Ufuna ukunakekelwa udokotela ongaphandle, umtholampilo noma esibhedlela? Ungakhokha okuningi kunokuba ungathanda uma uhlala ku-inethiwekhi. Eqinisweni, nge- HMO s ne- EPO s, umshuwalense wakho wezempilo angeke akhokhe noma yini ukunakekelwa kwe- out-of-network . Ngisho noma umshuwalense wakho wezempilo iPPO noma uhlelo lwe-POS olunikela ekunakekelweni kwakho kokuphuma ngaphandle kwenethiwekhi, ingxenye yakho yesikweletu izoba mkhulu kakhulu kunalokho ojwayele ukukhokha ukunakekelwa kwenethiwekhi.
Kodwa-ke, ngaphansi kwezimo ezithile, uhlelo lwakho lwezempilo luzokhokhela ukunakekelwa kwe-out-of-network ngezinga elifanayo elikhokhela ukunakekelwa kwe-in-network, ekulondolozeni imali eningi. Kufanele wazi ukuthi ungazibuza nini futhi kanjani.
Uma uhlelo lwakho lwezempilo luzokhokhisa ama-In-Network Rates for Out-of-Network Care
Umshuwalense wezempilo ulawulwa imithetho yezwe. Umbuso ngamunye uhlukile komakhelwane bawo, ngakho-ke okulandelayo yiziqondiso ezijwayelekile ezisebenza emazweni amaningi. Kodwa-ke, uma imithetho yakho yombuso ihlukahluka, uhlelo lwakho lwezempilo lungalandela imithetho ehlukile.
Izinhlelo zezempilo zingase zibheke ukukhokhela ukunakekelwa okuthola ngaphandle kwe-inethiwekhi njengokungathi uyitholile kumhlinzeki we- in-in ngezimo ezilandelayo:
- Kwakuyisimo esiphuthumayo futhi waya ekamelweni eliphuthumayo eliseduze elisakwazi ukuphatha isimo sakho. Kulesi simo, uhlelo lwakho lwezempilo lungase lufinyeleleke "esimweni esiphuthumayo" njengendlebe yokuzwa indlebe, ukukhwehlela okugubhayo, noma isiqephu esisodwa sokuhlanza. Kodwa, kungenzeka ukuthi uhlinzekele ukunakekelwa okuphuthumayo okuvela ngaphandle kwenethiwekhi ngezinto ezifana nokuhlaselwa kwenhliziyo okusolwa, ukushaywa, noma ukulimala okusongela izitho.
- Akunabanikezeli be-inthanethi lapho ukhona. Lokhu kungasho ukuthi uphumile edolobheni uma ugula futhi uthola inethiwekhi yakho yezinhlelo zezempilo awufihli umuzi owawuvakashele. Kungasho futhi ukuthi ungaphakathi kwendawo yakho ejwayelekile yokuhlela impilo, kodwa inethiwekhi yakho yezinhlelo zezempilo ayifaki uhlobo lochwepheshe oludingayo, noma ochwepheshe be-in-network kuphela ku-200 miles. Kuzo zombili izimo, uhlelo lwakho lwezempilo luzokwazi ukuhlinzekela ukunakekelwa kwe-in-network kwinani le-in-network uma uxhumana nohlelo lwezempilo ngaphambi kokuthola ukunakekelwa.
- Uphakathi komjikelezo owuyinkimbinkimbi yokwelashwa (cabanga nge-chemotherapy noma ukufakelwa komzimba) lapho umhlinzeki wakho ngokuzumayo ephuma ekubeni in-inethiwekhi ukuya ngaphandle kwenethiwekhi. Lokhu kungenzeka ngenxa yokuthi umhlinzeki wakho wehlisiwe, noma wakhetha ukuhamba, inethiwekhi. Kungenzeka futhi ngenxa yokuthi ukuguqulwa komshuwalense wezempilo kushintshiwe. Isibonelo, mhlawumbe unomsebenzi osuselwa emsebenzini futhi umqashi wakho akasasanikeli uhlelo owawube nalo eminyakeni eminingi ngakho waphoqeleka ukuba ushintshe kuhlelo olusha. Kwezinye izimo, uhlelo lwakho lwezempilo lwanamuhla luzokuvumela ukuba uqedele umjikelezo wakho wezokwelapha nomhlinzeki wangaphandle wenethiwekhi ngenkathi ubhekene nokukhathalela ngenani le-in-network.
- Inhlekelele yemvelo yenza kube nzima ukuthi uthole ukunakekelwa kwenethiwekhi . Uma indawo yakho isanda kudabula isikhukhula, isiphepho, ukuzamazama komhlaba, noma umlilo ovuthayo okwakuthinta kakhulu izindawo eziku-inthanethi endaweni yakho, uhlelo lwakho lwezempilo lungase luzimisele ukugada ukunakekelwa kwakho kokuphuma ngaphandle kwenethiwekhi kumazinga enethiwekhi ngoba Izakhiwo ze -network azikwazi ukukukhathalela.
- Kunesimo esandisayo sokwenza ukunakekelwa kwe-in-network kunzima noma okungeke kube nokwenza ukunakekelwa kwe-in-network kunenani elibiza kakhulu kunokunakekelwa kwenethiwekhi. Lezi zimo ezikhethekile, izimo ezikodwa okufanele zibhekwe ngazo ngesinye isisekelo. Uzobe ucela uhlelo lwakho lwezempilo ukwenza okukhethekile, kuwe kuphela, futhi nje lesi siqephu sokunakekelwa. Nazi ezinye izibonelo ezicatshangelwayo:
- Ufunda ukuthi udokotela ohlinzayo we-in-network unesilinganiso sokutheleleka kokuthunyelwa kwe-post-op izikhathi eziyisihlanu eziphakeme kunomhlinzeki ohlinzayo wangaphandle kwedolobha. Awekho amanye ama-surgeon ase-in-network. Kumele ube nokuhlinzwa, futhi usemithi (noma unesifo) okwenza kube nzima kuwe ukulwa nezifo. Kulesi simo, ucela uhlelo lwezempilo ukwenza okuhlukile ngokusekelwe engozini yakho yokuthola isifo, ubunzima bakho ukulwa nokutheleleka, kanye nesilinganiso esiphakeme sokutheleleka komhlinzeki we-in-network. Kuzodingeka uqinisekise uhlelo lwakho lwezempilo kuzoba nemali engcono kakhulu kubo ukumboza ukunakekelwa kwakho kokuphuma ngaphandle kwenethiwekhi ezingeni le-in-network kunokuba ukhokhele ukwelashwa okungase kubize kanye nemiphumela eminye ye-post-op ukutheleleka.
- Usuvele uthola isahlukaniso esivumayo. Umyeni wakho wangaphambili yiyona kuphela ye-neurosurgeon ye-in-network ngaphakathi kwendawo engamakhilomitha angu-300, futhi une-tumor ebuchosheni efuna ukuhlinzwa. Awufuni nje kuphela ukuthi umyeni wakho wangaphambili enze lo msebenzi, futhi awufuni ukuthi afinyelele kumarekhodi akho ezokwelapha ezizimele. Buza uhlelo lwakho lwezempilo ukwenza okhethekile futhi umboze i-neurosurgeon engekho ngaphandle kwenethiwekhi njengokungathi yayisenethiwekhi.
Indlela Yokuthola Impilo Yakho Yokugubungela Ukunakekelwa Kwama-Network Okungenani Amanani Engaphakathi
Okokuqala, kufanele ucele uhlelo lwakho lwezempilo ukwenza lokhu, uhlelo lwezempilo ngeke luvolontiya nje. Ngaphandle kokunakekelwa kokuphuthumayo, izinhlelo eziningi zezempilo ngeke zijabule ngempela ngokuhlinzekela ukunakekelwa kwe-in-network kumazinga oku-inethiwekhi. Kusho ukuthi uhlelo lwezempilo luzokhokhela okungaphezulu ukunakekelwa kwakho noma kuzodingeka luchithe isikhathi nesisebenzi sesikhathi sokusebenza ukuze uxoxe ngamanani atholakalayo okwelashwa nomhlinzeki wangaphandle. Noma kunjalo, lokhu akusho ukuthi uhlelo lwezempilo ngeke lukhokhise amazinga angaphakathi. Kuzodingeka nje wenze impikiswano ekholisayo mayelana nokuthi kungani udinga ukunakekelwa okungaphandle kwenethiwekhi nokuthi kungani ukusebenzisa umhlinzeki we-inthanethi ngeke kusebenze.
Uzoba nethuba elingcono lokuphumelela uma uhlela kusengaphambili. Uma lokhu kungukunakekelwa okuphuthumayo, faka uhlelo lwakho lwezempilo ngalesi sicelo ngaphambi kokuthi uhlele ukuthola ukunakekelwa kokuphuma kwenethiwekhi. Le nqubo ingathatha amasonto. Yenza umsebenzi wesikole ukuze ukwazi ukuqinisa ingxabano yakho namaqiniso, hhayi nje imibono. Cela usizo lwe-in-network yakho yokunakekelwa udokotela oyinhloko ukubhala incwadi ohlelweni lwakho lwezempilo noma ukhulume nomqondisi wezokwelapha wezempilo yakho ukuthi kungani isicelo sakho kufanele sihlonishwe. Izinkulumo zemali, ngakho-ke uma ungabonisa ukuthi ukusebenzisa umhlinzeki wangaphandle kwenethiwekhi kungasindisa kanjani imali yenkampani yomshuwalense wezempilo ngokuhamba kwesikhathi, lokho kuzosiza imbangela yakho.
Uma uxhumana necebo lakho lempilo, gcina ubuchwepheshe, ubuhle obuhle. Qinisekisa, kodwa ungabi namanyala. Uma unenkulumo yefoni, thola igama nesihloko somuntu okhuluma naye. Bhala konke phansi. Ngemuva kwengxoxo yefoni, cabanga ukubhala incwadi noma i-imeyili efingqa ingxoxo yefoni bese uyithumela kumuntu okhulume naye, noma kumphathi wayo, njengesikhumbuzi semininingwane yengxoxo. Thola izivumelwano ngokubhala.
Uma uxoxisana ngokukhishwa kwe-in-network kunamazinga we-in-network, kukhona okungenani izinto ezimbili zokuxoxisana: ukwabelana ngezindleko kanye nemali eqondakalayo nangokwezifiso .
- Izingxoxo zokwabelana ngezindleko: Uma uthola ukunakekelwa kwe-out-of-network ngokusebenzisa uhlelo lwe-PPO noma i-POS, ungase ube ne- deductible ephakeme yokunakekelwa kwe-out-of-network kunokuba ukunakekelwa kwe-in-network. Imali owayikhokhela ngaphambili kwi-in-network deductible yakho ingase ingabonakali ekubhekaneni ne-out-of-network deductible, ngakho-ke ungase uqale yonke indawo ku-zero. Ukwengeza, ukubambisana kokunakekelwa kwe-out-of-network kuvame ukuphakama kakhulu kunokunakekelwa kwe-in-network. Xoxa ngokunakekelwa okumele ukhokhwe ngokusebenzisa isilinganiso se-in-net deductible rate kanye ne-in-network coinsurance rate, njengoba nje usebenzisa umhlinzeki we-in-network.
- Ukukhokhiswa kwemali yokukhokha / okulinganiselwe: Uma usebenzisa umhlinzeki ongaphandle kwe-inthanethi, usengozini yokulinganisa imali engakhokhiswa okungabangela ekukhokheni amaphesenti amakhulu kakhulu ebhilikithi kunalokho owabikezele. Abaqinisekisi bezeMpilo bazobheka ibhilikithi engaphandle kwe-inthanethi, bathi, $ 15,000 bese uthi okuthile kumphumela we "Lokhu ukukhokha kuphakeme kakhulu kuleyo nsizakalo. Lo mthethosivivinywa awunangqondo. Ukukhokha okujwayelekile nokujwayelekile kwesevisi kungu-$ 10,000, ngakho-ke sizokhokha isabelo sethu se-$ 10,000. "Ngeshwa, ungase ukhokhwe ukukhokha u-$ 5,000 umehluko ngaphezu kokuhlanganyela kwakho kwezindleko. Funda kabanzi mayelana nalokhu ku-" Ukulinganisa Ukulinganisela-Okuyiyo nokuthi Kusebenza Kanjani ."
Uma uxoxisana nokunakekelwa kwe-out-of-network kumazinga oku-inethiwekhi, qiniseka ukulungisa umehluko phakathi kwalokho okushiwo ngumhlinzeki wakho we-out-of-network nokuthi yikuphi uhlelo lwakho lwezempilo olucabangela ukuthi lunengqondo. Lokhu kungabandakanya uhlelo lwakho lwezempilo oludweba inkontileka nomhlinzeki wakho wokuphuma ngaphandle kwenethiwekhi yesiqephu esisodwa sokunakekelwa ngesilinganiso esithile sokuxoxisana. Qinisekisa ukuthi inkontileka inesigatshana "sokukhokhiswa kwebhalansi" ukuze ungabambeki nganoma yiziphi izindleko ngaphandle kwe-deductible, copay, ne-coinsurance.