Indlela Iziqondiso Zokuqapha Zisebenza Kanjani
Izinkampani zomshuwalense wezempilo, Medicare , nezibhedlela zihlale zifuna izindlela zokulondoloza imali. Ukukubeka esimweni sokubuka usebenzisa izinkombandlela zokubheka kusindisa imali, kepha kungase kuphephe ukubiza okungaphezulu.
Uma ufakwa esibhedlela, ukwazi ukuthi uke wangeniswa njengesiguli noma ukubeka isimo sokubheka kubalulekile kuwe ngokwezezimali.
Yingakho kubalulekile, nokuthi kufanele ukwenze.
Yini Isimo Sokubheka?
Uma ufakwa esibhedlela, ubelwe isimo sesineke noma isimo sokubona. Ubanikezwe isimo sesineke uma unezinkinga ezinkulu ezidinga ukunakekelwa okukhulu kwezobuchwephesha, abanolwazi.
Ubanikezwe isimo sokubuka uma ungaguli ngokwanele ukuthi udinga ukungenwa iziguli, kodwa ugula kakhulu ukuze unakekele ehhovisi likadokotela wakho. Noma, ungabelwa isimo sokubuka lapho odokotela bengenaso isiqiniseko sokuthi ugula kangakanani. Bangakubona esibhedlela futhi bakwenze unesifo sokugula uma uguga, noma uvumele uhambe ekhaya uma uthola ngcono.
Ngingazi kanjani ukuthi ngabe Ngisemthethweni Wokubheka Isimo noma Isimo Sokugula?
Njengoba iziguli zokubona ziwuhlobo lokwelapha, ezinye izibhedlela zinendawo ekhethekile yokubona noma iphiko lesibhedlela ngenxa yeziguli zazo ezibhekwayo. Kodwa, izibhedlela eziningi zibeka iziguli zazo ezibhekene nazo ezigumbini ezifanayo neziguli zabo.
Lokhu kwenza kube nzima kuwe ukutshela ukuthi unesifo sengqondo noma isiguli sokubona. Ngeke ucabange ukuthi, ngenxa yokuthi usegumbini lesibhedlela esivamile, noma embhedeni wesibhedlela kunokuba ube ne-gurney, uyisiguli.
Futhi awukwazi ukucabanga kusukela usesikhathini esibhedlela izinsuku ezimbalwa ungumuntu ogulayo.
Nakuba ukubhekwa kuhloswe isikhathi esifushane, akusebenzi ngaso sonke isikhathi ngaleyo ndlela.
Indlela kuphela yokwazi ukubuza .
Ukubhekwa Kwami Noma Isimo Sokugula Kungabani?
Izibhedlela kanye nodokotela akugcini nje ukukunika isikhundla esisodwa noma esinye ngoba bazizwa sengathi, ngoba isimo esisodwa sibonakala singcono, noma ngenxa yokuthi ucela ukuba ubelwe isimo esithile. Esikhundleni salokho, kunemihlahlandlela kazwelonke eshicilelwe encwadini ye-Medicare Benefit Policy Manual yokunquma ukuthi ubani obelwe isimo sesiguli, futhi ubani obelwe isimo sokubuka.
Lezi ziqondiso azicacile kodwa zinkimbinkimbi futhi zingashintsha njalo ngonyaka, ngakho-ke izibhedlela nezinkampani zomshuwalense zisebenzisa insizakalo ezishicilela izindlela zokubasiza ukuba basebenzise iziqondiso kumguli ngamunye. Izinsizakalo ezimbili ezithandwa kakhulu yizinyathelo zikaMcKesson ze-InterQual kanye neMilliman Care Guidelines.
Lezi ziqondiso zokugula nezilaleli ngokuvamile zikhuluma ngezinhlobo ezimbili zezinqubo. Umgogodla wokuqala ubuhlungu bokugula kwakho: ingabe uyagula ngokwanele ukuthi udinga ukungenwa kwesiguli?
Isigaba sesibili ubukhulu bezinsizakalo ozidingayo: ingabe ukwelashwa okudinga kakhulu ngokwanele noma okunzima kangangokuthi isibhedlela yindawo kuphela ongayithola ngayo leyo ngozi ngokuphepha?
I-criterion iphuzu ngalinye liye labulala wonke amaphuzu wokuhlola okungaqondile afaka phakathi izinto ezifana nemiphumela yokuhlolwa kwegazi , ukutholakala kwe-X-ray , iziphumo zokuhlolwa ngokomzimba, kanye nezinhlobo zokwelapha oye wazibekwa.
Uma usungiswa esibhedlela, umphathi wezehlakalo esibhedlela noma umhlengikazi wokubuyekeza ukuhlola uzohlola icala lakho, uqhathanise ukutholwa kukadokotela wakho, ukuxilongwa kwakho, imiphumela yezivivinyo zakho nezifundo, kanye nokwelashwa kwakho okubekiwe ngemikhombandlela. Uzobe esebenzisa leyo mihlahlandlela ukusiza udokotela wakho abelane nawe noma isimo sokubona, noma isimo sesiguli.
Kungani Kufanele Isimo Sokubheka noma Isimo Sengqondo Sokugula?
Uma unesifo esibhedlela, kodwa i-Medicare noma inkampani yakho yomshuwalense wezempilo inquma ukuthi kufanele ubelwe isimo sokubuka, singenqaba ukukhokhela zonke iziguli ezihlala esibhedlela.
Cishe ngeke uthole lokhu kuze kube yilapho isibhedlela sithumele isimangalo futhi siphikisiwe yinkampani yomshuwalense amasonto noma ngisho nezinyanga ngemuva kokuhlala esibhedlela.
Eqinisweni, amaCenter for Medicare kanye neMedicaid Services inkontileka izinkampani ukuba zifune amarekhodi e-Hospitals ezigulisa iziguli emzamweni wokuthola iziguli ezibhekene neziguli ezingase ziphathwe ngesimo sokubheka. Lokhu kwenzeka izinyanga noma ngisho nangemva kweminyaka-yeqiniso. Khona-ke, i-Medicare ithatha yonke imali eyakhokhela esibhedlela ngenxa yalowo mvume.
Izibhedlela zizama ukulandela imihlahlandlela eseduze ngoba yiyona elula futhi eyamukeleke emhlabeni jikelele indlela yokubangela ukuthi kungani bakunike lona isimo esithile. Isibonelo, uma inkampani yakho yomshuwalense wezempilo noma uMedarela ephika isimangalo sakho ngoba inqume ukuthi kufanele ube nesimo sokubheka esikhundleni sezinga lokugula, isibhedlela sizokulwa nokuphika ngokubonisa ukuthi uhlangabezane nemihlahlandlela ye-InterQual noma ye-Milliman ngesimo owabelwe ngaso . Uma isibhedlela singahambisani nemihlahlandlela eseduze, sengozini yokuphika izicelo.
Kodwa, uma ubelwe isimo sokubheka esikhundleni sezinga lokugula, nakuba kungenjalo cishe umshwalense wakho uzophika isimangalo sakho sonke, ungase uthathe ukushaya kwezimali. Ngokuvamile, isabelo sakho sezindleko zezinsizakalo zokubeletha sikhulu kunokwabelana kwakho kwezindleko zokuvuma iziguli.
Njengoba iziguli zokubona ziwuhlobo lokwelapha, izikweletu zabo zihlanganiswe ngaphansi kwe- Medicare Part B , noma izinsizakalo zokugula ziyingxenye yomgomo womshuwalense wezempilo, kunokuba ngaphansi kwe- Medicare Part A noma esibhedlela ingxenye yenqubomgomo yomshuwalense wezempilo. Ukuhlinzekwa kwezidakamizwa kungaba namazinga aphezulu okubambisana nokwedluliselwa kokugula (lokhu kuyiqiniso ikakhulukazi uma useMedare, njengoba Ingxenye B ine-coinsurance engenayo i-cap ngaphandle kwesikhwama ngaphandle kokuthi unesidingo se- Medigap noma i-Medicare Advantage ). Ngakho-ke, ungaqeda ukukhokha ingxenye enkulu yenkokhelo yezinsizakalo zokubheka okungaphezu kwalokho ozoyikhokhela izinsizakalo zezokwelapha.
Uma useMedare, isimo sokubheka sizophelela ekukhokheleni ngaphezulu uma udinga ukuya ekhaya labahlengikazi ukuvuselelwa ngemuva kokuhlala esibhedlela. I-Medicare ivame ukukhokhela izinsizakalo ezinjengezokwelapha ngokomzimba ekhaya elihlengikazi isikhathi esifushane. Kodwa, ufanelekela kuphela le nzuzo uma usuyisiguli izinsuku ezintathu. Uma usesikhathini sokubheka izinsuku ezintathu, ngeke ukwazi ukufaneleka.
Lokhu kusho ukuthi uzodingeka ukhokhe lonke umthethosivivinywa ekhaya elihlengikazi kanye nezinsizakalo zalo zokubuyisela wena ngokwakho. Ungalindela lo mthethosivivinywa ube yizinkulungwane zamadola ayizinkulungwane.
Imithetho emibili-phakathi kwamabili
Ngo-2013, amaCenter for Medicare and Medicaid Services (CMS) akhiphe isiqondiso esibizwa ngokuthi "ukubusa okuphakathi kwamabili phakathi kwamabili" okusiza ekuthuthukiseni ukuthi yiziphi iziguli okufanele zivunyelwe njengeziguli futhi zihlanganiswe ngaphansi kwe-Medicare Part A (esibhedlela) kunezingxenye B (iziguli ). Umthetho uthi uma udokotela ovuma ukuthi ulindele ukuthi isiguli sidinga ukuba sesibhedlela isikhathi esithile okungenani sibe nezinyanga ezimbili, ukunakekelwa kuyobe kukhishwa ngaphansi kweMediartial Part A.
Ngonyaka ka-2015, i-CMS ivuselele ukubusa kokubili kwamabili ukuze kuhlinzeke ukuguquguquka okungaphezulu kwezimo ze-case-by-case. Imikhombandlela emisha isabisa ngokuphindaphindiwe ukuhlala esibhedlela okufaka okungenani imizuzu emibili ngaphambi kokuthi i-Medicare Part A isebenze, kodwa futhi bayishiya egumbini elincane lokuqaphela udokotela. Uma udokotela ekholelwa ukuthi ukwelashwa kwesiguli kuvunyelwe ukungena esibhedlela ngisho nalapho ukuhlala esibhedlela kulindeleke ukuthi kube nesikhathi esingaphansi kwamabili, udokotela angakwazi ukuvuma isiguli njengesiguli.
Ingabe Kufanele Ngilwe Nesimo Sokugula, noma Ngibeke Isimo Sokubheka?
Nakuba kuphazamisekile, akuyona indaba enkulu yokuxazulula isimo sokubheka noma ukulwa nesimo sogulayo njengoba kuyinto yokuqinisekisa ukuthi usezingeni elifanele futhi uqonde ukuthi kusho ukuthini kwisabelomali sakho.
Ukufuna ukuthi wena uphinde wabelwe isimo sesineke uma usuhambisana nemigomo yesimo sokubheka kungase kubonakale sengathi kungakusindisa imali uma izindleko zakho zokubambisana ziphakeme kakhulu ekunakekeleni iziguli (isimo sokubuka), futhi kunenzuzo kakhulu ukunikezwa ukunakekelwa kwengane uma useMedare futhi uzodinga ukunakekelwa ngemuva kwesikhungo sokunakekela abanekhono. Kodwa, khumbula, inkampani yakho yomshuwalense wezempilo ingase inqabe ukukhokha imali yesibhedlela uma inquma ukuthi ubanikezwe ngokungalungile isimo sesiguli. Ngeke wena noma esibhedlela ngeke uphumelele ekulwa nokuphikisana nokumangalelwa ngoba awuzange uhambisane neziqondiso zesimo sesineke.
Lokho kusho, kuwukuhlakanipha ukubuza ukuthi yiziphi iziqondiso ezithile ezasetshenziselwa ukunquma ukuthi kufanele ube nesimo sokubheka esikhundleni sezinga lokugula. Ungase ubuze ukuthi yiziphi izinhlobo zokwelapha, imiphumela yokuhlola, noma izimpawu ezizokufanelekela ukuba ube nesimo sogulane ngesifo esifanayo. Ukwengeza, cabangela ukucela ukuthi ukhulume nomuntu ovela ehhovisi lokukhokhisa ongakwazi ukulinganisa izindleko zakho ezingaphandle kwezepolitiki noma ngabe unesifo esibhedlela.
Uma ugula kakhulu ukwenza lokhu ngokwakho, unganika imvume yokuba nelungu lomndeni elithembekile, umngane, noma ummeli weziguli ukubuza le mibuzo, bese ulandela izimpendulo.
Imithombo:
Amasevisi we-Medicare ne-Medicaid Services, I-Fact Sheets: Ukubusa Okubili-Midnight, 10-30-2015.