国家医保局启动首批医保项目目录制定工作

国家医保局于9月16日发布《国家基本医疗保险医疗服务项目目录(第一批)制定工作方案》，正式启动首批国家医保项目目录的制定工作1。首批先制定心血管系统、呼吸系统、眼科、妇科、放射治疗、麻醉、护理、临床量表评估、口腔种植、辅助生殖、产科、放射检查和康复等13类项目目录，后续分批制定其他类别1。

纳入医保项目目录的医疗服务须满足三项基本条件：列入现行版国家医疗服务价格项目立项指南；临床必需、安全有效、价格适宜；对基本医疗保险基金支出的影响可控1。方案明确了不予纳入的情形，包括国家明确规定或立项指南建议实行市场调节价的项目，美容、非功能性整容、减肥、健康体检、预防、保健等非疾病治疗类服务，以及临床应用不够充分、具有重大安全隐患或风险的项目1。

制定的医保项目目录首先用于跨省异地就医结算，再逐步与各省医疗服务项目医保支付范围做好衔接1。

The National Medical Insurance Bureau released a work plan on September 16 to establish the first batch of the National Basic Medical Insurance Medical Service Project Directory. 1 The initiative marks the beginning of a systematic effort to standardize medical service coverage across the country's insurance system.

The first phase will establish directories across thirteen medical categories, including cardiovascular, respiratory, ophthalmology, obstetrics and gynecology, radiation therapy, anesthesia, nursing, clinical scale assessment, dental implants, assisted reproduction, obstetrics, radiological examination, and rehabilitation services. 1 The directory will employ specific criteria for inclusion: medical services must be listed in the current national medical service price project establishment guidelines, be clinically necessary and proven safe and effective with appropriate pricing, and have manageable financial impact on the basic medical insurance fund. 1 Services explicitly excluded are those subject to market pricing under national regulations, cosmetic or non-functional procedures, weight loss treatments, health screenings, preventive care, and other non-disease treatment categories, as well as services with insufficient clinical application evidence or significant safety concerns. 1

The newly developed directory will first support cross-provincial medical settlement for patients receiving care outside their home provinces, with gradual integration into each province's medical service coverage framework occurring in subsequent phases. 1