Abaqinisekisi baye baqalisa amanethiwekhi amaninzi njengendlela yokugcina imali
Uninzi lwethu lisetyenziswe kwingcamango yokuba izicwangciso zeeinshorensi zempilo yabucala zinomncedisi womncedisi. Abathumeli be-inshurensi bathetha iingqungquthela zemvumelwano kunye noogqirha abathile kunye nezibhedlele ukudala inethiwekhi yomboneleli, kunye nabanini-migaqo ngokubanzi kufuneka bafumane unonophelo kubaboneleli bee-network (izicwangciso zikawonkewonke ezifana neMedicaid kunye neMedareri nazo zinabathengi abathatha inxaxheba; abaninzi ababonelela inxaxheba kunye ne-Medicare, nangona kungenjalo abaninzi bayamkela iMedicaid, uninzi lwabagqirha lithatha iMedicaid).
I-PPOs ngokubanzi ivumela izigulane ukuba zibone ababoneleli ngaphandle kwenethiwekhi, kodwa i-out-of-pocket maximum ingaphezulu kuneemida ezilungiselelwe ukunakekelwa kwenethiwekhi. IipPOs ziphindaphinda kabini i-out-of-pocket ephezulu kwiinkathalo ezifunyenwe ngaphandle kwenethiwekhi, nangona ziba zixhaphake kakhulu kwii-PPOs ukuba zibe neelami ezingapheliyo zokugcina i-pocket ye-care-out-of-network (oko kukuthi, ukuba uya ngaphandle kwintanethi , akusenakho ikhefu malunga nokuba kufuneka uhlawule kangakanani inxalenye yeendleko).
Ii-HMO nee-EPO ngokubanzi zifuna izigulane ukuba zisebenzise ababoneleli ngee-network kwaye zingabinakekeli ngononophelo lwentlalo ngaphandle kwayo, ngaphandle kokuba kubekho ingxamiseko.
Tiered Networks
Iintanethi zeTiered zenza ingqwalasela yesizwe ekupheleni kuka-2015 xa i-Horizon Blue Cross Blue Shield igxininisa inethiwekhi ye-Omnia e-New Jersey. E-Illinois, umhlaba we-Lincoln Health (i-ACA-eyenziweyo CO-OP) nayo isebenzisa amanethiwekhi amaninzi, kwaye ayafumaneka kwiimakethe zomntu ngamnye kunye neqela kwiindawo ezininzi.
Okubaluleke kakhulu, amanxibelelwano amaninzi avumela i-inshurensi yezempilo ukuba igcine inethiwekhi yabo yonke inkulu, ngelixa iyanciphisa ngokufanelekileyo amalungu amaninzi kwinethiwekhi encinci - kodwa ukhetho luya kwilungu.
Ngomnatha womnatha, amalungu ahlawula iindleko ezingaphantsi kwee-pocket xa bebona umboneleli kwi-network top tier.
Bakhululekile ukubonelela ababoneleli kwi-network tier ephantsi, kodwa baya kuhlawula ngaphezulu kwiindleko ezingaphandle kweentlawulo xa benza.
Imilinganiselo ye-ACA kwiindleko ezingaphandle kwee-pocket isasebenza xa isigulane sikhetha ukubona umniki-ntanethi kodwa kungekho kwinqanaba eliphezulu. Ngethuba nje umniki-nkonzo ekhompyutheni yesicwangciso, iindleko zegulane zeenzuzo zezempilo ezibalulekileyo ngexesha lonyaka aziyi kudlulela umda obekwe ngu-ACA (ngo-2016, loo $ 6,850 ibe yedwa, kunye ne-13,700 zamawaka kwintsapho; , yanda ukuya ku-$ 7,150 kumntu oyedwa kunye ne-14,300 zamawaka kwintsapho ).
Kwaye isicwangciso sinokubeka isigxina esiphezulu se-pocket kwiinkonzo ezifunyenweyo kwi-network top of providers (nantsi umzekelo ovela kwi-Horizon Blue Cross Blue Shield e-New Jersey - kungakhathaliseki ukuba izigulane zisebenzisa esinye isondlo okanye ngabaxhasi ababini, i-out-of-pocket maximum yee-year isangokufanayo).
Kodwa izigulane ezikhetha ababoneleli abaphezulu ziza kuhlawula iindleko ezingaphantsi kwexesha-kwipokothoni zithengwa (umzekelo, i-copay ye-$ 15 yokubona ugqirha endaweni ye-$ 30, okanye i-copay ukubona ugqirha endaweni yokuba hlawula i-deductible kunye ne-coinsurance, okanye ayikho into ehlawulwayo esikhundleni se-$ 2,500 echithwayo). Kwizigulane ezingapheliyo ukudibanisa iplani ye-out-of-pocket ebudeni bonyaka, kukho intshisekelo ebalulekileyo yokusebenzisa oogqirha nezibhedlele kwinqanaba eliphezulu lenethiwekhi.
I-Tiered Networks ayikho entsha
Iinqununu zeTiered azikho ezintsha - zidlulele phambili kwi-ACA kwaye sele zide ziyizicwangciso zezempilo zisebenzise ukulwa neendleko ezikhulayo. Isicwangciso se-Horizon BCBS sika-Omnia eNew Jersey sinamaxabiso angama-15% angabizi ngaphaya kweenjongo ezifana ne-Horizon ngo-2015 ezingazange zisebenzise intanethi. Akumangalisi ukuba iiprayimari ezisezantsi ezicwangcisiweyo zintengiso zikhangeleka kubathengi nabaqeshi.
Ukuqulunqwa kwabasebenzi
Abaqinisekisi bezeMpilo bangasebenzisa iintlobo zamatriki ukwenzela ukuba ngubani oogqirha kunye nezibhedlele eziphelela kuyo. Ngokuqhelekileyo, ukulinganiselwa kwexabiso kunye neendleko zisetyenzisiweyo, nangona ababoneleli abaphezulu bavuma ukuvuma amanani ehlawulelo ephantsi kwi-insurer yezempilo, kwintengiso yokuba baya kufikelela ngokuqinisekileyo bafumana umthamo wesigulane esiphezulu njengomboneleli ophezulu.
Kodwa kukho ukuphikisana xa kungaqondakali ukuba ngabaphi abathwali beemetriki basebenzise ukukhetha ukuba oogqirha nezibhedlele baya kuphelisa njani kwi-top tener. E-New Jersey, abenzi bomthetho baye bathatha inxaxheba, kwaye imigaqo emininzi yomthetho sele iqaliswe ukulungisa amanxibelelwano athile kunye nokubonakaliswa ngokucacileyo malunga nendlela ababoneleli banikezelwa ngayo. Isiqingatha sezibhedlele zikarhulumente siphelile kwizibini ezibini (oko kukuthi, umgca ongakhethiweyo) phantsi koyilo lwe-Horizon BCBS ye-Omnia, kwaye akuyiyo into evuyisayo ngayo.
Abenzi bomthetho kunye nabaxhasi babathengi banenkxalabo yokuba izibhedlele kwiindawo ezingabandakanywanga zizakuphelisa ukulahlekelwa yintlawulo yemali ngenxa yokunciphisa umthamo wesigulane (kuba izigulane ziza kukhetha izibhedlele enye ukuze zisebenzise iindleko ezingaphantsi kwee-pocket) , kwaye oko kunokubangela ubuhlungu abathengi abahlala kufuphi nezibhedlele ezi-2 - ngakumbi xa izibhedlele ezibhekiselweyo zizibhedlele "zokhuseleko" ezibona umthamo omkhulu wezigulane ezingenasiphelo kunye nezingaxhaswanga.