Quick guide on the use of the Voluntary Health Insurance (VHI) policy provided by “MAKS” insurance company 1 What is “MAKS”? What kind of functions does it perform? 2 How does “MAKS” support the HSE Englishspeaking employees? 3 What are the functions of “MAKS” English-speaking specialists? 4 What is an insurance case? 5 What is not an insurance case? “MAKS” is an insurance company, provider of insurance services for HSE employees in 2015. It arranges and renders medical assistance to the extent covered by the insurance programme and in the facilities indicated in this programme. Medical assistance is provided to the Insured person upon occurrence of an insurance case. A Description of the VHI programme is provided on pages 5-8 of this guide, see Scope_of_services. The following “MAKS” English-speaking specialists provide support 24/7: Dmitry Sergeev – tel. 8 903 796 10 47 (24/7) e-mail dsergeev@makc.ru Tatiana Golubkina – tel. 8 916 684 36 86 (24/7) e-mail dmsdog@makc.ru and Elena Gazazyan - tel. 8 495 276 00 10*9190 (Monday-Thursday from 9.00 to 18.00 Friday from 9.00 to 17.45) Support the Insured English-speaking employees in matters such as: - the scope of medical services covered by the programme - doctors’ appointments - calling an ambulance - home visits - admission to hospital. An insurance case is: - an acute disease - an aggravation of a chronic disease - a trauma (including burns and frostbites). The following services are not regarded as insurance cases and, hence, are not covered: - those organized on the Insured person’s own will without medical indications - general medical examination - those not covered by the programme - those included into the list of exclusions from the VHI programme (pages 8-10 of this guide, see Exclusions). All necessary tests and examinations are covered until a noninsurance case is diagnosed. ! The Insurer continues to provide medical services to the Insured even if a disease not covered by the insurance programme has been diagnosed during the period of validity of the insurance contract (policy). Treatment of the disease is not provided. 6 What is a Policy? 7 Where can you receive medical assistance? The Policy of Voluntary health insurance is issued by “MAKS” insurance company. The Policy is a blue plastic card. The Policy number is written on the front side of it as “Полис № XXXXX.XXXXXX”. You will need to provide this number on any medical assistance request by phone. You will need to SUBMIT the Policy when you get emergency medical care, for admission to hospital and at doctor’s home visit. Outpatient treatment, including dental care and home visits (within the Moscow MKAD Ring Road) is provided on the basis of: “Medincentre” of RF Ministry of Foreign Affairs hereinafter Polyclinic Address: 4th Dobryninsky pereulok, building 4, Moscow. Metro station “Dobryninskaya” 1 http://www.medin.ru/eng/contacts/address Direct phone number: 8 499 237 17 06 - English-speaking staff (for home visits arrangement, appointments to physicians, including children’s appointments, doctors’ reception hours, etc.). Working Hours: Monday – Friday from 8 am to 9 pm Saturday from 9 am to 6 pm Dentistry: Monday – Friday from 8 am to 8 pm Saturday from 9 am to 4 pm Pediatric Department: Monday – Friday from 8:30 am to 8 pm Saturday from 9 am to 3 pm Ambulance team: 8 499 237 17 06 (during working hours) 8 499 237 39 04 (24/7) 8 499 237 53 95 (24/7) Home Visits: during working hours of the Polyclinic. 8 How to make an appointment? With all questions regarding medical arrangements, including both general appointments at the Polyclinic and ambulance service, you can address “MAKS” English-speaking specialists. Please make sure you can provide your insurance policy number written on the front of the blue plastic card you have received. For outpatient and dental services it is necessary to contact the Polyclinic. To make an appointment for the 1st time: ! On your 1st visit to the Polyclinic you will need to obtain a Card* and a Pass*. So please inform the contacting specialist that this is your 1st visit to the Polyclinic. You may call either: 1. The reception of the Polyclinic: 8 499 237 17 06. You will need to provide your full name, age, or 2. “MAKS” English-speaking specialists. You will need to provide your full name, age, № of the Policy. ! If you want to make an appointment for your family member it is necessary to provide HIS/HER full name, age, № of the Policy. *What is the Card? The Card issued by the Polyclinic, contains medical information on the health condition of the patient, and is kept at the registration office of the medical facility. The Pass issued by the Polyclinic, ensures your admission to the facility, and is obligatory for medical assistance. Both the Card and the Pass are issued at room 114, 1st floor of the medical facility. The following documents are required: your Policy, Passport and 1 photo. Room 114 working hours: - Monday - Friday – 8 am – 9pm - Saturday – 9am – 6 pm - Sunday – closed ! Please make sure to arrive approximately 30 minutes before the appointment time to obtain the Card and the Pass. *What is the Pass? To make subsequent appointments: You may call: 1. The reception of the Polyclinic: 8 499 237 17 06. You will need to provide your full name, age, № of the Card/Pass (they coincide). 2 9 10 11 12 13 14 What should you do if a doctor at an appointment at a medical facility says that a certain service cannot be provided? What is emergency medical care? What is the emergency phone number? Is emergency care provided all over Russia, in any city/town (during business trips, vacations)? Is medical assistance provided outside Russia? In what cases and how is a home visit arranged? 2. “MAKS” English-speaking specialists. You will need to provide your full name, age, № of the Policy, № of the Card/Pass (they coincide). ! If you want to make an appointment for your family member it is necessary to provide HIS/HER full name, age, № of the Policy, № of the Card/Pass. It is necessary to call “MAKS” English-speaking specialists (24/7) and inform about the situation. 1st option The specialist will determine the lawfulness of the denial and specify the relevant clause in the VHI programme that confirms it. 2nd option The specialist will determine the possibility of the service’s coverage and contact the doctor to confirm further provision of the service. 3d option The specialist will determine the possibility of the service’s coverage and arrange the service provision in another medical facility, informing the Insured about the address of the medical facility, the date and the time beforehand. You will need to provide your full name, age, № of the Policy, and the reason for refusal. Emergency medical care is provided in life-threatening situations (fever, traumas, pains, etc.) You may call: 1. Polyclinic’s ambulance team: 8 499 237 17 06 (during working hours) 8 499 237 39 04 (24/7) 8 499 237 53 95 (24/7) 2. “MAKS” English-speaking specialists (24/7). Emergency medical care is provided within Moscow Ring Road. It is necessary to provide your full name, age, № of the Policy, the address where the doctor is needed and the problem. ! If you want to call an ambulance for your family member it is necessary to provide HIS/HER full name, age, № of the Policy, the address and the problem. Emergency care is provided in any Russian city/town. To receive emergency care it is necessary to call 03 (for calls from local fixed telephones) or 112 (for calls from mobile phones). In case it is impossible to reach the number you may call “MAKS” English-speaking specialists 24/7. Provide your full name, age, Policy number, the address where a doctor is needed, and the reason for a doctor’s visit. No. Home visits are provided (within Moscow Ring Road) on medical grounds only to the Insured who cannot visit a medical facility due to health conditions, and needs to stay in bed and be examined by a physician at home To arrange a home visit, please call the Polyclinic: 8 499 237 17 06 Home visit calls are taken every day except Sunday from 8:30 am to 1 pm. Home visits are made during the working hours of the Polyclinic: For adults For children 3 Monday 8 am – 9 pm Saturday 9 am – 6 pm Monday 8:30 am – 8 pm Saturday 9 am – 3 pm In case of serious health problems after 1 pm or on Sunday you may call emergency care. You will need to provide your full name, age, number of the Card/Pass (they coincide), the address where the doctor is needed, and the reason for home visit. If it is impossible to get through or to receive English-speaking support, call “MAKS” English-speaking specialists (24/7). You will need to provide your full name, age, № of the Policy, the address where the doctor is needed, the reason for home visit. 15 16 What should be done if a Russian-speaking doctor came for a home visit? What should be done if an emergency admission to the hospital is required? 17 What should be done if a planned admission is required? 18 What should be done if necessary medical services cannot be provided in the facilities ! If you wish to arrange a home visit for a family member it is necessary to provide HIS/HER full name, age, № of the Policy, the address where the doctor is needed, and the reason for home visit. It is necessary to call “MAKS” English-speaking specialists. The specialist will try to resolve the problem and will be able to translate the doctor’s consultation and prescription. 1st option If you are at an appointment at the Polyclinic: - The Polyclinic employee contacts the insurance company over the phone and states the emergency admission necessity. - The insurance company specialist arranges admission to one of the facilities in accordance with the VHI programme. - If transportation from the Polyclinic is required, the insurance company employee arranges it in an ambulance car 2nd option If you are at home: A doctor from an ambulance team states the necessity of emergency admission - The doctor contacts the insurance company and states the necessity for emergency admission - The insurance company specialist arranges admission to one of the facilities in accordance with the VHI programme. - The transportation to the hospital is carried out in an ambulance car. 1st option If you are at an appointment at the Polyclinic: - The Polyclinic employee contacts the insurance company over the phone and states the planned admission necessity. - The insurance company specialist arranges a consultation prior to hospital admission in accordance with the programme at one of the Moscow hospitals (to be considered per case). 2nd option If you are at home: - The Polyclinic doctor states the necessity of the planned admission to the hospital. - It is necessary to contact “MAKS” English-speaking specialists - You will be informed on the exact time and location of admission. It’s necessary to contact “MAKS” English-speaking specialists. If you speak Russian, you may call “MAKS” switchboard at +8 800 333 44 03. 4 stipulated in the VHI programme? What should be done if: - you cannot settle the problem with MAKS; - you want to comment on MAKS’ services; - you or your family member have lost the Policy 19 Contact the Department of social services of National Research University – Higher School of Economics. Tel.: 8 495 621 70 78 Contact persons: Kiruhina Galina Viktorovna e-mail: gkiruhina@hse.ru Natalia Romanova (English speaking) e-mail: nsromanova@hse.ru Address: 20, Myasnitskaya street, room 326K, 9:30 am - 6 pm. Scope of services under VHI programme 2015: The insurance company “MAKS” provides services and covers costs for medical services upon medical condition in case of acute disease, aggravation of chronic disease, trauma, intoxication. Treatment and Diagnostic Visits to Physicians: - - initial, repeated, consulting visits to physicians and specialized departments doctors, such as: therapist, cardiologist, pulmonologist, gastroenterologist, urologist, gynecologist, gynecologistendocrinologist, neurologist, ophthalmologist, otolaryngologist, surgeon, endocrinologist, dermatologist, proctologist, allergist, traumatologist, orthopedist, angiologist, phlebologist, breast specialist/physician, radiologist, infectious disease specialist, physiotherapist, arthrologist, neurosurgeon; consultations of the following specialists (until a diagnosis has been established): oncologist, hematologist, rheumatologist, nephrologist, psychotherapist (only once); preparation for elective surgery; medical consultation and council of highly qualified specialists of relevant clinics and medical institutions; medical documents: issue of medical documents, including temporary disability assessment (issue of sick leave certificates of Form 095/u), drug prescriptions (except for discounted ones), children sick leave certificates (095/u form), pre-school, school and student certificates, certificates for sports and health recreation events, referrals and extracts from medical cards upon medical condition. Diagnostic Examination: - - - - Laboratory Diagnostics: general clinical tests, chemistry panel, hormonal tests (except for determination of reproductive hormones); coagulation tests, microbiological tests, complete blood count; PCR-based diagnostics for infectious diseases; serological tests, cytological and microscopic tests. Diagnostics of STDs, including initial culture based, PCR-based and serological diagnostics (up to 5 positions during the period of the insurance contract) and after treatment control tests of determined diseases. Allergic diseases diagnostics: skin allergic testing; Ig E general testing; tumor markers (upon medical condition) Instrumental Diagnostic Methods: X-ray tests, including mammography; endoscopic examination; ultra-sound examination (including Doppler sonography); extracranial and transcranial vessels scanning; radionuclide diagnostics (excluding positron emission tomography); computed tomography, magnetic resonance imaging (including soft tissues); surgical and anaesthetic management. Functional diagnostics: electrocardiography, echocardiography, ambulatory blood pressure monitoring, 24-hour ECG monitoring; cycle ergometry, phonocardiography; functional evaluation of 5 external respiration; electroencephalography; rheoencephalography; rheovasography; 24 Hour Holter ECG Monitoring; colonoscopy. Medical treatment and procedures: - Procedures and surgeries carried out by doctors under regional anesthesia without hospitalization; physiotherapeutic procedures: electrotherapy; phototherapy (except for ultraviolet blood irradiation); magnetotherapy; thermotherapy; laser therapy (except for laser blood irradiation); inhalations; hydrotherapy (except for recreational swimming in a pool, underwater spine traction and hydro massage); ultrasound therapy. - classical therapeutic hand massage (1 course of up to 10 procedures during the period of the insurance contract); - group therapeutic exercises (1 course of up to 10 procedures during the period of the insurance contract); - manual therapy (1 course of up to 10 procedures during the period of the insurance contract); - corporeal acupuncture (1 course of up to 10 procedures during the period of the insurance contract); - immunoprophylaxis (single influenza vaccination during the period of the insurance contract); - shockwave therapy in traumatology (1 course of up to 5 sessions during the period of the insurance contract). - Outpatient procedures (consultations, diagnostic examination, treatment procedures) on the following: type 2 diabetes mellitus (except for diabetic complications) - not more than 2 cases for the Policyholder company during the period of the insurance contract); - medical treatment at ‘day hospital’ basis or a ‘one day hospital’ basis; - pre-admission examination; - pre-admission testing; - prenatal care till 8 weeks; therapeutic abortion; - skin diseases treatment (except for , including those for improving mental health of the insured); - acute hepatitis treatment. Minor surgeries at ambulatory care clinic: minor surgery, all procedures, injections using disposable material. Dental care: - - - consultations of dentists in therapy, surgery and periodontology; diagnostic examination: X-ray study, radiovisiography, orthopantomography, electro-odontodiagnostics; local anesthesia: topical, infiltration and block anesthesia; preventive dentistry: dental cavity treatment; pulpitis and periodontitis treatment, mechanic and medication root canal treatment, root canal filling with gutta-percha points, filling paste; cavities filling and tooth coronal part restoration with if less than ½ of the crown is destroyed; light and chemical cured dental filling; treatment of acute parodentium diseases and parodentium aggravation; acute oral mucosa diseases treatment; Modern light and chemical cured dental filling are to be used. surgical dentistry: tooth extraction; incision and drainage of abscess; periotitis and periodontitis treatment incisions; pericoronitis treatment with operculum excision; treatment of benign neoplasms of maxillofacial area; physiotherapeutic procedure in acute cases; acute pain dental help (acute state relief); supragingival calculus removal while acute state of parodontium tissue treatment (once during the period of the insurance contract); 6 - application of fluoride lacquer in case of hard tooth tissues hyperesthesia(once during the period of the insurance contract); Home care: Home care is provided in case of an acute disease if the Insured person cannot visit a clinic due to his/her state of health and needs bed rest and to be monitored by a physician at home including: - medical assistance (initial consultation of physician, active care until recovery, issue of sick leave certificates, necessary treatment prescription, consultations of specialists); doctor’s orders by paramedical personnel; tests collection by laboratory assistant (except for dysbacteriosis feces analysis) upon doctor’s order). Ambulance services: Ambulance service is provided 24/7 at the territory of Moscow within the Moscow MKAD Ring Road in case of life-threatening condition and diseases requiring emergency medical assistance. Scope of services: - visit of qualified ambulance team to the place of living or work at any time, patient examination; express-diagnostics, urgent medical assistance and medical emergency relief; medical transportation to hospital provided urgent admission is required. Specialized ambulance cars must be equipped with the relevant clinical equipment and medicines. Hospital service (emergency and planned admission): - Emergency admission to hospital concerns life-threatening diseases of the Insured which require immediate hospital treatment. Hospital service is provided in case of surgical diseases in the following hospital departments: abdominal, thoracic, vascular, cardio and general surgery; neurosurgery; traumatology, urology, gynecology, otolaryngology, ophthalmology. Admission to the above units provided in case of acute illness and exacerbation of diseases for: - Conducting a wider range of diagnostic examination using computed tomography and magnetic resonance imaging, Doppler ultrasound, modern endoscopic techniques, angiography; - Rendering expert assistance including conventional surgery, endovascular, laser, and endoscopic surgery, and also surgical procedures applying atraumatic surgical techniques such as lithotripsy and laparoscopy. Therapeutic diseases are treated in the following departments: medical unit, cardiology, rheumatology, neurology, pulmonary and endocrine units, gastroenterology, dermatology, infectious disease unit. Care of the insured person in one of the above departments involves: - - A wider range of diagnostic examination using computed tomography and magnetic resonance imaging, Doppler ultrasound, modern endoscopic techniques, 24 Hour Holter ECG Monitoring, Transesophageal Electrocardiography; A wider range of pharmacotherapy and medical procedures, including all types of massage, acupuncture, manual therapy, hydrotherapy, physiotherapy; 7 - - Restorative and rehabilitative treatment after hospital treatment of the insured event upon authorization of clinical expert committee; Critical care, anaesthetic management, neurosurgery ring the period of the insurance contract; Extracorporeal treatment: hemodialysis, plasmapheresis, hemosorption, hemofiltration, ultraviolet and laser irradiation, ozone therapy (within intensive care); Reparative treatment of cardio-vascular diseases (including coronary artery bypass grafting and stenting) in case of emergency admission upon vital signs assessment (without costs of expendable materials); ectopic pregnancy (in case of emergency admission on assessment of vital signs). Exclusions from the VHI programme 2015 The Insurance company does not cover the costs of medical services rendered to the Insured for the following diseases and/or their consequences and aggravation (after diagnose is established) unless the insurance programme otherwise provide: I. - - II. - Coverage of medical services for the following diseases and their aggravation: malignant oncological diseases, central nervous system neoplasms, malignant blood and hematopoietic diseases; congenital and hereditary diseases, congenital anomalies (organs and tissues malformations), chromosomal disorders and abnormalities; epilepsy and epileptic syndrome; mental and behavioral disorders, including alcohol, drug and toxic substance abuse; HIV and AIDS, venereal diseases (syphilis, gonorrhea, chancroid (soft chancre), lymphogranuloma venereum, venereal granuloma; STDs, including chlamydia infection, ureaplasmosis, mycoplasma, genital herpes, cytomegalovirus infection, gardnerella vaginalis, human papillomavirus (HPV)), beyond the limit covered by insurance programme; type 1 and 2 diabetes mellitus (except for outpatient care); acute and chronic viral hepatitis (except for hepatitis A and E), hepatic fibrosis and cirrhosis; tuberculosis, sarcoidosis, amyloidosis, psoriasis, deep (systemic) mycoses, onychomycosis; diseases accompanied by chronic renal and hepatic failure, requiring extracorporeal treatment; systemic autoimmune skin and connective tissue diseases, deforming dorsopathies (except for osteochondrosis), inflammatory polyarthropathies, arthrosis (except for posttraumatic arthrosis), Bechterew's disease; multiple sclerosis, Parkinson disease, other extrapyramidal and movement disorders; acute and chronic radiation sickness; occupational diseases. Coverage of the following medical services: Services not stipulated in the insurance contract, without doctor’s prescription, at the discretion of the Insured; treatment of pathological states and injuries arising from or related to alcohol, drug and other substance abuse and its residual effects, and in states caused by psychoactive substances; visits and consultations of specialists, diagnostic examination, procedures and other services connected with pregnancy and its complications (including abortion), except for emergency assistance within the scope of services provided in case of ectopic pregnancy, metrorrhagia during the 8 - - - - - - - first trimester, antenatal care and childbirth, postpartum condition and/or diseases and their complications; visits and consultations of specialists, diagnostic examination, procedures and other services for family planning, procedures for impregnation or its prevention, including artificial insemination or in-vitro fertilisation, drug contraception and surgical sterilization; infertility diagnostics and treatment, erectile dysfunction (including impotence, peyronie's disease), other sexual dysfunction; genetic tests; procedures on caries treatment of teeth if more than ½ of the crown is destroyed (as of the first diagnostic and therapeutic visit to a specialist, after dental cavity preparation) and on teeth with prosthetic and orthodontic devices (except for emergency acute pain relief for acute inflammation or trauma); treatment of noncarious tooth defects (wedge-shaped tooth defects, dental enamel erosion and hypoplasia); diagnostics, treatment and elimination of orthodontic defects; preventive (dental fissure sealing, plaque and calculus removal, fluoride-containing dental preparations and lacquer application, and the like) and cosmetic (cosmetic teeth restoration, including veneers and laminates, teeth whitening, and the like) procedures, including filling replacement without medical reason and beyond the limit covered by insurance programme; visits and consultations of specialists, diagnostic examination, procedures concerning prosthodontics and preparation for it, including removal of tooth pulp, dental extraction, implant dentistry and preparation for it; preventive and surgical treatment of parodontium tissue beyond the limit covered by insurance programme; visits to specialists for diagnostics and treatment of condyloma, trichopathy, and dermatopathy such as calluses, warts, papilloma, molluscum contagiosum, nevus, hyperkeratosis; skin flaws correction, including for improving mental health of the insured; diagnostics and treatment in medical institutions involving original techniques not stipulated in the insurance contract; hydrocolonotherapy, hydrotherapy and pelotherapy (except provided within restorative (health resort) treatment); dry immersion therapy; mechanical therapy, shockwave therapy, mechanic massage, course treatment of chronic diseases involving programme device treatment (“Andro-Gin”, “Yarilo”, “Multiamg”, programme complexes in ophthalmology and the like, kinesitherapy, “Gemocode” test and the like, and other methods beyond the limit covered by insurance programme; visits to specialists: kinesiotherapist, nutritionist, geneticist, speech therapist, psychologist, speechlanguage pathologist, phoniatrician, somnologist beyond the limit covered by insurance programme; psychotherapy and computer psychodiagnostics; specific allergen testing (skin tests, standard and/or individual allergen panel testing, except provided in cases of emergency admission and specific hyposensitisation therapy, including SIT (Specific immunotherapy); clinic and laboratory diagnostics and treatment of immune system diseases beyond the limit covered by insurance programme; diagnostics and treatment (including procedures) for cosmetic reasons and aesthetic purposes, or for improving mental health of the insured; weight management, veins sclerotherapy, colon therapy; any medical and other services for recreational, cosmetic and preventive purposes; diagnostics and treatment of eating disorders (obesity, binge eating, undernutrition) and osteoporosis; diagnostics and treatment of rhonchopathy and sleep apnea; foot deformity, including platypodia; spine curvature disorders treatment; traditional medicine for diagnostics (acupuncture, auricular, thermoacupuncture, electroacupuncture, manual, energoinformational diagnostics, iridology, pulse diagnosis and the like) and treatment (hirudotherapy, homeopathy, phytotherapy, apitherapy, chromotherapy, and the like) and recreation (chi kung, breathing practices, music therapy, and the like); 9 - - - - extracorporeal blood treatment (including programmed hemodialysis, endovenous laser therapy, and the like), except for the cases of extracorporeal blood treatment upon medical condition in critical care unit; ozone therapy; hypobaric, normobaric and hyperbaric oxygenation, except for cases of hyperbaric oxygenation upon medical condition in critical care unit; preparation for planned inpatient treatment, if the insurance programme does not provide for “planned inpatient treatment”; diagnostics and treatment within “day hospital” basis or a “one day hospital” basis, if the insurance programme does not provide for “planned inpatient treatment”; regular medical check-up of the insured with chronic diseases and higher risks for certain disease; services beyond the limit covered by insurance programme concerning individual risks (types of medical assistance); The Insurance Company does not cover: organs and tissues transplantation (implantation); corrective eye surgery, including laser surgery; hearing aid (lost hearing restoration with hearing aids – diagnostics, choice, support and service), cochlear implants); septoplasty; submucosal resection of nasal septum; elective neurosurgery treatment; elective reconstructive surgery, including in cases of disease and anomalies of cardiovascular and musculoskeletal systems; elective surgery of spinal disk herniation (protrusion); orthopedic prosthetics (restoring functions of lost or missing organs and body parts) – limbs, joints, eyes, teeth, and the like); pacemakers, prostheses, endoprostheses, implants, osteosynthesis and fixation plates, angiography, angioplasty and stenting sets (except for vena cava filter placed in emergency cases), medical equipment, medical appliances for eyesight and hearing correction, medical appliances and expendables for treatment of patients with any diseases; certificates and other medical documents for swimming pools, sports, recreation activities; for obtaining driver and firearms license; for health resorts, sanatoriums, children recreation centres, health resort records (except if the insurance programme covers restorative (health resort) treatment); certificates and medical documents for any other purposes unless the insurance programme otherwise provide. 10