目的: 探讨长三角和京津冀等区域医疗保险支付范围一体化的现状及存在的问题,为优化医保政策,提高医疗保障的公平性与可及性提供证据支撑。方法: 通过政策梳理和实地调研,对比分析两区域在药品、医疗服务项目、医用耗材等医保支付范围的一体化现状及实施挑战。结果: 各省市在现存医保支付范围（即存量部分）上尚缺乏系统性的协商与调整。由于民族药、中药饮片和医疗机构制剂具有较强的地方特色,目前尚无统一的纳入标准和监管审批流程;各地医疗服务项目在编码、名称、内涵、计价单位和价格标准等方面仍存在分类不一的问题;医用耗材尚缺乏统一的单独收费政策和采购模式。在医保支付范围新增目录（即增量部分）上,各省市的步调也并不一致。新增中药饮片、民族药、医疗机构制剂缺乏区域协商机制,新增医疗服务项目与国家立项指南的统一标准仍存在差异。结论: 长三角、京津冀两大经济水平较高的区域医保支付范围存在较大差异。为推进医保支付范围一体化,各地应以国家顶层设计为依托,建立权威的区域发展协调机制,优化医保目录调整规则,提升医保基金统筹水平,同时在政策实施中兼顾区域经济差异,通过中央财政拨款和区域内医保基金筹集的形式,逐步设立再保险分摊机制和专项基金池,以分担基金风险。此外,应着力强化医保基金区域协同监管,建立信息共享平台,提升跨区域就医结算的便利性,以促进医保支付范围一体化。

Objective: The paper explores the current status and problems regarding the integration of medical insurance payment scope in regions such as the Yangtze River Delta and Beijing-Tianjin-Hebei, providing evidence to optimize medical insurance policies and enhance the fairness and accessibility of healthcare security. Methods: Through policy review and field research, a comparative analysis was conducted on the integration status and implementation challenges of medical insurance payment scope for drugs, medical service items, and medical consumables in the two regions. Results: Systematic negotiation and adjustment regarding existing medical insurance payment scope (i.e., the "existing items") are still absent among provinces and cities. Due to strong local characteristics of ethnic medicine, Chinese herbal decoction pieces, and institutional preparations, unified inclusion criteria and regulatory approval processes are absent. Medical service items still face inconsistencies in classification across regions regarding coding, nomenclature, definition, pricing units, and price standards. Unified separate charging policies and procurement models for medical consumables remain inadequate. Regarding newly added items in the medical insurance payment scope (i.e., the "increment"), provinces and cities also lack synchronized progress. New additions of Chinese herbal decoction pieces, ethnic medicine, and institutional preparations lack regional negotiation mechanisms. Newly added medical service items still deviate from the unified national standards outlined in the national project guidelines. Conclusion: Significant disparities exist in the medical insurance payment scope between the two economically advanced regions. To advance integration of medical insurance payment scope, various regions should establish an authoritative regional coordination mechanism based on national top-level design, optimize adjustment rules for the National Reimbursement Drug List and enhance medical insurance fund pooling. Meanwhile, they should consider regional economic differences in policy implementation, and gradually establish reinsurance risk-sharing mechanisms and special fund pools—funded through central fiscal allocations and regional medical insurance fund contributions—to mitigate fund risks. Furthermore, while strengthening regional collaborative supervision of medical insurance funds, building an information-sharing platform, and improving the convenience of cross-regional medical expense settlement to promote integration of medical insurance payment scope.