IQela eliManyeneyo labanikezeli ngezeMpilo
Inkonzo yomninimshurensi wezempilo yinkampani yabanikezeli benkonzo yezempilo abanesivumelwano kunye ne-inshurensi yezempilo (nge- HMO, EPO, okanye i-PPO ) ukubonelela ngononophelo.
Inethwekhi yesicwangciso sempilo ibandakanya ababoneleli bezempilo njengamagqirha enyango lokuqala, oogqirha bezodwa, iilabhu, izibonelelo ze-X, iinkampani zonyango lwezempilo ekhaya, izibhedlele , izibonelelo zonyango, amaziko okungena kwamanye amazwe, amaziko okugulisa, ama-podiatrists, kunye namaziko okuhlinzwa okufanayo.
Iinkampani ze-inshorensi zempilo zifuna ukuba usebenzise ababoneleli kwinethiwekhi yabo ngezizathu ezibini ezibalulekileyo:
- Laba bahlinzeki badibane nemigangatho yemigangatho yezempilo.
- Bavumelwene ukuba bamkele izinga lokunciphisa intengiso kwiinkonzo zabo, kwintengiso yomqulu wesigulane abaya kufumana ngokuba yinxalenye yesicwangciso senethiwekhi.
Kutheni Iingxelo Zakho Zomnxeba wezeMpilo
Uya kuhlawula ii- copay ezincinci kunye ne-coinsurance xa ufumana unonophelo wakho kumnikezeli we-in-network, xa kuthelekiswa xa ufumana unonophelo wakho kumnikezeli wangaphandle. Enyanisweni, ii- HMO ezininzi aziyi kuhlawula ngenyameko oyifumene nomniki-ngaphandle wenethiwekhi ngaphandle kweemeko ezongeziweyo . Ngaphandle kwee- PPO ezinqabileyo zithintela i-inshurensi yama-20 okanye i-30 ye-inshurensi ye-inshurensi kubaboneleli bee-network kunye ne-60 okanye i-60 ye-insenti ye-inshurensi ye-inshurensi yabanikezeli benethiwekhi, kwaye banamathuba athathekayo aphezulu kunye nama- max- out-pocket when you go ngaphandle komnatha.
Isibonelelo se-in-network isicwangciso sakho sempilo ngokukhawuleza, ukuqokelela kuphela i-copay okanye imali echithwayo evela kuwe ngexesha leenkonzo (ukwenzela uhlalutyo lwemali, ipesenteji yenani elipheleleyo -kubakho ngaphezu kwesilinganiselo esicatshulwa njenge-copay kunye ne-deductible- Ngokubhetele ukucela umniki-mali ukuba ahlawule i-inshurensi yokuqala, kwaye ngoko ibhajethi yakho iya kuchongwa ngokusekelwe kwisantya esithethathethwayo ukuba umphathiswa unalo nomboneleli).
Nangona kunjalo, umboneleli-ngaphandle wenethiwekhi akanakho ukufaka ifowuni yomshuwalense kuwe. Enyanisweni, abaninzi bafuna ukuba uhlawule lonke i-bill kwaye uze ufake ibango kwinkampani yakho yinshurensi ukwenzela ukuba inkampani yomshuwalense inokukuhlawula. Yimali eninzi phambi kwakho, kwaye ukuba kukho ingxaki kwibango, nguwe olahlekelwe yimali.
Umnikezeli we-intanethi akavumelekanga ukuba alinganise-inkokhelo . Bamele bamkele isantya semvumelwano, kuquka i-copay okanye i-coinsurance yakho, njengentlawulo epheleleyo okanye baya kuphulaphula isivumelwano sabo kunye nenkampani yomshuwalense wezempilo.
Kodwa ekubeni ababoneleli-ngaphandle benethiwekhi abanakho isivumelwano kunye nenkampani yakho yomshuwalense, loo mithetho ayisebenzisi kubo. Kwamanye amazwe, umnikezeli-ngaphandle wenethiwekhi unokukuhlawulisa nantoni na ayayikhethayo, kungakhathaliseki ukuba inkampani yakho yinshorensi yomshuwalense ithi yintlawulo efanelekileyo neyesiko kule nkonzo. Ekubeni inkampani yakho yomshuwalense iya kuhlawula kuphela ipesenti yemali efanelekileyo kunye neyesiko, uya kuba kwi-hook ye-bill yebhanki yonke kunye nomnikezeli-ngaphandle-wenethiwekhi. Ngaloo ndlela, umboneleli we-inthanethi ngokuqhelekileyo uyona khetho olufanelekileyo.
Inethiwekhi yomboneleli iguqula phantsi kwe-ACA
Umthetho ononophelo loNonophelo, ojongene nokuchithwa kunye nokutshintshwa phantsi kolawulo lweTrump , kufuna ukuba izicwangciso zempilo zikhuphe iinkonzo eziphuthumayo zentlalo kunye nekwabelana ngeendleko eziya kusebenzisa xa umniki-nkonzo ebekho kwinethiwekhi.
Kodwa akukho mfuneko yokuba igumbi lokuphucula i-out-of-network lwamkele inkokhelo yakho yenqanaba lempilo yenethiwekhi njengentlawulo-ngokupheleleyo. Oko kuthetha ukuba isibhedlele isavunyelwe ukuhlawulela ibhajethi yakho ngenxalenye yenkathalo yongxamiseko oyifumeneyo engazange ihlawulwe yintlawulo yezinga lenqanaba lomnatha (ungabona indlela oku kwenzeka ngayo, xa ucinga ukuba izicwangciso zezempilo zixubusha iintlawulo kunye nezibhedlele zabo, kunye nesibhedlele esingaphandle kwe-network asinakuqwalasela loo maxabiso aphantsi ukuba anele).
Kwimarike yomntu ngamnye (i-inshurensi yezempilo ozithengayo kuwe, kunokuba ufumane kumqeshi okanye kwinkqubo karhulumente efana ne- Medicare okanye iMedicaid ), amanethiwekhi anikezelayo anqamle ngaphezu kweminyaka embalwa edlulileyo.
Kukho izizathu ezahlukeneyo zezi, kuquka:
- Abathwali bomshuwalense wezempilo baye bajolise ekufuneni ababoneleli ababonelela ngexabiso elifanelekileyo
- Amanethiwekhi amancinci anika abathwali amandla amaninzi ngokubaluleka kwexabiso.
- Izicwangciso ze-PPO ezicwangcisiweyo ziyakuthi zitsalane izigulane ezigulayo, kwaye iindleko zamabango eziphumo ziphezulu.
- Iimfuno ze- HMO kunye neemfuno zamasango zibanceda abaqinisekisi bahlale behlawule iindleko, ngokuchasene ne-PPOs apho izigulana zikhethwa ukuya ngqo kwizakhono eziphezulu.
Abathwali be-inshurensi kwimarike nganye abanakusetyenziselwa ukunyangwa kwezokwelapha ukukhanyela ukuhanjiswa kubantu abaneemeko zangaphambili (kwakhona, oku kungatshintsha phantsi koLawulo lweTrump), kunye nokukhawulelwa kufuneka banikele ngokufanelekileyo ngokufanayo kunye nokubonga, ngenxa ye- ACA iimfuno zezempilo eziyimfuneko. Abathwala nabo banqunywe ngokwemali yepesenti yeedola eziyimali ezingenakukwazi ukuchitha kwiindleko zolawulo.
Konke oku kuye kwabashiya ngeendlela ezimbalwa zokuncintisana ngexabiso. Enye indlela abayenzayo isatshintshile kwi-network ephezulu ephezulu ye-network PPO isicwangciso sokunciphisa i-HMO yenethiwekhi. Oku kuye kwaba yinkalo kumazwe amaninzi kwiminyaka embalwa edlulileyo, kwaye abanye bathi abanalo naziphi na izithuthi ezinkulu ezibonelela izicwangciso ze-PPO kumakethi athile. Kuba ngababhalisile abanempilo, oku akusiyo ingxaki, kuba abafuni ukufumana uluhlu olubanzi lwababoneleli abakhoyo abafuna ukuqhubeka besisebenzisa. Kodwa intsebenziswano ye-Intanethi ye-PPO iyakwenza isibheno kubabhalisi abagulayo-nangona iiprayimari eziphezulu-kuba zivumela ukufikelela kwiinkalo eziphangaleleyo zeengcali kunye nezibonelelo zonyango. Ekubeni izicwangciso zempilo azikwazi ukuchasana nababhalisi abagulayo ngokuzikhanyela ukufihla, abaninzi abathwali baye bakhetha ukunciphisa amanethiwekhi abo endaweni yoko.
Kwamanye amazwe, amanxibelelwano amaninzi sele ekhona, kunye nokwabelana ngeendleko eziphantsi kwizigulane ezisetyenziselwa ukubonelela kwiinkampani ezikhethiweyo.
Konke oku kuthetha ukuba kubaluleke kunanini ngaphambili ukuphonononga iinkcukacha zesistim sakho senethiwekhi, mhlawumbi ngaphambi kokuba usebenzise i-coverage yakho. Qinisekisa ukuba uyazi ukuba isicwangciso sakho siza kubakhokela ukunakekelwa kwe-network (abaninzi banako) kwaye ukuba baya kuyenza, baya kubabiza kangakanani. Qinisekisa ukuba uyazi ukuba isicwangciso sakho sifuna ukuba ufumane ukuthunyelwa kwirejista yakho yokhathalela oyintloko ngaphambi kokuba ubone ingcali, kwaye yiziphi iinkonzo eziphambi kokugunyazwa ngaphambili . Okwazi ngakumbi malunga nenethiwekhi yakho yechungechunge, kuya kuba nzima xa usuqedile ukusetyenziswa kwenkcazo yakho.
Ukuhlaziywa nguLouise Norris.
> Imithombo:
> Housedocs.house.gov. Ukuhlanganiswa koKhuseleko lweMonde kunye noMthetho woNonophelo onoxanduva . Njengoko ichitshiyelwe ngoMeyi 1, 2010.
> Kaiser Family Foundation. Ukuchaza Ukuguqulwa Kwezempilo: Ukulungiswa Kwezonyango (MLR). NgoFebruwari 29, 2012.