Yini i-HMO?

Ukuchazwa Kwezempilo Kenkampani

Ukwazi ukuthi yiluphi uhlelo lomshuwalense wezempilo okufanele ulukhethe kungaba yisinqumo esikhohlisayo. Akudingeki ukuthi ulinganise izindleko ngezidingo zakho zempilo kuphela, kepha kwesinye isikhathi imigomo nokunikezwayo kuyadida nje. Kwiphepha lethu le- Uchungechunge oluchaziwe lwezempilo , sizama ukudiliza lolu limi oluyinkimbinkimbi. Lapha, sixoxa ngohlelo lwezempilo olwaziwa nge-HMO.

Ngabe i-HMO imeleni? Kusho ukuthini?

I-HMO isichazamazwi senhlangano yokugcinwa kwezempilo. Luhlobo lwecebo lomshuwalense wezempilo elidinga ukuthi usebenzise kuphela abahlinzeki bezokunakekelwa kwezempilo abaphakathi kwenethiwekhi. Laba ngodokotela (kanye nezinye izinsizakalo zezokwelapha ezinjengamalebhu nezibhedlela) ezinenkontileka nohlelo lwakho lomshuwalense. Wena can iya kubahlinzeki abangaphandle kwenethiwekhi yakho ukuthola izinsizakalo zezokwelapha, kepha uhlelo lwe-HMO ngokuvamile ngeke lukhokhele izindleko ngaphandle kwalolo lwezokunakekelwa okuphuthumayo.

Kubalulekile ukuthi wazi ukuthi uma unezimo eziphuthumayo zezokwelapha, kufanele ufike esibhedlela esiseduze — noma ngabe i-HMO yakho isebenza nayo noma cha. Ngokuvumelana ne ezempilo.gov , zonke izinhlelo kufanele zikusize ukukhokhela ukunakekelwa okuphuthumayo, noma ngabe uya kudokotela noma esibhedlela ngaphakathi kwenethiwekhi yabahlinzeki be-HMO noma cha.

Ama-HMO asebenza njengezinhlelo zomshwalense wendabuko ngokuthi:

• khokha njalo ngenyanga imali ekhokhwayo (imali ephindaphindwayo yokuba nomshuwalense wezempilo), futhi
• kufanele ukhokhe ikopisha (setha imali oyikhokhiswa ngezinsizakalo ezinjengokuvakasha kukadokotela noma i-X-ray), imali ekhishwayo (inani odingeka ukuthi ulikhokhe minyaka yonke ngaphambi kokuba umshuwalense wakho wezempilo uqale ukukhokha izindleko), kanye ne-coinsurance (iphesenti lezindleko eziphelele zokunakekelwa ukhokha ngemuva kokuthi uhlangane nokudonswayo kwakho).

Ngokuvumelana ne ezempilo-science.org, Ama-HMO asedume kakhulu kunezinye izinhlelo eziningi zokunakekelwa kwezempilo e-United States selokhu uhulumeni ongumbuso we-Affordable Care Act (ACA) waqala ukusebenza ngo-2014. California Ihhovisi Lommeli Weziguli iphawula ukuthi cishe izakhamizi ezingama-50% zaseCalifornia zimbozwe ama-HMO.

Asebenza kanjani ama-HMO?

Uma ukhetha i-HMO yohlelo lwakho lomshuwalense wezempilo, kufanele ukhethe udokotela wokunakekelwa okuyisisekelo (i-PCP) ngaphakathi kwenethiwekhi yohlelo olungisa konke ukunakekelwa kwakho kwezokwelapha. (Uma udokotela obukade umsebenzisa engekho kunethiwekhi ye-HMO, kungadingeka ukuthi ukhethe okusha.) Lo dokotela uzonakekela izidingo zakho zokunakekelwa kwezempilo, njengokuhlolwa kwakho kwaminyaka yonke, ukugoma, kanye nokunye ukwelashwa okujwayelekile ukunakekelwa.

Uma une-Medicare, ungakhetha ukuthola uhlelo lomshuwalense wesitayela se-HMO ngohlelo lwe-Medicare Advantage (olwaziwa nangokuthi yi-Medicare Part C) -okuphikisana ne-Original Medicare, engasebenzisi inethiwekhi yodokotela.

Uma udinga ukubona uchwepheshe ngenkinga yezokwelapha-ngokwesibonelo, ungumgijimi odabule i-ACL-kuzofanele uthole ukuhanjiswa kusuka ku-PCP yakho kumhlinzeki oku-inethiwekhi. Uma uhamba ngaphandle kokudluliselwa, noma unquma ukubona umuntu ngaphandle kwenethiwekhi uma kungenasimo esiphuthumayo, ungahle ubhekane nazo zonke izindleko zokunakekelwa udokotela akunikeza khona. Ngaphezu kwalokho, abesifazane bavame ukuya kudokotela wokubelethisa / kwabesifazane wezifo zabesifazane abaphakathi kwenethiwekhi ukuze banakekelwe ngaphambi kokubeletha nabesifazane kahle ngaphandle kokudluliselwa futhi izinsizakalo zihlanganiswe. Kodwa noma kunjalo, ukuze ungabambeki ngokunakekelwa obucabanga ukuthi kumbozwe uhlelo lwakho lomshuwalense wezempilo, kubalulekile ukuthi ufunde imininingwane yohlelo lwakho lwe-HMO futhi uqonde kahle ukuthi iziphi izinsizakalo ozozibophezeleka ngazo uma ungaphuma kwinethiwekhi.

Kungani umuntu angakhetha i-HMO?

I-HMO iyindlela evimbela kakhulu yomshuwalense wezempilo njengoba ikhawulela odokotela abazobakhokha ngomshwalense. Uma ukhetha ukuphuma kwinethiwekhi, ungabambeka ngokukhokha zonke izindleko zalokho kunakekelwa. Kepha, ngasohlangothini oluhle, ngoba ukhawulelwe kakhulu, uvame ukukhokha kancane kuma-premium womshuwalense wezempilo wama-HMO uma kuqhathaniswa nezinye izinhlelo zezempilo. Lokho kungaba yisibusiso kumuntu omncane osemncane, onempilo othola ukunakekelwa kwezempilo kuphela ekunakekelweni kokuvikela, njengokuhlolwa minyaka yonke. Ngaphezu kwezindleko eziphansi zokuhlanganisa ezempilo, UKaiser Permanente uphawula ukuthi ezinye izinzuzo zama-HMOs yilezi:

• Izindleko eziphansi zemithi kadokotela, futhi
• Ukuba nodokotela oyedwa owazi izidingo zakho zezokwelapha futhi aqondise konke ukunakekelwa kwakho.

Lapho izindleko zibaluleke kakhulu kunokuguquguquka, i-HMO ingaba ukhetho olufanele lomshuwalense wezempilo kuwe.

Uyini umehluko phakathi kwe-HMO ne-PPO?

I-PPO ngesinye isifinyezo — lesi simele inhlangano enikelwayo yabahlinzeki. Izinhlelo ze-PPO zehlukile kunalezo ze-HMO ngoba zikuvumela ukuthi uphume kunethiwekhi uyonakekelwa ngaphandle kokudluliselwa futhi ngaphandle kokuthi ukhokhe izindleko ezigcwele uma wenza kanjalo. Awudingi ngisho nokukhetha udokotela wokunakekelwa okuyisisekelo. Ngenkathi uzokonga imali ngokuhlala nabahlinzeki benethiwekhi, i-PPO ngokujwayelekile izokhokhela okungenani okunye ukunakekelwa okungaphandle kwenethiwekhi okutholayo. Isibonelo, i-PPO yakho ingakhokha u-80% wesikweletu sakho sezokwelapha lapho uvakashela umhlinzeki okwinethiwekhi (futhi uzokhokha ama-20%). Kepha uma uphuma kunethiwekhi, ingahle ithathe kuphela ama-60% wezindleko-ikushiye wenze imfoloko ngaphezulu kwezindleko ezingama-40%. I-PPO iyindlela ekhangayo kubantu abathanda iqembu labo lodokotela futhi abangakhathazeki ngokukhokha imali ethe xaxa ngenkululeko yokukwazi ukufinyelela kubo lapho kudingeka. Uma une-Medicare, ama-PPO nawo ayatholakala ngaphansi kohlelo lwe-Medicare Advantage.

Ngemininingwane engaphezulu, funda i-athikili yethu ku- HMO vs. PPO .