Ukuthunyelwa ngumhlobo okhethekileyo wokuphambi kokuvunywa kwamalungu esicwangciso sezempilo-ngokukodwa abo abane- HMO- banokufumana kwi-medical care oyinqununu ngaphambi kokuba babone ugqirha okanye omnye ugqirha ngaphakathi kwintanethi efanayo.
Ezinye izicwangciso zifuna ukuthunyelwa ukuba kubhalwe ngokuthe ngqo kumgqirha, ngelixa abanye baya kwamkela umnxeba ovela kwicir
Ukuze uqinisekise ukuba yonke into ihamba ngokumalunga nokubona ingcali , kufuneka usebenze, kwaye qi ni sekise ukuba i-insurer yakho ifumane ukuhanjiswa ngaphambi kokuba wenze i-aphoyintimenti kunye nengcali yakho. Oko uya kukwazi ukuba ukutyelela kwakho kwiingcali kuya kugutyungwa phantsi kwecwangciso lwakho lononophelo lwempilo.
Ukudluliselwa kunye ne-HMO
Imibutho yokulondoloza impilo, okanye i-HMO, idinga umntu ukuba akhethe ugqirha wezonyango . Ugqirha wokunakekelwa ngokusisigxina ke uxanduva lokulawula yonke loo nkathalo yempilo yomntu eya phambili. Ugqirha oyintloko oyinyango uba nexanduva lokwenza iziphakamiso ngokubanzi kwiinkqubo zonyango, ukutyelela ochwepheshe, amayeza kunye nokunye. Udokotela ojongene nokunyamekela ugqirha unika neenkonzo zokuthunyelwa kuzo nayiphi na iinkonzo eziyimfuneko okanye ukutyelela kwizentengiselwano. Aba bathumelayo bakuvumela ukuba uye kuhamba omnye ugqirha okanye ugqirha kwi -network planning plan .
Ukuba awunalo ukuthunyelwa kwiregistri yakho yokhathalela, okanye ugqiba ukuya kumgqirha ohlukile ngaphandle kwenethiwekhi yesicwangciso sakho sezempilo, kuya kufuneka ukuba uhlawule lonke okanye uninzi lweendleko zaloo nkathalo, njengoko ikhutshwe yi-HMO. I-HMO iquka kuphela ukutyelela ngaphakathi kwintanethi.
Ii-HMO ziye zixhaphake kakhulu kwiimarike zempilo yomshuwalense kwiminyaka embalwa edlulileyo njengoko abatshorensi basebenza ukulawula iindleko. Intshumo ye-inshurensi yempilo kwezinye iindawo ayinayo nayiphi na inketho yePPO.
Ukudluliselwa kunye nePPO
Ukudluliselwa kwakhona akuyimfuneko kwi- PPO . Umbutho onikhethiweyo umboneleli isicwangciso sempilo esineenkontileka kunye nenethiwekhi enkulu yabanikezeli "abakhethiweyo". Unako ukukhetha ukunakekelwa kwakho okanye inkonzo ngaphandle kwenethiwekhi. Ngokungafani nenhlangano yokugcinwa kwempilo, kwi-PPO akudingeki ukhethe ugqirha wezempilo oyintloko kwaye awudingi ukuhanjiswa ukuba ubone abanye ababoneleli kwinethiwekhi.
Ngenxa yezi zinto ziguquguqukayo, izicwangciso ze-PPO zihlala zibiza ngakumbi kunezicwangciso ze-HMO kunye nezinye iinzuzo ezifananisiweyo. Kwaye nabo banamathemba ekutsaleni ababhalisekayo ngeemeko zempilo, kuba abo bantu baya kukulungele ukuhlawula iiprayimari eziphezulu ukwenzela ukuba bafikelele kwiinkalo ezahlukeneyo zononophelo zonyango abangabonwa ngaphandle kokuthunyelwa. Le nxalenye yeso sizathu sokuba ngamnye umrhwerenyi wemakethe uye wasuka kude kwi-PPOs kwiminyaka yamuva.
Intlawulo
Inkokhelo ye-inshurensi yeenkonzo ngaphakathi kwenethiwekhi ekhethiweyo iyahluka phakathi kwama-HMO kunye nee-PPOs.
In-Network:
I-HMO kunye ne-PPO: Kungakhathaliseki ukuba unayo i-HMO okanye i-PPO, kwiinkonzo ze- in-network uza kuba noxanduva lweemali-mali kunye ne- deductible , kunye ne- coinsurance ukuba isicwangciso sakho sisisebenzisa.
I-Out-of-Network:
I-HMO: Kwi-HMO, awuqhelekanga nakwezinye iinkonzo ezingaphandle kweenkonzo.
I-PPO: Kwi-PPO, kukho ukugcinwa kwenkonzo yokunakekelwa kwe-out-of-network, kodwa umniki-ntle ukhululekile ukulungelelanisa i-bill yakho ngenxalenye yokuba umgcini wakho umgcini-mali awufihla ukususela ekubeni umboneleli akakutyikityi isivumelwano kunye ne-inshurensi yakho. . Ukuba ukhetha ukuphuma ngaphandle kwenethiwekhi ekunyamekeleni kwakho, kuya kufuneka ukuba uhlawule umniki-ntlawulo kuqala, uze uhlawulelwe yi-PPO. Izicwangciso ezininzi ze-PPO zineemali ezidlulileyo zonyaka kunye neepasimali ezingaphandle kweenkonzo zokunakekelwa kwe-network, kwaye ngokuqhelekileyo ziqhelekileyo ukubona iiprogram ze-PPO ngaphandle komda kwiindleko ezingaphandle kwe-pocket oya kuyenza xa uphuma ngaphandle umnatha.