Yini Ongayilindela Uma Ujoyina Inhlangano Yokugcinwa Kwezempilo
Ukuqonda ukuthi i-HMO ingukuthi nokuthi isebenza kanjani kubalulekile ekukhetheni uhlelo lwezempilo ngesikhathi sokubhalisa okuvulekile kanye nalapho usebenzisa i-HMO yakho ngemuva kokubhalisa.
Kuyini i-HMO?
I-HMO imele inhlangano yokugcinwa kwezempilo , uhlobo lokuphathwa kwempilo yomshuwalense wezempilo. Njengoba igama libonisa, enye yezinhloso eziyinhloko ze-HMO ukugcina amalungu ayo aphile. I-HMO yakho ingathanda ukuchitha imali encane ngaphambi kokuvimbela ukugula kunemali eningi ngokuhamba kwesikhathi lapho uzama ukuyiphatha.
Uma usuvele unesifo esingapheli , i-HMO yakho izama ukulawula leso simo ukuze ikugcine unempilo ngangokunokwenzeka.
Kusukela ngo-2016, abantu abangaphezu kwezigidi ezingu-92 baseMelika babebekwa nge-HMO. Lokhu kuhlanganisa abantu emisebenzini exhaswe ngabasebenzi nabaxhaswe ngabanye, kanye nabantu baseMedare Advantage HMOs kanye ne-Medicaid yokunakekelwa kwe-HMOs.
Isebenza kanjani?
1. Kumelwe ube nodokotela oyinhloko yokunakekelwa.
Udokotela wakho oyinhloko wokunakekelwa , ngokuvamile umhlengikazi , umqeqeshi wezempilo noma udokotela wezingane, uzoba udokotela wakho oyinhloko futhi uzoxhumanisa konke ukunakekelwa kwakho. Ubuhlobo bakho nodokotela wakho wokunakekela oyinhloko kubaluleke kakhulu ku-HMO. Qinisekisa ukuthi ukhululekile naye noma wenze ushintsho. Unelungelo lokukhetha udokotela wakho wokunakekelwa oyinhloko uma nje enethiwekhi yenethiwekhi ye-HMO. Uma ungakhethi owodwa, umshwalense wakho uzokunika eyodwa.
2. Udokotela wakho wokunakekela oyinhloko kufanele akubheke nganoma yiluphi ukwelashwa okhethekile.
Udokotela wakho wokunakekelwa oyinhloko nguye ozokwenza ukuthi ungazidingi yini ezinye izinhlobo zokunakekelwa noma awudinga ukuthunyelwa kuwe ukuze uwuthole. Izibonelo zibona ochwepheshe, ukuthola ukwelashwa ngokomzimba noma ukuthola imishini yezokwelapha njengesihlalo sabakhubazekile. Ukufuna ukudluliselwa kuqinisekisa ukuthi ukwelashwa, izivivinyo kanye nokunakekelwa okukhethekile okutholayo kuyadingeka ngokwemithi.
Ngaphandle kokudluliselwa, awunayo imvume yalezo zinsizakalo kanye ne-HMO ngeke zikhokhele zona.
Inzuzo yalesi simiso ukuthi iziguli zithola izinsizakalo ezingadingekile. Kodwa ukuphazamiseka ukuthi iziguli kufanele zibone abahlinzeki abaningi (udokotela oyinhloko kanye nodokotela) futhi ukhokhe ama-copay noma enye ukwabelana ngezindleko kokuvakashelwa ngalunye.
3. Kufanele usebenzise abahlinzeki be-in-network.
Njalo i-HMO inolwazi lwabahlinzeki bezempilo ezisevisi yomhlinzeki wayo. Labo banikezeli bahlanganisa insizakalo eminingi yokunakekelwa kwezempilo kuhlanganise nodokotela, ochwepheshe, ama-pharmacy, izibhedlela, ama-laboratory, ama-x-ray nezikhungo zokukhulumisana. Uma ukhathalela ngaphandle kwe-inethiwekhi , i-HMO ngeke ikhokhele; uzobe unamathela ekukhokheleni konke okukhokhwayo ngokwakho .
Ukunakekelwa kwe-out-of-network ngokungahambi kungaba yiphutha elibi kakhulu uma une-HMO. Gcwalisa umshwalense kumakhemikhali angaphandle kwe-inthanethi noma uthole ukuhlolwa kwegazi okwenziwe yilebhu engalungile futhi ungabambelela kumthethosivivinywa wamakhulu noma ngisho nezinkulungwane zamaRandi.
Kungumsebenzi wakho ukwazi ukuthi yiziphi abahlinzeki abakhona-inethiwekhi nge-HMO yakho. Lokhu akuyinkimbinkimbi kakhulu ne-HMO njengoKaiser Permanente lapho abahlinzeki benethiwekhi bebonke besakhiweni esifanayo futhi bangaboni muntu kodwa iziguli zikaKaiser.
Kodwa, uma une-HMO nomshuwalense njengo-United Healthcare, i-Aetna, noma i-WellPoint, abahlinzeki bayo be-inthanethi ngeke bahlale endaweni efanayo futhi bavame ukubona iziguli ezingezona amalungu e-HMO. Ngeke ucabange lokho, ngoba nje lebhu ibheke phansi ihholo ehhovisi likadokotela wakho, ukuthi lebhu in-inethiwekhi nge-HMO yakho. Kufanele uhlole.
Kukhona okunye okuhlukile emithathu ekudingeni ukuhlala ku-inethiwekhi:
- Iziphuthumayo zangempela.
- I-HMO ayinayo umnikezeli we-inthanethi wenkonzo yokukhethekile oyidingayo. Lokhu akuvamile. Kodwa, uma kwenzeka kuwe, phambi kokuhlela ukunakekelwa okukhethekile okuvela ngaphandle kwenethiwekhi ne-HMO- gcina i-HMO yakho ku-loop.
- Uphakathi kwenkambo eyinkimbinkimbi yokwelapha okukhethekile uma uba yilungu le-HMO, futhi isazi sakho asiyona ingxenye ye-HMO. Ama-HMO amaningi anquma ukuthi ungaqeda yini ukwelashwa kanye nodokotela wakho wamanje esimweni sokwethenjelwa.
4. Izimfuneko zakho zokwabelana ngezindleko ku-HMO ngokuvamile ziphansi.
Ukwabelana ngezindleko ezinjengezinkampani ezidonswayo , amakhophi we-copayments , kanye ne- coinsurance kugcinwa ubuncane nge-HMO. Amanye ama-HMO axhaswe ngumqashi awadingi nanoma iyiphi i-deductible (noma une-deductible encane) futhi adinga kuphela ikhodi encane kwezinye izinsizakalo. Ngenxa yokwabelana kwezindleko eziphansi kanye nama- premium aphansi, ama-HMO abhekwa njengenye yezinketho zempilo yomshuwalense wezempilo.
Kodwa-ke, emakethe yomshuwalense wezempilo, lapho amaphesenti angaba ngu-7 abantu base-United States etholakele khona ngo-2016, ama-HMO athambekele ekutheni abe nezindleko eziphakeme kakhulu nezindleko ezingaphandle. Kwamanye amazwe athi, izinhlelo kuphela ezitholakalayo emakethe ngayinye yi-HMOs, ngama-deductibles afinyelela phezulu njengama-dollar ayizinkulungwane eziningana. Ezingxenyeni eziningi, kunamathuba amaningi okukhetha okutholakala emakethe ngayinye ngokwezinhlobo zenethiwekhi (i- HMO, i-PPO, i-EPO, noma i-POS ), ngokumelene nemakethe exhaswe ngumqashi, lapho ukukhetha kwenethiwekhi kwenethiwekhi kuhlala khona ngokuqinile.
I-HMO kanye nezinye izinhlobo ze-Insurance Health
Zonke izinhlobo zomshuwalense wezempilo wokunakekelwa okuphethwe (okufaka phakathi cishe konke ukuthunyelwa kwangasese e-US) kunezinye izinto ezifanayo. Isibonelo, akukhohlelo lwezempilo lokunakekelwa oluphethwe luyokhokhela ukunakekelwa okungekho isidingo sempilo, futhi zonke izinhlelo zokunakekelwa eziphathisiwe zinezinhlelo ezikhona zokubasiza ukuthi baqaphele ukuthi ukunakekelwa kuyadingeka yini, futhi yini ukunakekelwa okungenayo.
Izinhlelo zokunakekelwa eziphethwe njengezinhlelo ze-PPOs, EPOs, kanye ne-POS zihlukile kuma-HMO ngezindlela eziningana. Abanye bazokhokha ukunakekelwa kwe-out-of-network, futhi abanye ngeke (kufanele bonke, uma kuyiphuthumayo ngempela). Abanye banesidingo sokubelana ngezindleko eziphansi ngenkathi abanye benesidingo esikhulu futhi badinga ukuqinisekiswa okubalulekile. Abanye badinga udokotela oyinhloko wokunakekelwa, kodwa abanye abakwenzi.
Ungafunda kabanzi mayelana nokwahlukana phakathi kwezinhlobo zezinhlelo zezempilo ku- HMO, PPO, EPO & POS-Uyini umehluko nokuthi yikuphi okungcono kakhulu?
> Imithombo:
> Kaiser Family Foundation. Ukuphepha Kwezempilo Kwempilo Yonke Inani Labantu. 2016.
> K aiser Family Foundation. Inani lokubhalisa kwe-HMO. NgoJanuwari 2016.