Kunezizathu eziningi ongase uhambe ngaphandle kwenethiwekhi yakho yomhlinzeki womshuwalense wezempilo ukuze unakekele. Kodwa-ke, ukukhathazeka ngaphandle kwe-inethiwekhi kwandisa ingozi yakho yezezimali kanye nengozi yokuba nezindaba zekhwalithi nokunakekelwa kwezempilo oyitholayo. Nakuba ungeke uqede ngokuphelele ingozi yakho eyengeziwe, unganciphisa uma wenza umsebenzi wakho wesikole kusengaphambili .
Ngaphambi kokuphuma ngaphandle kwenethiwekhi, thola ukuqonda okucacile izingozi ezihilelekile nokuthi yini ongayenza ukuze uziphathe. Qala ngokuqonda ukuthi kungani ukuthola ukunakekelwa kwezempilo ngaphandle kwenethiwekhi kuthatha ingozi enkulu.
Kungani Ukunakekelwa Kwangaphandle Kwezingosi Kungengozini Yezemali
Ulahlekelwa isaphulelo sezinhlelo zempilo.
Uma inkampani yakho yomshuwalense wempilo yamukela udokotela, imitholampilo, esibhedlela, noma olunye uhlobo lomnikezeli kwinethiwekhi yomhlinzeki walo, lixoxisana namanani ahlisiwe ezinsizakalo zalo mhlinzeki. Uma uphuma ngaphandle kwenethiwekhi, awuvikelwe isaphulelo sakho sezempilo. Isaphulelo esisodwa esixoxisanayo ozothola isaphulelo ozoxoxa ngaso. Njengoba ungenazo izingxoxo ezixhasiwe kakhulu kubasebenzi ukuqinisekisa ukuthi uthola inzuzo enhle, unengozi eyengeziwe yokukhokhiswa kakhulu ekunakekeleni kwakho.
Isabelo sakho sezindleko sikhulu
Isabelo sakho sezindleko yi- deductible , copay , noma i- coinsurance okufanele ukhokhele noma yimuphi umsebenzi onikeziwe.
Uma uphuma ngaphandle kwenethiwekhi, isabelo sakho sezindleko siphakeme. Kuphakama kangakanani kuncike kunjani uhlobo lomshuwalense wezempilo onayo.
Uma uhlelo lwakho lwezempilo luyi- HMO noma i- EPO , lungase lungabheki ukunakekelwa kokuphuma kwenethiwekhi nhlobo. Lokhu kusho ukuthi uzoba nomthwalo wokukhokha 100% wezindleko zokunakekelwa kwakho ngaphandle kwenethiwekhi.
Uma uhlelo lwakho lwezempilo luyi- PPO noma uhlelo lwe-POS, lungase lunikeze ezinye izindleko zokunakekelwa kwe-out-of-network. Kodwa-ke, ngeke ukhokhe njengephesenti enkulu yalowo mthethosivivinywa njengoba ngabe ngabe ukhokhele uma ngabe uhlale kwinethiwekhi. Isibonelo, ungase ube nokuqinisekiswa kwe-20% kokunakekelwa kwenethiwekhi kanye nokuqinisekiswa kwe-50% kokunakekelwa kwe-out-of-network.
Ngisho noma ukukhipha kwakho kungathinteka. Uma uhlelo lwakho lwezempilo lunikeza ekubhekiseni ukunakekelwa kokunakekelwa ngaphandle kwenethiwekhi, ungathola ukuthi unokukhishwa okulodwa kokunakekelwa kwe-inthanethi kanti enye, ephakeme, ekhishwa ngokunakekelwa kwe-out-of-network .
Ungaba ibhalansi-ikhokhelwe.
Uma usebenzisa umhlinzeki we-in-network ukuze uthole amasevisi wezinhlelo zempilo, lowo mhlinzeki uvumile ukungakukhokhisi nganoma yini enye ngaphandle kwe-deductible, copay, ne-coinsurance ehlelwe nguhlelo lwakho lwezempilo.
Uma usebenzisa umhlinzeki wangaphandle, hhayi kuphela lowo mhlinzeki angakukhokhela noma yini ayifunayo, angakukhokhela nanoma yikuphi okusele ngemuva kokuba inkampani yomshuwalense wezempilo ikhokhe ingxenye yayo. Ukukhokhwa kwe-balance balance, lokhu kungakudla izinkulungwane zamaRandi.
Nakhu ukuthi kusebenza kanjani. Unquma ukusebenzisa umhlinzeki wangaphandle wenethiwekhi ye-catheterization yakho yenhliziyo. I-PPO yakho inama-50% okuqinisekisiwe kokunakekelwa kwe-out-of-network, ngakho-ke ucabanga ukuthi uhlelo lwakho lwezempilo luzokhokha isigamu sezindleko zokunakekelwa kwakho kwe-out-of-network, futhi uzokhokha enye ingxenye.
I-catheterization yenhliziyo iza ne-bill ye $ 15,000, ngakho ucabanga ukuthi uzokweleta u-$ 7,500, akunjalo? Akulungile!
I-PPO yakho izobuka lelo bhilidi le-$ 15,000 futhi lisho into emphumela wokuthi "Lokho kukhulu kakhulu. Ukukhokha okunengqondo kwalokhu kunakekelwa ngu-$ 6,000, ngakho-ke sivumela ukukhokha okungu-$ 6,000 kuphela. Sizokhokha ingxenye yethu ye $ 6,000 enengqondo. "I-PPO ikhokha u-$ 3,000.
Umhlinzeki wangaphandle-wenethiwekhi akakhathaleli ukuthi uhlelo lwakho lwezempilo olucabangela ukuthi uyakhokhisa. Ifaka imali yakho ye-PPO engu-$ 3,000 yokukhokhwa kwebhilidi engu-$ 15,000 futhi ikuthumela ibhilikhithi yokulinganisa (yingakho lokhu kubizwa ngokuthi ukukhokha imali ). Manje usufanele ukhokhe u- $ 12,000 kunama- $ 7,500 owacabanga ukuthi uzokweleta.
Ukhawulela ukuvikela ukuphuma kwakho kwepokhethi.
Inqubomgomo yakho yomshuwalense wezempilo engaphandle kwepokhethi iklanyelwe ukukuvikela ezindlekweni ezingelapheli zokwelashwa. Ibeka i-cap, noma isiphezulu, esilinganisweni esizokhokhwa unyaka ngamunye kuma-deductibles, ama-copays, no-coinsurance. Isibonelo, uma uhlelo lwakho lwezempilo lungaphandle kuka-$ 6 600, uma ukhokhela inani elilodwa lamaRandi angu-6 600 kumadoladokhumenti, ama-copays, kanye no-coinsurance kulo nyaka, ungayeka ukukhokha lezo zindleko zokwabelana ngezindleko. Uhlelo lwakho lwezempilo lubamba i-100% yethebhu yezindleko zakho zokunakekelwa kwempilo ezikuyo yonke unyaka.
Kodwa-ke, izinhlelo eziningi zempilo azikwelethi ukuthi uthola up-of-network ekubhekaneni nokuphuma kwakho kwepokhethi. Njengoba ukuphuma ngaphandle kwepokhethi kungase kube yinto ekhona phakathi kwakho kanye nencithakalo ephelele yezimali uma uthuthukisa isimo sezempilo esibizayo, ukhetha ukunakekelwa ngaphandle ukuvikela lokho okungekho emphakathini okuzokwandisa kuzokwandisa ingozi yakho yezezimali.
Ikhwalithi Yezinkinga Zokunakekelwa Nge-Out-Of-Network Care
Abantu abaningi bafuna ukunakekelwa kwe-network ngoba bezwa ukuthi bangathola izinga eliphezulu lokunakekelwa kunokuba abahlinzeki babo be-in-network bahlinzeke ngempilo yabo. Ngenkathi lokhu kungase kwenzeke noma kungabi yiqiniso, qaphela ukuthi ungase ulahlekelwe ezinye izivikelo zekhwalithi uma uphuma ngaphandle kwenethiwekhi.
Ungase ube nezinkinga ekuxhumaniseni ukunakekelwa kwakho.
Ikakhulukazi ezinhlelweni zezempilo ezingeke zikhokhelwe noma yikuphi ukunakekelwa kwe-out-of-network, azikho izinhlelo ezinhle zokunakekelwa okubushelelekile kokunakekelwa okunikezwa ngumhlinzeki wangaphandle wenethiwekhi ngokunakekelwa okunikezwa ngabanikezeli bakho be-in-network.
Ekugcineni, i -onus ikuwe ukuze uqiniseke ukuthi odokotela bakho abangaphakathi nohlelo bayakwazi ukuthi udokotela wakho ophuma ngaphandle kwenethiwekhi wenza, futhi ngokuphambene nalokho. Uzoba kokubili isiguli kanye nedatha yolwazi phakathi kwabahlinzeki bakho abahlala njalo kunethiwekhi kanye nomhlinzeki wakho ongaphandle kwenethiwekhi.
Ngaphambi kokuvuma ngokungenangqondo ukuthi le buck ihamba nawe ... qaphela ukuthi le buck ngeke neze ayeke. Ngeke udingeke ungene kanye nje ukuze ugcwalise leli gap lokuxhumana. Kuzodingeka uyenze njalo lapho unayo i-aphoyintimenti, uthole ukuhlolwa, ushintshe empilweni yakho, noma ushintsho ohlelweni lwakho lwezokwelapha.
Awubheki nje igebe lokuxhumana phakathi kwabadokotela bakho, noma; uzobe wenza phakathi komnikezeli wakho ongaphandle kwenethiwekhi kanye nesiphakamiso sakho sezempilo, futhi. Isibonelo, uma i-cardiologist yakho engaphandle kwe-intanethi efuna uku-oda ukuhlolwa noma ukwelashwa okudinga ukugunyazwa kwangaphambili kusuka kwenkampani yakho yomshuwalense, uzobe unesibopho sokuqinisekisa ukuthi uthola lokho kuqale ukugunyazwa. Uma ungatholi ukugunyazwa kwangaphambili, uhlelo lwakho lwezempilo lungenqaba ukukhokha .
Uzolahlekelwa ukuhlolwa kwesimo sezempilo kwabahlinzeki.
Ngaphambi kokuvumela umhlinzeki wezempilo ukuba ahlanganyele kwinethiwekhi yomhlinzeki wayo, uhlelo lwakho lwezempilo luyamkhombisa. Lokhu kungase kube lula njengokuhlola ukuthi amalayisensi omhlinzeki asemeni noma ukuthi izakhiwo zivunyelwe yizinhlangano eziqinisekisiwe zokunakekelwa kwezempilo njengeJCAHCO. Noma kunjalo, inqubo yokuqinisekisa ingaba yinkimbinkimbi kakhulu futhi ichazwe ngokuningiliziwe kunalokho, ukunikeza isevisi okungaba nzima kuwe ukuziphindaphinda. Ukwengeza, izinhlelo eziningi zezempilo zinezinhlelo eziqhubekayo zokuqapha ikhwalithi yokunakekelwa okuhlinzekwa amalungu abo ngabanikeli be-in-network. Abahlinzeki abangalingani namanani ekhwalithi banengozi yokulahla enethiwekhi.
Uma uphuma ngaphandle kwenethiwekhi, ulahlekelwa inetha lokuphepha lezinhlelo zokuhlola kanye nezokuqapha kwekhwalithi yakho yezempilo.
Uzolahlekelwa ukubaluleka kwepulani lakho nabahlinzeki.
Uma unenkinga noma impikiswano nomhlinzeki we-in-network, inkampani yakho yomshuwalense wezempilo ingaba ngummeli onamandla egameni lakho. Njengoba uhlelo lwakho lwezempilo lumelela izinkulungwane zamakhasimende kulowo mhlinzeki, umhlinzeki uzobona ukuthi uhlelo lwezempilo luphonsa isisindo esinamandla ngemuva kwempikiswano yakho. Uma uhlelo lwezempilo lungacabangi ukuthi umhlinzeki uziphatha ngendlela efanele, kungase kumlahle ngisho nasenethiwekhi yakhe. Nakuba izinto ezingavamile ukuqhubekela phambili manje, kuhle ukukwazi ukuthi unomuntu ophethe eceleni kwakho.
Ngakolunye uhlangothi, umhlinzeki wangaphandle wenethiwekhi akakwazanga ukukhathalela ukuthi iyiphi inkampani yakho yomshuwalense wezempilo. Ukwengeza, kungakhathaliseki ukuthi lesi sigameko esidabukisayo esabangela ukuphikisana kwakho, inkampani yakho yomshuwalense wezempilo ngeke ichithe isikhathi sayo ekukhuthazeni ngomhlinzeki wangaphandle ongenakuyithonya.
Indlela Yokusingatha Izingozi Ezikhulayo Ezihlobene Nokunakekelwa Kwangaphandle Kwenethiwekhi
Njengoba uzoba nendima ebalulekile ekuqinisekiseni ukuthi uthole ukunakekelwa kwekhwalithi kusuka kumhlinzeki wakho wokuphuma ngaphandle, funda. Lezi zixhumanisi zingakusiza:
Indlela Yokucwaninga Iziqinisekiso Zokudokotela .
Indlela Yokuthola Idokhumenti Yezokwelapha NgokweDokotela .
Indlela Yokukhetha Isibhedlela Esihle kakhulu .
Qinisekisa ukuthi abahlinzeki bakho be-out-of-network banamarekhodi avela kubanikezeli bakho be-in-network, nokuthi abahlinzeki bakho be-inthanethi banamarekhodi kusuka kubanikezeli bakho be-out-of-network. Iningi labantu kuzodinga ukuthola amarekhodi abo kwezokwelapha. Indlela Yokucela Amarekhodi Ezokwelapha Zakho .
Ukuqondisa ukunakekela kwakho kunakekelwa ngokucophelela ngemininingwane. Udinga ukuba uchwepheshe wezwe ongcono kakhulu ekunakekeleni kwezempilo. Ungumphathi weqembu lakho lokunakekelwa kwezempilo, futhi udinga ukugijimela ngalokho okwenziwa yilungu ngalinye lamalungu akho nokuthi kungani.
Ngaphezu kokunikeza amarekhodi wezokwelapha, udinga ukuthatha amanothi akho uma unakekela. Ukusebenzisa amanothi akho, unganika ukubuyekezwa okusheshayo kwamazwi kubanikezeli bakho mayelana nezinguquko kwamanye ama-providers 'izinhlelo zokunakekelwa kwakho. Kumele ukwazi ukuchaza ukuthi kungani umnikezeli enza izinguquko ohlelweni lwakho lokunakekelwa akwenzile, hhayi nje ukuthi lezi zinguquko zini.
Njengoba uzobe ukhokhela ingxenye enkulu yokunakekelwa kwakho uma uthola ukukhathazeka ngaphandle kwe-inethiwekhi, udinga ukwazi ukuthi izindleko ziyoba yini ngaphambi kokuthola ukunakekelwa. Hlela ukuxoxisana ngesilinganiso esinqunyiwe nomhlinzeki wakho ongaphandle kwe-network; awufuni ukukhokha "isilinganiso se-rack." Uma uhlelo lwakho lwezempilo lunikeza ekukhokheni ukunakekelwa kwe-out-of-network, buza ukuthi isilinganiso salo esinengqondo nesokwezifiso kukukhathalela oyodinga. Lezi zinsiza zizosiza: