Ukunakekelwa kokunakekelwa okuqondayo kuyisici esiyinhloko sokukhetha uhlelo lwezempilo
Ukuze ukhethe umshwalense wezempilo ongcono kakhulu wena nomndeni wakho, kufanele uqonde umehluko phakathi kohlelo lwezempilo lwe-HMO, PPO, EPO, ne-POS. Lezo ziyizincazelo ezihlukahlukene zezinhlelo zokunakekelwa eziphethwe ezitholakala ezindaweni eziningi.
Sibutsetelo
- I-HMO = Inhlangano Yokulondoloza Impilo: I- HMO inamaphrimiyamu aphansi ngenyanga kanye nokwabiwa kwezindleko ezincane kunezinhlelo ezinemihibelo emincane yenethiwekhi, kodwa zidinga ukuhanjiswa kwe-primary care provider (PCP) futhi ngeke zikhokhele ukunakekelwa ngaphandle kwenethiwekhi ngaphandle kwezimo eziphuthumayo .
- I-PPO = Inhlangano Yomhlinzeki Oyithandayo : Ama- PPO athole lelo gama ngoba anenethiwekhi yabahlinzeki abakhetha ukuthi uyisebenzise, kodwa bazoqhubeka bekhokha ukunakekelwa kokuphuma kwenethiwekhi. Njengoba kunikezwe ukuthi kuncane kakhulu kunamanye amafomu okuhlela, bavame ukuba nama-premium aphezulu ngenyanga futhi bafune ukwabelana ngezindleko eziphakeme. Nakuba izinhlelo ze-PPO zaziyindlela ejwayelekile esikhathini esidlule, ziye zaziwa kakhulu eminyakeni yamuva nje njengoba izinhlelo zezempilo zinciphisa ubukhulu bamanethiwekhi abahlinzeki bawo futhi zishintsha kakhulu kuma-EPO nama-HMO ngomzamo wokulawula izindleko. I-PPOs isavamile phakathi kwezinhlelo zezempilo ezixhaswe ngumqashi, kodwa zanyamalala ngokuphelele emakethe yomshuwalense ngamunye kwezinye izifunda (umshuwalense ngamunye uhlobo oluthengayo wena-kuhlanganise ngokusebenzisa ukushintshaniswa kwendawo yakho-okungafani nokuthola kumqashi )
- I-EPO = Inhlangano Yomhlinzeki Oyingqayizivele : Ama- EPO athola lelo gama ngoba anenethiwekhi yabahlinzeki abasebenzisa kuphela . Kufanele unamathele kubahlinzeki kulolu hlu noma i-EPO ngeke ikhokhe. Kodwa-ke, i-EPO ngokuvamile ngeke ikuenze uthole ukuhanjiswa kudokotela oyinhloko wokunakekela ukuze uvakashele udokotela. Cabanga nge-EPO njengofana ne-PPO kodwa ngaphandle kokuhlinzekwa kokunakekelwa kwe-out-of-network.
- I-POS = Indawo Yesevisi: Izinhlelo ze-POS zifana nama-HMO kepha azivimbeli kakhulu ukuthi uvunyelwe, ngaphansi kwezimo ezithile, ukuba unakekelwe ngaphandle kwenethiwekhi njengoba ungathanda nge-PPO. Njengama-HMO, amapulani amaningi we-POS adinga ukuthi ube nokudluliselwa kwe-PCP kuwo wonke ukunakekelwa ukuthi kungaphakathi noma ngaphandle kwenethiwekhi.
Ukubhekisela, izinhlelo zokunakekelwa okungezona eziphathiwe zibizwa ngokuthi izinhlelo zokusiza.
Lezi izinhlelo zezempilo ezingenawo amanethiwekhi omhlinzeki, futhi zivele zibuyisele ingxenye yezindleko zakho kunoma iyiphi insizakalo yezokwelapha ehlanganisiwe. Amalungiselelo okubonga awazange atholakale emashumini ambalwa edlule futhi ajwayelekile kakhulu namuhla. Amasu okusiza amazinyo asejwayelekile, kepha cishe zonke izinhlelo zokuthengisa zezokwelapha zisebenzisa ukusetshenziswa ukunakekelwa okuphethwe
[Amalungiselelo okukhokhela izidakamizwa ezixilongwa ngezokwelapha abhekwa ngaphandle kwezinzuzo ngaphansi koMthetho Wokunakekelwa Okunganakekelwayo, futhi azihambisani nemithethonqubo yawo; Ukufakwa ngaphansi kwepulani elihlelekile kungabhekwa njengokubambisana okubalulekile, okusho ukuthi abantu abanamapulani ababhekwa njengabeshuwalense, futhi bangaphansi kwesigwebo somuntu ngamunye we-ACA .].
Qaphela ukuthi esinye isichazamazwi esasetshenziswa njalo, i- HSA , ayibheki uhlobo lokunakekelwa okuphethwe. I-HSA imelela i-akhawunti yokulondoloza impilo, futhi izinhlelo ze-HSA-ezifanelekayo zingaba ama-HMO, ama-PPOs, ama-EPO, noma amapulani we-POS. Izinhlelo ze-HSA-ezifanelekayo kufanele zihlangabezane nezidingo ezithile zokuhlela izinhlelo ezibekwa yi-IRS, kodwa azikhawulelwanga ngokwezihlobo zokunakekelwa okuphethweyo.
Ukuze ukhethe uhlobo oluhle lwepulani lempilo ngesimo sakho, udinga ukuqonda izindlela eziyisithupha ezibalulekile izinhlelo zezempilo zingahluka nokuthi indlela ngayinye yalezi zizokuthinta kanjani.
Okulandelayo, udinga ukufunda ukuthi ama-HMO, ama-PPOs, ama-EPO, nama-POS ahlela kanjani umsebenzi ngamunye, ngokwalowo maphoyinti ayisithupha.
Amaphuzu Wokuhluka
Izindlela eziyisithupha eziyisisekelo ama-HMOs, ama-PPOs, ama-EPO kanye nama-POS ahlukahluka yilokhu:
- Kungakhathaliseki ukuthi uyadingeka yini ukuthi unedokotela oyinhloko yokunakekelwa (PCP) noma cha
- Kungakhathaliseki ukuthi uyadingeka yini noma cha kudingeka ube nokudluliselwa ukuze ubone udokotela noma uthole amanye amasevisi
- Kungakhathaliseki ukuthi kufanele ube nezinkonzo zokunakekelwa kwezempilo ngaphambi kokugunyazwa noma cha
- Kungakhathaliseki ukuthi uhlelo lwezempilo luzokhokhela yini ukunakekelwa oluthola ngaphandle kwenethiwekhi yomhlinzeki
- Ukwabelana okungakanani izindleko oziphetheyo uma usebenzisa umshwalense wakho wezempilo
- Kungakhathaliseki ukuthi kufanele yini ukufaka izimangalo zomshuwalense noma cha
Indlela Ukuqhathaniswa Kwamapulani
Imithetho yomshuwalense wezempilo ihlukahluka kusuka kwesifunda kuya kwesifundazwe futhi ngezinye izikhathi uhlelo aluyikunamathela ngokuqinile kumklamo wokuhlela ojwayelekile. Sebenzisa le tafula njengomhlahlandlela jikelele, kodwa funda ukuphrinta okuhle kwi-Summary of Benefits and Cover for plan ngayinye ocingayo ngaphambi kokubhalisa. Ngaleyo ndlela uzokwazi ngokuqinisekile ukuthi yiluphi uhlelo olulindeleke kuwe, nokuthi yini ongayilindela kuyo.
| Kudinga i-PCP | Kudinga ukudluliselwa | Kudinga ukugunyazwa kwangaphambili | Ihlawulela ukunakekelwa okungaphandle kwenethiwekhi | Ukwabelana ngezindleko | Ingabe kufanele ufake amafomu wokufaka isicelo? | |
|---|---|---|---|---|---|---|
| I-HMO | Yebo | Yebo | Akuvamile okudingekayo. Uma kudingeka, i-PCP iyayenza. | Cha | Ngokujwayelekile phansi | Cha |
| I-POS | Yebo | Yebo | Akuvamile. Uma kudingeka, i-PCP cishe iyakwenza. Ukunakekelwa kwe-out-of-network kungase kube nemithetho ehlukile. | Yebo, kodwa kudinga ukudluliselwa kwe-PCP. | Ngokujwayelekile ngaphakathi kwe-inethiwekhi, ephakeme kakhulu ngaphandle kwe-inethiwekhi. | Izicelo zokuphuma ngaphandle kwenethiwekhi kuphela. |
| I-EPO | Cha | Cha | Yebo | Cha | Ngokujwayelekile phansi | Cha |
| I-PPO | Cha | Cha | Yebo | Yebo | Ngokuphakeme kakhulu, ikakhulukazi ukunakekelwa kwe-out-of-network. | Izicelo zokuphuma ngaphandle kwenethiwekhi kuphela. |
Isidingo Somdokotela
Ezinye izinhlobo zomshuwalense wezempilo zidinga ukuthi ube nodokotela oyinhloko yokunakekela. Kulezi zinhlelo zezempilo, indima ye-PCP ibaluleke kakhulu ukuthi uhlelo luzokwabela i-PCP uma ungasheshi ukhethe eyodwa ohlwini lwaloluhlelo. Ama-HMO namaPOS amapulani adinga i-PCP.
Kulezi zicwangciso, i-PCP ingudokotela wakho oyinhloko oqondisa zonke ezinye izinsizakalo zokunakekelwa kwezempilo. Isibonelo, izixhumanisi zakho ze-PCP oyidingayo njengezokwelapha ngokomzimba noma i-oxygen ekhaya. Uphinde uqondise ukunakekela okuthola kuchwepheshe.
Ngenxa yokuthi i-PCP yakho inquma ukuthi ungayidinga yini noma ungayifuni ukubona udokotela noma uhlobo oluthile lwezinsizakalo zokunakekelwa kwezempilo noma ukuhlolwa, kulezi zindlela i-PCP yakho isebenza njengomlindisango olawula ukufinyelela kwakho ezinsizakalo zokunakekelwa kwezempilo okukhethekile.
Kuzinhlelo ngaphandle kwemfuneko ye-PCP, ukuthola ukufinyelela kumasevisi okukhethekile kungase kube ngaphansi kwesimo esibucayi, kodwa unomthwalo wemfanelo omkhulu wokuxhumanisa ukunakekelwa kwakho. I-EPO ne-PPO izinhlelo azidingi i-PCP.
Isidingo sokudluliselwa
Ngokuvamile, izinhlelo zezempilo ezidinga ukuthi ube ne-PCP nazo zidinga ukuba ube nokudluliselwa kusuka ku-PCP yakho ngaphambi kokuba ubone udokotela noma uthole noma yiluphi olunye uhlobo lwezinsizakalo zokunakekelwa kwezempilo ezingekho esimweni esiphuthumayo. Ukufuna ukudluliselwa kwindlela yenkampani yomshuwalense wezempilo yokugcina izindleko ngokuhlola ngokuqiniseka ukuthi udinga ngempela ukubona lochwepheshe noma uthole leyo nkonzo ebiza noma ukuhlolwa.
Ukunciphisa kule mfuneko kufaka ukubambezeleka ekuboneni ochwepheshe futhi kungenzeka ukuthi awuvumelani ne-PCP yakho mayelana nokuthi ungadingeki yini ukubona isiprofetho noma cha. Ngaphezu kwalokho, isiguli singase sibe nezindleko ezengeziwe ngenxa ye-copay edingekayo ekuvakasheni kwe-PCP kanye nokuvakashela ochwepheshe.
Izinzuzo ezidingekayo zifaka isiqiniseko sokuthi uya olwazini olufanele nolwazi lokuxhumanisa ukunakekelwa kwakho. Uma unolwazi oluningi, i-PCP yakho iyazi ukuthi isiphi isazi ngasinye esikwenzayo futhi siqinisekisa ukuthi ukwelashwa okukhethekile okhethekile akuhambisani nomunye nomunye.
Yize kujwayelekile ukuthi i-HMO ne-POS ihlele ukuba nezidingo zokudlulisela emuva, izinhlelo ezithile zokunakekelwa eziphethwe ukuthi zivame ukuthunyelwa kwe-PCP ziye zashintshela "imodeli yokufinyelela" evumela amalungu ukuba abone ochwepheshe ngaphakathi kwenethiwekhi ngaphandle kokudluliselwa. Ngakho-ke nakuba kunezinto ezijwayelekile mayelana nezinhlelo zokunakekelwa eziphathisiwe, akukho okunye okufaka esikhundleni sokufunda okuhle kuhlelo lwakho noma amapulani owacabangayo.
Ukugunyazwa kwangaphambi
Ukugunyazwa kwangaphambili noma isidingo sokugunyazwa ngaphambi kushiwo inkampani yomshuwalense wezempilo idinga ukuba uthole imvume kubo ngezinhlobo ezithile zemisebenzi yokunakekelwa kwezempilo ngaphambi kokuba uvunyelwe ukuba uthole lokho. Uma ungayitholi igunya lokugunyazwa ngaphambilini, uhlelo lwezempilo lungenqaba ukukhokha inkonzo.
Izinhlelo zezempilo zigcina izindleko ngokuhlola ngokuqiniseka ukuthi udinga ngempela izinsizakalo ozitholayo. Ezimweni ezidinga ukuba ube ne-PCP, lowo dokotela ngokuyinhloko unesibopho sokuqinisekisa ukuthi udinga ngempela amasevisi othola kuwo. Izinhlelo ezingadingi i-PCP (njenge-EPO ne-PPO izinhlelo) zisebenzisa ukugunyazwa kwangaphambili njengendlela yokufinyelela umgomo ofanayo: uhlelo lwezempilo lukhokhela kuphela ukunakekelwa okudingekayo ngokwezempilo.
Amacebo ahluke ngokuthi yiziphi izinhlobo zamasevisi okumelwe agunyazwe ngaphambilini kodwa cishe yonke indawo idinga ukuthi izibhedlela ezingekho ngaphansi kwezimo eziphuthumayo kanye nokuhlinzekwa zihlinzekwe ngaphambilini. Abaningi badinga ukugunyazwa kwangaphambili kwezinto ezinjenge-MRI noma i-CT, izidakamizwa ezibiza kakhulu, nemishini yezokwelapha ezifana ne-oxygen yasekhaya nemibhede yesibhedlela.
Ukugunyazwa kwangaphambi kwesikhathi kwenzeka ngokushesha futhi uzoba negunya ngaphambi kokuba ushiye ihhovisi likadokotela. Ngokuvamile, kuthatha izinsuku ezimbalwa. Kwezinye izimo, kungathatha amasonto.
Ukunakekelwa kwe-Out-of-Network
Ama-HMO, ama-PPOs, ama-EPO, nama-POS ahlela wonke amanethiwekhi omhlinzeki. Le nethiwekhi ihlanganisa odokotela, izibhedlela, ama-laboratory kanye nabanye abahlinzeka ukuthi banesivumelwano nehlelo lwezempilo noma, kwezinye izimo, basebenze uhlelo lwezempilo. Amacebo ahluke ngokuthi ngabe uzoba nokuhlinzeka ngezinsizakalo zokunakekelwa kwezempilo kubahlinzeki abangekho kwinethiwekhi yabo.
Uma ubona udokotela ongaphandle kwe-network noma uthole ukuhlolwa kwegazi okwenziwe ekhelini langaphandle, ezinye izinhlelo zezempilo ngeke zikhokhelwe. Uzobe unamathela ekukhokheleni wonke umthethosivivinywa wokunakekelwa owawutholile ngaphandle kwenethiwekhi. Ngaphandle kwalokhu kunakekelwa okuphuthumayo. Izinhlelo zokunakekelwa ezithintekayo zizohlinzekela ukunakekelwa okuphuthumayo okutholakala ekamelweni eliphuthumayo lenethiwekhi uma nje uhlelo lwezempilo luvuma ukuthi ukunakekelwa kwakudingeka ngempela futhi kwakha isimo esiphuthumayo (inothi ukuthi umhlinzeki wangaphandle ongakuthola imali umehluko phakathi kwalokho abakhokhisayo nokuthi yini oyikhokhela yona).
Kwezinye izinhlelo, umshuwalense uyokhokhela ukunakekelwa kwe-out-of-network. Noma kunjalo, kuzodingeka ukhokhe amaphesenti amakhulu wezindleko kunalokho obekuyokhokha uma ngabe uthola ukunakekelwa okufanayo ku-inethiwekhi.
Kungakhathaliseki ukuthi umdwebo wezinhlelo, abahlinzeki be-out-of-network ababoshiwe yiziphi izinkontileka ezinenkampani yakho yomshuwalense wezempilo. Ngisho noma umshuwalense we-POS noma i-PPO akhokha ingxenye yezindleko, umhlinzeki wezokwelapha angakukhokhela umahluko phakathi kwamacala abo avamile nokuthi yini umshwalense wakho okhokhela wona. Uma benza, unesibopho sokukhokha. Lokhu kubizwa ngokuthi ukukhokhiswa kwe-balance , futhi kungokomthetho emazweni amaningi ekunakekelweni kwe-out-of-network, ngisho nasezimo eziphuthumayo.
Ukwabelana ngezindleko
Ukwabelana ngezindleko kuhilela ukukhokhela ingxenye yezindleko zakho zokunakekela impilo-uhlanganyela izindleko zokunakekela impilo yakho nenkampani yakho yomshuwalense wezempilo. Ama-Deductibles , ama- copayments , nokuqinisekiswa kwemali yizo zonke izinhlobo zokwabelana ngezindleko.
Izinhlelo zezempilo zihluke ngohlobo luni kanye nokwabelana okubiza izindleko. Ngokuvamile, izinhlelo zokunakekela ezithintekayo ezengeziwe zikuvuza ngokuzidingo eziphansi zokubelana ngezindleko, kanti izinhlelo eziningi zempilo ezivumela ukuthi uthathe ingxenye enkulu yebhilidi ngokusebenzisa ama-deductibles aphezulu, ukuqinisekiswa kwezimali noma i-copayments.
Kodwa lokhu kuye kwashintsha njengoba isikhathi sihamba. Eminyakeni yama-80 no-90, kwakuvame ukubona ama-HMO angenayo i-deductible nhlobo. Namuhla, i-HMO ihlela ngama-dollar angu-1 000 + ajwayelekile (emakethe ngayinye, ama-HMO abe yizinhlelo eziningi kakhulu ezindaweni eziningi, futhi zivame ukuhlinzekwa ngama-deductibles ama $ 5,000 noma ngaphezulu).
Kuzinhlelo ezikhokha ingxenye yezindleko zakho, uma ubona abahlinzeki be-out-of-network, amacala akho okuphuma ngaphandle kwe-pocket azoba aphezulu kakhulu (ngokuvamile kabili) kunokuba abeke uma ubona odokotela be-in-network. Ngakho-ke isibonelo, uma uhlelo lwakho lunemali eyi-$ 1,000 ekhishwe, kungase kube ne-$ 2,000 enqunyiwe ekunakekelweni kwe-out-of-network.
Umkhawulo ophezulu kulokho okuzokhokha ukukhokha izindleko ezingaphandle (kufaka phakathi i-coinsurance) cishe kuyoba ngaphezulu uma uphuma ngaphandle kwenethiwekhi yakho. Kubalulekile futhi ukuqaphela ukuthi ezinye izinhlelo ze-PPO kanye ne-POS zishintshe kwi-cap engenamkhawulo ezindleko ezingaphandle kwezimpahla lapho amalungu efuna ukunakekelwa kwe-in-network. Lokhu kungaqeda ukubiza kakhulu abathengi abangazi ukuthi i- plan yesikhwama sezindleko ezingaphandle kwe-pocket (njengoba kudingwa yi-ACA) isebenza kuphela ngaphakathi kwenethiwekhi yomhlinzeki wezinhlelo.
Izicelo zokufaka
Uma uthola ukunakekelwa kwe-inethiwekhi, ngokuvamile ubophezele ukufaka amaphepha okufaka isicelo nenkampani yakho yomshuwalense. Uma uhlala ku-inethiwekhi, udokotela wakho, esibhedlela, ubunikazi, noma omunye umhlinzeki uzofaka noma yiziphi izimangalo ezidingekayo.
Kuzinhlelo ezingabheki ukunakekelwa kwe-out-of-network, ngokuvamile akusikho isizathu sokufaka isimangalo ngaphandle kokuthi uthola ukunakekelwa okuphuthumayo ngaphandle kwe-inethiwekhi ngoba umshwalense wakho ngeke akubuyisele izindleko.
Kusabalulekile ukugcina ithrekhi yalokho oyikhokhile, noma kunjalo, njengoba ungakwazi ukudonsa izindleko zakho zezokwelapha ekubuyiselweni kwentela yakho (uma zingaphezu kwamaphesenti angu-7.5 wemali engenayo; lokhu kuzokwanda kuze kube ngu-10% kusukela ngo-2019 ). Noma, uma unayo i- HSA , ungazibuyisela ngokwakho (ngesikhathi noma isevisi, nanoma yisiphi isikhathi esikhathini esizayo) ngezinkokhelo zangaphambi kwentela ezivela ku-HSA yakho, ucabanga ukuthi awukhiphi izindleko zakho zezokwelapha ekubuyiseleni intela yakho (ungakwazi 'Yenza kokubili; lokho kungaba ukuphinda kabili).
Indlela Udokotela Wakho Ozuza Ngayo
Ukuqonda ukuthi udokotela wakho ukhokhelwa kanjani kungakusiza ngezimo lapho kunconywa khona izinsizakalo ezingaphezu kwalokho okudingekile, noma izimo lapho kungase kudingeke khona ukuphoqa ukunakekelwa okungaphezu kwalokho okunikezwayo.
Ku-HMO, udokotela ngokuvamile ungumsebenzi we-HMO noma ukhokhelwe indlela ebizwa ngokuthi i- capitation . Ukuthungatha kusho ukuthi udokotela unikezwa imali ethile ngenyanga ngayinye yamalungu e-HMO aphoqelekile ukuba anakekele. Udokotela uthola inani elifanayo lemali yelungu ngalinye noma lelo lungu lingafuna izinsizakalo ngenyanga noma cha.
Nakuba izinkokhelo zokukhokha ezithintekayo zidikibala ukuyala ukuhlolwa kanye nokwelapha okungadingekile, inkinga ngokuthunjwa ukuthi akusikho isikhuthazo esikhulu sokwenza okudingekayo , noma ngabe. Eqinisweni, umkhuba onenzuzo kakhulu ungaba neziguli eziningi kodwa ungahlinzeki ngamasevisi kunoma iyiphi yazo.
Ekugcineni, izikhuthazo zokuhlinzeka ngokunakekelwa okudingekile ku-HMO ziyisifiso esiqotho sokunikeza ukunakekelwa okuhle kwesiguli, ukwehla kwezindleko zesikhathi eside ngokugcina amalungu e-HMO enempilo, izinga lomphakathi kanye nokweneliseka kwamakhasimende, kanye nokusongelwa kwe-suit compliance.
Ku-EPO nama-PPOs, odokotela bavame ukukhokhelwa njalo ngesikhathi banikeza inkonzo. Lapho iziguli zibona usuku, imali eyengeziwe. Ngaphezu kwalokho, izinto ezengeziwe udokotela azenza ngesikhathi sokuvakashelwa, noma ukuvakashelwa kwesinqumo sezokwelapha eziyinkimbinkimbi kudinga, uma udokotela ekhokhelwa ukuvakasha lokho. Lolu hlobo lwenkokhelo lokukhokha luyaziwa njengemali-ye-service.
Ukuphazamiseka kokuhlelwa kwenkokhelo yokukhokhwa kwemali yukuthi ukunikeza udokotela imali ukuze anikeze ukunakekelwa okungaphezu kwalokho okungadingeka. Ukuvakashelwa okulandelayo okulandelayo kuyadingeka, imali engaphezu kwalokho udokotela akwenzayo. Kanti futhi, njengoba udokotela ekhokhelwa ukuvakashelwa okuyinkimbinkimbi, akumangalisi ukuthi iziguli zinokuhlolwa okuningi kwegazi, i-X ray, kanye nohlu olude lwezinkinga ezingapheli.
Ngenxa yokuthi abantu bangase banakekele okwengeziwe kunalokho okudingekile, amalungiselelo okukhokha okukhokhelwa insizakalo aholela ekwenzeni izindleko zokunakekelwa kwezempilo kanye nemishanguzo yemishwalense yempilo ephezulu.
I-Medicare ne-Medicaid
Kulinganiselwa ukuthi amaphesenti angama-36.7 abantu base-US abhalisiwe ku-Medicaid noma i-Medicare. Lezi zinhlelo zezempilo ezisebenza ngohulumeni. Ngokwesiko, uhulumeni (federal for Medicare; federal kanye nezwe for Medicaid) bavele bakhokhela abahlinzeki ngezempilo ngqo lapho ababhalisile wathola ukunakekelwa.
Kodwa emashumini eminyaka amuva, kuye kwaba khona ukushintshela ekunakekelweni okuphethwe eMedicaid naseMedare. Kusukela ngo-2014, izingxenye ezingaphezu kwezingxenye ezintathu ze-Medicaid ezibhalisiwe zisezinhlelo zokunakekelwa kweMedicaid (izivumelwano zikahulumeni ngezinhlelo ezilodwa zezempilo noma ngaphezulu; ababhalisile bangase bathole ikhadi le-ID ye-Blue Cross Blue Shield, ngokuphambene nekhadi le-ID kusuka kuhulumeni Uhlelo lwe-Medicaid). Ngo-2017, ingxenye yesithathu yabakwa-Medicare ababhalisile yayisezinhlelo zokunakekelwa okuphethwe (Medicare Advantage).
Yikuphi Okuhle Kakhulu?
Kuncike ekutheni ukhululekile kangakanani nemingcele nokuthi uzimisele kangakanani ukukhokha. Uma uhlelo lwakho lwezempilo lukhulula kakhulu inkululeko yakho yokuzikhethela, ngokwesibonelo, ngokungakhokheli ukunakekelwa kwe-out-of-network noma ngokucela ukuba udluliselwe kudokotela wakho ngaphambi kokuba ubone udokotela, okungenani kuzodla izindleko zeprimiyamu futhi ngokukwabelana ngezindleko. Inkululeko enkulu yokuzikhethela le plan ivumela, uma kungenzeka ukuthi ukhokhele leyo nkululeko.
Umsebenzi wakho ukuthola ukuthola ibhalansi okhululekile kakhulu. Uma ufuna ukugcina izindleko zakho ziphansi futhi ungacabangi imingcele yokuhlala ku-inethiwekhi futhi uthole imvume evela ku-PCP yakho ukubona isazi, mhlawumbe i-HMO ingeyakho. Uma ufuna ukugcina izindleko eziphansi, kodwa kukutshela ukuba uthole ukuthunyelwa kwesazi, cabanga nge-EPO.
Uma ungakhathazeki ukukhokha ngaphezulu, kokubili amaphrimiyamu wenyanga kanye nokwabelana ngezindleko, i-PPO izokunika kokubili ukuguquguquka kokuphuma ngaphandle kwenethiwekhi nokubona ochwepheshe ngaphandle kokudluliselwa. Kodwa, ama-PPO afika nomsebenzi owengeziwe wokuthola ukugunyazwa kwangaphambili kusuka kumshuwalense ngezinsizakalo ezibizayo, futhi bavame ukuba yindlela ebiza kakhulu.
Uma uthengisa ukwaziswa kwakho (okungafani nokukuthola kumqashi wakho), kungenzeka ukuthi awunayo izinketho ze-PPO, njengoba izinhlelo zomakethe zomuntu ngamunye ziye zashintsha kakhulu kumodeli we-HMO. Futhi uma uthola ukwaziswa okuvela kumqashi wakho, ububanzi bezinketho zakho zokuhlela kuzokwenzeka ngokujwayelekile ngobukhulu bomqashi wakho. Abaqashi abakhulu bavame ukunikeza izinketho eziningi zokuhlela, kanti umqashi omncane angase abe necebo elilodwa elitholakalayo labasebenzi ukuba bamamukele noma banqabe.
Izwi elivela
Cishe zonke izinhlelo zomshuwalense wezempilo zanamuhla zilawulwa izinhlelo zokunakekelwa, kodwa kukhona ukuhluka okuphawulekayo ngokulingana kwenethiwekhi yomhlinzeki kanye nezidingo ukuthi izinhlelo zizosetshenziselwa amalungu.
Okubalulekile: ayikho uhlobo oluhle lokuhlela impilo. Ngamunye ufana nephuzu elilinganayo lezinsizakalo phakathi kwezinzuzo ezibhekene nemingcele futhi phakathi kokuchitha okuningi ngokuqhathanisa nokuchitha kancane. Ukuqonda umehluko phakathi kwe-PPO, i-EPO, i-HMO, ne-POS yisinyathelo sokuqala ekunqumeni ukuthi ungakhetha kanjani uhlelo lomshwalense lwempilo oluzosebenza kangcono wena nomndeni wakho.
> Imithombo:
> Congress.gov. I-HR1 - Umthetho wokuhlinzekela ukubuyisana ngokuhambisana nezihloko II no-V zesinqumo esiphelelene nesabelomali sonyaka wezimali 2018 >. Yenzelwe 12/22/2017.
> UGaba, uCharles. Ama-Signups we-ACA, Ukuphulukiswa Kwezempilo Kwezokuphulukiswa Kwebonke Abantu Base-US Ngesinye Ishadi. NgoMashi 2016.
> HealthCare.gov, Uhlelo Lwempilo Yomshuwalense Nezinhlobo Zokuxhumana: Ama-HMO, ama-PPOs, nokuningi.
> Kaiser Family Foundation, Medicare Advantage Spotlight 2017: Ukuvuselelwa Kwemakethe Yezokubhalisa. Juni 2017.
> Kaiser Family Foundation, Total Medicaid ephethwe Ukubhalisa Care, 2014.