Ukuqonda iMibutho yabanikezeli abakhethiweyo
Ngaba ucinga ngokusayinela iplani ye-inshurensi yezempilo ye-PPO? Qinisekisa ukuba iya kuhambelana neemfuno zakho ngokuqonda indlela isebenza ngayo. Ngaba usuvele ubhalise kwi-PPO? Ukuqonda indlela esebenza ngayo kuya kunceda usebenzise i- inshorensi yakho yempilo ngokufanelekileyo kwaye ugweme iimpazamo ezibiza.
Ukuqonda iiPPO
I-PPO imele intlangano yomnikeli okhethiweyo. IipPOs zineli gama kuba ziluhlu lwababoneleli bezempilo ezikhethayo ukuba zifumane unyango lwakho lwezempilo.
Ukuba ufumana unonophelo lwazo lwezempilo kulaba bahlinzeki abakhethiweyo, uhlawula ngaphantsi.
Ii-PPO zihlobo lolawulo lwe-inshorensi yempilo yonyango njengabantakwabo abakude, imibutho yokulondoloza impilo okanye ii-HMO. Zonke izicwangciso zempilo zononophelo ezilawulwayo zilawula malunga nendlela onokufumana ngayo impilo yakho. Ukuba awuhambanga imigaqo yocwangciso lokunyamekela, ungayikhokheli loo nkathalo, okanye uya kuhlawulwa ngokufanele ubeke inxalenye enkulu yeendleko zokunyamekela ngaphandle kwepokothini lakho.
Indlela yokuCwangciswa kweNkqubo yokuNakekelwa kwezeMpilo kuGcina iindleko phantsi
Zonke izicwangciso zempilo zononophelo ezilawulwayo zile mithetho ukuze kugcinwe iindleko zonyango kwi-check. Imigaqo ngokuqhelekileyo yenza oku kwindlela ezimbini ezibalulekileyo:
- Unciphisa iinkonzo zakho zokunakekelwa kwezempilo kuphela kwizinto eziyimfuneko zonyango okanye ezenza iindleko zonyango lakho linciphise ixesha elide, njengononophelo lokukhusela .
- Bayayinqanda ukuba ngubani okanye apho unokufumana khona iinkonzo zonyango, kwaye baxoxisana izaphulelo ezivela kubaboneleli bezempilo ovunyelwe ukufumana unyango lwezempilo.
Indlela iPPO isebenza ngayo
I-PPOs isebenza ngale ndlela ilandelayo:
- Uhlawula inxalenye; I-PPO ihlawula inxalenye.
I-PPO isebenzisa ukwabelana ngeendleko zokunceda ukugcina iindleko zokujonga. Xa ubona ugqirha okanye usebenzise iinkonzo zonyango, uhlawula inxalenye yeendleko zale nkonzo ngokwendlela yokuncitshiswa , ukuthengiswa kwemali kunye neefayili .
Ukwabelana ngeendleko luyinxalenye yenkqubo yePPO yokuqinisekisa ukuba ufuna ngokwenene iinkonzo zonyango olufumanayo. Xa kufuneka uhlawule into ekunyamekeleni kwakho, kunye ne-encayment encinci, awuvumelekanga ukuba ungasebenzise iinkonzo ezingenakunyulwa. Nangona kunjalo, ngokubonga kuMthetho woNonophelo olungabonakaliyo , i-PPO ayinakufuna nayiphi na ukwabelana ngeendleko kwiinkonzo zokukhusela.
Ukwabelana ngeendleko kunceda ukucutha iindleko zokunyamekela kwakho. Xa uhlawula ngakumbi kwiindleko zokunyamekela kwakho, i-PPO yakho ayihlawuli phantsi kwaye iyancinci ingagcina iindleko ze- premium zenyanga.
- Ukuba usebenzisa inethiwekhi ye-PPO yabanikezeli, uhlawula ngaphantsi.
Imida yePPO evela kuye okanye apho ungayifumana khona iinkonzo zonyango ngokusebenzisa inethiwekhi yabanikezeli benkonzo yezempilo kunye nabo baxoxise izaphulelo. Inethwekhi ye-PPO ayibandakanyi nje kuphela oogqirha, kodwa zonke iinkonzo ezinonophelo zokunakekelwa kwezempilo ezinjengama-lab, ii-x-ray izixhobo, oogqirha bezonyango, ababoneleli bezonyango, izibhedlele kunye namaziko otyando.
I-PPO inikeza inkuthazo yokuba unakekele kwiinkonzo zayo zababoneleli ngokukuhlawula iipayili okanye i-coinsurance ephezulu xa ufumana unonophelo lwenkonzo. Ngokomzekelo, unokufumana i-copay ye-$ 40 ukuze ubone umgqirha we- in-network , kodwa i-50% yepesenti yokuhlawuliswa kwemali ekuboneni ugqirha ongaphandle. Ukuba unogqirha ongaphandle kwintengiso uhlawula i-$ 250 kweso sikhenkethi, uya kuhlawula i-$ 125 endaweni ye-copay ye-$ 40 oya kuhlawulwa ngayo ukuba wayesebenzisa udokotela we-in-network.
Nangona kunjalo, nangona uhlawula ngakumbi xa usebenzisa abanikezeli bezempilo be-out-of-network , enye yezinto eziphambili ze-PPO kukuba, xa usebenzisa abanikezeli benethiwekhi ngaphandle, i-PPO ubuncinci incedisa into ejongene neendleko zezo nkonzo. Le ngenye yeendlela i-PPO ehluke ngayo kwi-HMO. I-HMO ayiyi kuhlawula nayiphi na into yokuba uyayikhathalela ngaphandle kwe-network.
- Kufuneka ufumane iinkonzo zangaphambili ezigunyazwe yi-PPO.
Enye yeendlela i-PPO iqinisekisa ukuba ihlawula kuphela iinkonzo zonyango eziyimfuneko ngokwenene kukufuna ukuba ufumane imvume phambi kokuba unemibuzo eninzi, iinkqubo okanye unyango. Ukuba awufumani imvume kwi-PPO yakho phambi kokuba unikwe iinkonzo, i-PPO ayiyi kuhlawula.
Ii-PPO zifani naziphi iimvavanyo, iinkqubo, iinkonzo kunye nezokwelapha ezifuna ukugunyazwa kwangaphambili, kodwa kufuneka usole ukuba uya kufuna ukugunyazwa kwangaphambili kwananto ebiza okanye nayiphi na into enokufezekiswa ngokuthe xaxa ngendlela eyahlukileyo. Ngokomzekelo, unako ukufumana imirhumo yezilwanyana ezindala ezizaliswe ngaphandle kokugunyazwa kwangaphambili kodwa kufuneka ufumane imvume yakho ye-PPO yegama elibizayo-igama lomhlaza ukuze uphathe imeko efanayo.
Xa wena okanye ugqirha wakho ebuza i-PPO kwisigunyaziso sangaphambili, i-PPO mhlawumbi iyafuna ukwazi ukuba kungani ufuna loo vavanyo, inkonzo okanye unyango. Ngokuzama ukuzama ukuqinisekisa ukuba unyanzelekile loo nkathalo, kwaye akukho ndlela engafanelekanga yokufeza injongo enye. Ngokomzekelo, xa ugqirha wakho wamazinyo ecela ugunyaziso lwangaphambi kokuhlinzwa, i-PPO yakho inokufuna ukuba uzame unyango lokuqala. Ukuba uzama unyango lomzimba kwaye aluyi kulungisa ingxaki, ngoko i-PPO ingahamba phambili kwaye igunyaze ukuhlinzwa kwakho kwedolo.
Umehluko phakathi kwe-PPO kunye nezinye iindidi ze-Inshorensi yempilo
Izicwangciso zokunyamekela eziphathekayo ezifana nee-HMO, imibutho ehlinzekwayo kuphela (ii-EPOs) kunye neeprogram zokunikwa kweenkonzo (POS) zihluke kwii-PPO kunye nakwezinye iindlela ngeendlela ezininzi. Abanye bahlawula ukunyamekela kwenethiwekhi; abanye a ba Abanye banokubelana ngeendleko ezincinci; abanye banokudityaniswa okukhulu kwaye bafuna i- coinsurance ebalulekileyo kunye ne-copays. Abanye bafuna ugqirha wokunakekelwa kweprayimari (PCP) ukuba usebenze njengomgcini wakho wesango, ekuvumela ukuba ufumane iinkonzo zonyango ngokudluliselwa kwi-PCP yakho; abanye abenzi. Ukongeza, ii-PPOs zibiza kakhulu ngenxa yokuba zinika inkululeko enkulu yokuzikhethela.
> Umthombo:
> Humana. I-HMO kunye ne-PPO: Nguwuphi na onelungelo kuwe? 2017.