Umhlinzeki wezokunakekelwa kwempilo ngumuntu noma inkampani enikeza inkonzo yokunakekelwa kwezempilo kuwe. Ngamanye amazwi, umhlinzeki wakho wokunakekelwa kwezempilo uyakukhathalela.
Igama elithi "umhlinzeki wezempilo" ngezinye izikhathi lisetshenziswe ngokungalungile ukubhekisela ohlelweni lomshuwalense wezempilo, kodwa umshuwalense wezempilo uhlukile ekunakekelweni kwezempilo.
Obani Abahlinzeki Bempilo?
Umhlinzeki wezokunakekelwa kwezempilo okungenzeka owaziwa kakhulu yi- PCP noma udokotela wakho wokunakekela oyinhloko.
Kodwa, kukhona zonke izinhlobo ezahlukene zokuhlinzeka ngempilo. Noma yiluphi uhlobo lwezinsizakalo zokunakekelwa kwezempilo olungadingeka luhlinzekwa uhlobo oluthile lomhlinzeki wezempilo.
Nazi ezinye izibonelo ezingezona odokotela zabahlinzeki bezempilo:
- Umhlinzeki wezinto ezibonakalayo ezikusiza ukuba ululame ekulimazeni kwakho kwamadolo.
- I-Home Health Care Company eyinikeza umhlengikazi wakho wokuvakashela.
- Inkampani yezokwelapha ehlala isikhathi eside ehlinzeka nge-oxygen yakho noma ngesihlalo sabakhubazekile.
- Ikhemisi yakho.
- I-laboratory edonsa futhi iqhube ukuhlolwa kwegazi lakho.
- Isikhungo sokucabanga esenza ama-mammograms, ama-X-rays, ne-MRI akhomba.
- Uchwepheshe wezinkulumo osebenza nawe ukuqinisekisa ukuthi ungakwazi ukugwinya ukudla ngokuphepha ngemva kokushaywa yisifo.
- Umtholampilo wokuhlinzwa ophuthumayo lapho wenza khona ikholonoscopy yakho.
- I-laboratory ekhethekile eyenza ukuhlola kwakho kwe-DNA.
- Isikhungo sokunakekelwa okuphuthumayo noma ukuhamba-emtholampilo endaweni yokuthenga yezitolo.
Okwenza Kubalulekile
Ngaphezu kokuncamelayo okuqondene nawe ngabani abahlinzeki okungcono ukuthi bakunakekele, izinqumo zakho zokuhlinzekela ngezizathu zezezimali nezomshuwalense.
Izinhlelo eziningi zezempilo zinikeza amanethiwekhi amanethiwekhi . Lawa amanethiwekhi ngamaqembu abahlinzeki abavumelene ukuhlinzeka ngamasevisi kumalungu ehlelo lwezempilo ngesilinganiso esinqunyiwe futhi abahlangabezane nezindinganiso zekhwalithi ezidingekayo ngumshwalense wakho. Uhlelo lwakho lwezempilo lukhetha ukuthi usebenzisa abahlinzeki bayo be - inthanethi kunokusebenzisa abahlinzeki be- out-of-network .
Eqinisweni, ama-HMO nama- EPO ngeke akhokhele izinsizakalo ozitholayo kumhlinzeki wezokunakekelwa kwezempilo ongaphandle kwenethiwekhi ngaphandle kwezimo ezandayo . I-PPOs, futhi kancane kancane izinhlelo zezempilo ze-POS, ngokuvamile zizokhokhela ukunakekelwa okuhlinzekwa ngabanikezeli bezinhlelo ezingaphandle. Noma kunjalo, zikukhuthaza ukuba uthole ukunakekelwa kwakho kubanikezeli be-in-network ngokukukhokhisa ikhophi yokukhokhela ephakeme noma u-coinsurance uma usebenzisa umhlinzeki wangaphandle.
Uma uthanda udokotela wakho noma omunye umhlinzeki wezempilo, kodwa abengekho inethiwekhi ngecebo lakho lempilo, unakho ongakhetha kukho. Ngesikhathi sokubhalisa okulandelayo okuvulekile , ungashintsha ohlelweni lwezempilo olubafaka kwinethiwekhi yaso.
Ungaphinda ukhawuleze ohlelweni lwakho lwezempilo olucela ukuthi lumboze ukunakekelwa okuvela kulo mhlinzeki wangaphandle wenethiwekhi njengokungathi kunakekelwa kwenethiwekhi. Uhlelo lwakho lwezempilo lungase lukulungele ukwenza lokhu uma usephakathi kwesimiso sokwelashwa okuyinkimbinkimbi esetshenziswa noma ephethwe yile mhlinzeki.
Enye isizathu sokuthi uhlelo lwakho lungavumela lokhu ukuthi ungabonisa ukuthi kungani umhlinzeki wakho engcono kunalo msebenzi kunomhlinzeki we-in-network. Isibonelo, unayo idatha yekhwalithi ebonisa ukuthi lo dokotela ohlinzayo unesilinganiso esincane kakhulu sezinkinga zokuthunyelwa kwe-post-op kuno-ohlinzayo osebenza ngaphakathi?
Ungabonisa ukuthi lo dokotela ohlinzayo unolwazi olunzulu kakhulu ekwenzeni inqubo yakho engavamile neyinkimbinkimbi? Uma ngabe odokotela abahlinzayo be-in-network benza kuphela inqubo udinga izikhathi ezingu-6, kodwa ohlinzayo wakho ongaphandle kwe-network uye wakwenza kabili ngesonto iminyaka eyishumi, unethuba lokukholisa umshwalense wakho.
Uma ungakwazi ukuqinisekisa uhlelo lwakho lwezempilo olusebenzisa lo mhlinzeki ngaphandle kwenethiwekhi kungase ulondoloze imali ngokuhamba kwesikhathi, ungase ukwazi ukunqoba isikhalazo sakho.
Ukuqonda uhlu olubanzi lwabahlinzeki kungakusiza ukuba ugweme izikweletu ezimangalisa
Izikweletu zezimangalo ezenzekayo uma kwenzeka isiguli siphathwa esibhedlela, kodwa sithola ukwelashwa noma amasevisi kumhlinzeki wangaphandle.
Isibonelo, ungase ube nokuhlinzwa kwamadolo esikhungweni senethiwekhi yakho yezempilo, futhi kamuva uthole ukuthi umhlinzeki wezokwelapha ohlala isikhathi eside esibhedlela esisebenzisayo awunenkontileka ngecebo lakho lomshuwalense.
Ngakho-ke ngaphezu kokuba uhlangabezane nesiphakamiso sakho sezempilo ku-inethiwekhi ngaphandle kwe-pocket esiphezulu, ungase futhi ugcine ukhokhela izinkokhelo ezingaphandle kwamasevisi we-knee brace kanye nezinsimbi zokuhamba, i-walker, noma isitulo sabakhubazekile ogcina nabo emva ukuhlinzwa.
Uma wazi ngokwengeziwe uhla lwabahlinzeki abathintekayo ekunakekelweni kwezokwelapha, kungcono ukuthi ulungiselele, okungenani ezimweni ezingekho eziphuthumayo. Ezinye izifundazwe zidlulisele imithetho yokunciphisa ukuchayeka kweziguli ukulinganisela ukukhokhiswa ezimweni lapho abanye abahlinzeki esikhungweni esinikeziwe abayona ingxenye yamanethiwekhi omshwalense lapho isikhungo sisebenza khona.
Kodwa ngokujwayelekile, imibuzo engaphezulu oyicelayo kusengaphambili, iyoba ngcono nakakhulu. Buza mayelana nenethiwekhi yomshuwalense ukubandakanyeka kwanoma yikuphi abahlinzeki abangakuphatha-ngokuqondile, noma ngokungaqondile, njengoba kungaba njalo ngempahla ehlala isikhathi eside yezokwelapha, izidakamizwa ze-radiologists kanye nama-lab. Buza esibhedlela noma emtholampilo uma kukhona ukunikezwa kwe-in-network kwimeko ngayinye, futhi usho isifiso sakho sokusebenzisa abahlinzeki-inethiwekhi-egcina engqondweni ukuthi "umhlinzeki" uya ngaphesheya kudokotela owengamele ukunakekelwa kwakho.
> Imithombo:
> Hoadley, uJack; Ahn, Sandy; Lucia, Kevin. URobert Wood Johnson Foundation & Isikhungo Sokuvuselelwa Kwempilo Yomshuwalense (i-Georgetown University Health Policy Institute). Ukukhokhwa kwemali: Ukuthi amazwe avikela kanjani abathengi emalini angalindelekile? Juni 2015.
> I-National Academy yeNqubomgomo YezeMpilo kaHulumeni, Umthetho Wokukhokhiswa Kwezimangalo Ezingenakwenzeka Ngonyaka ka-2016.