I-Exclusive Provider Organisation (EPO)
Ngaba uye wacinga ukubhalisa kwisicwangciso sezempilo se-EPO? Ukuba kunjalo, kubalulekile ukuqonda ukuba zeziphi izicwangciso kunye nendlela ezisebenza ngayo, ukuqinisekisa ukuba isicwangciso siya kuhlangabezana neemfuno zakho.
Kuthekani ukuba sele unayo inshuwalense yezempilo ye-EPO? Ukuqonda i-ins kunye nokuphuma kwendlela i-EPO yakho isebenza ngayo kukunceda usebenzise isicwangciso sakho sezempilo ngokufanelekileyo kwaye ugweme iimpazamo ezibiza.
Yintoni i-EPO (i-Exclusive Provider Organization)?
Udidi lwe-inshorensi yezempilo yonakekelo, i-EPO imele umbutho onikezelayo kuphela . I-inshurensi yezempilo ye-EPO yafumana leli gama kuba kufuneka ufumane unyango lwempilo yakho kuphela kubaboneleli bezempilo kwiipontraki ze -EPO kunye, okanye i-EPO ayiyi kuhlawula ukunyamekela.
Njengabo bazala babo, ii-PPOs kunye nee-HMO, izicwangciso zezempilo ze-EPO zinemithetho yokukhupha iindleko malunga nendlela ofumana ngayo unyango lwakho lwempilo. Ukuba awuhambanga imithetho ye-EPO xa ufumana iinkonzo zonyango, ayiyi kuhlawula ukunyamekela.
Imigaqo yezempilo ye-EPO iphambili malunga neendlela ezibalulekileyo zokuqulunqa indleko:
- Kuphi na ofumana iinkonzo zonyango lwempilo kuncinci kubanikezeli banikeze i-EPO ukuba baxoxise izaphulelo.
- Iinkonzo zononophelo lwezempilo zikhawulelwe kwizinto eziyimfuneko okanye ezinokwenyuka kweenkonzo zempilo ezincinci ngexesha elide, njengononophelo lokukhusela .
Inkonzo Yomshuwalense Wezempilo ESE?
Yintoni oyifunayo ukuba uyisebenzise ngokusebenzisa i-inshurensi yakho ye-inshurensi ye-EPT?
Qinisekisa ukuba ufunde umgaqo-nkqubo we-inshorensi yempilo ngokucophelela. Ukuhlala kwi-network kunye nokufumana ukugunyazwa kwangaphambili xa kuyimfuneko kunokukugcina imali eninzi. Makhe sijonge kwiingcamango ezibalulekileyo ukuqonda.
Iimfuneko zokuXhawula indleko kwi-EPO ziphantsi
Ukwabelana ngeendleko ngumsebenzi apho wena kunye nenkampani yakho yomshuwalense ukuhlawula inxalenye yeenkonzo kwaye uhlala ugcinwa ubuncinane kunye ne-EPO.
Oku kubandakanya ukuhlawulelwa , ukuhlawulwa kwemali , kunye ne- coinsurance . Enyanisweni, ezinye ii-EPO azifuneki nayiphi na imali okanye i-coinsurance kuwo onke, kwaye ihlawulisa imali encinci ngexesha leenkonzo. Ngenxa yokwabelana kweendleko eziphantsi kunye nama- premium aphantsi, i-EPO yenye yeyona nkcaso yeyona nkcitho ye-inshorensi yempilo.
Kumele Usebenzise Umnikezeli Wenethiwekhi
Yonke i-EPO inoluhlu lwababoneleli bezempilo ababizwa ngokuba ngumncedisi womnatha. Le nethwekhi inika yonke inkonzo enokuzicingela inkonzo yokunakekelwa kwezempilo kuquka noogqirha, iingcali, iifommine, izibhedlele, ii-lab, ii-ray-facilities, i-therapists, i-oxygen ekhaya, nokunye.
Esicwangciso sezempilo se-EPO, unokufumana iinkonzo zonyango kuphela kubaboneleli bee-network . Ukuba ukhathalela ngaphandle kwe-network , i-EPO ayiyi kuhlawula; uya kubambelela ukuhlawula i-bill yakho ngokwakho. Ukunyamekela ngenyameko yokunakekelwa kwenethiwekhi kunokuyiphutha elibi kakhulu xa une-EPO.
Ekugqibeleni uxanduva lwakho lokukwazi ukuba ngabaphi ababoneleli abakwi-network kunye ne-EPO yakho. Ngokomzekelo, awukwazi ukucinga ukuba ngenxa yokuba ibhuleji ihla iholo kwiofisi yakho ye-EPO, udityaniswe ne-EPO yakho. Kufuneka uhlole. Ngokufanayo, ungacingi ukuba isibonelelo sokubakho esikwenzayo sonyaka ophelileyo sise-network kunye ne-EPO yakho kulo nyaka.
Unxibelelwano lwamanethiwekhi atshintsha. Ukuba wenza loo ngqiqo kwaye uyiphutha, kuya kufuneka uhlawule yonke ibhilim ye-mammogram.
Kukho izimbalwa ezintathu kwiimfuno ze-in-network:
- Ukuba i-EPO ingenayo umnikezeli we-inthanethi wenkonzo ekhethekileyo. Ukuba oku kwenzeka kuwe, qulunqa ukhathalelo lwangaphandle lwentengiso kunye ne-EPO. Gcina i-EPO yakho kwi-loop.
- Ukuba uphakathi kwenkqubo eyinkimbinkimbi yonyango olukhethekileyo xa uba ilungu le-EPO, kwaye ingcali yakho ayiyiyo inxalenye ye-EPO. I-EPO yakho iya kugqiba isigqibo sokuba ngaba ungagqiba uqeqesho lwenkcazo kunye nogqirha wakho ngoku.
- Ukunyameka okwenyaniso. Ukuba unesifo, isifo senhliziyo, okanye enye inkxalabo yokwenene kufuneka uhambe kwinqanaba eliphuthumayo elikufutshane nokuba awukho kwinethiwekhi kunye ne-EPO yakho. Uninzi lwe-EPO luya kuhlawula iindleko zonyango olujongene nxamnye noxakeka kwiziko elikufuphi elikufutshane nakwiindawo ezinjenge-in-network ukunakekelwa. Ukuba ufuna ukungeniswa kwisibhedlele ukusuka kwi-ER, ke, i-EPO yakho inokucela i-ER ngaphandle kwenethiwekhi u-ER ukuba ikudlulisele kwisibhedlele se-intanethi ukuze samkelwe.
Awunayo Impilo Yonyango
Isicwangciso sakho sezempilo se-EPO asiyi kufuna ukuba ube negqirha lokunakekelwa kweprayimari (PCP) , nangona ukufumana i-PCP isengcamango enhle.
Akudingeki ukuba ube nokubhekiselele kwi-Specialist
Nge-EPO awuyi kufunwa ukuba uhanjiswe ngaphambi kokuba ubone ingcali. Oku kwenza kube lula ukubona oyingcali kuba usenza isigqibo ngokwakho, kodwa kufuneka uqaphele ukuba ubona iingcali kuphela eziku-network kunye ne-EPO yakho. Inzuzo yokuba ne-PCP kukuba bahlala beqhelana neengcali kuluntu, kwaye ezininzi iingcali zizinomdla okhethekileyo phakathi koxanduva lwazo, umzekelo, ezinye i-oncologists jikelele zingaba nomdla okhethekileyo kumhlaza wesifuba kanti enye ingenomdla okhethekileyo kumhlaza wemiphunga.
Uya Kucelwa ukuba ufumane ukugunyazwa kwangaphambili kwiiNkonzo eziNinzi
I-EPO yakho iya kufuna ukuba ufumane imvume kwezinye iinkonzo, ngokukodwa ezo zinto zibiza kakhulu. Ukuba inkonzo ethile idinga ukugunyazwa kwangaphambili (ukugunyazwa kwangaphambili) kwaye ukuba awufumani, i-EPO yakho inokungafuni ukuhlawula. Uninzi lwexesha iinkonzo ezifuna ukugunyazwa zizinkonzo ezikhethiweyo kwaye ezingekho ngeenkonzo ezingxamisekileyo, ngoko ukulibazisa ixesha elincinci akuyi kubakho ubomi besongela ubomi.
Ukugunyazwa kwangaphambili kukunceda i-EPO yakho igcine iindleko ngokuqinisekisa ukuba ufuna ngokwenene iinkonzo ozifumanayo. Kwizicwangciso ezinjenge-HMO ezifuna ukuba unogqirha wokunakekelwa kweprayimari, i-PCP yakho inoxanduva lokuqinisekisa ukuba ufuna ngokwenene iinkonzo ozifumanayo. Ekubeni i-EPO yakho ayifuni ukuba ube ne-PCP, isebenzisa ukugunyazwa kwangaphambili njengendlela yokufikelela enye injongo: i-EPO ihlawula kuphela izinto eziyimfuneko ngokwenene.
Iiplani ze-EPO ziyahluka malunga noluphi uhlobo lweenkonzo ezifunekayo ngaphambili. Uninzi lufuna ukugunyazwa kwangaphambili kwezinto ezinjengeMRI kunye ne-CT, izidakamizwa ezidumileyo, utyando, izibhedlele, kunye nezixhobo zonyango ezifana ne-oxygen ekhaya. I-EPO's Summary of Benefits kunye ne-Coverage kufuneka ikuxelele ngokumalunga nemfuneko yokuphambi kokugunyazwa, kodwa kufuneka ulindele ukuba nayiphi inkonzo eninzi izakufuneka iguqulwe ngaphambili.
Nangona ugqirha wakho unokuzivolontiya ukuba afumane imvume phambi kwakho, ekugqibeleni uxanduva lwakho lokuqinisekisa ukuba ufumana inkonzo yangaphambi kokugunyazwa ngaphambi kokuba ufumane unyango lwempilo. Ukuba awuyiyo, i-EPO yakho inelungelo lokungafuni ukuhlawula ukunyamekela, nokuba ngaba unonophelo luyimfuneko kwaye uyifumana kwi-network-provider.
Ukugunyazwa kwangaphambili kuthatha ixesha. Ngamanye amaxesha, uya kuba negunya phambi kokuba ushiye iofisi yegqirha. Ngokuqhelekileyo, kuthatha iintsuku ezimbalwa. Kwiimeko ezimbi, okanye ukuba kukho ingxaki ngokugunyazwa, kunokuthatha iiveki. Khangela iingcebiso zethu malunga nendlela yokufumana isicelo sokugunyazwa kwangaphambili esavunyelwe .
Akufanele Ufake izicelo zamabango
Akunakuze ulahlekelwe ngamatyala kunye nefom yefowuni xa unesi-inshorensi yezempilo ye-EPO kuba yonke inkathalo yakho inikwe inethiwekhi. Umniki-nkonzo wakho wokunakekelwa kwempilo kwi-intanethi iprogram yakho yezempilo ye-EPO ngqo ngokunyamekela kwakho. Uya kuba noxanduva lokuhlawula imali yakho, ukuhlawulwa kwemali kunye ne-coinsurance.
Ngaphantsi kwi-inshorensi yezempilo ye-EPO
I-EPO inezinye iimpawu ezifanayo kunye nee-HMO kunye nezinye iimpawu ezifanayo ne-PPOs. Ngaloo ndlela, ungacinga ukuba i-EPO ibe ngumzabalazo phakathi kwe-HMO kunye ne-PPO. Abantu abaninzi bathanda ukhululo lokukwazi ukulungisela ukuqeshwa kunye neengcali ngaphandle kokubonisana nodokotela oyintloko. Ngexesha elifanayo, oku ngamanye amaxesha kunokuba ngumngeni kuba unganci kwiingcali ezithile ngaphakathi kwintanethi yakho. Ukuba ne-EPO kukufuna ukuba uhlanganyele ngokucwangcisekileyo ekucwangciseni iinkonzo ezibizayo okanye iinkqubo, kwaye ushiya unobangela obunzima bokugqiba naziphi na izigunyaziso ezifunekayo ngaphambili. Ngokubanzi, ukuhlanganiswa kwama-premium ayo aphantsi kunye nokwabelana ngeendleko eziphantsi kwenza ama-EPO abe yinto enhle kubantu abaninzi. Ukuba uyifumana ingqondo njengoko uthelekisa izicwangciso ezahlukeneyo, khangela ukuba uqhathaniswa ne-HMOs, ii-PPOs, ii-EPOs. nezicwangciso zePOS .
> Umthombo:
> Healthcare.gov. Isicwangciso soMbutho we-Provider (EPO). https://www.healthcare.gov/glossary/cacclusive-provider-organization-epo-plan/