Yintoni onokuyilindela xa Ujoyina iNyango yoLondolozo lwezeMpilo
Ukuqonda ukuba yi-HMO kunye nendlela abasebenza ngayo kubaluleke xa ukhetha isicwangciso sezempilo ngexesha lokubhalisa okuvulekile kunye nokusebenzisa i-HMO yakho emva kokuba ubhalise.
Yintoni iHMO?
I-HMO imele inhlangano yokugcinwa kwempilo , uhlobo lwe-inshorensi yezempilo yonakekelo . Njengoko igama lithetha, enye yeenjongo eziphambili ze-HMO kukugcina amalungu ayo aphilile. I-HMO yakho ingathanda ukuchitha imali encinci phambi kokukhusela isifo kunokufumana imali eninzi emva koko xa uzama ukuyiphatha.
Ukuba sele unesifo esingapheliyo , i-HMO yakho iya kuzama ukulawula loo mqathango ukugcina unempilweni ngokusemandleni.
Ukususela ngo-2016, abantu abangaphezu kwezigidi ezingama-92 baseMerika baxhomekeke kwi-HMO. Kwabandakanya abantu abakwizibonelelo ezixhaswe ngumqeshi kunye nezicwangciso zeemarike, kunye nabantu abakwi- HMO kunye ne-Medicaid.
Ingaba isebenza kanjani?
1. Kumele ube negqirha lokunyamekela.
Ugqirha wakho oyintloko ugqirha , ngokuqhelekileyo ugqirha weentsapho, umqeqeshi okanye umntwanantwana, uya kuba ngugqirha wakho oyintloko kwaye uya kulungelelanisa yonke yakho inkathalo. Ulwalamano lwakho kunye nogqirha wakho wokunakekela obalaseleyo lubaluleke kakhulu kwi-HMO. Qinisekisa ukuba ukhululekile kunye naye okanye wenze utshintsho. Unelungelo lokuzikhethela ugqirha wakho wokunyamekela ngokusisiseko xa ehlala kwinethiwekhi ye-HMO. Ukuba awuyikuzikhethela wena, u-insurer wakho uza kukunika enye.
2. Ugqirha wakho wokunyamekela ugqirha kufuneka akubhekiselele naluphina unyango olulodwa.
Unogqirha wakho oyintloko uyayenza isigqibo sokuba ngaba unayo yini enye intlobo yononophelo kwaye kufuneka wenze ukuthunyelwa kwakho ukuba uyifumane. Imizekelo ibona ingcali, ukufumana unyango lomzimba okanye ukufumana izixhobo zonyango ezifana nesihlalo sabakhubazekile. Ukufuna ukuhanjiswa kukuqinisekisa ukuba unyango, iimvavanyo kunye nenkathalo ekhethekileyo oyifumanayo imfuneko yempilo.
Ngaphandle kokudluliselwa, awunayo imvume kwezo nkonzo kwaye i-HMO ayiyi kubahlawula.
Inzuzo kule nkqubo kukuba izigulane zithola iinkonzo ezingekho mfuneko. Kodwa umonakalo kukuba izigulane kufuneka zibone abahlinzeki abaninzi (ugqirha wezempilo oyintloko kunye neengcali) kunye nokuhlawula ii-copay okanye enye ukwabelana ngeendleko kwintyelelo nganye.
3. Kufuneka usebenzise ababoneleli nge-network.
Yonke i-HMO ineloluhlu lwababoneleli benkonzo bezempilo abanomncedisi womncedisi wayo. Abo baboneleli bahlanganisa uluhlu oluninzi lweenkonzo zonyango olubandakanya oogqirha, iingcali, iifommine, izibhedlele, ii-lab, i-x-ray nezixhobo zeengcali. Ukuba ukhathalela ngaphandle kwe-network , i-HMO ayiyi kuhlawula; uya kubambelela ukuhlawula i-bill yakho ngokwakho .
Ukunyamekelwa ngengozi kokunxibelelana kweenethiwekhi kungenza iphutha elibi kakhulu xa unayo i-HMO. Gcwalisa i-prescription kwi-pharmacy ye-out-of-network okanye ufumane iimvavanyo zakho zegazi ezenziwe ngeprole engafanelekanga kwaye unokubambelela ngebhilidi yamakhulu okanye amawaka eedola.
Kuxanduva lwakho ukwazi ukuba ngabaphi ababoneleli abakwi-network kunye ne-HMO yakho. Oku akunzima kakhulu kwi-HMO njengoKaiser Permanente apho ababoneleli benethiwekhi bahlala kwisakhiwo esifanayo kwaye babone mntu kodwa izigulane zikaKaiser.
Kodwa, ukuba unayo i-HMO kunye ne-inshurensi njenge-United Healthcare, i-Aetna, okanye i-WellPoint, ababoneleli be-intanethi abayi kuhlala behlala kwindawo enye kwaye bavame ukubona izigulane ezingekho amalungu e-HMO. Awukwazi ukucinga ukuba, ngenxa yokuba lebhu ihla iholo kwiofisi yakho yegqirha, ukuba lebhu in-network kunye ne-HMO yakho. Kufuneka uhlole.
Kukho iintlobo ezintathu kwiimfuno zokuhlala kwi-network:
- Eziphuthumayo.
- I-HMO ayinawo umnikezeli wenethiwekhi yeenkonzo ezikhethekileyo. Oku kunqabile. Kodwa, ukuba kwenzeka ntoni kuwe, qulunqa kwangaphambili ukunyamekela okwenziwe ngaphandle kwenethiwekhi kunye ne-HMO- gcina i-HMO yakho.
- Uphakathi kwenkqubo eyinkimbinkimbi yonyango olukhethekileyo xa uba ilungu le-HMO, kwaye ingcali yakho ayiyiyo inxalenye ye-HMO. Uninzi lwe-HMOs lugqiba ukuba ngaba ungayigqiba inkqubo yokonyango kunye nogqirha wakho okhoyo kwimeko yeemeko.
4. Iimfuno zakho zokwabelana ngeendleko kwi-HMO zihlala ziphantsi.
Ulwabiwo lweendleko ezifana nokuncitshiswa , iipayili kunye ne- coinsurance kugcinwa ubuncinci kunye ne-HMO. Ezinye i-HMO ezixhaswe ngumqeshi azidingi nayiphi na i-deductible (okanye i-deductible encinci) kwaye idinga kuphela ikhoyayithi encinci kwezinye iinkonzo. Ngenxa yokwabelana kwabo ngeendleko eziphantsi kunye nama- premium aphantsi, ii-HMO zibhekwa njengenye yeyona nkcenkceshe yokhetho lwezempilo.
Nangona kunjalo, kwiimarike zempilo yomshuwalense, apho ama-7 ekhulwini labantu base-United States bafumene u-2016, ii-HMO zivame ukuba nezindleko eziphezulu kunye nezindleko zangaphandle. Kwamanye amazwe, izicwangciso kuphela ezifumaneka kwiimarike nganye zi-HMOs, kunye neentengo ezidityanisiweyo ezifikelela phezulu njengama-dollar angamawaka. Kwiindawo ezininzi, kukho ukukhetha okuncinane kwiimarike ngokwemiqathango yenethiwekhi (i- HMO, i-PPO, i-EPO, okanye i-POS ), ngokubhekiselele kumakethi axhaswe ngumqeshi, apho ukukhethwa kwenethiwekhi kunokuhlala kunamandla.
I-HMO kunye nezinye iintlobo zeeNtshumo zeMpilo
Zonke iintlobo ze-inshorensi yempilo yonyango (ezibandakanya yonke i-coverage yangasese e-US) zinezinto ezifanayo. Umzekelo, akukho cwangciso solawulo lwempilo yonakekelo luya kuhlawulela ukunakekelwa okungekho mfuneko yonyango, kwaye zonke izicwangciso zononophelo ezilawulwayo zineenkqubo ezikhoyo ukuze zibancede ukuba zibone ukuba yintoni inkathalo eyimfuneko yokwenza impilo, kwaye yintoni enonophelo.
Izicwangciso zokunyamekela eziphathekayo ezifana ne-PPOs, ii-EPO kunye ne-POS izicwangciso ziyahluka kwii-HMO ngeendlela ezininzi. Abanye baya kuhlawula ukhathalelo lwangaphandle kweenethiwekhi, kwaye abanye abayi kuthi (bonke kufuneka, ukuba ngokwenene unokwenzakala). Abanye banemfuno ephantsi yokwabelana ngeendleko ngelixa abanye banokudityaniswa kwezinto ezinobuncwane kwaye bafuna i-coinsurance ebalulekileyo. Abanye bafuna ugqirha wezonyango, kodwa abanye abayifuni.
Unokufunda okungakumbi malunga neentlukwano phakathi kweentlobo zeeplani zezempilo, i- HMO, i-PPO, i-EPO & i-POS-Yintoni eyahlukileyo kwaye yintoni eyona nto iphezulu?
> Imithombo:
> Kaiser Family Foundation. UmNyango weNtsholongwane wezeMpilo yoBonke abaLuntu 2016.
> K aiser Family Foundation. Ukubhaliswa kweHMO Iyonke. NgoJanuwari 2016.