Indlela Izikhokelo Zokuqwalasela Zisebenza Ngayo
Iinkampani zomshuwalense yezempilo, i- Medicare , kunye nezibhedlele zihlala zifuna iindlela zokonga imali. Ukunikezela kwisimo sokubheka usebenzisa izikhokelo zokubakhokela kubasindisa imali, kodwa unokuphelisa imali eninzi.
Xa ufakwa esibhedlele, ukwazi ukuba uvumelekile ukuba unikwe isigulane okanye ubeke isimo sokubaluleka kubalulekile kuwe.
Nesi sizathu sokuba kubalulekile, kwaye kufuneka wenze ntoni.
Ziyini isimo sokuqwalasela?
Xa ufakwa esibhedlele, ubelwe isimo sokugula okanye isimo sokujonga. Ubanikezelwa kwiimeko zesifo soogulana xa unengxaki ezinzima ezifuna ubugcisa obuphezulu, unonophelo lwezakhono.
Unikwe isikhundla sokujonga ukuba awugulanga ngokwaneleyo ukuba ufuna ukungena ngesigulane, kodwa ugula kakhulu ukuba unakekele kwi-ofisi yakho ugqirha. Okanye, unako ukunikezelwa kwisimo sokujonga xa oogqirha bengayiqinisekanga ukuba ugula kangakanani. Banokukugcina esibhedlele kwaye bakwenze unesifo sokugula xa uguga, okanye uvumele ukuba uye ekhaya xa ulunge.
Ndingazi njani ukuba ndibekwa iSimo sokuBheka okanye iSimo soPhala?
Ekubeni izigulane zokubona zihlobo lwesiphene, ezinye izibhedlele zineendawo ezikhethiweyo okanye iphiko lesibhedlele ngenxa yezigulane zazo. Kodwa, izibhedlele ezininzi zibeka izigulane zabo ezigqalayo kumagumbi afana nezigulane zabo.
Oku kwenza kube nzima kuwe ukuba uchaze ukuba unesifo sengqondo okanye isigulane esibhekeleyo. Awukwazi ukucinga ukuba, ngenxa yokuba uhlala kwigumbi lesibhedlele rhoqo, okanye kwisibhedlele esibhedlele kunokuba ube kwi-gurney, unesi sifo.
Akunakukwazi ukucinga ekubeni usesibhedlele iintsuku ezimbalwa unesifo sengqondo.
Nangona ukuqwalaselwa kuhloswe ixesha elifutshane, akusoloko kusebenza ngaloo ndlela.
Indlela yodwa yokwazi ukuyibuza .
Ukuqwalaselwa kwam kwimeko okanye isifo sengqondo esinikwayo?
Izibhedlele kunye noogqirha abagcini nje ukukunika isikhundla esinye okanye esinye ngenxa yokuba bazive ngathi, kuba isimo esinye sibonakala singcono, okanye ngenxa yokuba ucela ukuba unikezwe kwimeko ethile. Kunoko, kukho izikhokelo zesizwe ezipapashwe kwiNcwadana yoMgaqo-nkqubo woNcedo lwezeMpilo ukufumana ukuba ngubani obelwe isimo sengqondo sokugula, kwaye ubani obelwe isikhundla sokujonga.
Ezi zikhokelo zicaca kodwa zincomekayo kwaye zingatshintshwa unyaka wonke, ngoko ke ezininzi izibhedlele kunye neenkampani zomshuwalense zisebenzisa inkonzo epapasha imigaqo yokubanceda ukuba basebenzise izikhokelo kwisigulane ngasinye. Iinkonzo ezibini ezithandwa kakhulu yiMcKesson ye-InterQual Criteria kunye neMikhombandlela yokuNakekelwa kweMilliman.
Ezi zikhokelo zezigulane kunye nezikhokelo zokuqwalasela ngokuqhelekileyo zijonganisa iintlobo ezimbini zeendlela zokuzikhethela. Umqathango wokuqala ngowona bunzima besifo sakho: ngaba uyagula ngokwaneleyo ukuba ufune ukungena ngesigulane?
Isigxina sesibini kukubaluleka kweenkonzo ofuna zona: ngaba unyango oludinga ngokwaneleyo okanye obunzima ukuba isibhedlele yindawo kuphela onokuyifumana ngokukhuselekileyo loo unyango?
Icandelo ngalinye lemiqathango liye labulawa ngokubaluleka kwamaphuzu okuvavanya okungaquka izinto ezifana neziphumo zokuhlolwa kwegazi, iziphumo ze- X-ray, iziphumo zokuhlolwa kwemzimba, kunye neentlobo zonyango oye wachazwa.
Xa ufakwa esibhedlele, umphathi wecala lesibhedlele okanye umhlengikazi wokuphonononga ukusetyenziswa uza kuhlola imeko yakho, ngokuthelekisa iziphumo zakho zogqirha, ukuxilongwa kwakho, iziphumo ezivela kwiimvavanyo zakho kunye nezifundo, kunye nonyango lwakho olumiselweyo kunye nezikhokelo. Uya kusebenzisa ezo zikhokelo ukuze ancede ugqirha wakho abelane nawe kwimeko yokujonga, okanye isimo sengqondo sokugula.
Kutheni Kufuneka Isimo Sokuqwalaselwa Kwempawu okanye Isimo Sengxaki Yokugula?
Ukuba unesifo sengqondo, kodwa i-Medicare okanye inkampani yakho yomshuwalense yempilo inquma ukuba kufuneka ubelwe isimo sokujonga, singenakho ukuhlawula sonke isibhedlele sokuhlala esibhedlele.
Mhlawumbi awuyikufumanisa oku kude ukuba isibhedlela sithumele ibango kwaye saliphikisana nenkampani ye-inshorensi okanye iinyanga emva kokuba uhlala esibhedlele.
Enyanisweni, amaCandelo e-Medicare kunye neMedicaid Services iinkampani zifuna ukukhangela iirekhodi zezigulane zezigulane ze-Medicare ngenzame yokufumana izibhedlele ezingenagulana ezingaphendulwa kwimeko yokujonga. Oku kwenzeka iinyanga okanye nangemva kweminyaka-ye-nyaniso. Emva koko, i-Medicare ithatha yonke imali eyayihlawula esibhedlele ngenxa yoko kwamkelwa.
Izibhedlele zizama ukulandela izikhokelo ngokususela ekubeni oko kulula kwaye ininzi iyakwamkela indlela yokwenza isizathu sokuba bakunike loo ndawo ethile. Ngokomzekelo, ukuba inkampani yakho yomshuwalense okanye i-Medicare iphika ibango lakho kuba lizimisele ukuba kufuneka libe yimeko yokujonga kunokuba unesifo sesibhedlele, isibhedlele siya kulwela ukukhanyela ngokubonisa ukuba udibene nezikhokelo ze-InterQual okanye iMilliman malunga nesimo owabelwe ngaso . Ukuba isibhedlele ayilandelanga izikhokelo ngokusondeleyo, ingozi yokumangalelwa kwebango.
Kodwa, ukuba unikwe isikhundla sokujonga indawo kunokuba unesifo sengqondo, nangona kungenakwenzeka ukuba wakho umshwalense uya kukhanyela ibango lakho lonke, usenokuthi uthathe i-hit hit. Ngokuqhelekileyo, isabelo sakho seendleko zeenkonzo zonyango zikhulu kunesabelo sakho seendleko zokubakholiswa kwabangenayo isigulane.
Ekubeni izigulane zokubonwa zihlobo lwesiphene, iibhokhwe zabo zigqitywe phantsi kwe- Medicare Part B , okanye iinkonzo zonyango ziyingxenye yenkqubo yomshuwalense wezempilo, kunokuba phantsi kweCandelo le- Medicare Part A okanye inxalenye yesifo se-inshorensi yempilo. Ukukhutshwa kwezilwanyana ezingapheliyo kunokufumana amaxabiso angaphezulu kwee- coinsurance ngaphezu kokugqithiswa kwezigulane (okwenyani ngokukodwa xa uhlala kwi-Medicare, ekubeni iNgxenye B ine-coinsurance engekho ngaphandle kwe-pocket ngaphandle kokuba unesicwangciso seMedigap okanye i-Medicare Benevantage ). Ngoko, unokugqibela ukuhlawula inxalenye enkulu ebhaliweyo yokubonelela iinkonzo kunokuba ubuya kuhlawula iinkonzo zonyango.
Ukuba uhlala kwi-Medicare, isimo sengqondo siya kugqitywa kukubiza ngakumbi xa ufuna ukuya kwikhaya lononophelo lokuvuselela emva kokuhlala esibhedlele. I-Medicare ivame ukuhlawula iinkonzo ezinjengezilwanyana zonyango kwikhaya labahlengikazi ixesha elifutshane. Kodwa, ufanelekela kuphela le ntlawulo xa unesifo sesifo sesithuba seentsuku ezintathu. Ukuba uhlala kwindawo yokujonga iintsuku ezintathu, awuyi kufaneleka.
Oku kuthetha ukuba uya kufuneka uhlawule yonke ibhili yekhaya lononophelo kunye neenkonzo zayo zokubuyisela. Unokulindela eli bhili-mali libe ngamawaka angamawaka eedola.
I-Two-Midnight Rule
Ngo-2013, ii-Centers ze-Medicare kunye neeNkonzo zeMedicaid (CMS) zanikezela izikhokelo ezibizwa ngokuthi "umbini-ubusuku obuphakathi kwamabini" okunceda ekugqibeleni ukuba zeziphi izigulane kufuneka zivunywe njengezigulane kwaye zigqitywe phantsi kwe-Medicare Part A (izibhedlele) ngaphandle kweCandelo B ( ). Umgaqo uthi ukuba ugqirha owamkelayo ulindele ukuba isigulane sidinga ukuba sisibhedlele kwithuba elithile elithatha ubuncinci emibini, ukunyamekelwa kuya kuhlawulwa phantsi kwe-Medicare Part A.
Ngo-2015, i-CMS ihlaziye umbuso-ubusuku bombusuku ukubonelela ukulungelelaniswa kwamanani athathwe ngamacala athile. Izikhokelo ezintsha zihlala zibiza ukuhlala kwisibhedlele esibonisa ubuncinane ubuncinane ezimbini phambi kweCandelo le-Medicare Part A, kodwa ziphinde zishiye igumbi elinesigqirha sokuqaphela ugqirha. Ukuba ugqirha ukholelwa ukuba unyango luvumelekile ukungenwa ngesifo sengqondo nangona xa isibhedlele sihlala silindele ukuba sibe nobude bemizuzu emibini, ugqirha unokukwazi ukuvuma isigulane njengesigulana.
Ngaba Ndifanele Ndilwe neNgxaki yokugula, okanye i-Settle for Status Observation?
Nangona kuphazamisekile, akuyona into ebalulekileyo yokulungelelanisa imeko okanye ukulwa nesimo sengqondo sokugula njengokuba kuyimfuneko yokuqinisekisa ukuba unesimo esifanelekileyo nokuqonda oko kuthetha ukuthini uhlahlo lwabiwo-mali.
Ukufuna ukuba uphinde ubelwe kwisimo sengqondo somntu osweleyo xa ulungelelanisa imilinganiselo yokujonga imeko ingabonakala ngathi ingakusindisa imali ukuba iindleko zakho zemali zonyango ziphezulu kunonophelo lwangaphantsi (isimo sengqondo sokujonga), kwaye kuya kunceda ukuba unikezelwe ngononophala ukuba uhlala kwi-Medicare kwaye uya kufuna uncedo emva koko kwiziko lokunakekela abanonophelo. Kodwa, khumbula, inkampani yakho yomshuwalense yempilo inokungafuni ukuhlawula ibhilikhwe yesibhedlele ukuba inqunywe ukuba yenziwe ngokungalunganga kwisimo sengqondo sokugula. Akunjalo wena okanye isibhedlele uya kuphumelela ukulwa nokubhikishwa kwebango kuba awuzange uhambisane nezikhokelo zesimo sengqondo sokugula.
Oko kwathiwa, kulungile ukubuza ukuba zeziphi izikhokelo ezisetyenzisiweyo zokuthatha isigqibo sokuba kufuneka ube kwisimo sokuqwalasela kunokuba unesifo sengqondo. Unokuphinda ubuze ukuba zeziphi iintlobo zonyango, iziphumo zokuvavanya, okanye iimpawu eziza kukufanelekela ukuba ube nesimo sengqondo esinesifo sengqondo ngesifo esifanayo. Ukongezelela, cinga ukucela ukuba uthethe nomntu ovela kwiofisi yokuhlawula ukuba unokuthelekisa iindleko zakho ngaphandle kwe-pocket ingaba uyimeko yokujonga okanye unesifo.
Ukuba ugula kakhulu ukwenza oku ngokwakho, unika imvume yokuba nelungu lentsapho elithembekileyo, umhlobo, okanye ummeli wesiguli ukubuza le mibuzo, kwaye ulandele iimpendulo.
Imithombo:
Amaziko e-Medicare kunye neeNkonzo zeMedicaid, i-Fact Sheet: I-Two-Midnight Rule, 10-30-2015.