It became known for what kind of medical care under compulsory medical insurance Russians will now have to pay

Recently, the Russian Federation adopted new rules for the provision of paid medical services by medical organizations, which will come into force on September 1, 2023. The authorities explain that the document is intended to more clearly distinguish between the conditions for the provision of paid and free services in order to prevent “substitution of free assistance provided under the state guarantees program.” The rules will be the same for all medical institutions – both public and private, and departmental.

Patients, on the other hand, do not interfere with understanding what is still free for them, and most importantly, how to get this free really free of charge, that is, for free. Experts of the CHI system help with this.

To begin with, for many years the country has been annually adopting the Program of State Guarantees for the Free Provision of Medical Assistance to the Citizens of the Russian Federation. It spells out what treatment of a particular disease the state pays for and under what conditions, and also names all the deadlines for waiting for medical care.

Recall that it is free for those who have a compulsory medical insurance policy: primary health care (aka polyclinic); specialized medical care, including high-tech, which implies hospital treatment; palliative and emergency care.

The new rules indicate when and under what conditions medical institutions will be able to take money for all of the above.

For example, if a patient contacts a medical institution on his own, the medical organization has the right to conclude an agreement with him for the provision of paid medical services. True, there are exceptions provided for by the law, Article 21 of the Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, which fixes the procedure for obtaining free care in polyclinics and hospitals, as well as the patient’s right to choose a medical organization and a doctor.

According to the expert of the insurance medical organization Mikhail Pushkov, the procedure for obtaining medical care is regulated, including medical indications: “For example, a patient can take tests, undergo instrumental, diagnostic examinations, and receive medical assistance from a narrow specialist in a polyclinic, a patient can be referred by a doctor.

But in the absence of a referral, all diagnostic and therapeutic procedures that the patient simply wants to carry out for himself in the absence of medical indications, he must pay for himself.

For example, to receive routine medical care in a hospital, you need a doctor’s referral that determines the need for such hospitalization. And the choice of a medical organization for treatment is also determined by the direction.

At the same time, it is the responsibility of the attending physician to tell the patient about all the medical organizations that work on compulsory medical insurance and provide the assistance he needs. It is important that, according to the law, the doctor does not have the right to refuse to refer to the medical organization chosen by the patient, subject to the specified conditions. If in the region no one provides the necessary type of assistance under compulsory medical insurance, there are no specialists or equipment, the doctor is obliged to issue a referral to a medical organization in another region.

Summing up what has been said, Pushkov summarizes: if there are indications for hospitalization, the patient cannot be denied free treatment and offered to conclude a contract for paid medical care. If there are no indications, but the patient wants to be examined, they have the right to offer to pay for it.

Be that as it may, all emergency assistance is free. It is provided for any shock, coma, respiratory, cardiovascular, renal, hepatic insufficiency and other life-threatening conditions.

Another situation in which a patient may be offered to be treated for a fee in an institution operating under compulsory medical insurance: he wants to be treated anonymously. In addition, if the patient wishes an individual medical observation post (without indications for that), money will also have to be paid for this. As the co-chairman of the All-Russian Union of Patients Yuri Zhulev notes, paid medicine works in cases where the patient wants more comfort, but, for example, if a person has medical indications, an individual medical observation post is provided free of charge.

The possibilities of paid medicine will also extend to drug provision: if, for example, patients want to be treated with drugs that are not included in the list of vital and essential drugs, even if they are indicated to them, but are not due to vital indications or replacement due to individual intolerance to drugs. “All medicines prescribed by the attending physician during the period of hospitalization are free for the patient. In the clinical guidelines there is a recommended list of them in the treatment of a particular disease. But often patients find information in other sources about more effective ones, for example, medicines that are not included in the Vital and Essential Drugs list. Then the medical organization can offer him to buy them on his own,” says Pushkov.

In addition, the patient may be offered medical nutrition and medical devices for a fee, which are not purchased at the expense of the budget and are not subject to payment under the CHI. But they cannot offer the patient to pay for drugs or a medical device that should be provided free of charge in a hospital. Patients will have to go through the programs of state guarantees, compulsory medical insurance programs and lists of vital and essential drugs or call for advice at their medical insurance organization (CMO, its name is on the compulsory medical insurance policy).

In order not to become a hostage of such a situation and not to pay for what is supposed to be free, OMS experts recommend clarifying the details. “If you are offered to pay for a particular drug, you should definitely find out about the reasons for prescribing it, ask questions about the indications for the use of drugs offered for a fee, check the indications in the instructions for use, and clarify why the drug is not included in free medical care.

The same rule applies in the case of an offer to pay for a particular medical product. This will help avoid the imposition of paid services,” advises Alexey Starchenko, a member of the Public Council for the Protection of Patients’ Rights under Roszdravnadzor.

The new resolution, experts say, contains a very important clause that the medical organization is obliged to inform the patient, when concluding a contract for paid medical care, about the possibility of obtaining the appropriate types and volumes of medical care without charging a fee within the framework of the basic and territorial programs of state guarantees of free provision of medical care to citizens. assistance, as well as the waiting time for the provision of free medical care. “So if you are offered to conclude an agreement on paid services, you need to clarify where and when you can get such help for free,” recommends Starchenko.

If the patient is satisfied with the terms and conditions of treatment under the program of state guarantees, the clinic is obliged to provide assistance free of charge and cannot impose it on a paid basis.

But, alas, situations are not uncommon when the waiting periods are long, and the clinic offers to “speed up the process” for money. Human rights activists say that in this situation, your rights are violated. The patient’s refusal to conclude an agreement cannot be the reason for reducing the types and volumes of medical care provided to him without charging a fee within the framework of the program and the territorial program, the Resolution says.

If, nevertheless, you suspect that something is unclean and they are trying to spin you for money, contact your insurance representatives – CMO employees who should solve the problems of patients. In which case, that is, if the irreparable happened and you paid for a free one, the CMO should help you return the money. In this case, it is important to keep all checks and contracts for the provision of paid medical services. This is a working problem solving algorithm adopted in many countries.