CSHI | Корпоративный фонд "University Medical Center"

CSHI

Health is the greatest value for all people.

Compulsory health insurance became one of the main implementations of 2017 in Kazakhstan. If earlier health insurance for many years operated in the category as voluntary, the introduction of compulsory health insurance in Kazakhstan bears a tremendous change.

Implementation of Mandatory Social Health Insurance (MSHI) has begun in January 1, 2020. The MSHI system is based on equal access of all the insured to a package of services, regardless of contribution amount. Moreover, when applying for help under MSHI, a patient is not limited in the volume and cost of medical services.

The Kazakhstani model of MSHI system is socially oriented. It means that the state pays contributions for almost 11 million citizens from 15 benefit-entitled categories of population.

There are two packages: Guaranteed Volume of Free-of-Charge Medical Assistance (GVFMA) and Mandatory Social Health Insurance (MSHI) under which people can receive medical assistance.

The state guarantees free-of-charge medical assistance under GVFMA. Pursuant to the Decree of the Government of RK as of October 16, 2020 No. 672, it includes the following services:

– Emergency medical service (including medical aviation as well as the services of mobile medical teams for diseases that worsen the epidemiological situation in the country).

– Servicing in outpatients’ clinics (diagnostics, treatment and management of most common diseases; screenings for target groups of population; pregnancy follow-up; preventive vaccinations).

– Diagnostics and treatment upon:

  • socially significant diseases (tuberculosis, HIV, etc.)
  • chronic diseases (diabetes, arterial hypertension, viral hepatitis, rheumatoid arthritis, etc.).

– Medical assiatnce in in-patient-replacing and in-patient conditions in the manner determined by an authorized body (including cases of isolating individuals who were in contact with a patient having an infectious or parasitic disease that poses a danger to others).

– Provision of medicines when delivering specialized care and in accordance with the list of diseases against which preventive vaccinations are carried out. In addition, categories of citizens registered in dispensaries for certain diseases and conditions can receive medicines free-of-charge.

Follow the link to find more information on the medical services provided under GVFMA: adilet.zan.kz/rus/docs/P2000000672#z56.

People insured in MSHI system get an extended access to medical assistance based on the package.

Pursuant to the Decree of the Government of RK as of June 20, 2019 No. 421, the MSHI package includes the following medical services:

  • specialized medical care on an outpatient basis, including:
  1. preventive medical examinations;
  2. appointments and consultations of medical specialists under referral issued by a district doctor;
  3. case follow-up of individuals having chronic diseases by medical specialists;
  4. delivery of emergency and elective dental care to certain categories of population according to the list approved by an authorized body;
  5. diagnostics services, including laboratory diagnostics (ultrasound, X-ray, CT, MRI);
  • specialized (high-tech) in-patient medical assistance (emergency/elective form, including carrying out medical and diagnostics activities at the admission department of 24/7 hospital);
  • medical rehabilitation.
  • provision of medicines when delivering specialized care in in-patient and in-patient-replacing conditions based on the list of medical devices for certain categories of citizens with certain diseases approved by an authorized body.

Follow the link to find more information on the medical services provided under MSHI package: adilet.zan.kz/rus/docs/P1900000421.

Pursuant to the Law of RK “On MSHI” (adilet.zan.kz/rus/docs/Z1500000405) contributions should be made monthly. Also, it is important that there are no missing payments for the last 12 months, starting from January 2020. If there are gaps, the “insured” status is not assigned.

After the introduction of Mandatory Social Health Insurance, citizens often ask the following question: “When should I pay?”, “For whom should I pay?”, “How much to pay?”, “How to pay?”, “What to pay for?”.

Thus, who and how pays for MSHI.

Compulsory health insurance became one of the main implementations of 2017 in Kazakhstan. If earlier health insurance for many years operated in the category as voluntary, the introduction of compulsory health insurance in Kazakhstan bears a tremendous change.

The system of compulsory health insurance will help Kazakhstan keep pace with the times, as well as stimulate further development of the insurance market.  After all, it is not a secret for anyone that the developed countries of the world practice health insurance, and is a major part of life.

The state guarantees free medical care:

  1. First aid and sanitary aviation;
  2. Out-patient and polyclinic care for socially significant diseases, diseases that are dangerous to others, according to the list determined by the authorized body, as well as persons who do not have the right to medical care in the system of compulsory social health insurance in accordance with the Law of the Republic of Kazakhstan “On compulsory social health insurance “, which includes: primary; consultative and diagnostic assistance by the referral of a specialist in primary health care and specialized specialists;
  3. Inpatient care: planned inpatient care only for socially significant diseases, diseases that pose a danger to others, according to the list determined by the authorized body, by the referral of a specialist in primary health care or a medical organization within the planned number of hospitalization cases determined by the authorized body; for emergency indications – regardless of the referral;
  4. Inpatient-substituting care for socially significant diseases, diseases that are dangerous for others, according to the list determined by the authorized body, by the referral of a specialist in primary health care or a medical organization;
  5. Prophylactic immunization.

The CSHI will include:

  1. Out-patient and polyclinic care (except for medical care for socially significant diseases, diseases that are dangerous to others, according to the list determined by the authorized body), including: primary health care, consultative and diagnostic assistance by the referral of a specialist in primary health care and specialized specialists;
  2. Outpatient drug provision by prescription;
  3. Inpatient care (with the exception of medical care for socially significant diseases, diseases that are dangerous to others, according to the list determined by the authorized body): scheduled inpatient care for a specialist in primary health care or a medical organization within the planned number of hospitalization cases, including high-tech medical services, for emergency indications – regardless of whether there is a referral of a specialist in primary health care and or medical organization;
  4. Hospital-assisted care (with the exception of medical care for socially significant diseases, diseases that are dangerous to others, according to the list determined by the authorized body) – by the referral of a specialist primary health care or medical organization.

How to protect your patient rights?

One of the major tasks of the Fund is to protect the patient rights. That is why, the Fund experts monitor the quality of medical assistance and check the reasons of refusal to deliver it.

However, often citizens do not know where to apply to protect their rights if they are faced with a lack of understanding during servicing in medical organizations.

Option 1. Patient Support Service

Without wasting time, call the Patient Support Service established to control delivery of medical services and resolve situations on the spot.

*such the Service operates in each medical organization

In each clinic the Service:

  • executes internal control of medical assistance quality
  • detects violations when delivering medical services
  • considers requests and complaints.

Option 2. Contact a region`s Health Department Call Center

All the medical organizations are subordinate to Health Departments, that is why one can influence an issue settlement by contacting the department`s call center.

Option 3. “Qoldau 24/7” mobile app

After you submit a request via “Qoldau 24/7”, the Social Health Insurance Fund specialists:

  • contact a medical organization
  • request information
  • check a service delivery status or reasons for refusal to deliver a medical assistance

*A number is assigned to your request using which you can track a request status

Option 4. SaqtandyryBot in Telegram.

  • Find “SaqtandyryBot” in Telegram and launch it
  • Select “Submit request to 1406” command in main menu
Submit a request: History of requests:
Indicate region, name of medical organization, issue enables checking a status of generated request

Option 5. Integrated Call Center (1406)

  • 24/7
  • considers requests based on the three-level request processing model:
  1. First level: issues requiring consulting
  2. Second and third levels: requests requiring detailed consideration
  • The Fund specialists contact a medical organization, request information, check a service delivery status or reasons for refusal to deliver a medical assistance.

Option 6. “People`s Control” section on fms.kz website

Submit a request via the Social Health Insurance Fund website:

  • Go to fms.kz website
  • Open “People`s Control” section
  • Select a task: make a complaint or suggestion.
Make a complaint: Make a suggestion:
Indicate region, outpatients`clinic, diagnosis, date of visit, IIN. Select a complaint reason Fill in the required data and formulate a text

A source: https://egov.kz/cms/en/articles/health_care/osms