I-HMO vs. PPO: Ukwazi umehluko ezinhlelweni zokunakekelwa kwezempilo

Inkampani

Ukukhetha uhlelo olufanele lomshuwalense wezempilo wena nomndeni wakho kungumsebenzi owesabekayo. Ngezindleko ezikhuphukayo zokunakekelwa kwezempilo, kungaba nzima ukulinganisela ukuthola uhlelo olungabizi kakhulu nohlelo olunikeza ukunakekelwa okuhle kakhulu. Isinyathelo sokuqala sokuthatha isinqumo ukuqonda ukuthi uhlelo ngalunye lusebenza kanjani. Kulesi sihloko, siqhathanisa izinhlobo ezimbili ezithandwayo zamapulani — i-HMO vs. PPO — bese sibheka izici ngalunye.

Yini i-HMO?

AnI-HMO, efushane nge-Health Maintenance Organisation, uhlobo lohlelo lwezempilo olusebenzisa odokotela bokunakekelwa okuyisisekelo (PCPs) ukusiza ukuxhumanisa ukunakekelwa kweziguli zabo. Basebenzisa inethiwekhi yodokotela, izibhedlela, nabanye abahlinzeki bezempilo. Uma ukhetha uhlelo lwe-HMO, ukhetha iPCP kunethiwekhi yabo. I-PCP yakho ivame ukuxhumanisa izinsizakalo zakho zezokwelapha ezidingekayo, inikeze ukuhanjiswa kokuhlolwa nokuvakashelwa ngochwepheshe benethiwekhi, futhi ngokujwayelekile ithola imibiko nemiphumela yokuhlolwa. Azivami ukumboza ukunakekelwa okungaphandle kwenethiwekhi, ngaphandle kwezimo eziphuthumayo.

Yini i-PPO?

I-PPO, emele i-Preferred Provider Organisation, uhlobo lohlelo lwezempilo olunenethiwekhi yodokotela, izibhedlela nabanye abahlinzeki bezempilo; noma kunjalo, banikela ngokuguquguquka okwengeziwe lapho befuna ukunakekelwa. Bayakhokhela ukunakekelwa kwezinye izinsizakalo zokunakekelwa kwezempilo ezingaphandle kwenethiwekhi, kepha bavame ukukwenza lokho ngezinga eliphansi futhi umuntu onomshwalense angabhekana nengxenye yezindleko sezizonke. Awudingi ukuthunyelwa ukuze ubone isazi.

I-HMO vs. PPO: Uyini umehluko?

Ngaphezu komehluko phakathi kwenethiwekhi nangaphandle kwenethiwekhi okuhambisana nama-HMO nama-PPO, kunezici ezahlukahlukene ezihambisana nezinkampani zomshuwalense wezempilo ngamunye. Okulandelayo kuqhathanisa ezinye izici.

Ama-PPO anamanethiwekhi amakhulu abahlinzeki

Womabili ama-HMO nama-PPO anenethiwekhi yodokotela, izibhedlela nabanye abahlinzeki bezempilo. Izindleko zakho zokuphuma ephaketheni zincane uma usebenzisa abahlinzeki bezokwelapha kule nethiwekhi.

Ama-HMOs adinga ukuthi ukhethe umhlinzeki wokunakekelwa okuyinhloko enkombeni yenethiwekhi. Lokhu kuvame ukubuyela emuva kakhulu ohlelweni — ukuthi uvame ukukhawulwa kunombolo yabahlinzeki. Ngokwengeziwe, kuzodingeka ukuthi ubone i-PCP ngaphambi kokubona ongoti. Okuhlukile okuvamile kuzidingo zokudlulisela ukunakekelwa kwabesifazane / kokubelethisa. Awudingi ukuthunyelwa ukuze ubone labodokotela, kepha kusadingeka ukuthi babe ngaphakathi kwenethiwekhi yakho yomhlinzeki.

Izinhlelo ze-PPO zinemikhawulo embalwa kunethiwekhi yabo yabahlinzeki. Unokuguquguquka okukhulu, futhi amanethiwekhi we-PPO ngokuvamile makhulu kunama-HMO. Abaningi abadingi ukuthi ukhethe udokotela wokunakekelwa okuyisisekelo lapho ubhalisela uhlelo, futhi bayakhokhela abanye ukunakekelwa ngaphandle kwenethiwekhi , imvamisa nge-copay ephakeme noma isilinganiso se-coinsurance. Ngokuvamile kunabanikezeli bezinikezeli, lapho i-tier 1 ingabahlinzeki bakho be-in-network, i-tier 2 ikhokhwe ngenani elincane (nangezindleko eziphakeme zabathengi), futhi i-tier 3 ikhokhwe ngezinga eliphansi kakhulu (nangezindleko eziphakeme kakhulu zabathengi).

Ama-HMO anezindleko eziphansi zokuphuma ephaketheni

Lapho unquma izindleko zakho zizonke zomshuwalense wezempilo, udinga ukufaka izindleko ezingaphandle kwezikhwama. Lokhu kufaka ama-premium, ama-deductibles, i-coinsurance, nama-copayments.

I-Premium

TO imali ekhokhwayo inani elibekiwe olikhokha ngenyanga ukuze ube nomshuwalense wezempilo noma ngabe uyisebenzisa kuleyo nyanga. Izinhlelo eziphansi ze-premium zivame ukudonswa okuphezulu futhi okuphambene nalokho. Uma unomshuwalense wezempilo ngomqashi wakho, leli nani kungenzeka ukuthi likhishwe emholweni wakho bese likhokhelwa umhlinzeki womshuwalense.

Ama-HMO ajwayele ukuba namaphrimiyamu aphansi kunama-PPO kepha umehluko kungenzeka ungabi mkhulu.

Iyadonswa

Imali edonswayo yonyaka yimalini okudingeka uyikhiphe ephaketheni ezindlekweni zokunakekelwa kwezempilo ezihlanganisiwe ngaphambi kokuba inkampani yomshuwalense ikhokhe izimangalo. Ungaba nemali ebanjwayo ehlukanisiwe yengxenye yezokwelapha nengxenye kadokotela yohlelo lwakho. Ukudonswa kwemali kungaba engxenyeni eyodwa yohlelo — njengokulaliswa esibhedlela noma imiyalelo - okufanele yaneliswe ngaphambi kokukhokha noma yiziphi izimangalo.

Ama-HMOs ngokuvamile anokudonswa okuphansi kunezinye izinhlobo zamasu, kufaka phakathi ama-PPO. Amanye ama-HMO awanawo ama-deductibles.

Coinsurance

Coinsurance kuyiphesenti lezindleko zokunakekelwa kwezokwelashwa obhekene nakho ukuzikhokha ngemuva kokuhlangabezana nokudonswa kwemali yakho. Isibonelo, uma unesiqiniseko semali engama-20% futhi uthola isikweletu sikadokotela esingu- $ 1,000, ubhekene ne- $ 200, futhi inkampani yomshuwalense izokhokha okusele.

Ama-HMOs ngokuvamile awanaso isiqinisekiso semali.

ICopay

I-copayment, noma i-copay , inani elibekiwe lemali oyikhokhayo lapho ubona udokotela noma uthola incwadi kadokotela; imvamisa iyahluka ngokuya ngensizakalo yokunakekelwa kwezempilo. Isibonelo, lapho uvakashela udokotela wakho wokunakekela oyinhloko, i-copay yakho ingaba ngama- $ 20; $ 40 onguchwepheshe; noma u- $ 250 wokuvakashelwa kwegumbi lezimo eziphuthumayo. Ama-copays kadokotela avame ukugoqelwa ngokususelwa kuzidakamizwa ezijwayelekile nezegama.

Ama-HMO ngokuvamile adinga ukukopishwa kokunakekelwa okungavimbeli futhi ama-PPO adinga amakhophi wezinsizakalo eziningi. Qaphela: Ama-Copays awasetshenziswanga ekubanjweni kwemali yonyaka.

Ubukhulu obuphuma ephaketheni

Ngokwengeziwe, kufanele wazi ngohlelo okuphezulu ephaketheni . Uma ufinyelela leli nani ngonyaka owodwa, inkampani yomshuwalense ikhokha izinsizakalo zakho ezihlanganisiwe ngo-100% engxenyeni esele yonyaka wekhalenda.

Zonke izinhlelo zemakethe zinemikhawulo engaphandle kwephaketheni. Okwe-2020 , umkhawulo ophuma ephaketheni ngu- $ 8,150 wabantu ngabanye kanye ne- $ 16,300 yemindeni.

Ukubuyisa: HMO vs. PPO
	I-HMO	I-PPO
Izindleko	Amaphrimiyamu asuselwa ezicini ezahlukahlukene, njengokuthi uhlala kuphi, iminyaka yakho, nokuthi unohlelo lomndeni yini. Ngokuvamile, amaphrimiyamu we-HMO aphansi kunezinye izinhlelo (ezinjenge-PPOs) ezikunikeza ukuguquguquka okungaphezulu. Ngokwengeziwe, ungakhokha imali encane ngokudonswa kwemali, ama-copay nemibhalo enikezwa ngama-HMO.	Amaprimiyamu e-PPO aphezulu kune-HMOs. Ubuye ukhokhele ngaphezulu izindleko ezingaphandle kwezikhwama ezinjengokudonswa kwemali nama-copay.
Inethiwekhi	Udinga ukuhlala kubanikezeli benethiwekhi ukuze wonge izindleko.	Unokuguquguquka kokuphuma kwenethiwekhi futhi uthole izindleko zokunakekelwa kwezempilo zimboziwe.
Ukudluliselwa	Uzodinga ukuthunyelwa ukuze ubone cishe nganoma yimuphi udokotela ongeyena udokotela wakho wokunakekela oyinhloko.	Awudingi ukuhanjiswa ukuze ubone abanye odokotela / ongoti.

Futhi Ingcono PPO HMO?

Ngokuya ngokuguquguquka kuma-PPO, abantu abaningi bakhetha lolu hlobo lwecebo. Amaphesenti angamashumi amane nane abasebenzi ababhalise kwi-PPO, kwathi abangu-19% babhalisa kwi-HMO, ngokusho kuka Inhlolovo Yezempilo Yomqashi ka-2019 . Kepha umbuzo ongcono ngothi, Yiluphi uhlobo lwecebo olungilungele kakhulu? Womabili ama-PPO nama-HMO anezinzuzo nokubi. Okukulungele kakhulu kuncike kuwe nasezidingweni zokunakekelwa kwezempilo zomndeni wakho.

Ngokuvamile, i-HMO ingaba nengqondo uma izindleko eziphansi zibaluleke kakhulu futhi awunankinga ngokusebenzisa i-PCP ukuphatha ukunakekelwa kwakho. Kodwa-ke, kufanele ubuyekeze izinsizakalo zenethiwekhi zohlelo kuqala, njengoba ezinye zingakhawulelwa. I-PPO ingahle ibe ngcono uma usuvele unodokotela noma iqembu lezokwelapha ofuna ukuligcina kodwa elingelona elenethiwekhi yakho yohlelo.

Imibuzo okufanele uyibuze uma ucubungula uhlelo lwe-HMO ifaka:

• Ngabe odokotela bami bakunethiwekhi ye-HMO? Uma kungenjalo, ngizimisele ukushintsha abahlinzeki?
• Ziyini izindleko zamaphrimiyamu nyangazonke?
• Ziyini izindleko ze-copay?
• Mina nomndeni wami siya kangaki kudokotela? Ngonyaka ojwayelekile, izindleko zami bezizoba yini?
• Ngabe ukhona emndenini wami onezimo ezibucayi zempilo noma odinga ukunakekelwa kwezempilo okubanzi?
• Ngabe ngizimisele ukuthola ukuhanjiswa lapho ngibona umhlinzeki wezokwelapha ngaphandle kwe-PCP yami?

Imibuzo okufanele uyibuze uma ucubungula uhlelo lwe-PPO ifaka phakathi:

• Ngabe odokotela bami bakunethiwekhi yohlelo? Uma kungenjalo, ingabe ngizimisele ukukhokha isiqinisekiso semali esiphezulu?
• Ingabe kukhona okudonswayo okunakekelwa ngaphandle kwenethiwekhi?
• Ziyini izindleko zamaphrimiyamu nyangazonke?
• Kungaba yini izindleko zokuvakasha kukadokotela ojwayelekile, ngokuya ngesilinganiso se-coinsurance?
• Ngingalinganisela izindleko zami zonyaka ezikhishwe ephaketheni?
• Ngabe kukhona umuntu emndenini wami onesimo sezokwelapha esisebenzelwa kahle abahlinzeki bezokwelapha abangaphandle kwe-Tier 1 noma esingabonanga ukuthi ngabe sibhalisiwe ku-HMO?

Yini ebiza kakhulu: i-HMO vs. PPO?

Ngokuvamile, ama-HMO anama-premium akhokhelwa nyanga zonke aphansi kunama-PPO, kodwa umehluko awubonakali ngaso sonke isikhathi. Ithebula elilandelayo linikezela ngokuqhathaniswa kwamaphrimiyamu aphakathi nenyanga nonyaka omshuwalense wezempilo onikezwa umqashi ngo-2019, ngokusho kwe Inhlolovo Yezokunakekelwa Kwezempilo Yomqashi Kaiser Permanente yango-2019 .

	I-HMO	I-PPO
Iphrimiyamu yanyanga zonke (engashadile)	$ 603	$ 640
Iphrimiyamu yanyanga zonke (umndeni)	$ 1,725	$ 1,807
Iphrimiyamu yonyaka (engashadile)	$ 7,238	$ 7,675
Iphrimiyamu yonyaka (umndeni)	$ 20,697	$ 21,683

Ishadi lisuselwe kusilinganiso sezwe lonke futhi alifaki lokho okunikelwa umqashi wakho. Ukukhishwa kwakho kwangempela kwabasebenzi kungahluka kakhulu kuhlobo ngalunye lwecebo. Umnyango wakho Wezabasebenzi ungakunika izibalo ezisuselwa kuzinhlelo ezinikelwe neminikelo yenkampani.

Kokubili i-Medicare nezinkampani eziningi zomshuwalense zinikela ngama-HMOs nama-PPOs. Uma ubona umhlinzeki wezokwelapha ongajwayelekile, hlola ukuthi ngabe uhlelo luhlanganisa yini lezi zinsizakalo. Abahlinzeki bezokwelapha okungezona ezendabuko bahlanganisa izidakamizwa, ama-acupuncturists, ama-reflexologists, kanye nabahlengikazi be-massage. Bheka ngokucophelela ukukhishwa bese ubale izindleko zokunakekelwa kwezempilo ngonyaka ojwayelekile ukuze usize ukunquma ukuthi yikuphi okulungele wena.

Usukulungele ukubhalisa?

Uma ungenayo umshuwalense ngomqashi wakho, ufuna ukuqala ezempilo.gov futhi ubone ukuthi yiziphi izinketho ezitholakalayo endaweni yangakini, kuchaza uMatt Woodley, umsunguli we creditinformative.com . Lapho, ungaqhathanisa izinketho, kufaka phakathi ama-HMO, ama-PPOs, ama-EPO [Izinhlangano Ezihlinzeka Ngabodwa], nezinhlelo zePOS [Point of Service]. Kufanele ubuyekeze ukufingqwa kwezinzuzo zohlelo ngalunye kanye nesethenjwa esiphambene nezidingo zakho zokwelashwa nezomndeni wakho. Kulabo abanamanethiwekhi, ungaqinisekisa ukuthi udokotela wakho oyinhloko usohlwini futhi, uma kungenjalo, ususe lelo hlelo uma ungafuni ukushintsha odokotela.

Akunandaba ukuthi ukhetha luphi uhlobo lohlelo, ngaphambi kokukhokhela incwadi kadokotela, hlola i-SingleCare ngamanani wendawo kanye nesigqebhezana. Uma usebenzisa i-SingleCare, imithi yakho ingaba ngaphansi kunalokho obuzokukhokha ngomshwalense .