I-Out-of-Pocket Max: Indlela eSebenza ngayo nendlela i-ACA iLawula ngayo
I- inshurensi yempilo engaphandle kwe-pocket isona sininzi semali oya kufuneka uyihlawule kwiindleko zempilo yakho yonyaka ngamnye, ucinga ukuba ufumana unonophelo olufakwe kwisicwangciso sakho se-inshorensi kunye nokusetyenziswa kwezibhedlele kunye noogqirha.
Emva kokuba uhlawule ngokwaneleyo kwii- deductibles , uhlawula kunye kunye ne- coinsurance ukuze ufikelele kwi-out-of-pocket yakho ephezulu, inkampani yakho yomshuwalense wezempilo iyakhokhela yonke into yakho inethiwekhi, unyango lwezempilo oluyimfuneko kwintsali yaloo nyaka.
Kodwa, ayisoloko isebenza ngaloo ndlela. Nangona i-out-of-pocket maximum yenzelwe ukunciphisa umngcipheko wezezimali xa unemali ephezulu yokunakekelwa kwempilo , ibonisa inkampani yakho yinshorensi yempilo ukuba ibe yingozi enkulu yemali. Ngoko, iinkampani ze-inshorensi zempilo zenze iindlela zokudala ukunciphisa umngcipheko. Ezi zixhobo zenza ukudideka malunga noko kubaluleke malunga nokugqithiswa kwe-out-of-pocket yakho, yiyiphi inshurensi yakho yempilo ehlawula emva kokuba ufikelele kuyo, kwaye umlinganiselo wakho ongaphandle kwipokotho.
Indlela i-Out-Of-Pocket Maximum isebenza ngayo ngokuqhelekileyo
Makhe sijonge umzekelo: Unedola ye-$ 1,000, i-coinsurance yama-20 ekhulwini kunye nomda ongaphandle kwe-$ 5,000 ngonyaka.
Uphula i-ankle yakho. Uya kuthatyathwa utyando ngalobo busuku. Isayithi lakho lokuqhawula isifo. Uhlala esibhedlele ezimbini kwiiveki, ube nokuhlinzwa ezimbini, kwaye ufumane ii-antibiotiki ze-IV ekhayeni ngokusebenzisa unyango lwezempilo kwezinye iiveki ezintathu.
Nantsi indlela iindleko zakho eziza kubanjwa ngayo ngaphandle kwe-out-of-pocket ephezulu ngokubhekiselele kwi -out-of-pocket ephezulu yama-5,000:
- Umrhumo wegumbi lakho loxinzelelo li-$ 4,000.
Ngaphandle komda ongaphandle kwe-pocket, uhlawula i-$ 1,000 echithwayo kunye ne-600 zamawaka kwi-coinsurance.
Ngomda wokuphuma kwipokethi, uhlawula i-$ 1,000 eyi-deductible kunye ne-$ 600 kwi-coinsurance.
- Isibhengezo sakho esibhedlele si $ 40,000.
Ngaphandle komda ongaphandle kwe-pocket, uhlawula i-$ 8,000 ye-coinsurance (iipesenti ezingama-20).
Ngomda ongaphandle kwipokotho, uhlawula kuphela ama-3 400. Ufikelele kwi-out-of-pocket yakho ephezulu kwaye uyeka ukuhlawula (i-$ 5,000 iyonke ivela kwi-$ 1000 yakho ehlawulwayo, i-$ 600 ye-coinsurance yokutyelela i-ER kunye ne-$ 3,400 ye-coinsurance ye-bill bill). - I-bill yakho yokunakekelwa kwempilo yasemakhaya i-$ 3,000.
Ngaphandle komda ongaphandle kwesikhokhelo, uhlawula i-$ 600 ye-coinsurance.
Ngomkhawulo ongaphandle kwesikhokelo, awuhlawuli nantoni na. I-insurer yakho yezempilo ihlawula iindleko zonke zempilo yakho yasekhaya ngenxa yokuba sele ufikelele kwi-out-of-pocket maximum. - Iindleko ezipheleleyo zeengxowa zakho eziphukileyo ziyi $ 47,000.
Ngaphandle komda ongaphandle kwesikhokelo, uhlawula i-$ 10,200; umshwalima wakho uhlawula i $ 36,800.
Ngomda ongaphandle kwesikhokelo, uhlawula i-$ 5,000; umshwalima wakho uhlawula i $ 42,000. - Ufuna iinkonzo ezininzi zononophelo zempilo emva konyaka.
Ngaphandle komda ongaphandle kwesikhokelo, ubuya kuhlawula i-20% ye-coinsurance.
Ngomda wokuphuma kwipokethi, awuhlawuli nto.
I-Out-Of-Pocket Rules Imigaqo eyahlukileyo ngo-2014
Umda we-Out-of-pocket wakho we-$ 5,000 usindise imali eninzi, kodwa kubiza inkampani yakho yenkampani yomshuwalense njengokuba ikugcine. Ngaphambi kokuba uMthetho woNonophelo ongenakunceda uqalise ukulawula umda we-pocket, ezinye i-insurers zempilo zasebenzisa izicwangciso ezahlukeneyo zokugcina iindleko zabo (kunye nama-premium) ngokuphantsi.
Ezi zihlengahlengiso zatshintshile ngaphezulu kweendleko zempilo yakho kuwe: uhlawula ngaphezulu, kwaye zihlawula ngaphantsi. Abatshutshisi basebenzise iindlela ezintathu ezisisiseko zokwenza oku, akukho namnye avunyelwe ukuba aqhubeke, ngenxa ye-ACA:
- Inkqubo yokuqala yenza kube nzima kuwe ukuba ufikelele umda ngokungaqinisekisi zonke iindleko zakho ngokubhekiselele kwi-out-of-pocket maximum. Umshurensi unokugqiba ekubeni angayikhokhanga enye okanye ngaphezulu kwezi zinto:
- Deductible
- Iikopi
- Uqeqesho lwezonyango
- Uhlalutyo lweemvavanyo
- Uxanduva lwe-Coinsurance yokunakekelwa kwe-offline -network
- Kwinkqubo yesibini, umgcini-mali awuzange akhokhe iipesenti ezingama-100 zempilo zakho zonyango emva kokuba ufikelele kwimingcele yakho.
Ngokomzekelo, isicwangciso sempilo sinokufuna ukuba uqhubeke nokuhlawula i-copay rhoqo xa ubona ugqirha nangona sele ufikelele kwi-out-of-pocket maximum. Kule meko, ukufikelela kwindawo ephezulu kunokukhusela ukuba uhlawule i-coinsurance kulo lonke unyaka, kodwa kungekhona ekuhlawuleleni ii-copays.
Funda umehluko phakathi kwama-copays kunye ne-coinsurance .
Ezinye izicwangciso zezempilo zingabandakanyi ukusetyenziswa kwemithi yesigqirha semithi ephuma ngaphandle kwe-pocket. Kule meko, kufuneka uqhubeke nokuhlawula isabelo sakho seendleko zemvume nangona ude ufikelele kwimida yakho yokuphuma ngaphandle. Ukuba unemali-mali engama-30 ekhulwini kumachiza, kwaye ubekho kwiziyobisi ze-biologic eziphezulu ezibiza i-$ 30,000 ngonyaka, uza kuhlawulela i-$ 9,000 kule nkunkuma nangona unayo i-$ 5,000 ngaphandle kwe-pocket. - Inkqubo yesithathu yenza ama-maximum ahlukeneyo angaphandle kwee-pocket kwiindawo ezahlukeneyo ze-inshorensi yakho yempilo. Umzekelo ogqithiseleyo unomlinganiselo ophezulu ongaphandle kwezilwanyana kwiyeza kunye ne-e-pocket ehlukeneyo kuyo yonke into.
Emva kokuba ufikelele kumda wokuphuma kwipokethi yeziyobisi , umgcini-mali uhlawule iipesenti ezili-100 zeendleko zemimiselo yakho, kodwa waqhubeka uhlawula isabelo sakho seendleko ezingekho ngeziyobisi. Emva kokuba ufikelele kwi-out-of-pocket ephezulu kuyo yonke enye indawo , umgcini-mali uhlawule iipesenti ezili-100 zeendleko zakho zokunakekelwa kwezempilo ezingekho kweziyobisi, kodwa waqhubeka uhlawula isabelo sakho seendleko zeziyobisi ngaphandle kokuba udibana ne-out-of- enkulu ipokothini yeziyobisi.
Inkampani ye-inshorensi yezempilo ayizange ifake iipesenti ezili-100 zempilo yakho kuze kube yilapho ufikelele kwimimiselo engaphandle. Ukuba umda ngamnye wawuyi-$ 5,000, uhlawule i-R10 000 ngaphambi kokuba isicwangciso sempilo siqale ukuhlawula ipesenti eziyi-100.
Umthetho woNonophelo ojongene noNcedo kunye nePhandle-ye-Pocket Maximum
Akunjalo kuphela iindlela zokunciphisa ingozi ezidibanisa abathengi, kodwa zashiya abantu beva ngathi baphathwa kakubi. Emva kwakho konke, ukuba unayo i-out-of-pocket ephezulu ye $ 5,000, kuba kutheni kufuneka ube nokuhlawula i-$ 9,000 ngaphandle kwe-pocket kwisigxina somthetho esasigcwele isicwangciso sakho sezempilo? Abenzi bomthetho baphendule kulo mthengi ukuphazamiseka ngokulawula umgaqo-mali we-inshorensi yempilo.
UMthetho woNonophelo ojongene noThathaka ungenza ama-maximum angama-pocket awanzima. Ibeka umda malunga nokuba ubuninzi be-out-of-pocket bungakanani ngonyaka. Kudinga ukuba ama-deductibles, copays, kunye ne-coinsurance zonke zizuzwe ngokukhawulelana nomda we-pocket. Le mfuneko iphelisa i-insurers yempilo yecandelo lokunciphisa ingozi.
I-ACA idinga ukuba izicwangciso zempilo zihlawule iipesenti ezili-100 zeendleko zokunyamekela kwabanikezeli bee-intanethi kulo nyaka wonke emva kokuba umda wokuphuma kwipokethi ufikelelwe. Le mfuneko iphelisa inombolo yesibini.
Ngo-2017, izicwangciso zezempilo ezingenakulinganisekanga azikwazi ukufumana ama-maximum angaphezulu kwe -7,150 kumntu oyedwa, okanye i-$ 14,300 kwintsapho (kunye nemimiselo engaphandle kwimizi kufuneka ihlanganiswe kwizicwangciso zempilo zentsapho , ngoko enye ilungu lentsapho alinakufunwa ukuhlawula ngaphezu kwama-7,150).
Ngo-2018, le mida iya kunyuka ibe ngama-7,350 ayi-$ 7,350 kwindoda. Njengoko kuhlala kunjalo, izicwangciso zezempilo ziya kuba nako ukufumana imida yokuphuma ngaphandle kwezantsi (ezi zininzi), kodwa zingekho ngaphezu kwazo.
I-ACA nayo idale inkxaso-mali ye- inshurensi yempilo ehlisa umgangatho ophezulu ongaphandle kwe-pocket kubantu abafanelekileyo abanendlela elula, kwaye kuya kuqhubeka nokusebenza ngo-2018.
Inkxaso kunye neninzi yokukhuselwa kwabathengi be-ACA yaqala ngoJanuwari 1, 2014. Nangona kunjalo, ezinye izicwangciso zezempilo zeqela azizange zihambelane kude kube yiplani yeminyaka eqala ngomhla okanye emva koJanuwari 1, 2015 (ukuba babephethe i-coverage yezokwelapha kunye neyonyango, bavunyelwe ukuba babe nemida eyahlukileyo ye-pocket ngo-2014). Kwaye izicwangciso ezingenakufuneka zihambelane nazo zonke imithetho ze-ACA, ngoko ziyakwazi ukuqhubeka zisebenzisa imithetho yazo endala ngokumalunga nama-maximi e-out-of-pocket. Kwizifundo ezisezivumela ukuba zikho, izicwangciso eziphezulu ziyakwazi ukuqhubeka nokusebenzisa ama-maximum angaphandle kwe-ACA, kodwa izicwangciso ezinkulu ziza kupheliswa ekupheleni kuka-2018.
Ndizikhusela Njani?
Musa ukutyhawula ngenxa yokukhuselwa kwabathengi. Kukho ezinye iindleko oza kuba noxanduva lokuhlawula emva kokudibana nokugqithiswa kwe-pocket. Ezi ziquka:
- Izinto ezizicwangcisayo izicwangciso zakho zezempilo aziyiyo imfuneko yonyango.
- Isabelo -ekhokhisiwe- sabelo kunye nokwabelana ngeendleko zokunakekelwa kwezempilo kwe-out-of-network .
- Izinto ezingakhange zifakwe kwisicwangciso sakho sezempilo njengophenyo lwezonyango.
- Ukwabelana ngeendleko kwizinto ezingabonwa njengezibonelelo zezempilo ezibalulekileyo. Ezi ntlawulo ezingabalulekanga ziyimfuneko eyongezelelweyo isicwangciso sakho sezempilo asinakukubonelela kodwa ukhetha.
- Ii-premium zempilo zomshuwalense.
Isicwangciso ngasinye sezempilo sinikeza iSishwankathelo seNzuzo kunye neSiphakamiso okanye iSicwangciso soShwankathelo soNgcaciso esichazela ukuba umlinganiselo wesiphakamiso siphume ngaphandle kunye kwaye awufumanisi. Qaphela oku xa uthelekisa izicwangciso ngexesha lobhaliso oluvulekile, okanye xa uthengela i-inshurensi yezempilo . Unokubiza kwakhona isicwangciso sakho sempilo uze ucele.
Akukho nto engabonakaliyo malunga nabagcini bomshuwalense bezempilo abazama ukunciphisa umngcipheko wabo xa nje bebenza ngaphakathi komthetho kwaye banikeze inkcazo ecacileyo yemigaqo yomgaqo-nkqubo. Umthwalo kukuqinisekisa ukuba uyaziqonda ngokupheleleyo imigaqo yesicwangciso sakho sezempilo. Kufuneka uqonde ukuba ungakanani kwi-hook yokunyaka ngamnye unyaka ukwenzela ukuba uhlahloye uhlahlo lwabiwo-mali kwaye wenze izicwangciso zexesha elibi kakhulu.
Ngaba i-AHCA yayingayitshintsha njani iMigaqo?
UMthetho wezeMpilo waseMelika (AHCA) wadlulisela iNdlu ekuqaleni kukaMeyi . I-Senate ibhala inguqu yabo, kodwa ayinayo nayiphi na ingxoxo okanye ingxoxo yomphakathi, ngoko asiyazi ukuba yiyiphi indima yeNdlu abayilungiselele ukuyigcina.
Kodwa iNdlu ye-bhili ye-bill iyigcine imida ye-ACA ngaphandle kwe-pocket. Nangona kunjalo, kuya kuvumela amazwe ukuba afune ukuxoshwa phantsi apho aphinde ahlaziye oko kubonwa njengenzuzo ebalulekileyo yezempilo . Kwaye imida ye-ACA ngaphandle kwe-pocket isebenza kuphela kwizibonelelo zempilo ezibalulekileyo. Ngoko, ukuba urhulumente wayevumelekile, umzekelo, abaqinisekisi bempilo ukubonelela ngezicwangciso zeemakethe ezingahambisani nokubeleka (ngokuhlaziya kwakhona iinkonzo zezempilo ezibalulekileyo kwaye kungabandakanywa ukunakekelwa kwababelethi kuloluhlu), iindleko zokunakekelwa kwababelethi ziya kupheliswa ngokupheleleyo. i-pocket yabazali abatsha, kwaye abayi kubala kwi-inshorensi yabo ngaphandle kwe-pocket ephezulu.
I-Senate inokwenza okanye ayiyi kugcina ilungiselelo elivumela amazwe ukuba ahlaziye kwakhona iintlawulo zezempilo eziyimfuneko, kodwa ukuba zenza, ziya kunciphisa ukukhuselwa okwenziwe yiC ACA kwiindleko ezingaphezulu kwe-pocket.
Imithombo:
Amaziko e-Medicare kunye neenkonzo zeMedicaid, i-Affordable Care Act Imibuzo yokuSebenza i-Set 18.
ISebe lezeMpilo kunye neNkonzo zoLuntu . > Ukhuseleko lomonde kunye noMthetho woNonophelo ojongene noThathaka; ImiGangatho ehambelana neNzuzo yezeMpilo ebalulekileyo, ixabiso lokuQinisekisa, kunye nokuVunywa . Februwari 25, 2013.
> I-Register Register, Umonde > Ukhuselo > kunye noMthetho woNonophelo ojongene noNcedo; Isaziso seNzuzo yeeNzuzo kunye neParameters yokuhlawula i-2018; Izilungiso kwiiNyanga zokuBhalisa eziKhethekileyo kunye neNkqubo yoCwangciso lwaBathengi esebenzayo kunye noCwangciso oluCwangcisiweyo >. Disemba 22, 2016.
United States Isebe Lemisebenzi. Imibuzo ye-FAQ malunga noMthetho ojongene noNonophelo ojongene noKhathalelo kwiCandelo XII. NgoFebruwari 20, 2013.
United States Isebe Lemisebenzi. Imibuzo ye-FAQ malunga noMthetho wokuNakekelwa koKhathalelo ongenakunyanzeleka (iSahlulo XVIII) kunye nokuPhathwa kweParity Health mentality, ngoJanuwari 9, 2014.