基本医疗保险覆盖面不断扩大,其在保护居民健康权益方面的重要性日益凸显,医保基金先行支付能够有效减轻参保人经济负担。然而,由于医保基金先行支付同时牵系着参保人自身利益与医保基金安全,在先行支付与追偿两大环节中都面临着一系列阻碍,主要体现在参保人先行支付申请困难与医保经办机构追偿困难两方面。本研究通过分析制度法理、剖析实践难题、借鉴国外经验,探索实体规则与程序机制优化的双重路径,以期为更好地保障医疗保险基金稳健运行提供有益参考。

The coverage of basic medical insurance has been continuously expanding, and its importance in safeguarding residents' health rights and interests has become increasingly prominent. The advance payment of basic medical insurance funds can effectively alleviate the financial burden of insured individuals. However, due to the simultaneous involvement of insured individuals' interests and the safety of medical insurance funds, this system faces a series of obstacles in both the advance payment and subrogation processes. These obstacles are mainly reflected in the difficulties faced by insured individuals in applying for advance payment and by medical insurance agencies in subrogation. This study explores dual paths for optimizing substantive rules and procedural mechanisms by analyzing the legal principles of the system, dissecting practical challenges, and drawing on foreign experience, to provide useful references for better ensuring the stable operation of basic medical insurance funds.