Ukuhlanganisa kuhlanganisiwe kuwo wonke amasha amaqembu omuntu ngamunye namancane
Ngaphambi koMthetho Wokunakekelwa Okunganakekelwa (ACA, owaziwa ngokuthi yi-Obamacare) ukusebenza, ukutholakala kokuhlinzekwa kwezinhlelo zomshuwalense wezempilo kuyehluka kakhulu kusuka kwesinye isimo kuya kwesinye. Ukuvikelwa kwabathengi kwakuyi-patchwork yemithetho esekelwe e-state eyayinamandla kwezinye izifundazwe futhi encane kwezinye.
Izidingo zikaHulumeni eziphelele kakhulu kune-ACA zisasebenza, kodwa kuzo zonke izimo, i-ACA isungule amazinga amancane.
Izinzuzo zezeMpilo ezibalulekile (EHBs) zinezinhlobo eziyishumi zokunakekelwa kwezokwelapha okumele zihlanganiswe- ngaphandle kwemingcele ye dollar ezizuzwaneni zonyaka noma zokuphila- zonke izinhlelo zeqembu ngalinye nezincane ezinsukwini eziphumelelayo zikaJanuwari 2014 noma kamuva. Ama-EHB ahlanganisiwe kungakhathaliseki ukuthi uhlelo ludayiswa yini ngokushintshaniswa noma ukushintshaniswa .
Amacebo amakhulu kanye nezinhlelo ezisezingeni eliphezulu zikhona, kodwa zinezinsuku eziphumelelayo ngaphambi kuka-2014. Ngakho-ke izidingo ze-EHB azisebenzisi izinhlelo ezinamakhono amakhulu, ngaphandle kokunakekelwa kokuvikela, okuyinto okudingeka ukuba ihlanganiswe kumuntu ozukulukazi-kodwa engakhulumi- izinhlelo. Izidingo ze-EHB nazo azisebenzi ezinhlelweni zeqembu elikhulu .
Nakhu okuyi-EHBs, nokuthi basebenza kanjani:
Ambulatory Services
Lokhu kuhlanganisa ukuvakashela amahhovisi odokotela nemitholampilo, kanye nokunakekelwa esibhedlela okuhlinzekwe ngesiguli.
Ukuphathwa kwezifo ezingapheli, ukunakekelwa kahle kwezempilo, nezinsizakalo zokuvimbela
Ukunakekelwa kokuvimbela kuhlanganiswa ngaphandle kokwabelana ngezindleko zesiguli (ie, inkampani yomshuwalense ikhokha izindleko ezigcwele), kodwa kuphela uma insizakalo yokuvimbela embuzweni ikhona ohlwini lokunakekelwa kokuvikela.
Kukhona ama-ejensi amathathu lapho izincomo zawo zisetshenziselwa ukwakha uhlu lokunakekelwa okuvimbekile. Lolu hlu lusekelwe ikakhulukazi ngokusekelwe kumasevisi athola isilinganiso "A" noma "B" kusukela e-US Preventive Services Task Force (USPSTF). Ukuhlolwa komdlavuza webele webesifazane abaneminyaka engama-40 kuya kwengu-49 kuphela kunokwesilinganiso "C" esivela ku-USPSTF, kodwa okuhlukile kwafakwa ukufaka phakathi ohlwini lwezinsizakalo zokuvimbela ngaphansi kwe-ACA.
Ngaphandle kwemikhombandlela ye-USPSTF, iKomidi Elilulekayo le-CDC Lemikhuba Yokugoma (ACIP) inikeza izincomo zokugoma, kanti i-Health Resources kanye Nezokuphathwa Kwezinsizakalo (HRSA) inikeza izincomo ezengeziwe zokunakekelwa kokuvikela abesifazane, izinsana nezingane.
Ukwelashwa kuhlanganiswa ngaphansi kokunakekelwa kokuvimbela, okusho ukuthi kuyatholakala ngaphandle kwezindleko kumuntu ophephile. Kodwa izinhlelo zomshuwalense wezempilo zidingeka kuphela ukumboza okungenani uhlobo olulodwa lwezinhlobo ezigunyaziwe ze-FDA zokubeletha kwabesifazane.
Izinsiza Eziphuthumayo
Nakuba izithwalense zempilo yomshuwalense zingakwazi ukukhawulela ukuhlinzekwa okuningi kubanikezeli be-inthanethi, akulona iqiniso ngezinsizakalo eziphuthumayo.
Umshwalense wakho wempilo akakwazi ukubeka ukwabiwa kwezindleko eziphezulu ekunakekeleni kwegumbi lokuphuthumayo esibhedlela esibhedlela, futhi kufanele akuvumele ukuba uye ekamelweni eliphuthumayo eliseduze, noma lingekho kwinethiwekhi yakho.
Imfuneko yokuthi inshuwalense yezempilo ihlinzekwe ukwelashwa okuphuthumayo futhi ibuyele ekuthuthweni kwe-ambulensi, kuhlanganise ne-ambulensi yomoya.
Kubalulekile ukuqaphela, noma kunjalo, ukuthi ukukhokhisa ibhalansi kusengaba yinkinga ezimweni eziphuthumayo lapho kusetshenziselwa amakamelo okuphuthumayo okuphuma ngaphandle kwenethiwekhi kanye / noma amasevisi we-ambulensi. Nakuba i-ACA idinga abathwali ukuba bavikele ukwelashwa okuphuthumayo emazingeni angaphakathi-inethiwekhi ngisho noma isibhedlela noma umhlinzeki we-ambulensi engaphandle kwenethiwekhi, lokho akuphoqeleli esibhedlela, odokotela abaphuthumayo, noma inkampani ye-ambulensi ekukhokhiseni isiguli ngokulingana ibhilidi labo, ngaphezu kwanoma yini ekhokhwa yinkampani yomshuwalense wegulane.
Ezinye izizwe ziye zavinjelwa ukukhokhiswa kwemali ezimweni ezimweni eziphuthumayo, futhi umthetho ofana nawo ucatshangelwe-kodwa awusaphasi-ezingeni likahulumeni.
Isibhedlela
Lokhu kuhlanganisa uhla olugcwele lokunakekelwa kwabagulayo, kubandakanya ukwelashwa odokotela nabahlengikazi, i-laboratories lab kanye nezinsizakalo zekhemisi, nokunakekelwa kokuhlinzwa.
Services Laboratory
Umsebenzi weLab owela ngaphansi kokunakekelwa kokuvimbela okuchazwe ngenhla uhlanganiswe kungekho ukwabelana ngezindleko zesiguli.
Olunye umsebenzi oludingekayo welebhu uhlanganiswa ngaphansi kweziqondiso ezijwayelekile zokuhlela izindleko.
Ukubeletha Nokubeletha Okusanda Kuzalwa
Lokhu kuhlanganisa konke ukubeletha, ukulethwa, nokunakekelwa kwezinsana, nakuba ukuhlolwa kokubeletha kuvame ukuhlanganiswa ngaphansi kokunakekelwa kokuvikela (kuchazwe ngenhla) futhi kungabanjwa ngaphandle kokwabelana ngezindleko kumama olindelekile.
Ngokusho kwe-HRSA, ukunakekelwa kokubeletha kungena ngaphansi kwesigaba sokunakekela abesifazane kahle. Futhi nakuba ezimweni eziningi ezihlanganiswa kanye ngonyaka, i-agency ithi uma kwezinye izimo "kungase kudingeke ukuvakashelwa eziningana ukuze uthole zonke izinsizakalo zokuvimbela ezidingekayo."
Ngaphezu kokuzihlola ngokwabo, kunezivivinyo ezithile eziqondile (for diabetes gestational, Hepatitis B, kanye nokungahambisani noR) okuhlanganisiwe kwabesifazane abakhulelwe ngaphansi kwesigaba sokunakekelwa kokuvikela, ngaphandle kokwabelana ngezindleko.
Impilo yengqondo nokuphathwa kabi kwezidakamizwa
Lokhu kubandakanya ukwelashwa kwesifo sengqondo kanye nokuphulukiswa kwabagulayo ngenxa yokwelashwa kwengqondo nokuphathwa kabi kwezidakamizwa.
Izidingo zempilo yengqondo zandulela i-ACA, nakuba i-ACA yandisa umthetho wobudlelwane ukuba usebenze kumacebo omakethe ngabanye kanye nokuqashwa okuxhaswe ngumqashi. Ngaphansi kwezimfuneko zomphakathi, uhlelo lwezempilo alukwazi ukuba nemikhakha yokuvikela imithi yengqondo yengqondo kunokuba inakekele ukwelashwa / ukwelashwa.
Izinsizakalo zezingane, kubandakanya ukunakekelwa kwamazinyo nokubona izingane
Ngokungafani namanye ama-EHB, amazinyo omntwana akudingeki afakwe ezinhlelweni zemishuwalense yezempilo emazweni amaningi. Esikhundleni salokho, ukushintshaniswa kungabanikela ngemigomo yamazinyo e-pediatric edayiswayo.
Uma izingxoxo zithengisa izinhlelo zokwelapha zamazinyo ezimele zodwa futhi umndeni uthengisa uhlelo lwezempilo kanye nesicwangciso sezinyosi zamazinyo ehlukene, kuphela izindleko zesicwangciso sezempilo zibalwa lapho kubalwa imali eyabelwe imali . Kodwa lokho kungashintsha, ngaphansi komthetho ohlongozwayo okhishwe yi-IRS ngoJulayi 2016 . Ngaphansi komthetho ohlongozwayo, izindleko zokuhlinzekwa kwamazinyo okubeletha izingane zizofakwa ekubalweni kwezinsizakalo ze-premium, noma ngabe ukuthengiswa kwamazinyo kuthengiswa nge-exchange njengenqubomgomo ehlukile, kunokuba kube yingxenye yecebo lempilo.
Asikho isidingo sokuthi izinhlelo zezempilo zimboze amazinyo noma umbono kubantu abadala.
Imithi yokwelashwa
Amacebo omuntu ngamunye nezincane kufanele ahlinzekwe izidakamizwa ezidinga izidakamizwa, futhi ama- formularies azo kufanele afake okungenani umuthi owodwa kuzo zonke izigaba zase-United States Pharmacopeia (USP) kanye nesigaba (noma ngaphezulu, uma uhlelo lohlelo lokubheka luhlanganisa okuningi).
Ama-formulamu nawo asetshenzisiwe ngamazwi avela kumakomiti e-pharmacy and therapeutics (P & T), kodwa angahluka kakhulu kusuka kumunye umshuwalense wezempilo kwenye.
Ngaphansi kweziqondiso zokunakekela zokuvimbela ezichazwe ngenhla, izinhlelo zezempilo kufanele zihlanganise-ngaphandle kwezindleko ku-insured-okungenani uhlobo olulodwa lwazo zonke izinhlobo zokuvimbela ukubeletha kwabesifazane abakwa-FDA.
Kwezinye izidakamizwa, imithetho yezinhlelo zokwabelana ngezindleko ziyasebenza, futhi izinhlelo zingadinga ukwelashwa kwesinyathelo (isidingo sokuthi umshwalense uqala ngezidakamizwa ezibiza kakhulu nezingozi kakhulu ukubona ukuthi ziyasebenza yini, ngaphambi kokuzama imithi ebiza imali ebiza kakhulu) .
Iningi lababheki bezempilo lihlanganisa izidakamizwa ezingxenyeni ezintathu, kusukela kwesinye kuya kwesine. Imithi eyodwa eyodwa inezindleko eziphansi kunazo zonke, kanti izidakamizwa ezine (noma izidakamizwa ezikhethekile) zinezindleko eziphezulu kakhulu.
Izinsizakalo zokuvuselela nokuhlomula
Lokhu kuhlanganisa kokubili ukwelashwa namadivayisi adingekayo ekuvuselelweni nasekuqinisekisweni.
Izinsizakalo zokuvuselela zigxila ekuvuseleleni amakhono alahlekile, njengokwelapha emsebenzini noma ngokomzimba ngemuva kwengozi noma isifo sohlangothi.
Izinsizakalo ezisebenzayo zinikeza usizo ngokuthola amakhono endaweni yokuqala, njengentetho noma ukwelashwa komsebenzi wengane engakhulumi noma ehamba ngokusho kokulindelwe.
Imikhawulo yenani lokuvakashelwa ngonyaka isebenza (nakuba izinhlelo zingenakubeka imingcele yeDola kumase-EHB, vakashela imingcele evunyelwe). Kwamanye amazwe, umkhawulo usebenza ekuhlanganiseni ukwelashwa ngokomzimba, ukwelashwa komsebenzi, kanye nokwelashwa kwenkulumo, kanti abanye banemingcele ehlukene yokwelapha ngalunye.
> Imithombo:
> Isikhungo Sokwaziswa Komthengi kanye Nokuqapha Umshuwalense, Umthetho WezeMpilo Nezokwelapha Umlutha Wezokwelapha.
> Izikhungo Zokulawulwa Nokuvinjelwa Kwezifo, Ikomidi Eliqondisayo Lemikhuba Yokugoma (ACIP).
> UMnyango wezeMpilo waseMelika kanye Nezinsizakalo Zabantu, Imithombo YezeMpilo kanye NokuPhathwa Kwezinsizakalo
> UMnyango WezeMpilo waseMelika kanye Nezinsizakalo Zabantu, Imithombo Yezempilo Nezokuphathwa Kwezinsizakalo, Izinkombandlela Zokuvimbela Amakhosikazi Abesifazane.
> I-US Preventive Services Task Force, USPSTF A and B Izincomo.