Abashuwalense baye basungula amanethiwekhi asebenzayo njengendlela yokugcina izindleko
Iningi lethu lisetshenziselwa umqondo wokuthi izinhlelo zomshuwalense wezempilo zangasese zinamanethiwekhi omhlinzeki. Abathwali bomshuwalense baxoxisana nezivumelwano ezithile nodokotela abathile kanye nezibhedlela ukudala inethiwekhi yomhlinzeki, futhi abanikazi bomgomo ngokuvamile kumele bathole ukunakekelwa kwabahlinzeki be-inthanethi (izinhlelo zomphakathi ezinjengeMedicaid neMediare nazo zinezihlinzeki ezibandakanyekayo; abahlinzeki abaningi babamba iqhaza nge-Medicare, futhi nakuba kungenjalo abaningi bamukela iMedicaid, iningi labodokotela bathatha iMedicaid).
I-PPOs ivumela iziguli ukuba zibone abahlinzeki ngaphandle kwenethiwekhi, kodwa ukuphuma okungaphandle kwepokhethi kungaba ngaphezu kwemingcele ebekwe ukunakekelwa kwe-in-network. Ama-PPO aphindaphinda kabili ukuphuma kwe-pocket okungaphezulu kokunakekelwa okutholiwe ngaphandle kwenethiwekhi, nakuba kubuye kube ngokwengeziwe kuma-PPO ukuthi abe nokukhululeka okungapheli kokukhipha isikhwama sokunakekelwa kwe-out-of-network (ie, uma uphuma ngaphandle kwenethiwekhi , angeke kube khona isikhala sokuthi kufanele ukhokhe kangakanani ingxenye yakho yezindleko).
Ama-HMO nama-EPO ngokuvamile adinga iziguli ukuba zisebenzise abahlinzeki be-inthanethi futhi ungabheki ukunakekelwa ngaphandle kwenethiwekhi nhlobo, ngaphandle uma kuphuthumayo.
I-Tiered Networks
Ama-Tiered amanethiwekhi agcinwe ukunakwa kwezwe ekupheleni kuka-2015 lapho i-Horizon Blue Cross Blue Shield igxilile inethiwekhi ye-Omnia e-New Jersey. E-Illinois, umhlaba we-Lincoln Health (i-ACA-eyakhiwe CO-OP) iphinde isebenzise amanethiwekhi ahlangene, futhi atholakalayo ezimakethe zomuntu ngamunye neqembu kwezinye izindawo eziningi.
Ngokuyinhloko, amanethiwekhi ahlanganisiwe avumela abathwali bomshwalense bezempilo ukuba bagcine inethiwekhi yabo yonke iminyene, ngenkathi kunciphisa ngokuphumelelayo amalungu amaningi kunethiwekhi encane kakhulu - kodwa ukhetho luya kulunga.
Ngenethiwekhi ethintekayo, amalungu akhokhela izindleko eziphansi ezingaphandle kwezepolitiki uma bebona umhlinzeki ku-network top tier.
Bakhululekile ukubona abahlinzeki kunethiwekhi engezansi, kodwa bazokhokha ngaphezulu izindleko ezingaphandle kwe-pocket uma bezenza.
Imikhakha ye-ACA ekudleni okungaphandle kwe-pocket isebenza nanxa isiguli sikhetha ukubona umhlinzeki osenethiwekhi kodwa hhayi ekhoneni eliphezulu. Uma nje umhlinzeki enethiwekhi yenethiwekhi, izindleko zesiguli ngezinzuzo ezibalulekile zezempilo phakathi nonyaka ngeke zidlule umkhawulo obekwe i-ACA (ngo-2016, leyo $ 6,850 yomuntu oyedwa, no-$ 13,700 ngomndeni; ngo-2017 , yanda ku- $ 7,150 kumuntu oyedwa kanye no-$ 14,300 emndenini ).
Futhi lolu hlelo lungenza ukuba kube nokukhululeka okufanayo kwezinsizakalo ezitholakalayo ezivela phezulu kwinethiwekhi yabahlinzeki (nasi isibonelo esivela ku-Horizon Blue Cross Blue Shield e-New Jersey - kungakhathaliseki ukuthi iziguli zisebenzisa abanikazi ababili noma abathathu abahlinzeki, i-out-of-pocket esiphezulu yonyaka isasebenza).
Kodwa iziguli ezikhetha abahlinzeki be-top-tier zizokhokha kancane ekukhunjweni okungaphandle kwezindleko zitholakele (isibonelo, i-copay ye-$ 15 ukubona udokotela esikhundleni se-$ 30, noma i-copay ukubona udokotela esikhundleni sokuthi ukhokhe imali ekhishwayo kanye ne-coinsurance, noma akukho deductible esikhundleni se-$ 2,500 ekhishwe imali). Ezigulini ezingapheli ukuhlangabezana nokuhleleka kweplanethi phakathi nonyaka, kunomthelela omkhulu wokusebenzisa odokotela nezibhedlela ezingxenyeni eziphezulu zenethiwekhi.
Ama-Tiered Networks Awakusha
Ama-Tiered amanethiwekhi awawona amasha - ayengaphambi kwe-ACA futhi sekuyisikhathi eside eselinye lamacebo amasu ezempilo asetshenziselwa ukulwa nezindleko ezikhulayo. Uhlelo lwe-Horizon BCBS luka-Omnia eNew Jersey luzabiza kakhulu ngo-15% kunezinguquko ezifanayo ze-Horizon ngo-2015 ezazingasebenzisi inethiwekhi ethintekayo. Akumangalisi ukuthi amaphrimiyamu aphansi kuma-networked tiered izinhlelo akhangayo kubathengi nabaqashi.
Ukunquma ama-Tiers
Ababheki bezempilo bangasebenzisa izinhlobo ezihlukahlukene zamamethrikhi ukuze banqume ukuthi yiziphi odokotela nezibhedlela eziphelela ekugcineni. Ngokujwayelekile, ukulinganisa kwekhwalithi nokusebenza kahle kwezindleko kusetshenziselwa, nakuba abahlinzeki be-top-tier bavuma ukwamukela amazinga aphansi okubuyiselwa kumshuwalense wezempilo, ekuhwebeni ukuthi cishe bayothola ivolumu ephakeme yesiguli njengomhlinzeki ophezulu.
Kodwa kungaba khona ukuphikisana uma kungaboni ukuthi yini abathwali be-metrics abasebenzisa ukunquma ukuthi iziphi izidakamizwa nezibhedlela ezizophela ekugcineni kwekhasi elifisa. E-New Jersey, abomthetho baye bahileleka, futhi izingqikithi zomthetho eziningana ziye zaqaliswa ukulungisa amanethiwekhi ahlanganisiwe kanye nokucaca ngokuqondene nendlela abahlinzeki abelwe ngayo isigaba. Isigamu sezibhedlela zikahulumeni siphelela emithathu (okungukuthi, umlingani ongakhethiwe) ngaphansi kohlelo lwe-Horizon BCBS luka-Omnia, futhi akunakuzwakala akujabuli ngalokhu.
Abathengi nabathengi babathengi futhi banakekelwa ukuthi izibhedlela ezingxenyeni ezingenabo abathandekayo zingagcina zihlupheka ngenxa yokunciphisa umthamo wesiguli (ngoba iziguli zizokhetha izibhedlela ezilodwa ukuze zisebenzise izindleko ezingaphansi kwezindleko) , futhi lokho kungalimaza abathengi abahlala eduze nalezi zibhedlela ezimbili - ikakhulukazi lapho izibhedlela ezibhekene nazo ziyizibhedlela "zokuphepha" ezivame ukubona umthamo omkhulu weziguli ezingenayo futhi ezingagciniwe.