医养结合机构中长护险与医保待遇政策衔接问题研究——以晋江市为例  

Study on the Policy Coherence Issue Between Long-Term Care Insurance and Healthcare Security Benefits in Integrated Medical and Elderly Care Institutions——A Case Study of Jinjiang City

作　　者：李长乐 陈清漂 魏耀 康莉莉 陈旻[1,2] 

机构地区：[1]福建医科大学卫生管理学院,福州350122 [2]福建省医药卫生体制改革研究会,福州350122 [3]泉州市医疗保障局晋江分局,泉州362200 [4]泉州市医疗保障基金中心晋江分中心,泉州362200

出　　处：《中国医疗保险》2025年第4期61-67,共7页China Health Insurance

基　　金：国家社会科学基金2023年度项目“长期护理保险政策推动公正责任与服务价值实现研究”(23BSH096)。

摘　　要：目的:理清长期护理保险(以下简称“长护险”)与基本医疗保险待遇(以下简称“医保待遇”)政策界限,探讨医养结合机构中长护险与医保待遇政策衔接的必要性和可能性。方法:检索、梳理相关文献,以晋江为研究对象,调研代表性医养结合机构,分析其长护险与医保待遇政策衔接产生的问题。结果与建议:在实践中,“无陪护”病房服务通过财政、医保、患者三方共担的支付方式,为医养结合机构基础生活照料服务的补偿提供了新的可能性。建议医保部门试行在居民医保参保人普通门诊报销超过封顶线后,为其提供长期医疗护理服务包,以减轻参保人经济负担。Objective:This study aimed to clarify the boundaries between long-term care insurance(LTCI) and basic medical insurance(BMI) benefits policies,and explore the necessity and possibility of policy coherence between LTCI and BMI benefits in integrated medical and elderly care institutions.Methods:Relevant literature was retrieved and analyzed,and typical integrated medical and elderly care institutions were investigated to analyze the problems arising from the connection between their LTCI and BMI benefits policies,taking Jinjiang City as the object of study.Conclusions and Suggestions:This study found that "nurse-free" ward service,through a payment model shared by the government(finance),medical insurance,and patients,offers new possibilities for compensating basic daily care services in integrated medical and elderly care institutions in practice.It is suggested that healthcare security departments could pilot providing medical nursing service packages for residents whose general outpatient reimbursement exceeds the cap under basic medical insurance for urban and rural residents,thereby alleviating the economic burden on the insured.

关 键 词：医养结合 长护险 医保待遇 

分 类 号：F840.684[经济管理—保险]