Правила ОМС: федеральный закон №326 и приказ Минздрава №158 — последние редакции документов

OMC


Российская система страхования является формой социальной защиты населения, созданной для обеспечения поддержки здоровья и лечения граждан.

Функционирование системы ОМС обеспечивается обширной законодательной базой, основу которых составляют статья 41 Конституции РФ и ФЗ №326.

Основная часть правил собрана также в Приказе Министерства здравоохранения России №158н от 28.02.2011 (последняя редакция от 11.01.2017) «Об утверждении Правил обязательного медицинского страхования».

Что такое ОМС?

ОМС — обязательное медицинское страхование, которое обеспечивает всем гражданам Российской Федерации равные возможности и условия при получении бесплатной медицинской помощи.

Основанием для предоставления услуги по системе ОМС является полис, который выдает страховая организация.

На получение полиса имеют право следующие категории граждан:

  • все работающие граждане РФ;
  • неработающие граждане (дети, студенты, пенсионеры, безработные состоящие на учете в центре занятости);
  • иностранные граждане, проживающие на территории РФ на постоянной или временной основе;
  • иностранцы – работники органов ЕАЭС и граждане Евразийского экономического союза;
  • беженцы (согласно Федерального закона от 19.02.1993г. № 4528-I «О Беженцах»).

Базовая — стандартная программа ОМС определяет виды медпомощи, перечень страховых случаев.

В рамках стандартной программы оказывается:

  • профилактическая медицинская помощь;
  • первичная медицинская помощь;
  • скорая помощь (за исключением эвакуации воздушным транспортом – самолетами, вертолетами);
  • диагностика заболеваний;
  • стационарное и амбулаторное лечение;
  • вакцинация;
  • покупка лекарств по льготным ценам;
  • диспансеризация детей;
  • ведение беременности, роды и послеродовых период.

В некоторых случаях по полису можно проходить лечение в частных клиниках, получать лекарственным препараты бесплатно или со скидкой 50%.

Общие положения

Федеральное законодательство, регламентирующее систему медицинского страхования, достаточно обширно.

Статьей 41 Конституции РФ гарантируется право каждого гражданина Российской Федерации на бесплатную медпомощь.

Основным нормативно-правовым документом, определяющим правила функционирования системы медицинского страхования, является Федеральный Закон №326 «Об обязательном медицинском страховании» от 29.11.2010 года.

Актуальная версия правил обязательного медицинского страхования собрана в последней редакции Приказа Министерства здравоохранения России N 158н от 28.02.2011 «Об утверждении Правил обязательного медицинского страхования».

Необходимо выделить несколько основных положений:

  1. Система обязательного страхования направлена на обеспечение бесплатной медицинской помощи за счет средств фондов.
    Простым языком это означает, что все граждане РФ обеспечены равными условиями предоставления медпомощи за счет государственного бюджета и средств ОМС.
  2. Финансирование системы ОМС осуществляется из территориальных и федерального фондов ОМС.
    Устойчивость системы обеспечивается обязанностью уплаты страховых взносов, размер которых регламентируется законодательством. Уплату взносов обязаны производить работодатели, в число которых входят и индивидуальные предприниматели, адвокаты и нотариусы, занимающие частной практикой.
  3. За неработающих граждан взносы осуществляются из бюджета субъектов РФ.

Правила оформления полиса

Полис ОМС выдает только страховые компании. Единый реестр страховых компаний размещен на сайте ФФОМС.

Чтобы получить полис необходимо подать заявление в пункте выдачи полисов.

Подать заявление можно лично либо через представителя. К заявлению необходимо предоставить обязательный пакет документов, который зависит от категории граждан:

Дети до 14 лет:

  • свидетельство о рождении;
  • СНИЛС (при наличии);
  • паспорт законного представителя (родителей).

Дети и взрослые от 14 лет:

  • паспорт;
  • СНИЛС.

Иностранцам, временно проживающим в России:

  • паспорт иностранного гражданина с отметкой о разрешении на временное проживание в России;
  • СНИЛС (если есть).

Иностранцам, постоянно проживающим в России:

  • паспорт;
  • вид на жительство;
  • СНИЛС (при наличии).

Беженцам необходимо предоставить удостоверение беженца либо другой документ, который подтверждает статус беженца.

Лицам, не имеющим гражданства РФ, для оформления страховки потребуется паспорт иностранного гражданина, вид на жительство и СНИЛС.

Если нет возможности предъявить оригинал паспорта или СНИЛС, то можно предоставить копии документов, предварительно заверив их у нотариуса.

В день обращения будет выдан временный полис, заверенный подписью и печатью, срок действия полиса – 30 дней.

Временный полис полностью заменяет обычный полис ОМС до момента его получения, со всеми вытекающими правами и обязанностями. По временному полису можно осуществить любое лечение в рамках стандартной программы ОМС.

Также граждане РФ могут получить электронный полис в виде пластиковой карточки, что необходимо указать заранее в заявлении.
Если в заявлении не будет отображено ваше желание получить электронный полис, то будет выдан полис бумажного образца.

На пластиковом полисе установлен электронный чип, в котором будет сохранена вся, необходимая для медицинской помощи, информация о владельце.

На самом полисе содержится основанная информация о застрахованном:

  • номер полиса;
  • ФИО;
  • дата рождения;
  • подпись.

Это необходимо на случай отсутствия в поликлиниках и стационарах электронного считывающего устройства.

Получение полиса

По факту изготовления полиса будет сообщено по номеру телефона либо по адресу электронной почты, указанному в заявлении.

Забрать готовый документ можно в месте подачи заявления.

Некоторые страховые компании предоставляют возможность выбрать способ выдачи документов:

  • выдача на месте работы;
  • доставка полиса на дом (для некоторых категорий граждан).

В случае чрезвычайных ситуаций страховая должна организовать мобильные пункты выдачи полисов.


Для обслуживания инвалидов, помещение, в котором выдаются полисы, должно быть оборудовано пандусами, перилами, обеспечивающими беспрепятственное передвижение инвалидных колясок.

Глухонемым, инвалидам по зрению и другим гражданам с ограниченными возможностями при необходимости должна быть оказана соответствующая помощь.

Существует возможность получения полисов через МФЦ.

Чем отличаются друг от друга, страховые компании, работающие по системе ОМС — https://strahovanie365.ru/medical/oms/strakhovye-kompanii/.

Замена полиса

Существует ряд случаев, в которых обязательно необходимо заменить полис ОМС.

Замена полиса должна производиться в следующих случаях:

  • смена одной страховой на другую (допустимо 1 раз в год, заявление необходимо подать не позднее 1 ноября);
  • изменение страховой компании при смене места жительства, если страховая там не представлена;
  • потеря либо повреждение полиса;
  • прекращения работы страховой в регионе проживания;
  • изменении личных данных (ФИО, пол, паспорт);
  • выявлении ошибок в выданном полисе.

Для замены необходимо обратиться в СК для заполнения заявления по установленной форме и предоставить специалистам следующие документы:

Необходимые документы:

  • паспорт/временное удостоверение личности либо свидетельство о рождении (для детей до 14 лет);
  • СНИЛС.

После подачи заявления на замену будет выдан временный документ — полис, который действителен в течение одного месяца до изготовления основного.

При переезде в другой регион — проверьте работает ли в нем ваша страховая компания.

Если полис получен в небольшой региональной страховой компании, при переезде в другой регион, где отсутствует представительство этой страховой, необходимо заменить медицинский полис.

В плановой медпомощи с этим страховым полисом будет отказано, так как медицинская организация не получит денежные средства за ваше обслуживание.

Чтобы избежать такой ситуации необходимо своевременно заменить полис ОМС.

Бумажный полис нового образца при смене страховой компании не меняют: на обратной стороне бумажного полиса делают отметку, а сам документ остается прежним.

Права и обязанности застрахованных

Застрахованные лица, согласно ФЗ №326, имеют право на:

  • медицинскую помощь, оказываемую бесплатно, при наступлении страхового случая, все страховые случаи перечислены в памятках страховых компаний;
  • выбор и замену страховой компании по собственному желанию;
  • осуществление выбора поликлиники, стационара, врача;
  • возмещение ущерба, в случае причинения вреда здоровью при ненадлежащем лечении;
  • получение информации о видах, условиях и качестве медицинской помощи;
  • защиту персональных данных;
  • получение питания при нахождении в стационаре;
  • отказ от лечения;
  • соблюдение врачебной тайны;
  • допуск адвоката и священнослужителя во время нахождения на стационарном лечении.

Также кроме прав, существуют обязанности:

  • получить полис ОМС, подав заявление в страховую компанию;
  • предъявлять полис при каждом обращении в медицинскую организацию за медпомощью;
  • менять полис при изменении ФИО, паспортных данных, места жительства (в ред. Федерального закона от 01.12.2012 № 213 ФЗ);
  • не нарушать режим лечения, в том числе находясь на больничном, и соблюдать правила поведения в медицинских организациях;
  • при смене места жительства и отсутствия в этом регионе представительства страховой копании, в которой был получен полис ОМС, сменить полис в течение одного месяца.

Как сделать ЭКО бесплатно — https://strahovanie365.ru/medical/oms/eko/.

Когда обращаться за помощью в страховую

Любой гражданин имеет право обратиться в филиал страховой компании, в которой был получен полис за консультацией либо с жалобой по причине:

Когда должна помочь страховая компания:

  • ненадлежащего качества лечения;
  • отказа в предоставлении медицинской помощи (отказ в плановой госпитализации по направлению врача, непредоставление диагностической помощи по направлению лечащего врача);
  • взимания денежных средств за медицинскую помощь (кроме помощи, не включенной в полис ОМС);
  • вынуждения приобретения средствами пациента лекарств при стационарном лечении.

Обратиться для получения ответа на вопросы или консультации в страховую компанию можно устно, письменно, через сайты страховой, по телефонам горячей линии.

Жалобы и претензии необходимо отправлять в письменном виде. Срок рассмотрения любого обращения граждан может составлять до 60 дней.

Работа с претензиями и жалобами проводится строго в соответствии с ФЗ №59 «О порядке рассмотрения обращений граждан РФ».

Порядок оказания медицинской помощи

Вся работа больниц, поликлиник, стационаров организуется и регулируется строго по ФЗ № 323 (статья 37).

Закон обязателен для исполнения всеми медицинскими организациями.

В законе освещены вопросы оказания медпомощи, установлены стандарты оказания медицинской помощи при возникновении всех видов заболеваний.

В законе содержатся:

  • этапы оказания медицинской помощи;
  • правила работы медицинской организации;
  • стандарты оснащения медикаментами, медицинским оборудованием.

Медицинская помощь в рамках ОМС предусматривает многообразие разных профилей заболеваний, в том числе:

  • травматологические;
  • ортопедические;
  • онкологические;
  • гинекологические;
  • заболевания органов брюшной полости;
  • челюстно-лицевая, сердечно — сосудистая хирургия;
  • трансплантация внутренних органов;
  • лечение тяжелых ожоговых травм;
  • педиатрия.

В случае отсутствия полиса ОМС бесплатно может быть оказана только скорая помощь.
Она может быть неотложной или экстренной, и это касается только заболеваний, которые представляют угрозу жизни.

Помощь будет оказана за счет бюджетных средств.

Система обязательного медицинского страхования обеспечивает согласованность работы медицинских и страховых организаций. Именно сложность этой системы привела к большому количеству законов, устанавливающих принципы и стандарты ее работы.

Большая часть законодательных документов, устанавливающих правила ОМС, со ссылками на сами документы, приведена в статье.


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