【作者】 李倩；

【导师】 孙淑云；

【作者基本信息】 山西大学 ， 行政管理， 2018， 硕士

【摘要】 医疗保险经办机构作为《中华人民共和国社会保险法》等法律法规授权的医保经办服务组织,在医保给付的政府行政机构主管——医保经办服务机构——医疗保险被保险人的三角关系中,具有双重身份,医保机构处于被管理者、受委托的经办主体地位的是在行政管理关系中“管理与被管理”的关系;医保机构处于服务地位,对国家享有社会给付请求权的是在给付国家背景下,公民处于“权利主体”。公民与特定给付主体之间的具体法律关系是在公民与国家间以:“请求给付权利——给付义务”为内容抽象国家给付的具体化,在这个法律关系之后给付主体不应该仅仅为享有行政权利的管理者,与此同时也应该成为给付义务的承担者。鉴于在医疗保险法律关系中,给付义务的主体是对医保基金运营有独立权利和能力的保险人,在这个基础上,我国的医保经办机构应当是从确定独立性、健全职能、强化能力等方面向保险人方向给予塑造。在社会保险的运行中,社会保险经办机构发挥着不可磨灭的作用。但是在我国现行的法律法规中,关于我国医疗保险经办机构的法律地位规定并不明确,而且学界对医疗保险经办机构的完善理论研究也是大多集中在经办能力的强化、职能的整合。所谓“在其位,谋其政”,对于医疗保险经办机构而言也是如此。要正确整合经办机构执掌的“政”,我们只有准确的确定经办机构在保险运行中的“位”,否则脱离法律定位能力的强化和职能整合解决不了社会保险中存在的根本问题,最后只能是“头痛医头,脚痛医脚”。本文选择在社会保险中职能丰富的医疗保险经办机构作为分析对象,立足于社会行政给付法律关系的整体,希望在这个基础上对我国的医疗保险经办机构之完善提出建议。更多还原

【Abstract】 Medical insurance agency is an organization officially authorized by Social Insurance Law of the People’s Republic of China and other laws and regulations to handle medical insurance.In the triangle of the head of a government agency that pays for health care,medical insurance agency and the insurant,medical insurance has a dual identity.In the administration management relationship,being the authorized organization,medical insurance is in the position of being managed.Being a facilitating agency,medical insurance has right of claim to the payment subject,the country with citizens being the subject of right.The legal relationship between citizens and the payment subject is the concrete embodiment of the relationship between the right and obligation of payment.In the relationship,the payment subject is not only the administration manager,but also the undertaker of obligation.In light of the fact that in the legal relationship,the payment subject takes the role of insurer being charge of payment and medical fund operation,the medical insurance agency should be developed to its independence,complete function and strengthening ability.In the social insurance operation,social insurance agencies play an indelible role.However,in the current laws and regulations of our country,the legal status of China’s medical insurance agencies is not clear.The theoretical research on the improvement of medical insurance agencies is also mainly focused on the strengthening and functional integration of handling capacity."as long as one occupies a position,he should do esactl what this position requires to do and achieve the espected results" So does medical insurance managment agency.To properly integrate the Government of agencies,we should first ascertain its Position,and the strengthening and integration without ascertaining position will not solve the fundamental problems in social insurance,and finally can only be "band-aid” approach.This research chose medical insurance with rich functions in social insurance as research object,based on the overall social administration payment legal relationship,hoping to give a proposition for perfecting medical insurance agencies.更多还原