Kusho ukuthini ukuthi 'ukuphuma kwenethiwekhi'?

Ukuchazwa Kwezempilo Kenkampani

Uya kokuqokwa okujwayelekile kudokotela omusha futhi-BAM! Ushaywe yisikweletu esikhulu kunokulindelekile ngisho nangomshuwalense wakho wezempilo. Uthola ukuthi le ntengo ephezulu yingoba umhlinzeki wezokunakekelwa kwempilo omsebenzisile uphumile kunethiwekhi. Kodwa kusho ukuthini lokho? Ake sithole!

Kusho ukuthini ukuphuma kwenethiwekhi?

I-Out-of-network ichaza udokotela, isibhedlela, noma indawo yokunakekelwa kwezempilo engeyona ingxenye yenethiwekhi yomhlinzeki wenkampani yakho yomshuwalense wezempilo. Lokhu kusho ukuthi umshwalense wakho awuxoxisananga ngaphambili ngesilinganiso senethiwekhi nalowo dokotela, isibhedlela, noma isikhungo, futhi uzokhokhiswa amaphesenti amakhulu kunawo wonke wemali ekhokhwayo yezokwelapha noma kuyo yonke imali oyikhokhayo, kuye ngohlelo lwakho oluthile lwezempilo.

Zonke izinhlelo zezempilo eziphethwe zinenethiwekhi, kufaka phakathi I-Medicaid futhi Imithi .

Okunye ukushaywa okuvela ekusebenziseni umhlinzeki ongaphandle kwenethiwekhi ukuthi ngokuvamile lezi zindleko azisetshenziswanga ekukhishweni kwakho uma uhlelo lwakho lungazibandakanyi izindleko ezingaphandle kwenethiwekhi. Ngeke zibheke kubukhulu bakho obuphuma ephaketheni noma.

Ake sihlukanise lokhu uma siqhathanisa i-out-of-network ne-in-network.

In-network vs. ngaphandle kwenethiwekhi

Uma ubhalisela uhlelo lokunakekelwa kwezempilo, inkampani yomshuwalense ikunikeza uhlu lodokotela, izibhedlela nezindawo zokunakekelwa kwezempilo ku-inethiwekhi . Ukuvakashela abahlinzeki be-in-network bezinsizakalo zezempilo kuzosho amanani aphansi kusukela inkampani yomshuwalense nomhlinzeki bexoxisane ngamanani. Ngaphandle kokuthi inkampani yakho yomshuwalense inikeze isibonelelo esivulekile sangaphandle kwenethiwekhi, ukuvakashela abahlinzeki bangaphandle kwenethiwekhi kuzosho ukuthi izindleko zakho zokunakekelwa kwezokwelashwa zizokwenyuka njengoba inkampani yakho yomshuwalense izomboza okuncane noma lutho.

Isibonelo, ubona umhlinzeki wakho wokunakekela oyinhloko ngoba izono zakho zibuhlungu. Uyabheka futhi ancoma ukuthi ubone uchwepheshe. Imali ephelele yalolo hambo eya kudokotela ingama- $ 100. Njengoba eku-network, isephulelo sisetshenziswa kwisamba esiphelele njengoba umshwalense wakho uxoxe ngaphambilini ngesilinganiso nalowo dokotela. Ake sithi, inani elihlisiwe manje lingu- $ 80. Ungaba nesibopho sensalela yomthethosivivinywa esele ngokuya nge-coinsurance yakho kanye ne-copay.

Kodwa-ke, ngemuva kokwenza ucwaningo oluthile, uyabona ukuthi uchwepheshe otholakala kalula okudingeka umbone ungaphandle kwenethiwekhi. Unquma ukuthatha ingozi bese ubhuka i-aphoyintimenti. Emasontweni ambalwa ngemuva kokuvakashelwa, uthola isikweletu se- $ 250. Njengoba lochwepheshe wayengekho kwinethiwekhi, asikho isaphulelo esisetshenziswayo kumbhilidi wezokwelapha ophelele, futhi inkampani yakho yomshuwalense ihlanganisa okuncane, noma okubi kakhulu, akukho lutho ngoba umhlinzeki ubengaphandle kwenethiwekhi futhi ama-copay kanye ne-coinsurance ngeke sebenzisa.

Ukubona ngaphakathi nangaphandle kwenethiwekhi ukuqhathanisa endaweni yakho, lokhu wokubala kungasiza. Ngokuvamile kungcono ukusebenzisa umhlinzeki wezokunakekelwa kwezempilo oku-in-network, uma kungenzeka, ngoba izindleko zizobe ziphansi.

Kubalulekile futhi ukuthi wazi ukuthi kukhona umehluko okwejwayelekile wezindleko phakathi izinhlelo zomshuwalense wezempilo lapho usebenza ngezimali ezingaphakathi kwenethiwekhi nezangaphandle.

• I-PPO imele Inhlangano Yomhlinzeki Ekhethwayo. Lezi zinhlobo zamasu ngokuvamile zinikela ngezinzuzo ezingaphandle kwenethiwekhi — yize, azilungile njengezinzuzo ezikunethiwekhi. Inkampani yomshuwalense izosiza ukukhokha ingxenye ethile yomthethosivivinywa futhi cishe uzokhokha ingxenye enkulu yesibambiso semali.
• I-HMO kufushane ngeNhlangano Yokulondolozwa Kwezempilo. Lezi zinhlobo zamasu ngokuvamile azinikeli ngezinzuzo ezingaphandle kwenethiwekhi — okusho ukuthi kuzofanele ukhokhe zonke izindleko ezingaphandle kwenethiwekhi ezikhwameni.
• EPO (noma i-Exclusive Provider Organisation) uhlobo lohlelo lwezempilo olubhekela kuphela izinsizakalo eziku-network (ngaphandle kwesimo esiphuthumayo).
• POS (aka Point of Service) uhlelo oludinga abaninipholisi ukuthi badluliselwe kudokotela wabo wokunakekela okuyinhloko ukuze babone uchwepheshe. Uzokonga imali ngokusebenzisa abahlinzeki abakwi-network, kepha ngokungafani ne-HMO, ungathola ukunakekelwa kumhlinzeki ongaphandle kwenethiwekhi.

Okunye okuhlukile kuzindleko zenethiwekhi ngaphandle kwezinethiwekhi izinsizakalo eziphuthumayo. Izinkampani zomshuwalense azikwazi ukukuhlawulisa ngama-copayments aphezulu kanye ne-coinsurance uma udinga ukunakekelwa okuphuthumayo esibhedlela esingaphandle kwenethiwekhi. Akudingeki nokuthi uthole ukuvunywa kwangaphambili kwezinsizakalo zegumbi eliphuthumayo lodokotela nezibhedlela ezingaphandle kwenethiwekhi. Kodwa-ke, uma igumbi lokuphuthumayo elingaphandle kwenethiwekhi lingenayo inkontileka nenkampani yomshuwalense, akubophekile ukwamukela inkokhelo yabo njengenkokhelo ephelele. Uma bekhokha imali engaphansi kwemali ekhokhwayo yegumbi lezimo eziphuthumayo ezingaphandle kwenethiwekhi, igumbi labezimo eziphuthumayo lingathumela umthengi imali eseleyo yemali engakhokhiwe.

Ngenzenjani uma udokotela wami engekho kwinethiwekhi?

Ake sithi uvakashele udokotela wezifo zabesifazane ofanayo iminyaka eyi-10, kepha ngemuva kokuqala umsebenzi omusha nokushintsha umshwalense wakho, uba ngumhlinzeki ongaphandle kwenethiwekhi. Ungase ungakwazi ukumvakashela ngoba awukwazi ukukhokhela izindleko ezingeziwe zokunakekelwa kwezempilo.

Kungenzeka kube kushibhile ukushintshela kudokotela oku-network. Kodwa-ke, uma ungafuni ukushiya udokotela wakho wamanje, khuluma naye ukuze ubone ukuthi kukhona yini ongakhetha kukho. Abanye odokotela bavumela iziguli ukuthi zikhokhe inani lemali, elingabiza kakhulu kunalokho izinkampani zomshuwalense ezikunikezayo uma ziqhathaniswa nezintengo ezingaphandle kwenethiwekhi — kepha ngeke kubhekwe kubukhulu bakho obudonswayo noma obuphuma ephaketheni.

Ungacela futhi umshwalense wakho wezempilo ukunwetshwa kwegebe lenethiwekhi, lapho umshwalense wakho uzomboza udokotela sengathi bakwi-network. Kodwa-ke, lokhu kuvame ukunikezwa kuphela ngezimo ezikhethekile, njengokuthi akekho omunye udokotela kuleso sipesheli kuleyo ndawo, njengoba ilahlekelwa yimali yezinkampani zomshuwalense wezempilo.

Ezinye izindlela ezingaphandle kwenethiwekhi

Izinzuzo zokunakekelwa ngaphandle kwenethiwekhi zibiza kakhulu. Kwezinye izimo, kungangcono ukuthenga uhlelo olusha lomshuwalense ngokutholakala okungcono kwenethiwekhi ngesikhathi ukubhaliswa okuvulekile noma Isikhathi Esikhethekile Sokubhalisa semicimbi emikhulu yempilo.

Enye yezindlela ezilula zokwehlisa izindleko zokunakekelwa kwezempilo ukusebenzisa i-SingleCare ukuxhasa izindleko zemithi ngenkathi ungaphansi komshuwalense. Vele ufune umuthi wakho bese uthola ifayela le- amanani ashibhile atholakalayo , noma ngaphandle komshuwalense.