Iqembu Elihlanganisiwe Labahlinzeki NgezeMpilo
Inethiwekhi yomhlinzeki yomshuwalense wezempilo iyinhlangano yabahlinzeki bezempilo abaye bavumelana ne-carrier yomshuwalense wezempilo (nge- HMO, EPO, noma i-PPO ) ukuhlinzeka ukunakekelwa esaphulelo.
Inethiwekhi yezinhlelo zezempilo ihlanganisa abahlinzeki bezempilo njengabanakekeli bokuqala , odokotela, ama-laboratory, izikhungo ze-X, ama-X-Ray, izinkampani zokunakekelwa kwezempilo ekhaya, iziguli, abahlinzeki bemishini yezokwelapha, izikhungo zokuxoshwa, izidakamizwa, ama-podiatrists kanye nezindawo zokuhlinzwa ezifanayo.
Izinkampani zomshuwalense wezempilo zifuna ukuthi usebenzise abahlinzeki enethiwekhi yabo ngezizathu ezimbili ezibalulekile:
- Laba bahlinzeki baye bahlangabezana nezindinganiso zekhwalithi yezempilo.
- Bavumelanise ukwamukela isilinganiso sesaphulelo sokuxoxisana ngezinsizakalo zabo, ekuhwebeni kwevolumu yesiguli abazoyithola ngokuba yingxenye yenethiwekhi yecebo.
Kungani Izindaba Zenethiwekhi Yakho Yezempilo
Uzokhokha ama- copay aphansi nokuqinisekiswa kwemali uma uthola ukunakekelwa kwakho kumhlinzeki we-in-network, uma uqhathaniswa nesikhathi uthola ukunakekelwa kwakho kumhlinzeki wangaphandle. Eqinisweni, ama- HMO amaningi ngeke akhokhe ngisho nokunakekelwa okutholakele kumhlinzeki wangaphandle ngaphandle kwezingcingo ezandayo . Ngisho ne- PPOs encane yokuvimbela ngokuvamile inkokhelo yomshuwalense we-20 noma 30 we-co-inshurenti kubanikezeli be-inthanethi kanye nomshuwalense wama-50 noma angu-60 umshwalense wabo abahlinzeki be-out-of-network, futhi bavame ukuba nama- deductibles aphezulu nakuma -pocket angaphandle kwe-pocket uma uya ngaphandle kwenethiwekhi.
Imithetho ekhokhelwa ukuhlinzekwa kwe-in-network yakho uhlelo lwezempilo ngokuqondile, ukuqoqa kuphela imali ye-copay noma imali ekhishweyo ngesikhathi sakho sezinsizakalo (for coinsurance, okuyinto iphesenti yenani eliphelele - ngaphandle kwezinga eliphansi njenge-copay futhi lidonswe- ngokuvamile kungcono ukucela umhlinzeki ukuthi akhokhele umshuwalense kuqala, bese-ke inkokhelo yakho izobe isuselwe ngokulinganisa isilinganiso esithintekayo ukuthi umphathisihlalo unomhlinzeki).
Noma kunjalo, umhlinzeki wangaphandle-wenethiwekhi angeke afake isicelo sakho somshuwalense. Eqinisweni, abaningi badinga ukuthi ukhokhe yonke imali yakho bese uhambisa isimangalo nenkampani yakho yomshuwalense ukuze inkampani yomshuwalense ingakhokha. Leyo imali eningi phambili phambi kwakho, futhi uma kunenkinga ngesimangalo, nguwe olahlekelwe imali.
Umhlinzeki we-in-network akavunyelwe ukulinganisela-ukukhokha . Kumelwe bathole isilinganiso esivumelanisiwe, kuhlanganise ne-copay yakho noma ukukhokhelwa kwezimali, njengokukhokha ngokugcwele noma bazobe bephula isivumelwano sabo nenkampani yakho yomshuwalense wezempilo.
Kodwa njengoba abahlinzeki be-out-of-network bengenayo inkontileka nenkampani yakho yomshuwalense, leyo mithetho ayisebenzi kubo. Kwamanye amazwe, umhlinzeki ongaphandle kwe-inthanethi angakukhokhisa noma yini ayikhethayo, kungakhathaliseki ukuthi inkampani yakho yomshuwalense wezempilo ithi imali enengqondo nangokwezifiso yale nsizakalo. Njengoba inkampani yakho yomshuwalense izokhokhisa kuphela iphesenti lemali ekhokhwayo neyomkhuba, uzobe usukhoneni lomthethosivivinywa wonke ngomhlinzeki wangaphandle. Ngakho-ke, umhlinzeki we-in-network ngokuvamile uyindlela engcono kakhulu.
Inethiwekhi yomhlinzeki ishintsha ngaphansi kwe-ACA
Umthetho Wokunakekelwa Okuncintisayo, obhekene nokubhekwa okungahle ube khona futhi uphinde uthunyelwe ngaphansi kwe-Administration Trump , kudinga izinhlelo zezempilo ukumboza izinsizakalo eziphuthumayo ze-network ngokuhlanganyela okwabelanayo izindleko abangayisebenzisa uma umhlinzeki esebenze inethiwekhi.
Kodwa akukho mfuneko yokuthi ikamelo eliphuthumayo le-out-of-network lamukele inkokhelo yakho yenethiwekhi yezinga lempilo njengenkokhelo ephelele. Lokho kusho ukuthi isibhedlela sisavunyelwe ukulinganisa imali ekhokhwayo ngenxa yesondlo esiphuthumayo owatholile engazange ikhokhwe ngenkokhelo yenethiwekhi yakho yezinga lenhlalakahle (ungabona ukuthi lokhu kungenzeka kanjani, uma ucabanga ukuthi izinhlelo zezempilo zixoxa ngezansi izinkokhelo ezinezibhedlela zabo zangaphakathi-network, kanye nesibhedlela esingaphandle kwenethiwekhi angeke sicabange ukuthi lawo macala aphansi anganele).
Emakethe ngayinye (umshuwalense wezempilo ozithengayo wena, kunokuba uthole kumqashi noma ohlelweni lukahulumeni olunjengeMedare noma iMedicaid ), amanethiwekhi omhlinzeki anciphise eminyakeni embalwa edlule.
Kunezizathu ezihlukahlukene zalokhu, kuhlanganise:
- Abathwali bomshuwalense wezempilo baye bagxile ekufuneni abahlinzeki abanikela ngezinga elihle kakhulu
- Amanethiwekhi amancane anika abathwali amandla amaningi okuxoxisana ngokwemali yamanani.
- Ama-PPO amaningi ahlela ukuheha iziguli ezigulayo, kanti izindleko zokufaka izicelo eziphakeme ziphakeme.
- Ama-HMO anesidingo sezinsizakalo asiza abaqashi ukuba bagcine izindleko phansi, ngokuphambene nama-PPO lapho iziguli zingakhetha ukuya ngqo kumchwepheshe obiza izindleko eziphakeme.
Abathwali bomshuwalense emakethe ngayinye abangeke basebenzise ukubhala phansi kwezokwelapha ukuphika ukufihlwa kubantu abanezimo ezikhona ngaphambili (futhi, lokhu kungashintsha ngaphansi kwe-Trump Administration), futhi ukufakwa okumele kuhlinzekwe kuzo kufanelana ngendlela efanayo, ngenxa ye- ACA's izidingo zezempilo ezibalulekile . Abathwali nabo banqunyelwe ngokwephesenti yamaRandi angama-premium angawasebenzisa ezindleko zokuphatha.
Konke lokhu kuye kwabashiya ngezindlela ezimbalwa zokuncintisana ngentengo. Enye indlela abayenzayo namanje ishintshe kusuka kunethiwekhi evulekile inethiwekhi PPO ihlela ukunciphisa HMO inethiwekhi. Lokhu kuye kwaba yinto ehamba phambili emazweni amaningi eminyakeni embalwa edlule, kanti abanye bathi abasenayo abathwali abakhulu abahlinzeka ngamapulani e-PPO emakethe ngayinye. Kubhalisa abanempilo, lokhu ngokuvamile akuyona inkinga, njengoba bengavumi ukuba nohlu olubanzi lwabahlinzeki abakhona abafuna ukuqhubeka bewasebenzisa. Kodwa ama-PPO amaningi enethiwekhi athambekele ekukhoneni ababhalisile abagulayo-naphezu kwamaprimiyamu aphezulu-ngoba avumela ukufinyelela kobubanzi obubanzi bezochwepheshe kanye nezikhungo zezokwelapha. Njengoba izinhlelo zezempilo zingasakwazi ukubandlulula ababhalisi abagulayo ngokuziphika, ukuthutha okuningi, abathwali abaningi baye bakhetha ukukhawulela amanethiwekhi wabo kunalokho.
Kwamanye amazwe, amanethiwekhi ahlanganisiwe manje ayatholakala, ngekwabelana ngezindleko eziphansi ezigulini ezisebenzisa abahlinzeki emkhakheni owathandayo wesithwali.
Konke lokhu kusho ukuthi kubaluleke kunanini ngaphambili ukubuyekezwa imininingwane yenethiwekhi yakho yezinhlelo zezempilo, okungcono ngaphambi kokuthi udinga ukusebenzisa ukufakwa kwakho. Qinisekisa ukuthi uyaqonda ukuthi ngabe uhlelo lwakho luzokwenzela ukunakekelwa kwe-out-of-network (abaningi abakwenzile) futhi uma befuna, kuzokubiza kangakanani. Qinisekisa ukuthi uyazi ukuthi uhlelo lwakho ludinga ukuthi uthole ukudluliselwa kusuka kudokotela wakho wokunakekela oyinhloko ngaphambi kokubona udokotela, futhi yiziphi izinsizakalo ezandulela ukugunyazwa ezidingekayo. Uma wazi ngokwengeziwe inethiwekhi yakho yezinhlelo, ngeke kube nokucindezeleka okuncane lapho ekugcineni kudingeka usebenzise ukufaka kwakho ukufaka isicelo esibalulekile sezokwelapha.
Kubuyekezwe nguLouise Norris.
> Imithombo:
> Housedocs.house.gov. Ukuhlanganiswa koMvikeli Wezokwelapha kanye noMthetho Wokunakekelwa Kwezinkinga . Njengoba ichitshiyelwe ngo-Meyi 1, 2010.
> Kaiser Family Foundation. Ukuchaza Ukuguqulwa Kwezempilo: I-Medical Loss Ratio (MLR). Ngo-February 29, 2012.