Objective: The paper attempts to analyze the mechanism and activation path of active participation behavior of urban and rural residents from a theoretical perspective, and propose driving strategies for activating participation behavior of urban and rural residents. Methods: Focusing on the phenomenon of urban and rural residents choosing not to participate in basic medical insurance in some regions, field visits were conducted in Jiangsu, Zhejiang and Shanxi Province, and semi-structured interviews were conducted with the heads of medical insurance claim management and fund administration agencies, village committee directors, and ordinary residents. We constructed a theoretical analysis framework for the active participation behavior of urban and rural residents in basic medical insurance, which was based on policy context, effectiveness and experience, and residents' behavior. Results: The active participation behavior of residents in insurance is influenced by the interaction between policy context and its experience and effectiveness. It is necessary to activate the active participation behavior of residents in the established policy context, and further attention should be paid to the evolutionary characteristics of active participation behavior of residents to achieve continuous and beneficial participation behavior. Conclusion: It is suggested to further optimize basic medical insurance public services, promote the fairness of basic medical insurance security for urban and rural residents, strengthen the effectiveness and experience of basic medical insurance for urban and rural residents, and drive urban and rural residents to actively participate in basic medical insurance.