Ukuqonda ngononophelo olulawulwayo luyinxalenye ebalulekileyo yokukhetha isicwangciso sempilo
Ukuze ukhethe i-inshurensi yezempilo engcono kuwe nentsapho yakho, kufuneka uqonde umehluko phakathi kwe-HMO, PPO, EPO, kunye ne-POS yezempilo. Ezi ziyi-acronyms kwiindidi ezahlukeneyo zokunakekelwa kwezicwangciso ezikhoyo kwiindawo ezininzi.
Sibanzi
- I-HMO = Umbutho wezoLondolozo lwezeMpilo: ii- HMO zivame ukuba neeprayimari zenyanga zancinci kunye nokwabelana ngeendleko ezincinci kunezicwangciso ezincinci zokuthintela inethwekhi, kodwa zifuna umboneleli wokunakekelwa kweprayimari (PCP) kwaye aziyi kuhlawula ukunyamekela ngaphandle kwenethiwekhi ngaphandle kwexesha likaxakeka. .
- I-PPO = Umbutho woMboneleli okhethiweyo : I- PPO ifumene negama ngenxa yokuba inethiwekhi yabanikezeli abakhethayo ukuba uyisebenzise, kodwa baya kuhlawula ukunyamekela kwenethiwekhi. Ngenxa yokuba ayithinteli ngaphaya kwezinye iindidi zezicwangciso, zivame ukuba neeprayimari zenyanga eziphezulu kwaye zidinga ukwabelana ngeendleko eziphezulu. Nangona iiplani ze-PPO zazinyathelo eliqhelekileyo kwixesha elidlulileyo, ziye zithandwa kakhulu kwiminyaka yamuva nje ngokuba izicwangciso zezempilo zinciphisa ubukhulu bezonxibelelwano zabo zomncedisi kunye nokutshintsha ngokunyuka kuma-EPO kunye nee-HMO ngenzame yokulawula iindleko. IipPOs zihlala ziqhelekileyo kwizicwangciso zempilo ezixhaswe ngumqeshi, kodwa ziye zaphela ngokupheleleyo kwimarike yomshuwalense kwamanye amazwe (inshuwalense ngamnye yintlobo oyithengayo ngokwakho-kuquka ukutshintshiselwa kwimeko yakho-ngokuchasene nokufumana kumqeshi ) U
- I-EPO = Umbutho woMboneleli wodwa kuphela : ii- EPO zifumana elo gama kuba zinethungelwano lwababoneleli abazisebenzisayo kuphela . Kufuneka unamathele kubaboneleli kwoluhlu okanye i-EPO ayiyi kuhlawula. Nangona kunjalo, i-EPO ngokuqhelekileyo ayiyi kwenza ukuba uhanjiswe kumgqirha wokunyamekela oyintloko ukuze u tyelele uchwepheshe. Cinga nge-EPO njengento efanayo ne-PPO kodwa ngaphandle kokuxhaswa kokunakekelwa kwe-offline-network.
- I-POS = Iphulo leNkonzo: Izicwangciso ze-POS zifana ne-HMO kodwa zingabinqandeli ukuba uvumelekile, phantsi kweemeko ezithile, ukuba unakekele ngaphandle kwenethiwekhi njengokuba uza ku-PPO. Njengama-HMO, ezininzi izicwangciso ze-POS zifuna ukuba ube nokuhanjiswa kwe-PCP kuwo wonke unonophelo nokuba ungaphakathi okanye ngaphandle kwenethiwekhi.
Ukubhekisela, izicwangciso zononophelo ezingekona ezilawulwayo zibizwa ngokuba yizicwangciso zentlawulo.
Ezi zicwangciso zezempilo ezingenayo amanethiwekhi omncedisi, kwaye ziphinde zibuyisele inxalenye yeentlawulo zakho nakweyiphi na inkonzo enyango. Izicwangciso zokuzihlawulela azizange zithandeke kwiminyaka embalwa edlulileyo kwaye zincabile namhlanje. Izicwangciso zokuncedisa amazinyo zisasaqhelekanga, kodwa phantse zonke izicwangciso zonyango ezinkulu zonyango zisebenzisa ukunyamekela
[Izicwangciso zezibonelelo ezizimeleyo zonyango ziqwalaselwa ngaphandle kwezibonelelo phantsi koMthetho woNonophelo ongenakunqwenelekayo, kwaye azixhomekeke kwimimiselo yayo; Isicwangciso esiphantsi kwesi sicwangciso sokuhlawulelwa esicwangcisiweyo asibheki njengobuncinci besikhokelo esibalulekileyo, oko kuthetha ukuba abantu abanezicwangciso ababheki njengesiqinisekiso, kwaye baxhomekeke kwisigwebo somntu ngamnye se-ACA ].
Qaphela ukuba esinye isivakalisi esisetyenziswe rhoqo, i- HSA , ayibhekiseli kulondolozo olulawulwayo. I-HSA imele i-akhawunti yokulondoloza impilo, kunye ne-HSA-ezifanelekileyo ezicwangcisiweyo zingaba yi-HMO, ii-PPOs, ii-EPO, okanye i-POS izicwangciso. Izicwangciso ezifanelekileyo ezifanelekileyo ze-HSA kufuneka zihlangabezane neemfuno ezithile zokucwangcisa izicwangciso ezibekwa yi-IRS, kodwa azikhawulelwanga ngokwemiqathango yokunyamekela okulawulwayo.
Ukuze ukhethe uhlobo olufanelekileyo lwesicwangciso sempilo kwimeko yakho, kufuneka uqonde iindlela ezintandathu ezibalulekileyo izicwangciso zezempilo zingahluka kwaye indlela nganye kwezi ziyakukuchaphazela ngayo.
Emva koko, kufuneka ufunde indlela i-HMO, i-PPOs, i-EPOs, kunye ne-POS ilungiselela umsebenzi ngamnye, ngokwezo ngongoma ezintandathu.
Amaphuzu okuhlukana
Iindlela ezi-6 eziphambili ze-HMOs, ii-PPOs, ii-EPO kunye ne-POS izicwangciso ziyahluka:
- Ingaba okanye unyanzelekile ukuba ube negqirha lokunakekelwa kweprayimari (PCP)
- Kuthe okanye kungenjalo kufuneka ukuba uhanjiswe ukuze ubone ingcali okanye ufumane ezinye iinkonzo
- Ukuba ingaba unayo kufuneka ube neenkonzo zokunakekelwa kwezempilo ngaphambi kokugunyazwa
- Kungakhathaliseki ukuba isicwangciso sezempilo siza kuhlawula ukunyamekela osifumana ngaphandle kwenethiwekhi yomnikezeli
- Ukwabelana ngexabiso elingakanani uxanduva lokuhlawula xa usebenzisa i-inshorensi yakho yempilo
- Kungakhathaliseki ukuba awukho okanye ufanele ufake ifayili yomshuwalense kwaye wenze iphepha
Zingakanani iimpawu
Imimiselo ye-inshorensi yempilo iyahluka ukusuka kummandla ukuya kwilizwe kwaye ngamanye amaxesha isicwangciso asiyi kubambelela ngokungqongqo kwisakhiwo esicwangcisiweyo. Sebenzisa le tafile njengesikhokelo esiqhelekileyo, kodwa funda ukushicilelwa okucwangcisiweyo kwiSishwankathelo seZibonelelo kunye neSiphakamiso kwisicwangciso ngasinye ocingisisa phambi kokuba ubhalise. Ngaloo ndlela uyazi ngokuqinisekileyo ukuba isicwangciso ngasinye siya kulindela kuwe, kwaye ungayilindela ntoni kuyo.
| I-PCP | Kudinga ukuhanjiswa | Kudinga ukugunyazwa kwangaphambili | Ulungele ukunyamekela kwenethiwekhi | Ukwabelana ngeendleko | Ngaba kufuneka ufake ifowuni yamaphepha? | |
|---|---|---|---|---|---|---|
| HMO | Ewe | Ewe | Ngokuqhelekileyo kufuneka. Ukuba kufuneka, i-PCP yenzayo. | Hayi | Ngokuphantsi | Hayi |
| POS | Ewe | Ewe | Ngokuqhelekileyo. Ukuba kuyadingeka, i-PCP yenze njalo. Ukunakekelwa kwe-Out-of-network ingaba nemithetho eyahlukileyo. | Ewe, kodwa kudinga ukuthunyelwa kwe-PCP. | Ngokuqhelekileyo ekungeneni kwenethiwekhi, ephakamileyo kwi-out-of-network. | Iimangalo ze-out-of-network kuphela. |
| EPO | Hayi | Hayi | Ewe | Hayi | Ngokuphantsi | Hayi |
| PPO | Hayi | Hayi | Ewe | Ewe | Ngokuqhelekileyo, ngokukodwa ukhathalelo lwangaphandle kwenethiwekhi. | Iimangalo ze-out-of-network kuphela. |
Isiqinisekiso seMgqirha
Ezinye iintlobo ze-inshorensi yezempilo zifuna ukuba ube nogqirha lokukhathalela. Kule zicwangciso zezempilo, indima ye-PCP ibaluleke kakhulu ukuba icebo liza kunika i-PCP kuwe ukuba awukhethi ngokukhawuleza ukhetho lwesicwangciso. Iiplani ze-HMO kunye ne-POS zifuna i-PCP.
Kule zicwangciso, i-PCP ingugqirha wakho oyintloko odibanisa zonke iinkonzo zakho zonyango. Umzekelo, i-PCP yakho idibanisa iinkonzo ozifunayo njengonyango lomzimba okanye i-oxygen ekhaya. Naye udibanisa unonophelo oluthola kwiingcali.
Ngenxa yokuba i-PCP yakho inquma ukuba ngaba awufuni okanye ufumane uhlobo oluthile lwenkonzo yolondolozo lwempilo okanye uvavanyo, kulezi zicwangciso i-PCP yakho isebenza njengomgcini-masango olawula ukufikelela kwakho kwiinkonzo zempilo ezizodwa.
Kwizicwangciso ngaphandle kwemfuneko ye-PCP, ukufikelela kwiinkonzo ezizodwa kunokungabi ngaphantsi kwelahleko, kodwa unembopheleleko eninzi yokulungelelanisa ukunakekelwa kwakho. Iiprogram ze-EPO kunye ne-PPO azidingi i-PCP.
Imfuneko yokudluliselwa
Ngokuqhelekileyo, izicwangciso zempilo ezifuna ukuba ube ne-PCP nazo zifuna ukuba uhanjiswe kwi-PCP yakho phambi kokuba ubone i-specialist okanye ufumane nayiphi na enye uhlobo lweenkonzo zokunakekelwa kwezempilo ezingxamisekileyo. Ukufuna ukuthunyelwa kwindlela yenkampani ye-inshorensi yempilo yokugcina iindleko ekuhloliseni ngokuqinisekisa ukuba ufuna ngokwenene ukufumana ingcali okanye ukufumana inkonzo enokubiza okanye uvavanyo.
Ukubambezeleka kule mfuneko kubandakanya ukulibaziseka ekuboneni oyingcali kunye nokungavumelani ne-PCP yakho malunga nokuba ungayifuni yini ukuba ufumane ingcali. Ukongeza, isigulane sinokuba neendleko ezongezelelweyo ngenxa ye-copay efunekayo ekutyelelekeni kwe-PCP kwakunye nohambo lweengcali.
Iinzuzo kwiimfuno ziquka isiqinisekiso sokuthi uya kwindawo echanekileyo yeengcali kunye noqhagamshelwano lobuchule lwenkonzo yakho. Ukuba uninzi lweengcali, i-PCP yakho iyazi ukuba yiyiphi inzululwazi eyenzayo kuwe kwaye iqinisekisa ukuba unyango oluthile lugqwesileyo aluhambisani.
Nangona i-HMO nePOS zicwangcisa ukuba zifunwe, ezinye iiplani zokunyamekela eziqhelekileyo ezifuna ukuba iPPP zihanjiswe ziye zatshintshela "ukufikelela okuvulelekileyo" imodeli evumela amalungu ukuba abone iingcali kwiinkqubo zomnatha ngaphandle kokuthunyelwa. Ngoko nangona kukho jikelele malunga nezicwangciso zononophelo ezilawulwayo, akukho nto ithatha indawo yokufundwa kakuhle kwicebo lakho okanye izicwangciso ozicingayo.
Ukugunyazwa kwangaphambili
I-pre-authorization okanye imvume yesigunyaziso ngaphambi kokuba inkampani ye-inshurensi yempilo idinga ukuba ufumane imvume kubo kwiintlobo ezithile zeenkonzo zononophelo zezempilo ngaphambi kokuba uvumeleke ukuba unakekele. Ukuba awufumani oko kugunyaziwe ngaphambili, isicwangciso sezempilo sinokungafuni ukuhlawula inkonzo.
Izicwangciso zezempilo zigcina iindleko ekuhloliseni ngokuqinisekisa ukuba ufuna ngokwenene iinkonzo ozifumanayo. Kwizicwangciso ezifuna ukuba ube ne-PCP, lowo ugqirha ngowona xanduva lokuqinisekisa ukuba ufuna ngokwenene iinkonzo ozifumanayo. Izicwangciso ezingadingi i-PCP (njenge-EPO kunye ne-PPO izicwangciso) sebenzisa ukugunyazwa kwangaphambili njengendlela yokufikelela kwinjongo enye: isicwangciso sezempilo sihlawulela kuphela uncedo oluyimfuneko.
Izicwangciso ziyahluka malunga noluphi uhlobo lweenkonzo ezimele zigunyazwe ngaphambili kodwa phantse yonke ifuna ukuba ukungeniswa kwezibhedlele ezingekho ngxamnye nezibhedlele zibe zigunyaziswe ngaphambili. Abaninzi bafuna ukugunyazwa kwangaphambili kwezinto ezifana ne-MRI okanye i-CT, izidakamizwa ezibiza kakhulu, kunye nezixhobo zonyango ezifana ne-oksijini yasekhaya kunye nemibhedlele yezibhedlele.
Ukubakho ukugunyazwa kwangaphambili kwenzeka ngokukhawuleza kwaye uya kuba negunya phambi kokuba ushiye iofisi yegqirha. Ngokuqhelekileyo, kuthatha iintsuku ezimbalwa. Kwezinye iimeko, kuthatha iiveki.
Ukunakekelwa kweNethiwekhi ngaphandle
Ii-HMO, ii-PPOs, ii-EPOs, kunye ne-POS izicwangciso zonke zinikezela amanethiwekhi. Olu thungelwano lubandakanya oogqirha, izibhedlele, ii-lab kunye nabanye ababoneleli abanesivumelwano kunye nesicwangciso sempilo okanye, kwezinye iimeko, baqeshwe kwisicwangciso sezempilo. Izicwangciso ziyahluka malunga nokuba uya kuba neenkonzo zokunakekelwa kwezempilo kwi-providers ezingekho kwinethiwekhi yazo.
Ukuba ubona ugqirha ongaphandle komnatha okanye uvavanyo lwakho lwegazi luqhutywe kwibhuyibhile yangaphandle, ezinye izicwangciso zempilo aziyi kuhlawula. Uya kubambelela ukuhlawula ibhilikhi yonke yokunyamekela oyenayo ngaphandle kwenethiwekhi. Ngaphandle kwalolu xanduva lwexakeka. Izicwangciso zononophelo ezilawulwayo ziya kubakhokela ngononophelo lwengxamiseko olufunyenwe kwigumbi elingxamisekileyo lwentlalo, ngaphandle nje kokuba isicwangciso sempilo sivuma ukuba unonophelo luyimfuneko kwaye lube yimeko engxamisekileyo (inqaku lokuba umnikeli-ngaphandle wenkonzo unokunokukuhlawula umahluko phakathi kokuya kuhlawulwa kunye nokuba yintoni umrhasi wakho ohlawula ngayo).
Kwezinye iiplani, i-inshurensi iya kuhlawula ukunakekelwa kwe-out-of-network. Nangona kunjalo, kuya kufuneka ukhokhe ipesenteji enkulu yeendleko kunokuba ubuya kuhlawula ukuba ufumene unonophelo olufanayo kwi-network.
Kungakhathaliseki ukuba isicwangciso soyilo, abanikezeli benethiwekhi-ngaphandle-baxhomekeke yiziphi na izivumelwano kunye nenkampani yomshuwalense wezempilo. Nangona i-inshorensi ye-POS okanye i-PPO ihlawula inxalenye yeendleko, umboneleli wezonyango unokukuhlawula ukuba ulwahlula phakathi kweentlawulo zabo eziqhelekileyo kunye nokuba yintoni i-inshurensi yakho ihlawula ngayo. Ukuba benza, unembopheleleko yokuyihlawula. Oku kubizwa ngokuba yi- balance balance , kwaye kusemthethweni kumazwe amaninzi ekunyamekelweni kwe-intanethi, nakwiimeko eziphuthumayo.
Ukwabelana ngeendleko
Ukwabelana ngeendleko kuquka ukuhlawula inxalenye yeendleko zonyango lwakho-unokwabelana ngeendleko zempilo yakho kunye nenkampani yakho yinshorensi yempilo. Ukuhlaziywa , ukuhlawulwa kwemali kunye ne- coinsurance zonke iintlobo zokwabelana ngeendleko.
Izicwangciso zezeMpilo zihluke ngaluhlobo luni na ukwabelana ngeendleko abazifunayo. Ngokuqhelekileyo, izicwangciso zempilo ezithintelayo zinokukuvuza ngento ephantsi yokwabelana ngeendleko, ngelixa ezinye izicwangciso zempilo ezivumelekileyo zifuna ukuba uthathe inxalenye ebalulekileyo yebhilida ngokuxhomekeka okuphezulu, uqinisekiso lwemali okanye iikopi.
Kodwa oku kuye kwatshintsha njengoko ixesha lihamba. Kwiminyaka yama-80 neye-90, kwakuqhelekile ukubona ii-HMO ezingenakucatshulwa. Namhlanje, i-HMO icebo ngeedola ezi-1 000 + eziqhelekileyo eziqhelekileyo (kwimakethi nganye, ii-HMO ziye zaba yizicwangciso eziphambili kwiindawo ezininzi, kwaye zihlala zinikelwa ngama-deductibles of $ 5,000 okanye ngaphezulu).
Kwizicwangciso ezihlawulela inxalenye yeendleko zakho, xa ubona ababoneleli bee-out-of-network, iindleko zakho zangaphandle ziza kuba ziphakamileyo (ngokuphindaphindiweyo kabini) kunokuba ziza kuba zibona oogqirha be-network. Ngoko, umzekelo, ukuba isicwangciso sakho sinemali engama-1 000 e-deductible, ingaba ne-$ 2,000 echithwe kwi-care-of-network ukunakekelwa.
Umda ophezulu malunga noko uza kuhlawula kwiindleko zangaphandle (kuquka u-coinsurance) kuya kuphakama kakhulu xa uphuma ngaphandle kwenethiwekhi yakho. Kwakhona kubalulekile ukuqaphela ukuba ezinye ii-PPO kunye ne-POS izicwangciso ziye zatshintshela kwinqwelo engenamkhawulo kwiindleko ezingaphandle kwee-pocket xa amalungu efuna ukunakekelwa kwenethiwekhi. Oku kungagqiba kuba kubi kakhulu kubathengi abangakwaziyo ukuba isicwangciso senqwelo-mali kwiindleko zangaphandle (njengoko kufunwa yi-ACA) kusebenza kuphela kwinethiwekhi yomnikezeli wecebo.
Ukufaka amaBango
Ukuba ukhathalela ngaphandle-wenethiwekhi, udla uxanduva lokufakela iphepha lebango kunye nenkampani yakho yinshuwalense. Ukuba uhlala kwi-intanethi, ugqirha, isibhedlele, ibrabhu, okanye omnye umboneleli uya kufaka naziphi na izimangalo ezifunekayo.
Kwizicwangciso ezingakhange zigcinwe ngononophelo lwangaphandle, kaninzi akukho sizathu sokufaka ibango ngaphandle kokuba ufumene ukunakekelwa kwimeko engxamisekileyo ngaphandle kwe-intanethi kuba umgcini-mali wakho akayi kubuyiselwa kwiindleko.
Kusabalulekile ukugcina umkhondo wento oye uyihlawula, nangona kunjalo, njengoko unokukwazi ukukhwela iindleko zakho zonyango kwi-tax return yakho (ukuba ngaba ngaphezu kwe-7.5 yepesenti yengeniso yakho; oku kuya kwanda ukuya kuma-10% ngo-2019 ). Okanye, ukuba unayo i- HSA , unokuhlawula ngokwakho (ngexesha okanye kwinkonzo, okanye nayiphi na ixesha elizayo) kunye neengxowa-mali zangaphambi kweerhafu ezivela kwi-HSA yakho, ekucingeni ukuba ungazihluthanga iindleko zakho zonyango kwi-tax return yakho. zenze zombini; ezo ziza kubanjwa kabini).
Indlela Ugqirha Ofumanayo Ehlawulwa ngayo
Ukuqonda ukuba ugqirha wakho uhlawulwa njani unokukuxwayisa kwiimeko apho kukho iinkonzo ezininzi ezicetyiswayo kunokuba ziyimfuneko, okanye iimeko apho ungadinga ukunyusa ukunyamekela ngaphezu kokunikezelwa.
Kwi-HMO, ugqirha ngokuqhelekileyo ungumqeshwa we-HMO okanye uhlawulwa yindlela ebizwa ngokuba yi- capitation . Ukuxhaswa kuthetha ukuba ugqirha unikezelwa ngemali ethile kwinyanga nganye kwilungu ngalinye le-HMO enyanzelekile ukuba alinakekele. Ugqirha ufumana inani elifanayo lemali kwilungu ngalinye nokuba ilungu lifuna iinkonzo kwinyanga okanye cha.
Nangona iiprogram zokufumana iintlawulo zithintela ukulungisa iimvavanyo kunye nonyango ezingenayo imfuneko, ingxaki ngokubethelwa kukuba akukho nto inokubangela ukuba kufuneke ukuba kwenziwe umyalelo wokubakhokelela. Enyanisweni, umkhwa unenzuzo kakhulu unokuba nezigulane ezininzi kodwa unganikezeli iinkonzo kunoma yimuphi wabo.
Ekugqibeleni, izikhuthazo zokubonelela ngoncedo olufunekayo kwi-HMO zinomnqweno onyanisekileyo wokubonelela ngononophelo lwezonyameko, ukuhla kweendleko zangexesha elide ngokugcina amalungu e-HMO enempilo, udidi lomgangatho woluntu kunye nokuxhaswa kwabathengi, kunye nosongelo lwe-suitpress.
Kwii-EPO kunye ne-PPOs, oogqirha bahlawula rhoqo xa banikela inkonzo. Ingakumbi izigulane abazibona ngosuku, imali engaphezulu. Ngaphezu koko, izinto ezininzi ugqirha azenza ngexesha lokutyelela ngamnye, okanye ukhetho oluya kunyanzelisa ukwenziwa kwezonyango lufuna, ngoko ugqirha uyahlawulwa ngokutyelela olo tyelelo. Olu hlobo lwenkqubo yokuhlawula luyaziwa njengomrhumo-wenkonzo.
Umgca we-intlawulo-ntlawulo yenkonzo yokufumana intlawulo kukuba unika inkxaso yokuxhasa ugqirha ukuba anike uncedo oluninzi kunokuba luyimfuneko. Ukuhambela okulandelelweyo okufunayo, imali eninzi ugqirha yenzayo. Kwakhona, ekubeni ugqirha uhlawulelwa ngakumbi ukutyelela ngokukrakra, akumangalisi ukuba izigulane zininzi iimvavanyo zegazi, ii-X-rays, kunye neluhlu olude lweengxaki ezingapheliyo.
Ngenxa yokuba abantu banokuzinyamekela kunokuba kuyimfuneko, amalungiselelo okuhlawula intlawulo-ngenkonzo aqhuba ukunyuka kweendleko zempilo kunye neeprojeyam zempilo zonyango .
I-Medicare neMedicaid
Inani elilinganiselwa kuma-36.7 ekhulwini labantu base-United States babhalise kwi-Medicaid okanye kwi-Medicare. Ezi zicwangciso zempilo zikarhulumente. Ngokwesiko, urhulumente (ulawulo lweMedareridi; umbuso kunye nombuso weMedicaid) bahlawulise ababoneleli bezempilo ngokukhawuleza xa abhalise befumana unonophelo.
Kodwa kwiminyaka emva nje, kubekho utshintsho olujongene nokunyamekelwa okulawulwayo kwiMedicaid kunye ne-Medicare. Ngomhla ka-2014, ngaphezulu kweekota ezintathu ze-Medicaid ababhalise kwiiplani zeMedicaid zonyango (izivumelwano zombuso kunye nezicwangciso zempilo ezininzi;) ababhalise banokufumana i-ID yeBlue Cross Blue Shield, ngokuchasene nekhadi le-ID evela kwilizwe Inkqubo yeMedicaid). Ngo-2017, okwesithathu kwabasebenzi ababhalise kwi-Medicare babekho kwizicwangciso zononophelo ezilawulwayo (i-Medicare Benevantage).
Yiyiphi Impumelelo?
Kuxhomekeke ekubeni ukhululekile kangakanani unemiqathango kunye nokuba uzimisele kangakanani ukuhlawula. Ingakumbi isicwangciso sempilo sinciphisa inkululeko yakho yokuzikhethela, ngokomzekelo, ngokungahlawulisi ukunakekelwa kwe-intanethi okanye ngokufuna ukuba uhanjiswe ugqirha ngaphambi kokuba ubone i-ingcali, ngaphantsi koko kuya kuhlawulwa kwii-premiums kwaye ukwabelana ngeendleko. Inkululeko enkulu yokukhetha isicwangciso semvume, ngakumbi unokuhlawula loo nkululeko.
Umsebenzi wakho ukufumana ibhalansi okhululekile ngayo. Ukuba ufuna ukugcina iindleko zakho ziphantsi kwaye ungakhathaleli imingcele yokuba uhlale kwi-intanethi kwaye kufuneka ufumane imvume kwi-PCP yakho ukuba ubone ingcali, mhlawumbi i-HMO yakho. Ukuba ufuna ukugcina iindleko eziphantsi, kodwa kukutshintshela ukuba ufumane ukuthunyelwa kwingcali, cinga i-EPO.
Ukuba awuyikucinga ukuhlawula ngaphezulu, kokubili kwiipresimenti zenyanga kunye nokwabelana ngeendleko, i-PPO iya kukunika zombini ukuguquguquka kokuphuma ngaphandle kwenethiwekhi kunye nokubona iingcali ngaphandle kokuthunyelwa. Kodwa, ii-PPO ziza kunye nomsebenzi owongezelelweyo wokuba ufumane imvume phambi kwe-inshurensi kwiinkonzo ezibiza, kwaye bahlala beyona ndlela ebiza kakhulu.
Ukuba uyithengisa yakho ingxelo (ngokuchasene nokuyifumana kumqeshi wakho), unokungenayo nayiphi na indlela yokukhetha i-PPO, njengoko izicwangciso zeemarike zodwa ziye zatshintshela kwi-HMO model. Kwaye ukuba ufumana ingxelo evela kumqeshi wakho, ubungakanani bezicwangciso zakho ziza kuxhomekeka kubukhulu bomqeshi wakho. Abaqeshi abakhulu bavame ukubonelela ngeendlela ezininzi, kodwa umqeshi omncinci unokufumana isicwangciso esisodwa sokuba abasebenzi bamkele okanye bayeke.
ILizwi
Phantse zonke izicwangciso ze-inshorensi zempilo zilawulwa izicwangciso zokunyamekela, kodwa kukho ukuhlukahluka ngokubanzi ngobukhulu benethiwekhi yomboneleli kunye neemfuno ezicwangciselwe ukusetyenziswa kwamalungu.
Umgca ophantsi: akukho luhlobo loluncedo lwezempilo. Ngamnye umgca we-balance balance between benefits and restrictions and between spending much lot vs. spending less. Ukuqonda umahluko phakathi kwe-PPO, i-EPO, i-HMO kunye ne-POS yinqanaba lokuqala ekunqumeni indlela yokukhetha isicwangciso se-inshurensi yezempilo eya kusebenza kakuhle kuwe nakwintsapho yakho.
> Imithombo:
> Congress.gov. HR1 - UMthetho wokubonelela ukuxolelana ngokulandela izihloko II kunye ne-V yesisombululo esifanayo kwisabelo-mali sonyaka-mali ka-2018 >. Yenziwe ngo-12/22/2017.
> UGaba, uCharles. I-ACA Signups, Ukuphulukiswa kweMpilo yoKhuseleko lwabantu bonke base-US kwiSahluko esisodwa. Matshi 2016.
> I-HealthCare.gov, iSicwangciso se-Intshumo yeMpilo kunye neNtlu zoNxibelelwano: ii-HMO, ii-PPOs, kunye nezinye.
> Kaiser Family Foundation, i-Medicare Benevantage Spotlight 2017: UkuBhaliswa kweMakethe yeMbuyekezo. Juni 2017.
> I-Kaiser Family Foundation, i-Total Medicaid ephethwe ngoBhaliso lwaBantwana, ngo-2014.