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How does the quality assurance work under the Voluntary Health Insurance contract?
The insurance company controls the relevance of
prescriptions and proper quality of the rendered medical
services. Any complaints for a particular service or a
medical part of the services are closely examined by QA
experts. The results of the analysis trigger decisions to
increase the service quality. The insurance company pays
for the services, rendered by medical institutions and
other providers; hence it is highly interested in
constructive cooperation with all service process
participants.
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Do medical institutions hand over documents to the insured persons?
Issuance of sick leaves is a part of the standard medical
assistance procedure. Children are provided with papers
for educational institutions. It is also possible to receive an
abstract from medical record for submittal to another
medical institution. In many cases, letters of information
for a driver’s committee or a swimming pool are not
included into the insurance program and are to be paid
additionally.
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Is it possible to receive services in various treatment facilities under one Voluntary Health Insurance policy?
If the insurance program envisages the receipt of services
at several treatment facilities, then one may appeal to any
of the chosen or recommended treatment facilities. It is
also possible to receive a “second opinion” under the
insurance program regarding a diagnosis or treatment
methods.
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Is there any difference between Voluntary Health Insurance programs for children and adults?
A vital difference of the Voluntary Health Insurance
program for children is the inclusion of scheduled
(preventive) examination and vaccination, stipulated by
the regulatory documents of the Ministry of Public Health
and Social Development of the Russian Federation. The
children insurance program includes specialized children
treatment facilities or family-type clinics with a
corresponding license. A peculiarity of children treatment
might be also orientation towards home treatment.
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Does the policy cover the cost pharmaceuticals?
Full cost of pharmaceuticals is usually covered only during
the hospitalization. In case of outpatient care – this is an
additional option called “payment of prescription
medicine, issued at a drug store,” which can be included in
the insurance contract with a certain amount limit.
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Is it possible to address the clinics, not listed in the Voluntary Health Insurance program?
In cases when there is a need of a consultation of a
domain expert or diagnostic study, which cannot be
provided by the local treatment facilities under the policy,
the Insurance company organizes and pays for all the
required services in the clinics with the aforementioned
capabilities. An appeal to a medical institution not
stipulated by the insurance program is only possible
following the approval by the Insurance company. In such
cases there can be several payment options – a payment
by the Insurance company or the Insured person pays with
later full or partial reimbursement of the services cost.
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Is there a fluctuation of the Voluntary Health Insurance program cost throughout the effective period of the contract?
The growth of the insurance risk might trigger the change
of the insurance program cost. This might happen, for
example, in case of the expansion of the insurance
program, or if a non-insured event was revealed – a
diagnosis, under which any further payment of medical
services under the insurance program shall not be made
without any supplementary premium. New personnel shall
be included into the insurance contact under the effective
programs and tariffs with due consideration of insurance
cost calculation till the end of the insurance contract
validity period. If a new program is required, Insurance
company experts shall calculate its cost.
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Why do doctors get approvals for prescriptions from the insurance company?
Peculiarities of contractual relationship between the
insurance companies and clinics provide for participation
of medical experts from the Insurer in the approval of
payment for high-priced, non-standard or any other
services. These approvals are required by the Medical
Assistance Quality Control system. This system shall give
objective evaluation if the rendered services comply with
the generally accepted treatment methods and the
insurance program.
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Is it necessary to contact the Insurance company if one needs to schedule an appointment with a doctor at a clinic?
If you are making an appointment for the first time at a specific clinic, then it is highly recommended to do this via medical assistance service of the Insurance Company.
Insurance programs provide for several options of service rendering:
- Direct access – a clinic has a list of attached Insured persons and can provide services to them without involvement of the insurance company. It should be well noted that the submittal of information from the insurance company to the clinic pursuant to the conclusion of the contact might take some time.
- Direct access at the initial appeal to the medical assistance service of the Insurance company – in this case the lists of attached persons are given to a clinic only in case of a request from an Insured person for an appointment at that clinic. The follow-up services are rendered similar to the aforementioned direct access option.
- Access via medical assistance service of an insurance company – all appeals for medical assistance are rendered with involvement of the medical assistance service.
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Does an insurance company provide any statistics under the Voluntary Health Insurance contract?
On one hand, provision of any information is governed by
the Personal Information Protection Act and Doctor-
Patient confidentiality, and on the other, is regarded as
the commercial secret of the insurance company.
However, if mutually agreed by the parties, partial
statistics may be disclosed, if dealing with the amount and
type of medical assistance provided, along with the list of
such medical institutions.
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What services are not included into Voluntary Health Insurance program?
A list of exclusions is usually given in the Insurance contract. Standard exclusions from the Voluntary Health Insurance contract are the following:
- Preventive care.
- Services, provided per Insured person’s request, without
any medical indications
- Services, for which one can address to the State
Programs of Treatment and Monitoring (e.g. tuberculosis)
- In case the conditions, under which the insured event
takes place, fall under Force Majeure (e.g. Acts of God or Military Operations).
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Is it required to fill in a medical form to conclude the insurance contract?
The necessity to undergo medical questioning is defined
by the number of Insured persons, their age and risks of
the insurance program. Questioning is usually
unnecessary, when the Insured personnel consists of not
more than 10 adults, without pension age staff. In any
other cases, some specific Insured persons may undergo
medical questioning in order to define an individual tariff
for standard or specialized insurance program.
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What risks shall be covered by the Voluntary Health Insurance contract?
The outpatient care is the basic risk of a Voluntary Health
Insurance program. All other risks can be optionally added
to the program. However, some of the risks, e.g. EHS, are
obligatory if there is a risk of emergency and scheduled
hospitalization. Specialized programs with a specific set of
included risks are also possible.
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What defines the cost of a Voluntary Health Insurance program?
The key factors defining the cost of a Voluntary Health Insurance program are the following:
- Risks included into the Insurance Program,
- Sex and age of Insured persons,
- Territorial location of the Insured persons’ residence and work
- List of the medical institutions stipulated by the
Insurance program. On some rare occasions, Insurance Company’s experts do the medical check of specific Insured persons.
