I-Exclusive Provider Organisation (EPO)
Ucabangele ukubhalisa ohlelweni lwezempilo lwe-EPO? Uma kunjalo, kubalulekile ukuthi uqonde ukuthi lezi zinhlelo ziphi nokuthi zisebenza kanjani, ukuqinisekisa ukuthi uhlelo luzohlangabezana nezidingo zakho.
Kuthiwani uma usuvele unomshuwalense wezempilo we-EPO? Ukuqonda ukungena nokuphuma kwe-EPO yakho kusebenza kuyokusiza ukuthi usebenzise uhlelo lwakho lwezempilo ngokuphumelelayo futhi ugweme amaphutha abizayo.
Iyini i-EPO (i-Exclusive Provider Organization)?
Uhlobo lomshwalense wezempilo wokunakekelwa okuphethwe, i-EPO imele inhlangano ehlinzeka ngokukhethekile . Umshuwalense wezempilo we-EPO unalo leli gama ngoba kufanele uthole ukunakekelwa kwezempilo kuphela kulabo abanakekelwa ngempilo i-EPO izivumelwano, noma i-EPO ngeke ikhokhele ukunakekela.
Njengabazala babo, ama-PPOs nama-HMO, izinhlelo zezempilo ze-EPO zinemithetho yokukhokha izindleko mayelana nokuthi uthola kanjani ukunakekelwa kwezempilo. Uma ungalandeli imithetho yakho ye-EPO uma uthola izinsizakalo zokunakekelwa kwezempilo, ngeke ukhokhele ukunakekela.
Imithetho yohlelo lwezempilo ye-EPO iphakathi kwezimboni ezimbili eziyisisekelo zokugcina izindleko:
- Kukuphi futhi othola khona izinsizakalo zokunakekelwa kwezempilo kunomkhawulo kubanikezeli abaye baxoxisana izaphulelo nge-EPO.
- Izinsizakalo zokunakekelwa kwezempilo zikhawulelwe ezintweni ezidingekayo kwezokwelapha noma ezenza izindleko zakho zokunakekelwa kwezempilo zinciphise ngokuhamba kwesikhathi, njengokunakekelwa kokuvimbela .
Usebenza kanjani umshuwalense wezempilo we-EPO?
Yini okudingeka ukwazi mayelana nokusebenzisa umshuwalense wezempilo we-EPT?
Qinisekisa ukuthi ufunda inqubomgomo yakho yomshuwalense wezempilo ngokucophelela. Ukuhlala ku-inethiwekhi nokuthola ukugunyazwa kwangaphambili uma kudingeka kuyakusindisa imali eningi. Ake sibheke imiqondo ebaluleke kakhulu ukuyiqonda.
Izindleko zokwabelana ngezindleko ku-EPO ziphansi
Ukwabelana ngezindleko ngumkhuba lapho wena kanye nenkampani yakho yomshuwalense ukhokhela ingxenye yamasevisi futhi uvame ukugcinwa okungenani nge-EPO.
Lokhu kufaka phakathi ama- deductibles , ama- copayments , nokuqinisekiswa kwemali . Eqinisweni, amanye ama-EPO awadingi nanoma yikuphi ukukhipha imali noma ukukhokhela imali, futhi nje ukhokha imali encane yokukhokhwa ngesikhathi sokusebenza. Ngenxa yokwabelana kwezindleko eziphansi kanye nama- premium aphansi, i-EPO ingenye yezinketho zempilo yomshuwalense wezempilo.
Kumele Usebenzise Umhlinzeki We-Inethiwekhi
Wonke ama-EPO anelungelo labahlinzeki bezempilo ababizwa ngokuthi inethiwekhi yomhlinzeki. Le nethiwekhi inika yonke insizakalo yokunakekelwa kwezempilo okucatshangwayo kubandakanya odokotela, ochwepheshe, ama-pharmacy, izibhedlela, ama-laboratory, ama-ray-ray, ama-radiologist, i-oxygen ekhaya, nokuningi.
Kuhlelo lwezempilo lwe-EPO, ungathola kuphela izinsizakalo zokunakekelwa kwezempilo ezivela kubahlinzeki be-in-network . Uma uthola ukunakekelwa kwe-inethiwekhi , i-EPO ngeke ikukhokhele; uzobe unamathela ekukhokheleni konke okukhokhwayo ngokwakho. Ukunakekelwa kwe-out-of-network ngokungahambi kungaba yiphutha elibi kakhulu uma une-EPO.
Ekugcineni umthwalo wakho wemfanelo ukwazi ukuthi yiziphi abahlinzeki abakhona-inethiwekhi ne-EPO yakho. Isibonelo, awukwazi ukucabanga ukuthi ngenxa yokuthi lebhu ibheke phansi ihholo ehhovisi lakho le-EPO udokotela, in-network ne EPO yakho. Kufanele uhlole. Ngokufanayo, ungacabangi ukuthi isikhungo sokubona izithombe esenza u-mammogram wakho ngonyaka odlule sisese-inethiwekhi ne-EPO yakho kulo nyaka.
Amanethiwekhi omhlinzeki ashintsha. Uma wenza lokho kucabanga futhi ulungile, kuzodingeka ukhokhele yonke imali ye-mammogram.
Kukhona okunye okungaphandle kwezimfuneko eziku-in-network:
- Uma i-EPO ingenayo umnikezeli we-inthanethi wenkonzo yokukhethekile oyidingayo. Uma lokhu kwenzeka kuwe, lungiselela ukunakekelwa okukhethekile okuvela ngaphandle kwenethiwekhi ne-EPO. Gcina i-EPO yakho ku-loop.
- Uma ungaphakathi kwenkambo eyinkimbinkimbi yokwelapha okukhethekile uma uba yilungu le-EPO, futhi ochwepheshe bakho akayona ingxenye ye-EPO. I-EPO yakho izothatha isinqumo sokuthi ungaqeda yini ukwelashwa ngodokotela wakho wamanje esimweni sokwethenjelwa.
- Ukuphuthumayo kweqiniso. Uma une-stroke, ukuhlaselwa yinhliziyo, noma esinye isimo esiphuthumayo seqiniso kufanele uhambe ekamelweni eliphuthumayo eliseduze eliseduze noma lingekho inethiwekhi ne-EPO yakho. Iningi le-EPO lizofaka izindleko zokunakekelwa okuphuthumayo ezitholakala esiteshini esiseduze nese-network njengokungathi kunakekelwa kwenethiwekhi. Uma udinga ukungeniswa esibhedlela kusukela ku-ER, noma kunjalo, i-EPO yakho ingacela i-ER ngaphandle kwenethiwekhi ukuthi ikudlulisele esibhedlela esise-inthanethi sokungeniswa.
Asikho isidingo sokuthi ube nodokotela oyinhloko
Ipulani yakho yezempilo ye-EPO ngeke ifune ukuthi ube nodokotela oyinhloko (ukunakekelwa kwe-PCP) , nakuba ukuthola i-PCP kusengumqondo omuhle.
Awudingi Ukuba Nokudluliselwa Kokubona Ochwepheshe
Nge-EPO ngeke kudingeke uthole ukuhanjiswa ngaphambi kokubona ochwepheshe. Lokhu kwenza kube lula ukubona isazi kusukela usenza isinqumo ngokwakho, kodwa kudingeka uqaphele ukuthi ubona ochwepheshe kuphela abano-inethiwekhi ne-EPO yakho. Inzuzo yokuba ne-PCP ukuthi bajwayele ukujwayela ochwepheshe emphakathini wakho, futhi ochwepheshe abaningi banesithakazelo esikhethekile ngaphakathi kokukhethekile kwabo, isibonelo, ezinye ze-oncologists jikelele zingaba nesithakazelo esikhethekile emdlalweni webele kodwa omunye angase abe nesithakazelo esikhethekile emdlavuza wamaphaphu.
Kuzodingeka Uthole Ukugunyazwa Ngaphambi Kwezinsiza Ezizimele
I-EPO yakho izodinga ukuthi uthole imvume yamanye amasevisi, ikakhulukazi lawo aphezulu kakhulu. Uma isevisi ethile idinga ukugunyazwa kwangaphambili (ukugunyazwa kwangaphambili) futhi uma ungayitholi, i-EPO yakho ingenqaba ukukhokha. Iningi lezinsizakalo ezidinga ukugunyazwa yizinsizakalo ezikhethiwe hhayi eziphuthumayo, ngakho ukuphuza isikhathi esincane ngeke kube yingozi.
Ukugunyazwa kwangaphambi kokusiza kusiza i-EPO yakho igcine izindleko phansi ngokuqinisekisa ukuthi udinga ngempela amasevisi owutholayo. Kuzinhlelo ezinjenge-HMO ezidinga ukuthi ube nodokotela oyinhloko wokunakekela, i-PCP yakho inesibopho sokuqinisekisa ukuthi udinga ngempela amasevisi owutholayo. Njengoba i-EPO yakho ingadingi ukuba ube ne-PCP, isebenzisa ukugunyazwa kwangaphambili njengendlela yokufinyelela umgomo ofanayo: I-EPO ikhokha kuphela izinto ezidingekayo ngempela emzimbeni.
Izinhlelo ze-EPO ziyahlukahluka ngokuthi yiziphi izinhlobo zamasevisi okumelwe zigunyazwe ngaphambilini. Iningi lidinga ukugunyazwa kwangaphambili kwezinto ezinjenge-MRI ne-CT, izidakamizwa ezibiza kakhulu, ukuhlinza, izikhungo zokwelashwa, kanye nemishini yezokwelapha njenge-oxygen ekhaya. Okufingqiwe kwe-EPO's Benefits and Cover kufanele kukutshele kabanzi mayelana nesidingo sokugunyazwa kwangaphambi kokugunyazwa, kodwa kufanele ulindele ukuthi noma iyiphi insizakalo eyabizayo izodinga ukugunyazwa ngaphambilini.
Nakuba udokotela wakho angase azitholele ukuzitholela imvume ngaphambili, ekugcineni umthwalo wakho wokuqinisekisa ukuthi uthola isevisi ngaphambi kokugunyazwa ngaphambi kokuthola ukunakekelwa kwezempilo. Uma ungenjalo, i-EPO yakho inelungelo lokulahla ukukhokhela ukunakekelwa, noma ngabe ukunakekelwa kwakudingeka ngokwezempilo futhi uyitholile kumhlinzeki we-in-network.
Ukugunyazwa kwangaphambi kwesikhathi kuthatha isikhathi. Ngezinye izikhathi, uzoba negunya ngaphambi kokuba ushiye ihhovisi likadokotela. Ngokuvamile, kuthatha izinsuku ezimbalwa. Ezimweni ezimbi, noma uma kunenkinga ngokugunyazwa, kungathatha ngisho namasonto. Bheka amathiphu ethu wokuthola isicelo sokugunyazwa esandulele .
Awudingi Ukufaka Izimangalo
Awudingi ukuhlukunyezwa ngezikweletu futhi ufake amafomu uma unomshuwalense wezempilo we-EPO kusukela konke ukunakekelwa kwakho kunikezwa ku-inethiwekhi. Umhlinzeki wakho wokunakekelwa kwezempilo we-in-network uyayikhokhisa uhlelo lwakho lwezempilo lwe-EPO ngokucophelela kokunakekelwa okutholayo. Uzobe unesibopho sokukhokha imali yakho, ukukhokha imali, nokukhokhela imali.
Ngaphansi kwe-EPO Insurance Insurance
I-EPO inezici ezithile ezifanayo nama-HMO nezinye izici ezifanayo nama-PPOs. Ngenxa yalokho, ungase ucabange i-EPO ukuba i-cross-breed phakathi kwe-HMO ne-PPO. Abantu abaningi bathanda ukukwazi ukuhlela i-aphoyintimenti nomchwepheshe ngaphandle kokubonisana nodokotela oyinhloko. Ngesikhathi esifanayo, lokhu kungase kube yinselele ngezinye izikhathi ngokuthi ulinganiselwe ochwepheshe abathile ngaphakathi kwenethiwekhi yakho. Ukuba ne-EPO kudinga ukuba uhlanganyele ekuhleleni izinsizakalo ezibizayo noma izinqubo, futhi ushiya ngokuyinhloko ukuthi unesibopho sokuqedela noma yikuphi ukugunyazwa kwangaphambili okudingekayo. Ngokubanzi, ukuhlanganiswa kwama-premiums ayo aphansi kanye nokwabelana ngezindleko eziphansi kwenza i-EPO ibe yinto enhle kubantu abaningi. Uma uthola ingqondo njengoba uqhathanisa izinhlelo ezihlukene, hlola ukufaniswa kwethu kwama-HMO, ama-PPOs, ama-EPO. kanye nezinhlelo ze-POS .
> Umthombo:
> Healthcare.gov. Uhlelo lwe-Exclusive Provider Organization (EPO). https://www.healthcare.gov/glossary/exclusive-provider-organization-epo-plan/