Ukudluliselwa kuwuhlobo olukhethekile lokuvunywa kwangaphambili kwamalungu omuntu ngamunye wezempilo - ikakhulukazi labo abane- HMO -bafuna ukuthola udokotela wabo wokunakekela oyinhloko ngaphambi kokubona udokotela noma omunye udokotela ngaphakathi kwenethiwekhi efanayo.
Amanye amapulani adinga ukuthunyelwa ukuba kubhalwe ngokuqondile kudokotela, kanti abanye bayokwamukela ucingo kusuka kudokotela wakho wokunakekela oyinhloko.
Ukuze uqinisekise ukuthi konke kuhambisane nokubona ochwepheshe , kufanele usebenze, futhi uqinisekise ukuthi umshwalense wakho uthole ukuhanjiswa ngaphambi kokwenza i-aphoyintimenti nomchwepheshe wakho. Lokho uzokwazi ukuthi ukuvakashelwa kwakho kuchwepheshe kuzotholakala ngaphansi kohlelo lwakho lokunakekela impilo.
Okudluliselwayo kanye ne-HMO
Izinhlangano zokunakekelwa kwezempilo, noma i-HMO, zidinga umuntu ukuba akhethe udokotela oyinhloko . Ngakho-ke udokotela oyinhloko ukhathalela ukunakekelwa konke ukunakekelwa kwezempilo komuntu. Udokotela wokunakekelwa oyinhloko uba nesibopho sokwenza izincomo mayelana nezifundo zokwelashwa, ukuvakashelwa ochwepheshe, imithi, nokuningi. Udokotela oyinhloko wokunakekelwa inikeza nokudluliselwa kwezinye izinsizakalo ezidingekayo noma ukuvakashelwa ochwepheshe ngaphakathi kwenethiwekhi. Lezi zihanjelwe zikuvumela ukuba uhambe ubone omunye udokotela noma ochwepheshe ngaphakathi kwenethiwekhi yezempilo .
Uma ungenalo ukudluliselwa kusuka kudokotela wakho wokunakekela oyinhloko, noma unquma ukuya kudokotela ohlukile ngaphandle kwenethiwekhi yakho yezinhlelo zezempilo, cishe uzokhokha konke noma izindleko eziningi zalokhu kunakekelwa, njengoba ngeke ihlanganiswe yi-HMO. I-HMO ngokuvamile ihlanganisa ukuhambela ngaphakathi kwenethiwekhi.
Ama-HMO asevele avame kakhulu emakethe yomshuwalense wezempilo ngamunye eminyakeni embalwa edlule njengoba abathinteli bebenza ukulawula izindleko. Ukushintshaniswa komshuwalense wezempilo kwezinye uthi akusenayo izinketho ze-PPO ezitholakalayo.
Okudluliselwayo kanye ne-PPO
Ukudluliselwa akudingekile ku- PPO . Inhlangano ehlinzekwayo yokuhlinzeka uhlelo lwezempilo olunezinkontileka ezinenethiwekhi enkulu yabahlinzeki "abathandayo". Uyakwazi ukukhetha ukunakekelwa noma isevisi yakho ngaphandle kwenethiwekhi. Ngokungafani nenhlangano yokugcinwa kwezempilo, ku-PPO akudingeki ukhethe udokotela oyinhloko yokunakekela futhi awudingi ukuthunyelwa ukuze ubone abanye abahlinzeki kunethiwekhi.
Ngenxa yalokhu kuguquguquka, izinhlelo ze-PPO zivame ukubiza ngaphezu kwe-HMO izinhlelo nezinzuzo ezifanayo. Futhi bavame ukuheha abantu ababhalisile ngezimo zempilo, ngoba labo bangabantu abazovuma ukukhokhela amaphrimiyamu aphezulu ukuze bathole uhla olubanzi lwabahlinzeki bezempilo abangabonwa ngaphandle kokudluliselwa. Lokhu yingxenye yesizathu sokuthi ngabanikezeli bezimakethe ngabanye abathengisa kude nama-PPO eminyakeni yamuva.
Ukukhokha
Inkokhelo yomshwalense yamasevisi ngaphakathi kwenethiwekhi ekhethiwe ihluka phakathi kwama-HMO nama-PPOs.
In-Network:
I-HMO ne-PPO: Kungakhathaliseki ukuthi unayo i-HMO noma i-PPO, ngezinsizakalo ze -inthanethi uzoba nemithwalo yemali yokukhokha kanye ne- deductible , kanye ne- coinsurance uma uhlelo lwakho luyisebenzisa .
I-Out-of-Network:
I-HMO: Ku-HMO, ngokuvamile awuhlanganisiwe kunoma yiziphi izinsizakalo ezingaphandle kwenethiwekhi.
I-PPO: Ku-PPO, ngokuvamile ukuhlinzekwa kokunakekelwa kwe-out-of-network, kodwa umhlinzeki ukhululekile ukulinganisa imali ekhokhwayo isabelo sakho somshuwalense asimbozi kusukela umhlinzeki engasayine isivumelwano ne-insurer yakho . Uma ukhetha ukungena ngaphandle kwenethiwekhi ekunakekeleni kwakho, ngokuvamile uzodinga ukukhokha umhlinzeki kuqala, bese uthola ukubuyiselwa yi-PPO. Amapulani amaningi e-PPO anama-deductibles aphakeme kakhulu nakwa-out-of-pocket ama-maximum for ukunakekelwa kwe-out-of-network, futhi kuya ngokuvame ukubona amapulani we-PPO engenamkhawulo ngaphandle kwezindleko ze-PPO ozothola uma uphuma ngaphandle inethiwekhi.