Yini i-PPO?

Ukuchazwa Kwezempilo Kenkampani

Uma kukhulunywa ngomshuwalense wezempilo, akukho ukushoda kwama-acronyms namagama angajwayelekile adingekayo ukuqonda ukuthi ukumbozwa kwezempilo kusebenza kanjani. Ngabe unayo noma ucabanga ukubhalisela i-PPO? Funda ukuthi kuyini, noma ngabe kuyinketho ekufanele, nokuthi ungazi kanjani ukuthi usunayo yini.

Yini i-PPO?

I-PPO uhlobo lohlelo lomshuwalense wezempilo. Imele inhlangano yomhlinzeki ekhethwayo. Ngama-PPOs, ukhokha kancane uma ubona umhlinzeki okwinethiwekhi yenkampani yakho yomshuwalense — leyo yingxenye oyithandayo. I-PPO yakho isivele ixoxisane ngesilinganiso esithile sezinsizakalo zokunakekelwa kwezempilo ezinikezwa yilaba bahlinzeki benethiwekhi.

Uyakwazi futhi ukubona abahlinzeki abaningi ngaphandle kwenethiwekhi ye-PPO yokunakekelwa kwezokwelapha. Kodwa-ke, ngokujwayelekile uzokhokha kakhulu abahlinzeki abangaphandle kwenethiwekhi nezinsizakalo zezokwelapha. Lokho kungenxa yokuthi asikho isivumelwano okuvunyelwene ngaso sezilinganiso ezisemthethweni phakathi kwe umhlinzeki ongaphandle kwenethiwekhi necebo lakho.

Kungani umuntu engakhetha i-PPO kune-HMO?

Ama-PPO angenye yezinhlobo ezithandwa kakhulu ezinhlelweni zomshuwalense wezempilo ngenxa yokuguquguquka kwazo. Nge-PPO, ungavakashela noma yimuphi umhlinzeki wezokunakekelwa kwezempilo ongathanda, kufaka phakathi ongoti, ngaphandle kokuthola ukuthunyelwa kudokotela wokunakekelwa okuyisisekelo (i-PCP) kuqala. Lokho kungasiza uma ungekho eduze kukadokotela okwinethiwekhi yakho yomhlinzeki, njengalapho usohambweni, noma uma usuvele unethimba lochwepheshe bezokunakekelwa kwezempilo onethezekile nabo, noma ngabe bengaphandle kwenethiwekhi.

Izinzuzo ze-PPO zifaka phakathi ithuba lokukwazi ukukhetha udokotela kanye nochwepheshe owufunayo ngaphandle kokuya kudokotela oyinhloko ekuqaleni, kuchaza I-Yuna Rapoport , MD, MPH, udokotela wezifo zamehlo eManhattan Eye eNew York City. Lokhu kubeka isiguli esihlalweni somshayeli.

PPO vs. HMO

Ama-PPO akuyona inketho yakho kuphela, kunjalo. Olunye uhlobo olujwayelekile lwecebo lomshuwalense wezempilo yi-HMO, noma inhlangano yokulondolozwa kwezempilo. Izinhlelo ze-HMO zinokwehluka okumbalwa okubalulekile kuma-PPO okungathinta ukukhetha kwakho kwenkampani yomshuwalense wezempilo.

Nge-HMO, imvamisa kufanele udlule kwi-PCP yakho ukuze udluliselwe ukuze ubone uchwepheshe okwinethiwekhi. I-HMO yakho nayo ngeke ihlanganise ukuvakashelwa kwabahlinzeki abangaphandle kwenethiwekhi ngaphandle kokuthi kuyisimo esiphuthumayo sangempela kwezokwelapha, futhi noma kunjalo, kungenzeka ukuthi uyingxenye yengxenye yomthethosivivinywa.

Kodwa-ke, uDkt Rapoport uthi kungaba nenani ezinhlelweni ze-HMO zeziguli. Inzuzo yama-HMOs isuka kumbono osuselwe ezinhlelweni, usho kanjalo. Ngokugcina ubudlelwano obusondelene nodokotela oyinhloko, kuncane ukuvakashelwa okungadingekile kochwepheshe, ukucabanga okuncane, nokuhlolwa okumbalwa kokuxilongwa. Imiphumela iyaqhathaniswa noma ingcono kune-PPO, futhi iziguli zinabo bonke odokotela babo abanconywe uhlelo.

Ngenkathi ukuthola ukudluliselwa ngaphambi kokubona uchwepheshe kungaba yibuhlungu, kusho nokuthi i-PCP yakho ibandakanyeka empilweni yakho ngendlela yokuthi kwesinye isikhathi odokotela abakwi-PPO bengekho, bakusize uhlanganise ukunakekelwa ngendlela efanele.

Ukuqhathanisa izindleko

Futhi-ke, awukwazi ukukhuluma ngomshuwalense wezempilo futhi ungasho izindleko eziphuma ephaketheni. Amanethiwekhi we-PPO ngokuvamile anezinga eliphakeme amaphrimiyamu , ama-copayments , futhi imali ekhishwayo yonyaka kunama-HMO ngokubuyisela ukuguquguquka okwengeziwe. Uma ubona umhlinzeki ongaphandle kwenethiwekhi, kungadingeka ukhokhe izindleko ngaphambili bese ufaka isimangalo sokubuyiselwa ingxenye. Uma ukwazisa ukuguquguquka futhi ungakhathali ukukukhokhela okuningi, i-PPO ingaba yindlela efanele yokunakekelwa kwezempilo kuwe.

Izindleko zokunakekelwa kwezempilo ngamanethiwekhi we-HMO ngokuvamile ashibhile ngokuphelele. Uzoba namaphrimiyamu aphansi kanye nama-copay ngokushintshanisa ngokusebenzisa i-PCP ukuxhumanisa ukunakekelwa kwakho kwezempilo. Kodwa-ke, ngokuvamile awukwazi ukubona abahlinzeki abangaphandle kwenethiwekhi abane-HMO. Uma wenza kanjalo, uzoba nesibopho sezindleko eziphelele.

OKUSHIWO: HMO vs. PPO

Ngokwengeziwe, ungacabanga ngohlelo oluphakeme lwezempilo oludonswayo (i-HDHP), inhlangano ekhethekile yokuhlinzeka (i-EPO), noma iphuzu lohlelo lwensizakalo (POS).

Ngazi kanjani ukuthi ngine-PPO?

Uzibuza ukuthi unaluphi uhlobo lomshuwalense wezempilo onawo? Imvamisa isho njalo ngemuva kwekhadi lakho lomshuwalense. Ikhadi lakho lingahle lichaze nokuthi uzokhokha malini kuma-copay ngokuvakashelwa odokotela. Ukushayela ucingo ngokushesha umhlinzeki wakho noma ukungena ku-akhawunti yakho eku-inthanethi nakho kunganikeza ukucaca okuthile.

Uma ungenayo i-PPO kakade futhi ufuna ukushintshela kuyo, kuzodingeka uyenze ngesikhathi ukubhaliswa okuvulekile —Imvamisa, kepha hhayi ngaso sonke isikhathi, ngoNovemba noma ngoDisemba — ngaphandle kokuthi uthole i- umcimbi wempilo ofanelekile . Imicimbi efanelekayo ifaka phakathiukuthuthela ku-zip code entsha noma esifundeni, ukushada, noma ukuthola umntwana.

Izinhlelo ze-PPO zingatholakala ngomqashi wakho, imakethe yezwe lakho (uma ikhona), noma indawo yemakethe yenhlangano. Indawo engcono ongayiqala ngalolu khetho ise-carecare.gov.

I-Medicare ibuye inikeze nge Inketho ye-PPO (phakathi kwe-HMO nezinye izinketho) ngaphansi kwe-Medicare Advantage (Ingxenye C) uma uneminyaka engama-65 noma ngaphezulu futhi ufanelekile. Okuthile okufanele ukukhumbule lapho ucubungula uhlelo lwe-PPO yilokho ama-akhawunti okonga ezempilo (ama-HSA) nama-akhawunti wokonga aguquguqukayo (ama-FSA) , kanye nezinto ezifana nekhadi lakho le-SingleCare, kungasiza futhi ekwehliseni izindleko zokunakekelwa kwakho kwezokwelashwa kanye nemiyalo oyinikezwa.