Ukuqonda iZicwangciso zoNonophelo lwezeMpilo
Ngoonobumba abaninzi ukuba ulandelele, akumangalisi ukuba ungadideka malunga nokuba yintoni umahluko phakathi kwe-HMO, PPO, POS ne-EPO.
Indlela elula kakhulu yokuyiqonda kukuba ukungafani okuphambili kuzo zonke zezi ndlela zithintela okanye ziguqule amanxibelelwano abasebenzisayo. Ngokutshintshwa kweenkonzo zonyango kunye nokunakekelwa kwezempilo, icebo labaxhasi bajonga ukufumana iindlela zokunciphisa iindleko zabo kunye namalungu okucwangcisa, ngokugqithiseleyo inethiwekhi yabanikezeli, ixabiso elininzi liphumelele isicwangciso.
Yingakho kukho iindlela ezahlukeneyo, ukhetho lwakho lwe-inshorensi yezempilo luza kwenza umehluko kwiindleko kwaye ujwayelane nezikhetho kunokukunceda ufumane i-inshurensi yempilo efikelelekayo .
Siza kuhlolisisa yonke into malunga nokunyamekela okwangoku apha kunye nokucacisa amanqaku aphambili kwiziko ngalinye le-HMO, PPO, i-POS ne-EPO.
Yisiphi iSicwangciso soNonophelo lwezeMpilo?
IziCwangciso zoNyango lwezeMpilo ziintlobo zee-inshorensi zempilo zonyango ezavela ekupheleni kwekhulu lama-20. Izicwangciso zempilo zonyango zilawulwa ngumgaqo-nkqubo winshorensi yempilo kumalungu ngamnye eqela okanye kumqeshi. Iqela okanye umqeshi sisicwangciso somxhasi wecebo lokunyamekela. Isicwangciso sokunakekelwa kwempilo esilawulwayo siya kunceda abaxhamli (amalungu esicwangciso) ngokufumana amaxabiso amaninzi okanye iinshurensi zonyango eziphuculwayo kwi-network health provider.
Izicwangciso zonyango zempilo zilawulwa zizicwangciso zabaxhasi ukuba baxoxisane nezindleko ezincitshisiwe kubaphathi bezobhedlele, ababoneleli ngeenkonzo zonyango kunye noogqirha, ngokubandakanya nabo kwinethiwekhi.
Ziyimpembelelo efanelekileyo kwimveli yemveli-yeenkonzo okanye izibonelelo ze-inshorensi yezempilo ngenxa yokuba babelana ngeendleko zempilo phakathi kwabantu, kunye neenkqubo zabo ze-inshorensi kunye namalungu omnatha wokunakekela.
Ekubeni uMthetho we-HMO udluliselwe ngowe-1973, izicwangciso zokunyamekela ezilawulwayo zafumaneka kuma-America amaninzi ngasekupheleni kweminyaka yama-80 kwaye sele zithathwe njengeyona nto inqabileyo yenkampani ye-inshorensi yempilo e-United States.
Izicwangciso zonyango zempilo ziyahlukahluka kwizicwangciso zamasiko ngokuqhelekileyo ukuba ngamalungu amaninzi kufuneka akhethe "ugqirha wezonyango" ekunxibelelaneni koogqirha obonelelwe ngecebo lokuxhasa. Ukuba yinxalenye yentsebenziswano kuya kunika amalungu aphuhliso ithuba lokufikelela kwiinkonzo ezivela kubaboneleli benkonzo yezempilo kwinkonzo kumaxabiso atyunjiweyo anciphisa iindleko zesicwangciso.
Izibonelelo zoPhuhliso lwezeMpilo eziPhathiweyo: i-HMO, i-PPO okanye i-POS
Isiphakamiso sesicwangciso sonyango solawulo lwempilo sinika izibonelelo kubo bobabini abaceba kunye nabaxhasi.
- Izicwangciso zonyango lwempilo zilawulwa ngamaxabiso athatywayo kunye nokufikelela okuqinisekileyo kwiinkonzo zonyango
- Amalungu enethiwekhi yomncediso wezempilo azuza ngokusasazwa kwabaxumi
- Cwangcisa amaLungu anethuba elilula kuba xa basebenzisana nababoneleli kwintanethi, bayakuphepha ukufakela iphepha kumalungu enethiwekhi kunye nababoneleli ngeenkonzo zonyango baneenkqubo zokuhlawula. Isicwangciso se-HMO senza oku kulula.
Iintlobo ezahlukeneyo zoPhuhliso lwezeMpilo: i-HMO, i-PPO, i-POS, i-EPO ichazwe
Izicwangciso zempilo zonyango zilawulwa ngenye indlela kwizicwangciso zonyango zempilo ezinjengezicwangciso zokuhlawulwa kweenkonzo-ntlawulo.
Kwiminyaka embalwa edluleyo, izicwangciso zempilo zonyango zilawulwa yintengiso yonyango njengoko izindleko zempilo zonyuka. Uluhlu lwesicwangciso esilawulwayo oluya kubakhokelela ukuba uyifumana njani iinkonzo zakho zezokwelapha ukuze uzuze ukufunda ngabo kunye nendlela abasebenza ngayo.
- Umbutho wezoMpilo (HMO)
- Umbutho woMboneleli okhethiweyo (PPO)
- Isicwangciso seNkonzo (POS)
- I-Exclusive Provider Organisation (EPO)
Intshuwalense yezeMpilo: Ukuqonda ukungafani kwiCandelo loCwangciso loNonophelo loKhathalelo
Kukho iintlobo ezahlukeneyo zeminshurensi yempilo okanye iMicrosoft Insurance Plans. Ngelishwa, uninzi lwabantu alujongi kwiinketho zonyango ezitholakalayo kubo kuba ngezinye iinkalo ukungafani kubonakala kunzima kwaye kunokuba kunzima. Uninzi lwabantu lujolise kwizinto eziphambili ezifana ne-deductible, i- coinsurance okanye ukuzama ukuqonda imigomo yomshuwalense wezempilo .
Kubalulekile ukuqonda ukuba isicwangciso sakho se-inshurensi yokunakekelwa kwempilo yonyango sisebenza njani ukuze ukwazi ukuba lunjani ukulungelelanisa kwiinkonzo zezokwelapha sakho isicwangciso esiza kukuhlawulela kwisiganeko ofuna ukufumana unyango. I-HMO kunye ne-PPO zineenzuzo zabo kodwa kunjalo nezinye izicwangciso ezifana neziCwangciso ze-Intshumo zeMpilo ye-Indemnity , ezingaphathwa zizicwangciso ze-inshorensi zonyango. Ukuqonda ukungafani kunokuba luncedo xa uzama ukugqiba ukuba ngaba uya kuziqinisekisa kwisicwangciso sakho sempesheni yomqeshwa, okanye iqabane lakho okanye isicwangciso se-inshorensi yezempilo . Unokufunda okungakumbi malunga nalolu khetho ngokufunda malunga ne- inshorensi yezempilo okanye ucinge ngeenzuzo xa ufaka isicelo se -inshurensi yempilo ye-inshurensi yezempilo yomntu .
Inkcazo ye-HMO
I-Health Care Maintenance Organisation, okanye i-HMO, inikezela abaqeshi okanye amaqela indlela yokunyamekela bonke abasebenzi babo okanye amalungu amanyathelo okunakekelwa kwempilo ngokunciphisa iindleko ngokuthetha kunye noogqirha abathile, izibhedlele kunye neeklinikhi. Laba bahlinzeki abathile kufuneka basebenziswe ngumqeshwa ngeemali ezincitshiswayo eziza kubonelelwa kwi-inshuwalense yabo yonyango. Kwisicwangciso se-HMO, unobuncinane obunokuguquguquka kodwa mhlawumbi unokuba namava elula kumabango ekubeni inethiwekhi ithatha uxanduva lokufaka amabango kuwe.
Inkcazo yePPO
Umbutho oMenzi weMveliso, okanye i-PPO, unika izindleko ezincinci kumalungu akhokhelwa kwi-inshurensi yezempilo. Kuyafana ne-HMO, kodwa abasebenzi okanye amalungu angakhetha ukhetho lwabagqirha abafuna ukubona kunokuba lukhutshwe kuphela kubanikezeli be-HMO. Ilungu linokukhetha phakathi kwelungu okanye umnikezeli ongabonisi.
Inkcazo yePOS
Ngesicwangciso seNdawo yeNkonzo, okanye i-POS, amalungu angakhetha umgqirha oye wavuma ukunika iinkonzo ngemali ehlawulelwe. Kwi-POS ilungu liya kufuneka lisebenzise ugqirha okhethiweyo njengendlela yesango ngaphambi kokuba aqhubele phambili kwiingcali. Ngamanye amagama, naliphi na umqeshwa onokufumana ingxaki yezokwelapha, ugqirha we-POS kufuneka uqhagamshelane kuqala ukuze athole inzuzo enkulu kwi-inshuwalense yezempilo.
Inkcazo ye-EPO
Ngomncedisi we-Provider Exclusive, okanye i-EPO, umqeshwa okanye ilungu lesicwangciso angakhetha kubaboneleli ngaphakathi kwintanethi kwaye akufuneki ukuba asebenze kunye nodokotela oyintloko. Nangona kunjalo, nayiphi na inkonzo enziwe ngaphandle kwintanethi ayinakukhutshwa kuzo zonke.
Ixabiso lokuthelekiswa kwee-HMO ezahlukeneyo, i-PPO, i-POS, iSicwangciso seNkxaso yezempilo ye-EPO
Izicwangciso ezinokuguqulwa okukhulu kunokuba zibi kakhulu ngenxa yokungabikho kwezivumelwano zelungu leenethwekhi zangaphambili. Nangona iiplani zihluka kodwa inani lamalungu, inkampani yomshuwalense kunye nezinye iimeko, i-HMO ingaqhelekanga ibe yindleko ephantsi yokunyamekela, kunye ne-PPO ibe phakathi kwendlela, kwaye i-POS mhlawumbi iyabiza ngaphezu kwe-HMO , njengoko kunika ukuguquguquka okukhulu. Khumbula ukuba nangayiphi na imeko, ingakumbi nge-EPO xa ufumana iinkonzo ezingaphandle kweenethwekhi okanye izibhedlele zamalungu, unokuhlawula iindleko ngokupheleleyo ngaphandle kwepokothini. Kufuneka uhlale ubiza isicwangciso sakho phambi kokuba ubone umntu ongeyena unxibelelwano wenkonzo yezempilo ukuze aqiniseke ukuba awuyi kuhamba ngeyona ntlawulo.
Yiyiphi iCwangciso loNonophelo eliLawulayo eliPhambili? HMO, PPO, POS okanye EPO
Zonke izicwangciso zononophelo ezilawulwayo ziyahluka kakhulu kwiintlawulo nakwiindleko zeefolongo , ngoko kubalulekile ukuhlaziya i-inshorensi yakho yempilo kunye nekheshurensi yezokhetho ngobulumko kwaye uzama ukufumana umgaqo-nkqubo olungele ukulungelelanisa imeko zakho. Ukuba uthanda ukuba nogqirha oyintloko ugqithise ukunyamekela kwakho izicwangciso zeHMO zi nokuba yintoni ofunayo. Ukuba ubona ezininzi iingcali, kodwa abafuni ukuhlala behamba ngogqirha wokunyamekela okona-PPO okanye i-POS inokusebenza kangcono kuwe. Gcina ukhumbule ukuba ngenxa yokuguquguquka okukhulu kwePPO okanye i-POS izicwangciso zinokuba ziphezulu kwiindleko zeefolthi kwaye nanini na ukuya kwiingcaphephe okanye ufumana unonophelo lwonyango ngaphandle kwenethiwekhi, uya kuhlawula ngaphezulu.
IMicicaid kunye neMigangatho yokuNakekelwa kwezeMpilo
Njengoko iinkonzo zempilo kunye nezicwangciso zonyango zempilo ziye zavela, abanye bathi ngoku banikezela izicwangciso zokuNakekela eziPhathwa ngeMedicaid. Unokufunda okungakumbi malunga neprogram ye-Medicaid yelizwe kunye nokuba unika ukhetho lokunyamekela ngokuphathelana neofisi yakho yomshuwalense wekhoshurensi .