《保险研究》20240909-《职工医保个人账户置换长期护理保险的法律构造》（王天玉）

［摘   要］医疗保障领域存在两种显著的资源配置需求，一方面是顶层设计提出加快建立长期护理保险制度，《“十四五”全民医疗保障规划》明确“从职工基本医疗保险参保人群起步”，职工需承担长期护理保险缴费义务；另一方面是职工医保个人账户沉淀资金过多，虽经2021年医保改革将“用人单位缴费30%”计入统筹基金，但仍无法有效激活和消化巨大的存量资金。职工医保个人账户具有受限制所有权属性，在已实现医保“统账结合”模式内部权益置换的基础上，可探索医疗保障整体框架下的跨险种权益置换。依据基本医疗卫生立法和政策走向，职工作为参保主体从医疗保险向长期护理保险整体移植的同时，可开通医保个人账户支付长期护理保险费的制度通道，实现个人账户受限制所有权与护理服务请求权之间的权益置换，发展基本医疗保障项目之间“大分类、小融通”的制度结构。

［关键词］职工医保；个人账户；长期护理保险；权益置换

［基金项目］本文获中国社会科学院学科建设“登峰战略”资助计划资助(DF2023YS32)。

［作者简介］王天玉，中国社会科学院法学研究所研究员，研究方向：劳动法和社会保障法。

The Legal Framework of the Exchange of Individual Accounts in Employee Medical Insurance for Long-Term Care Insurance System

WANG Tian-yu

Abstract：There are two critical needs for resources reallocation for the social medical insurance system.On the one hand,the top-level design aims to expedite the establishment of a long-term care insurance system.The "14th Five-Year" National Healthcare Security Plan stipulates that contribution to long-term care insurance should be borne by employees,commencing with participants in basic medical insurance.On the other hand,there is a surplus of funds accumulating in the individual accounts of employees’ social medical insurance.Although the 2021 healthcare reform integrated "30% of the employer’s contribution" into the unified fund,it remains insufficient to efficiently mobilize and utilize the substantial funds in the individual accounts of employees.The employee individual accounts possess restricted ownership attributes.Building upon the internal equity exchange model of the "integrated account" in the social medical insurance scheme that has already been realized,we can investigate cross-insurance plan equity exchange within the broader framework of the scheme.By aligning with primary medical and healthcare legislation and policy directives,and transplanting employees as the insured subject from medical insurance to long-term care insurance as a collective,a pathway for long-term care insurance premiums to be paid from the employee individual account can be established.This would allow for the exchange of rights and benefits between the restricted ownership of the individual account and the entitlement to request care services,while forming a structured system of "broad categorization and limited integration" among the basic medical insurance schemes.

Key words：social medical insurance for employees;individual account;long-term care insurance;rights and benefits exchange