues below.
The basic assistance program for the compulsory medical insurance policy is part of unified system providing social guarantees to citizens Russian Federation, as well as certain categories of foreigners or stateless persons. In addition to the federal one, the regions offer a territorial one, the volume of which depends on the allocated funds. The list of surgical interventions that can be performed as assistance to citizens within the framework of the mandatory health insurance is open and available for review.
All innovations are timely sent to insurance companies, medical institutions. It is important to keep in mind that not all activities are covered by insurance, different services are also provided depending on the insurance company. To find out which activities will be free, and what you will have to pay for, you can contact your doctor or the insurer with whom you have entered into a contract directly.
What operations can be done
In 2018, the list of free operations is large and is divided depending on the direction:
- Eyes. Treatment is paid for:
- lens cataract
- strabismus in children, including strabismus
- glaucoma
- congenital anomalies
- retinal deformities due to trauma
- Nose. Operations on it relate to the correction of the nasal septum (senoplasty), which caused impaired respiratory function, loss of smell, edema of mucous tissue, susceptibility to respiratory diseases, snoring, dryness in the nose and pain
- Removal of the gallbladder for cholecystitis, cholesterosis, gallstone disease
- Marmara operation for men in case of varicocele at 2, 3 stages, inability to excrete sperm, pain, aesthetics
- Gynecological diseases
- Joint arthroscopy
- Vein surgery
- Chest, including oncological diseases
- Valgus feet
There are many diseases that are treated with surgery. This list is not complete. Based on the situation, you should look for it in the list of those that are treated under the CHI program and are covered by a specific insurance company, since there may be restrictions.
Important! Surgical cosmetology is not a free service.
Who can get free medical services
Medical assistance according to the compulsory medical insurance is provided throughout Russia to citizens who have drawn up an insurance contract. At the same time, assistance is provided without reference to the place of residence, but there may be restrictions, since for residents of their region the list of services is more extended. Also, help is provided to people:
- awarded under licensing, scientific, publishing contracts
- who have drawn up an employment contract with enterprises in terms of production, consumption and distribution of goods
- farmers
- involved in the production of national goods, generic economic activities
- the unemployed, which include children under 18 years of age, guardians of children under 3 years of age, persons caring for disabled persons of group 1 or adults over 80 years of age
- medical workers, specialists of other special organizations, military personnel
- foreigners working officially
- refugees
Important! If there is no information about the insured person in the unified MHIF database, and he cannot confirm this with a policy, they have the right to refuse to provide free assistance.
Where can I get treatment free of charge?
Medical assistance under compulsory medical insurance is provided throughout the country. This applies to the emergency provision of services, with a planned, unscheduled appeal. The main condition is the participation of a medical institution in the MHIF system, assignment to a polyclinic. There can only be a limitation on service, since the volume of activities for those patients who are on a general basis or according to a regional program. In the latter case, more expensive services are paid for, and the list itself is larger.
A medical institution becomes a participant in the program immediately after signing a cooperation agreement on the health insurance program. If he has a quota, then they will not have the right to refuse to provide services. When considering the issue of providing services, you should be aware and remember that a planned operation may require a waiting time in turn. This is due to the limitation of quotas, that is, payment for transactions, since, as a rule, they are expensive, and there may be many who wish. The situation is similar with some types of surveys. For this reason, it is worth contacting a neighboring region or a private clinic.
When choosing a hospital for a planned operation, you should pay attention to the following factors:
- Insurance cover. It may not apply to given view operations (the situation may be different for another insurer, depending on the list of services and coverage).
- Location. Metropolitan clinics may have whiter modern equipment, while local clinics may have more experienced doctors.
- Waiting time in turn. In large cities with a high population density, you can wait for a year. During this time, the health situation may worsen. In other cities, the terms are several times shorter, which will speed up the process aimed at recovery.
- The cost of activities that need to be paid in addition to those procedures that will be covered by the insurance. Also important are items such as travel, accommodation of relatives, since the further the hospital is located, the more significant the costs are.
- Possibility of consulting. For the purpose of quick rehabilitation, recovery after surgery, it is important to be able to observe and learn about the measures that are appropriate for a particular person in his situation.
How to apply for a quota for a free operation - algorithm of actions
To get a quota for a free compulsory medical insurance operation, it is important to follow a certain sequence of actions, which include the following steps:
- Visit the doctor at the polyclinic at the place of attachment for examination, referral for examination, for tests.
- Based on the information received, the general condition of the patient, the doctor will be able to write a referral to the clinic, where the operations of the desired direction are performed. If the patient insists on a specific medical facility, a referral may be issued to it.
- Visit a specialized hospital, register, if required by the conditions of the clinic, make an appointment with a doctor.
- Arriving at the appointed time, take personal documents, confirming the identity, the referral from the doctor and all the information related to their health: the results of examinations, analyzes, insurance. After conducting an examination, having studied the medical documentation, the doctor decides on the need for treatment, the placement of the patient in the hospital. It is also in his competence to inform a person about the list of free, paid services... Additional tests may be prescribed for delivery already at the place of the operation.
- Within 10 days, the person is informed about the date of the operation.
- Hospitalization is carried out at the appointed time.
The number of quotas is determined based on the financial resources of the MHIF, individual regions to compensate for the costs of consumables, medicines, the work of medical personnel, performed surgical intervention. If a medical institution is state-owned, then its activities depend on funding, taking into account which the purchase of everything necessary, including equipment, takes place. For this, it is important to hold competitions to determine the most advantageous offers... For this reason, one should not rely on the use of the latest generation of consumables in order to receive assistance under the CHI, everything is chosen the most optimal, effective for providing assistance and recovery.
Required documents
Documents confirming the feasibility of performing surgical treatment, including for undergoing the compulsory medical insurance program, must directly relate to the patient's personality, medical documents relating to his health. This list includes:
- referral from the attending physician for surgery
- extract from the medical history
- survey results
- analysis data
- passport
- original insurance policy
- SNILS
- checks in case of making any payments (for medicines, examination)
Do I need to pay extra for the provision of services
As already mentioned, surgical procedures are free. In addition to the work itself, the costs of anesthesia are covered, consumables, the use of special equipment. It is illegal to request additional payment. Travel, accommodation, meals outside the hospital are financed independently. Services that are not included in the list provided under compulsory medical insurance are subject to payment:
- performing anonymous diagnostics at will (except for HIV)
- diagnostics, procedures in the field of sexopathologies
- speech therapist for adults
- vaccinations, except for those that relate to those provided under the compulsory medical insurance
- home visits for the purpose of counseling, diagnostics, treatment, except for cases when a person does not have physical ability arrive at the hospital
- postoperative procedures, which also applies to sanatorium treatment, unless it is included in the compulsory medical insurance
- cosmetology
- psychological support
- prosthetics, except for services covered by the compulsory medical insurance
- methodological assistance related to patient care
The duty of medical institutions is to inform patients not only about free services, but also about paid ones. It is useful to use the price lists that are posted on special stands in the reception area. When you are admitted to hospital, you may be advised of options that are available at an additional cost and that may affect your hospital stay. To clarify the claims that are offered, the patient has the right to contact the insurer. This also applies to payment for services, drugs.
In what cases they can refuse and what to do
It is not uncommon for a person to be denied a free operation. Money for services may also be required. In such a situation, people can agree with the statement, but they also have the right to receive a written justification for the refusal and familiarize themselves with the established conditions and procedures. At the same time, the patient protects his personal rights as a citizen who has issued an insurance policy. He can apply:
- to the insurer
- to the head physician
- to the district or city government health care
- territorial, federal administration of compulsory medical insurance
- to court
To get an informed decision on the complaint, you need to write a written statement in which it is important to state the essence of the problem in detail, clearly, in a business style. It also indicates:
- Full name, position of the person to whom the appeal is made
- Name, place of residence of the person whose rights have been violated
- insurance policy data
- data (requisites) of the hospital in which the provision of services was denied and in which there is a violation
- the time during which the treatment was carried out, the person was on treatment
- list of events that led to unreasonable spending personal funds and their cost
When filing complaints, evidence is required to confirm the correctness of the applicant. These include extracts from the medical history, receipts for payment.
Conclusion
The system of assistance to the population has been provided for more than one year, annually improving and providing better quality services, a larger number of quotas. In order to be served free of charge, it is advisable to consult with your doctor, who will tell you the right decision in an individual case. Do not forget about the possibility of carrying out treatment in other regions, as the queue "at home" can lead to complications, and "in the neighborhood" everything will be done faster, making waiting easier and speeding up recovery.
Video: Free prosthetics under the compulsory medical insurance policy
The Constitution of the Russian Federation guarantees all citizens free medical care under the compulsory health insurance policy (MHI). Types of free assistance provided under the compulsory medical insurance policy:
- primary health care(outpatient clinic);
- emergency,
- specialized medical care(with an established diagnosis, a specific disease is treated)
- high-tech medical care(treatment of diseases using high-tech, complex, costly methods of treatment).
The presence of the compulsory medical insurance policy confirms that the patient's treatment in public and some private clinics will be paid for from the compulsory health insurance fund, which is formed at the expense of mandatory contributions citizens.
Briefly about the CHI system
Payment for treatment in the compulsory medical insurance system is carried out according to specially formed tariffs for each disease, but does not depend on the method of treatment of this disease. The tariffs are the same for all medical institutions. The MHI tariff stipulates how many and what procedures, analyzes and studies the clinic can and should perform in the treatment of a certain disease.
The tariffs are the same for all clinics, which means that the patient can choose a more high-tech and well-equipped clinic, regardless of the cost of treatment. Mutual settlements with the clinic will be carried out by the insurance company.
Some expensive procedures within the framework of the CHI system can be performed only with a strict necessity, which the clinic must prove, otherwise they will simply not be paid for by the CHI fund. Therefore, the treatment of patients in the compulsory medical insurance system, unfortunately, has its limitations.
Medical institutions are forced to work according to the rules established by the CHI fund for each disease. It is important to say that providing patients with high-tech medical care(VMP), the so-called “quota” treatment, is also paid from the CHI fund and, accordingly, is carried out according to the algorithms described above.
But the tariffs of the VMP system are higher and are designed specifically for the provision of complex, high-tech treatment, which allows the clinic staff to use all the power of modern methods of treatment, advanced technologies and high-quality consumables.
Not all hospitals in Russia have the right to provide high-tech medical care. Each year, the Ministry of Health of the Russian Federation compiles a list of clinics that can treat patients with the VMP. The selected clinics receive a so-called task from the Ministry of Health, which determines the number of patients that the hospital can treat using the VMP.
V medical centers of federal significance under the compulsory medical insurance policy, only high-tech and specialized medical care is provided. The Clinic for Coloproctology and Minimally Invasive Surgery is part of the first Moscow State Medical University named after M.V. Sechenov, respectively, the same requirements apply to it.
How to get medical assistance under the compulsory medical insurance policy?
Option 1. By referral from the clinic
The compulsory medical insurance policy itself is required. If it is not there, and you are a citizen of the Russian Federation, you need to contact insurance company, which works with the territorial CHI fund, write an application and get a temporary policy immediately, and about a month later, a permanent CHI policy. After receiving the compulsory medical insurance policy, you need to attach to the clinic, which you can choose on your own. After that, you can apply for high-tech medical care under the compulsory medical insurance policy.
Referral from the clinic to which the patient is assigned (at the place of residence or at his choice). Such a referral to a city hospital or a federal center is issued to a patient in the event that the doctors of the polyclinic cannot independently diagnose the patient or conduct treatment. A referral from the clinic allows the federal medical institution, which is the First MGMU im. Sechenov and our Clinic, to provide the patient with primary, specialized and high-tech care.
In the clinic, you can get a referral for free consultation in our Clinic, and referral for free treatment.
Option 2. In the direction of the doctors of our Clinic.
Doctors of the Clinic of Coloproctology and Minimally Invasive Surgery in some cases can also issue referrals for treatment. The number of referrals is limited and covers certain types of diseases or complications.
You can find out about the possibility of free treatment under the compulsory medical insurance policy during an in-person consultation with a doctor. In this case, you will bypass the stage of approval and receipt of a referral in the clinic. Please note that there are a limited number of referrals for treatment under compulsory medical insurance, which are issued directly in our Clinic.
To issue a referral for the compulsory medical insurance policy through a doctor at the KKMH Clinic, you will need:
- compulsory medical insurance policy
- self-referral to the clinic only for treatment (not carrying out a set of diagnostic measures) with an already established diagnosis
