新增和存续的普惠型商业医疗保险比较研究  

A Comparative Study of New-Listed and Sustained Inclusive Commercial Medical Insurance

作　　者：陈非非 张璐莹[1] 俞纯璐 冯逸佳 齐怡嘉 李骄阳 陈星 童禧辰 陈文[1] 

机构地区：[1]复旦大学公共卫生学院,上海200032

出　　处：《中国医疗保险》2025年第2期13-18,共6页China Health Insurance

基　　金：国家自然科学基金“战略性购买视角下医保门诊按人头付费机制研究”(72374049)。

摘　　要：目的:对比新增和存续两种类别普惠型商业医疗保险之间的差异,为新上市保险的持续运行以及普惠型商业医疗保险的进一步发展提供参考。方法:系统收集2021—2023年全国各省市运行的普惠型商业医疗保险信息,依据存续状态将其划分为新增和存续保险,并对其参保人数、筹资标准、参保和赔付条件、保障待遇等方面进行对比分析。结果:新增保险的筹资标准比存续保险更高,但参保人数较低。参保和赔付条件上,较高保费的新增保险对既往症人群的赔付条件更高。在保障待遇方面,不同保费水平的新增保险相对于存续保险均减少了门诊慢性病和特殊病保障责任,而较高保费的保险增加了对基本医保支付范围外其他医疗费用的保障,并提高了综合封顶线。结论:普惠型商保应进一步优化产品保障方案设计,提升门诊慢特病保障,同时要扩大其覆盖人群,提升保险自身抗风险能力。Objective:The paper compares the differences between new-listed and sustained inclusive commercial medical insurance products to provide references for the sustainable operation of new-listed insurance products and the further development of inclusive commercial medical insurances.Methods:Information on inclusive commercial medical insurance in China from 2021 to 2023 was systematically collected.Based on their existence status,these insurances were classified into new-listed and sustained ones,and their number of participants,financing standards,requirements for enrollment and payment,and benefits were comparatively analyzed.Results:The financing standards for new-listed insurances were higher than sustained ones,yet the number of insured individuals was lower.In terms of participation and payment conditions,the new-listed insurances with higher premiums imposed stricter payment conditions for individuals with pre-existing conditions.In terms of benefits,the new-listed insurances reduced coverage for outpatient chronic and special diseases compared to sustained ones,and the insurances with higher premiums expanded their coverage to include other medical expenses not covered by basic medical insurance,and raised the overall cap.Conclusion:Inclusive commercial insurance should further optimize the design of security schemes,enhance outpatient chronic and special disease security,and expand coverage of the population to enhance its own anti-risk capacity.

关 键 词：普惠型商业医疗保险 新增保险 存续保险 比较研究 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]