Yintoni i-HMO?

Inkampani yezeMpilo ichaziwe

Ukwazi ukuba sisiphi na isicwangciso seinshurensi yezempilo esinokuthi sikhethe kunokuba sisigqibo esikhohlisayo. Ayisiyiyo kuphela ukuba kufuneka ulinganise iindleko ngeemfuno zakho zempilo, kodwa ngamanye amaxesha imigaqo kunye neminikelo iyadida ngokucacileyo. Kwiphepha lethu Uthotho lwempilo echaziweyo , sizama ukwaphula olu lwimi luyinkimbinkimbi. Apha, sixoxa ngesicwangciso sezempilo esaziwa njenge-HMO.

I-HMO imele ntoni? Ingaba ithetha ntoni?

I-HMO sisifinyezo sombutho wolondolozo lwezempilo. Luhlobo lwesicwangciso seinshurensi yezempilo efuna ukuba usebenzise kuphela abanikezeli beenkonzo zononophelo lwempilo kwinethiwekhi. Aba ngoogqirha (kunye nezinye iinkonzo zonyango ezinje ngeelebhu nezibhedlele) ezinesivumelwano nesicwangciso sakho seinshurensi. Wena unako yiya kubanikezeli ngaphandle kwenethiwekhi yakho yeenkonzo zonyango, kodwa isicwangciso se-HMO ngokwesiqhelo asizukuhlawula iindleko ngaphandle kokuba kukhathalelo olungxamisekileyo.

Kubalulekile ukuba uqaphele ukuba ukuba unonyango olungxamisekileyo, kuya kufuneka uye kwisibhedlele esikufutshane-nokuba i-HMO yakho ikhontrakthi nayo. Ngoku ka kwezempilo.gov , Zonke izicwangciso kufuneka zikuncede uhlawule ukhathalelo olungxamisekileyo, nokuba uya kugqirha okanye esibhedlele ngaphakathi kwenethiwekhi ye-HMO yabanikezeli okanye hayi.

Ii-HMOs zisebenza njengezicwangciso zeinshurensi yezempilo ngendlela yokuba:

• Hlawula ngenyanga ipremiyamu (umrhumo ophinda ubenayo i-inshurensi yezempilo), kunye
• kufuneka uhlawule ikopi (setha iifizi ohlawuliswa iinkonzo ezinje ngotyelelo lukagqirha okanye i-X-reyi), izinxibo ezitsalwayo (imali ekufuneka uyihlawule minyaka le ngaphambi kokuba i-inshurensi yezempilo iqale ukugubungela iindleko), kunye noqinisekiso lwemali (ipesenti yeendleko zizonke zononophelo Uhlawula emva kokuba udibene nokutsalwa kwakho).

Ngoku ka eyezempilo.org, Ii-HMO ziye zaduma ngakumbi kunezinye izicwangciso zokhathalelo lwempilo e-United States okoko urhulumente we-Federal Affordable Care Act (ACA) waqala ukusebenza ngo-2014. IOfisi yaseCalifornia yeGqwetha loMonde Qaphela ukuba phantse ama-50% abahlali baseCalifornia bagqunywe zii-HMOs.

Zisebenza njani ii-HMOs?

Xa ukhetha i-HMO yesicwangciso seinshurensi yakho yezempilo, kuya kufuneka ukhethe ugqirha wokhathalelo oluphambili (i-PCP) ngaphakathi kwenethiwekhi yesicwangciso oya kuthi emva koko alungelelanise lonke unyango lwakho. (Ukuba ugqirha obumsebenzisa akakho kwinethiwekhi ye-HMO, kuya kufuneka ukhethe entsha.) Lo gqirha uya kukhathalela iimfuno zakho zokhathalelo lwempilo, njengokuhlolwa kwakho konyaka, ugonyo, kunye nolunye unyango oluqhelekileyo inkathalo.

Ukuba unayo i-Medicare, unokukhetha ukufumana isicwangciso se-inshurensi yohlobo lwe-HMO ngenkqubo ye-Medicare Advantage (ekwabizwa ngokuba yi-Medicare Part C) -okuchasene ne-Original Medicare, engasebenzisi nethiwekhi yoogqirha.

Ukuba ufuna ukubona ingcali yengxaki yonyango-umzekelo, uyimbaleki ekrazule i-ACL-kuya kufuneka ufumane ukuthunyelwa kwi-PCP yakho kumboneleli wenethiwekhi. Ukuba uhamba ngaphandle kokuthunyelwa, okanye uthathe isigqibo sokubona umntu ngaphandle kwenethiwekhi xa ingongxamiseko, unokuba noxanduva lwazo zonke iindleko zokhathalelo akunikeza ugqirha. Ukongeza, abasetyhini banokuthi baye kugqirha wabakhulelweyo / ugqirha wababhinqileyo kukhathalelo lwaphambi kokubeleka kunye nolwabasetyhini ngaphandle kokuthunyelwa kwaye iinkonzo ziyagutyungelwa. Kodwa okwangoku, ukuze ungabambeki kukhathalelo ocinga ukuba lwalugutyungelwe sisicwangciso seinshurensi yakho yezempilo, kubalulekile ukuba ufunde iinkcukacha zesicwangciso sakho se-HMO kwaye uqonde ngokuthe ngqo ukuba zeziphi iinkonzo oza kubanjelwa uxanduva lokuba ungaphuma kwinethiwekhi.

Kutheni le nto umntu enokukhetha i-HMO?

I-HMO yindlela yokuthintela i-inshurensi yezempilo njengoko inyanzelisa oogqirha abaza kuyihlawula ngeinshurensi. Ukuba ukhetha ukuphuma kwinethiwekhi, ungabambeka ekuhlawuleni zonke iindleko zolo khathalelo. Kodwa, kwicala lokudibanisa, ngenxa yokuba unqongophele, uhlawula ngokubanzi kwiipremiyamu zeinshurensi yezempilo yee-HMO xa kuthelekiswa nezinye izicwangciso zezempilo. Leyo inokuba luncedo kumntu omncinci osempilweni, ofikelela kuphela kukhathalelo lwempilo kukhathalelo lothintelo, njengokuhlolwa konyaka. Ukongeza kwiindleko zempilo esezantsi, UKaiser Permanente Qaphela ukuba ezinye zezibonelelo ze-HMO zezi:

• Ixabiso eliphantsi kumayeza kagqirha, kunye
• Ukuba nogqirha omnye owaziyo iimfuno zakho zonyango kwaye aququzelele lonke ukhathalelo lwakho.

Xa iindleko zibaluleke ngaphezu kokuguquguquka, i-HMO ingaba yinto efanelekileyo yokukhetha i-inshurensi yezempilo.

Nguwuphi umahluko phakathi kwe-HMO ne-PPO?

I-PPO sesinye isifinyezo-esi simele umbutho womboneleli okhethiweyo. Izicwangciso ze-PPO zahlukile kwii-HMO kuba zikuvumela ukuba uphume kwinethiwekhi ukhathalelo ngaphandle kokuthunyelwa kwaye ngaphandle kokuhlawula iindleko ezipheleleyo xa usenza njalo. Nokuba awudingi ukukhetha ugqirha wokhathalelo oluphambili. Ngelixa uza kugcina imali uhlala kunye nabanikezeli benethiwekhi, i-PPO iya kuthi ihlawule ngokubanzi ubuncinci benkathalo engaphandle kwenethiwekhi oyifumanayo. Umzekelo, i-PPO yakho ingahlawula i-80% yetyala lakho lonyango xa undwendwela umboneleli we-in-network (kwaye uya kuhlawula i-20%). Kodwa xa uphuma kwinethiwekhi, inokuthabatha kuphela iipesenti ezingama-60 zeendleko-ikushiye wenze ifolokhwe ngaphezulu kwexabiso lama-40%. I-PPO lukhetho olunomtsalane kubantu abathanda iqela labo loogqirha kwaye bangakhathali ukuhlawula ngaphezulu inkululeko yokubanakho ukufikelela kuzo xa kufuneka. Ukuba unayo i-Medicare, ii-PPO zikwakhona phantsi kwenkqubo ye-Medicare Advantage.

Ngolwazi oluthe kratya, funda inqaku lethu ku HMO vs. PPO .