Objective:Against the backdrop of constructing a multi-tiered healthcare security system, this study focuses on the synergy mechanism between city-customized commercial health insurance and basic medical insurance. Methods:Based on the basic version data of 34 representative city-customized commercial health insurance products across China in 2025, this study quantitatively analyzes their synergy mechanism with basic medical insurance from six dimensions: operating entities, enrollment conditions, thresholds and deductibles, reimbursement ratios, coverage scopes, and payment and settlement methods. Results:City-customized commercial health insurance and basic medical insurance demonstrate good synergy in terms of operating entities, enrollment conditions, payment methods, and supplementary coverage for high-cost drugs outside the basic insurance catalog. However, significant obstacles remain, including coverage gaps caused by high deductibles, inadequate actual compensation for policyholders with pre-existing conditions, and insufficient data sharing that restricts precise product design. Conclusion:It is essential to clarify the tiered division of responsibilities between basic medical insurance and city-customized commercial health insurance, strengthen their coverage synergy, and establish a data-sharing mechanism between basic medical insurance and commercial insurance. These measures aim to enhance coverage precision and institutional sustainability, thereby building a systematic, efficient, and sustainable multi-tiered healthcare security system.
Key words
city-customized commercial health insurance /
basic medical insurance /
special drug list /
tiered division of responsibilities /
data sharing mechanism
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
References
[1] 中共中央,国务院.关于深化医药卫生体制改革的意见[EB/OL].(2009-03-17)[2025-10-23].https://www.gov.cn/gongbao/content/2009/content_1284372.htm.
[2] 新华社.中共中央国务院关于深化医疗保障制度改革的意见[EB/OL].(2020-03-05)[2025-11-25].https://www.gov.cn/zhengce/2020-03/05/content_5487407.htm.
[3] 国务院办公厅.关于加快发展商业健康保险的若干意见:国办发〔2014〕50号[A/OL].(2014-11-17)[2025-10-23].https://www.gov.cn/zhengce/content/2014-11/17/content_9210.htm.
[4] 刘晓婷,李忱运,田乐怡.“惠民保”可持续发展的挑战和对策探究[J].中国医疗保险,2023(4):113-120.
[5] 严睿,王恩楠,徐怀伏.惠民保特定高额药品保障现状与趋势分析[J].健康发展与政策研究,2025,28(5):540-545.
[6] 孙洁,黄艺飞.惠民保可持续发展:挑战及对策建议[J].价格理论与实践,2024(2):56-62.
[7] 新华社.中共中央国务院印发《“健康中国2030”规划纲要》[EB/OL].(2016-10-25)[2025-12-21].https://www.gov.cn/zhengce/2016-10/25/content_5124174.htm.
[8] 胡宏伟,刘堂森.“1+3+N”多层次医疗保障体系协同发展研究——基于待遇给付视角[J].中国医疗保险,2025(4):5-12.
[9] 黄国武. 中国多层次医疗保障发展思辨:基本多层向多元多层转型[J].社会保障评论,2022,6(4):67-82.
[10] 马振涛,文晓初.健康中国战略下我国商业健康保险定位价值、发展趋势及问题建议[J].中国医疗保险,2025(3):92-106.
[11] 胡宏伟,刘堂森.惠民保支持罕见病保障的现实挑战与优化方向——基于协同治理的视角[J].中国医疗保险,2024(9):111-123.
[12] 王毓丰,陈永法.商业保险衔接基本医疗保险的国际经验及启示[J].卫生经济研究,2019,36(9):60-64.
[13] 尚春晓,童禧辰,陈文,等.普惠型商业医疗保险特定高额药品保障研究[J].中国卫生资源,2023,26(1):88-91.
[14] 刘晓坤,王治,陈婕卿,等.基本医保与商业健康保险协同发展的国际经验与启示[J].中国医疗保险,2023(12):118-123.
[15] 郑功成.中国式现代化与多层次医疗保障体系建设[J].学术研究,2023(9):80-86+178.
[16] 许闲. 坚持“更普惠”宗旨探索十大迭代方向——《2023年城市定制型商业医疗保险(惠民保)知识图谱》解读[J].上海保险,2023(12):12-18.
[17] GARRISON L P, TOWSE A, BRIGGS A, et al.Performance-based risk-sharing arrangements-good practices for design, implementation, and evaluation: report of the ISPOR good practices for performance-based risk-sharing arrangements task force[J]. Value in health, 2013, 16(5): 703-719.
[18] 国家医疗保障局,人力资源社会保障部.关于印发《国家基本医保、生育保险和工伤保险药品目录》以及《商业健康保险创新药品目录》(2025年)的通知[EB/OL].(2025-12-07)[2026-03-16].https://www.nhsa.gov.cn/art/2025/12/7/art_104_18970.html.
[19] 国家金融监督管理总局.关于推动城市商业医疗险高质量发展的通知[EB/OL].(2025-07-30)[2026-03-16].https://www.nfra.gov.cn/cn/view/pages/governmentDetail.html?docId=1253070&itemId=861&generaltype=1.
