Ukuqonda Izinhlangano Ezihlinzekwa Ezihlinzekwayo
Ingabe ucabangela ukubhalisela uhlelo lwe-PPO yomshuwalense wezempilo? Qinisekisa ukuthi izohambisana nezidingo zakho ngokuqonda ukuthi isebenza kanjani. Usuvele ubhaliswe ku-PPO? Ukuqonda ukuthi kusebenza kanjani kuzokusiza ukuthi usebenzise umshuwalense wakho wezempilo ngempumelelo futhi ugweme amaphutha abizayo.
Ukuqonda i-PPOs
I-PPO imele inhlangano enikeziwe yokuhlinzeka. Ama-PPO athola leli gama ngoba anezinhlu zabahlinzeki bezempilo abayithandayo ukuthi uthole usizo lwakho lwezempilo.
Uma uthola ukunakekelwa kwakho kwezempilo kulabo abahlinzeki abathandayo, ukhokha kancane.
I-PPOs uhlobo lwezinhlelo zempilo yomshuwalense wezempilo ukunakekelwa okuphethwe njengabazala babo abade kakhulu, izinhlangano zokugcinwa kwezempilo, noma ama-HMO. Zonke izinhlelo zokunakekelwa kwezempilo eziphethwe ziphethe imithetho mayelana nokuthi kufanele uthole kanjani impilo yakho. Uma ungahambisani nemithetho yezinhlelo zokunakekelwa ephethwe, angeke akhokhele lokho kunakekelwa, noma uzohlawuliswa ngokubhekene nengxenye enkulu yezindleko zokunakekela ngaphandle kwephaketheni lakho.
Indlela Amalungiselelo Okunakekelwa Kwezempilo Okulawulwayo agcina ngayo izindleko phansi
Zonke izinhlelo zokunakekelwa kwezempilo eziphethwe zilawulwa lezi zimiso ukuze kugcinwe izindleko zezempilo ekuhloleni. Imithetho ngokuvamile yenza lokhu ngezindlela ezimbili eziyinhloko:
- Bawunciphisa amasevisi akho okunakekelwa kwezempilo kuphela ezintweni ezidingekayo ezempilo noma ezenza izindleko zakho zezempilo zinciphise ngokuhamba kwesikhathi, njengokunakekelwa kokuvimbela .
- Bakhawula ukuthi ubani noma kuphi ongathola khona izinsizakalo zokunakekelwa kwezempilo, futhi baxoxisana izaphulelo ezivela kubahlinzeki bezempilo ovunyelwe ukuthola usizo lwezempilo kusuka.
Indlela i-PPO isebenza ngayo
Ama-PPO asebenza ngezindlela ezilandelayo:
- Ukhokha ingxenye; i-PPO ibeka ingxenye.
I-PPO isebenzisa ukwabelana ngezindleko ukusiza ukugcina izindleko zihlolwe. Uma ubona udokotela noma usebenzisa izinsizakalo zezempilo, ukhokha ingxenye yezindleko zalezo zinsizakalo ngokwama- deductibles , u- coinsurance , kanye ne- copayments .
Ukwabelana ngezindleko kuyingxenye yesistimu ye-PPO ukuqinisekisa ukuthi udinga ngempela amasevisi wezempilo otholayo. Uma kufanele ukhokhe okuthile okunakekelwa kwakho, ngisho nekhophi encane, cishe awukwazi ukusebenzisa izinsizakalo ezingenelungelo elingenasisekelo. Kodwa-ke, ngenxa ye- Care Affordable Act , ama-PPO angeke adinge noma yikuphi ukwabelana ngezindleko zezinsizakalo zokuvimbela.
Ukwabelana ngezindleko kusiza ukwehlisa izindleko zokunakekelwa kwakho. Uma ukhokha ngokwengeziwe izindleko zokunakekelwa kwakho, kancane kancane i-PPO yakho ikhokha futhi ephansi ingagcina izinkokhelo zenyanga zama-premium .
- Uma usebenzisa inethiwekhi ye-PPO yabahlinzeki, ukhokha kancane.
Imingcele ye-PPO okuvela kuye noma lapho ungathola khona izinsizakalo zokunakekelwa kwezempilo ngokusebenzisa inethiwekhi yabahlinzeki bezempilo abaye baxoxisana izaphulelo. Inethiwekhi ye-PPO ayihlanganisi nje odokotela, kodwa yonke insizakalo yezinsiza zokunakekelwa kwezempilo njengama-lab, ama-ray ray, ama-radiologist, abahlinzeki bemishini yezokwelapha, izibhedlela kanye nezikhungo zokuhlinzeka ngeziguli.
I-PPO inikeza isikhuthazo kuwe ukuze uthole ukunakekelwa kwakho kusuka kunethiwekhi yabo yabahlinzeki ngokukushaja ama-copay aphakeme noma u-coinsurance uma uthola ukunakekelwa kwakho ngaphandle kwenethiwekhi . Isibonelo, ungase ube ne-$ 40 copay ukuze ubone udokotela ongaphakathi, kepha u-50% wemali yokukhokhiswa kwemali ngokubona udokotela ongaphandle kwenethiwekhi. Uma udokotela ophuma ngaphandle kwenkokhelo ekhokhisa u-$ 250 kulowo mahhovisi, uzokhokha u-$ 125 esikhundleni se-$ 40 ye-copay ozobe ukhokhiswa ngayo uma ungasebenzisa udokotela we-in-network.
Noma kunjalo, nakuba ukhokha ngaphezulu uma usebenzisa abahlinzeki bezempilo abangaphandle kwe-inthanethi , enye yezinto ezibonakalayo ze-PPO yukuthi, uma usebenzisa abahlinzeki be-out-of-network, okungenani i-PPO inika okuthile ezindlekweni zalawo masevisi. Lena enye yezindlela i-PPO ehluke ngayo i-HMO. I-HMO ngeke ikhokhe lutho uma uthola ukunakekelwa kwakho ngaphandle kwenethiwekhi.
- Kufanele uthole izinsizakalo ezigunyazwe ngaphambilini yi-PPO.
Enye yezindlela i-PPO iqinisekisa ukuthi ikhokha kuphela izinsizakalo zokunakekelwa kwezempilo okudingekayo ngempela ngokukudingela ukuba uthole imvume ngaphambi kokuthi ube nezivivinyo, izinqubo, noma ukwelashwa okubizayo. Uma ungatholi imvume kusuka ku-PPO yakho ngaphambi kokuba lezi zinsizakalo zenziwe, i-PPO ngeke ikhokhe.
Ama-PPO ahlukile lapho izivivinyo, izinqubo, izinsizakalo, kanye nokwelashwa okudinga ukugunyazwa kwangaphambili, kodwa kufanele usole ukuthi uzodinga ukugunyazwa kwangaphambili kwanoma yini ebiza noma yinoma yini engenziwa ngendlela engabizi ngendlela ehlukile. Isibonelo, ungase ukwazi ukuthola imithi yezidakamizwa zakudala ezigcwala ngaphandle kokugunyazwa kwangaphambi kokugunyazwa kodwa kufanele uthole imvume yakho ye-PPO yegama elibizayo lomuthi wegama lomkhiqizo ukuze uphathe isimo esifanayo.
Uma wena noma udokotela wakho ebuza i-PPO yokugunyazwa ngaphambilini, i-PPO cishe izofuna ukwazi ukuthi kungani udinga lokho kuhlolwa, isevisi, noma ukwelashwa. Kuzama ukuqiniseka ukuthi udinga ngempela ukunakekelwa, nokuthi akukho indlela engafanele yokufeza umgomo ofanayo. Isibonelo, uma udokotela ohlinzayo we-orthopedic ecela ukugunyazwa kwangaphambi kokuhlinzwa kwegciwane lakho, i-PPO yakho ingase ifune ukuthi uzame ukwelashwa ngokomzimba kuqala. Uma uzama ukwelapha ngokomzimba futhi engalungisi inkinga, i-PPO ingase iqhube phambili iphinde igunyaze ukuhlinzwa kwegciwane lakho.
Umehluko phakathi kwe-PPO kanye nezinye izinhlobo zemishwalense yempilo
Izinhlelo zokunakekelwa eziphethwe njenge-HMO, izinhlangano ezihlinzeka ngokukhethekile (EPOs) kanye nezinhlelo ze-point-of-service (POS) zihlukile kuma-PPO futhi zivela komunye nomunye ngezindlela eziningana. Abanye bakhokhela ukunakekelwa kwe-out-of-network; abanye abakwenzi . Abanye banokwabelana okungabizi izindleko; Abanye banokudonswa okukhulu futhi badinga ukuqinisekiswa okukhulu kwezimali kanye nama-copays. Abanye badinga udokotela oyinhloko wokunakekelwa (PCP) ukuze abe ngumgcini wakho wesango, okukuvumela ukuba uthole amasevisi ezempilo ngokudluliselwa kusuka ku-PCP yakho; abanye abakwenzi. Ngaphezu kwalokho, i-PPOs iyabiza kakhulu ngoba ikunika inkululeko eyengeziwe yokuzikhethela.
> Umthombo:
> Humana. I-HMO ne-PPO: Yikuphi Okulungile Kuwe? 2017.