Private clinics will be able to operate under compulsory medical insurance only if there is a need in the region

The criteria are necessary in connection with the update of No. 326-FZ "On Compulsory Medical Insurance" to No. 552-FZ. The new version of the main law in the field of compulsory medical insurance states that private clinics wishing to receive volumes of medical care from the TFOMS must undergo a high-quality selection.

Despite the fact that the thematic amendments come into force on September 1, 2025, the Ministry of Health proposes to approve the criteria themselves on March 1, 2026, that is, if the project does not change by the time of approval, private clinics can apply for work in 2026 under the previous notification scheme.

Among the formal parameters for joining the territorial compulsory medical insurance program for private clinics included in the project are the presence of a license and a website with basic information; integration with the Unified State Health Information System, the State Information System of Compulsory Medical Insurance and the regional segment of these systems; for those providing emergency care – integration with the dispatch service and 24-hour operation.

More serious requirements will be imposed on the quality and experience of clinics. Thus, if a clinic "did not participate in the territorial compulsory medical insurance program" (the regulator does not specify whether in a specific region or in the compulsory medical insurance system as a whole), then it must confirm its three-year experience. Also, for new organizations applying to provide high-tech medical care, inpatient medical care or selected diagnostic services (which ones are not specified), the requirement is to provide at least 300 cases of such treatment over the last three years or 150 over the last one.

An important clarification of the draft resolution is that these requirements are not relevant if, according to information from the regional Ministry of Health/Department of Health, there is an acute shortage of a particular type of medical care provided by a commercial player. The document does not describe how exactly the availability of these services is measured.

Among other things, a private clinic must not have had any violations, including formal ones, over the past two years, based on the results of previously conducted monitoring of the volume, timing and quality of medical care under the compulsory medical insurance.

Applications for participation in the territorial compulsory medical insurance program will be accepted by the TFOMS, and the final decision will be made by the commission for developing the territorial compulsory medical insurance program within ten working days after receiving the documents from the fund.

As the Ministry of Health specifies in the accompanying documents to the draft criteria, the procedure for including private clinics is necessary to weed out organizations that will not be able to work under Federal Law No. 323-FZ "On the Fundamentals of Health Protection" and that could potentially violate the rights of citizens to free medical care and "ineffectively and unreasonably" spend targeted funds. Judging by the statistics, this concerns the proposed regulation of the work of 3,132 private clinics registered in the Russian Federation.

The creation of barriers for the participation of clinics in compulsory medical insurance programs has been discussed in the professional community, the Federal Compulsory Medical Insurance Fund, the Ministry of Health and the government since 2020. Initially, it was assumed , for example, that only organizations that have been carrying out medical activities for the selected type of medical care for at least two years will be able to receive compulsory medical insurance volumes.