Ogwiritsira ntchito a inshuwalansi adayambitsa mapulogalamu othandizira ngati mtengo wopulumutsa ndalama
Ambiri a ife timagwiritsa ntchito lingaliro lakuti mapulani a inshuwalansi yaumwini amapereka mafaneti. Ogulitsa inshuwalansi akukambirana ndi madokotala ndi zipatala zinazake kuti apange chithandizo cha ogulitsa, ndipo ogwira ntchito za malamulo ambiri ayenera kulandira chisamaliro kuchokera kwa omwe amagwiritsa ntchito intaneti (mapulani a anthu monga Medicaid ndi Medicare ali ndi othandizira omwe akugwira nawo ntchito; ambiri opereka nawo ntchito amagwira nawo Medicare, ndipo ngakhale kuti si monga ambiri amalandira Medicaid, madokotala ambiri amatenga Medicaid).
PPOs amalola odwala kuti awone othandizira kunja kwa intaneti, koma kutalika kwa mthumba kungakhale kokwera kusiyana ndi malire omwe amasungidwa pa-intaneti. PPOs imakhala kawiri kawiri pamsana pa chisamaliro chomwe chinatulutsidwa kunja kwa intaneti, ngakhale kuti zimakhala zofala kwambiri kwa PPOs kukhala ndi miyeso yopanda malire ya chisamaliro cha kusamalidwa kwa intaneti (mwachitsanzo, ngati mutatuluka kunja kwa intaneti , sipangakhale kapu momwe muyenera kulipilira gawo lanu la ndalama).
Ma HMO ndi EPO amafunika odwala kuti azigwiritsa ntchito pa intaneti komanso osasamala zachinsinsi pokhapokha ngati zovuta.
Tiered Networks
Mabungwe a Tiered akhala akuyang'anitsitsa dziko lonse mu kugwa kwa 2015 pamene Horizon Blue Cross Blue Shield inagwedezeka pamtunda wotchinga Omnia akukonzekera ku New Jersey. Ku Illinois, Dziko la Lincoln Health (a ACA-lopangidwa CO-OP) limagwiritsanso ntchito makina, ndipo amapezeka m'misika yamagulu ndi magulu m'madera ambiri.
Zowonadi, mautumiki apamtima amalola ogulitsa inshuwalansi zaumoyo kuti azitha kugwiritsa ntchito makina awo onse, ngakhale kuti amachepetsa kwambiri mamembala awo pamtunda waung'ono - koma chisankho chiri kwa wothandizira.
Pogwiritsa ntchito intaneti, mamembala amalipiritsa ndalama zowonongeka powona wothandizira pa webusaiti yapamwamba.
Iwo ali omasuka kuti awone othandizira m'munsi mwachonde, komabe iwo amalipira ndalama zowonjezera ngati atero.
Zomwe ACA imapereka zogwiritsira ntchito ndalama zowonjezera zimagwiranso ntchito ngati wodwalayo asankha kuona wothandizira amene ali pa intaneti koma osati pamtundu wapamwamba. Malinga ngati wothandizira ali mu intaneti, ndalama zomwe wodwalayo amafunika kuti azipindule nazo m'chaka sichidzadutsa malire a ACA (chifukwa cha 2016, $ 6,850 a munthu mmodzi, ndi $ 13,700 pamtundu umodzi, mu 2017 , idakwera kufika pa $ 7,150 kwa munthu mmodzi yekha ndi $ 14,300 kwa banja ).
Ndipo ndondomekoyi ingapangitse kuti chiwerengero cha operekera chithandizo chikhale chokwanira. (Apa pali chitsanzo kuchokera ku Horizon Blue Cross Blue Shield ku New Jersey - mosasamala kanthu kuti odwala amagwiritsa ntchito othandizira awiri kapena awiri, chaka chokwanira chaka chonse chimakhala chimodzimodzi).
Koma odwala omwe amasankha anthu opanga mapepala apamwamba amapereka ndalama zochepa pokhapokha nthawi zonse chisamaliro chimalandiridwa (Mwachitsanzo, $ 15 copay kuti adziwe dokotala mmalo mwa $ 30, kapena copay kuti adziwe dokotala mmalo mwake kulipira deductible ndi coinsurance, kapena palibe deductible m'malo $ 2,500 deductible). Kwa odwala omwe samaliza kukwaniritsa mapulani omwe ali kunja kwa chaka, pali zolimbikitsa kwambiri kuti agwiritse ntchito madokotala ndi zipatala pamlingo wapamwamba wa intaneti.
Tiered Networks Sizatsopano
Mabungwe a Tieredo si atsopano - iwo adayambitsanso ACA ndipo akhala akupanga njira zambiri zothandizira kuthetsa kukwera mtengo. Ndondomeko ya Horizon BCBS ya Omnia ku New Jersey ili pafupi mtengo wa 15% kusiyana ndi momwe zolinga za Horizon zinalinganirana mu 2015 zomwe sizinagwiritse ntchito mautumiki ena. N'zosadabwitsa kuti mapepala apansi pamakonzedwe apakompyuta amakhala okongola kwa ogula ndi olemba ntchito.
Kusankha Ena
Ogwiritsira ntchito zaumoyo angagwiritse ntchito masitriyiti osiyanasiyana kuti adziwe madokotala ndi zipatala zomwe zimatha kumapeto. Kawirikawiri, makampani amagwiritsidwa ntchito moyenera, komanso amatha kulandira malipiro ochepa kuchokera kwa ogulitsa inshuwalansi, pochita malonda kuti atha kulandira voliyumu yapamwamba ngati wopereka ndalama.
Koma pangakhale kutsutsana pamene sakudziwa bwino zomwe othandizira mavitamini amagwiritsa ntchito kuti adziwe madokotala ndi zipatala ziti zomwe zidzathera kumapeto kwake. Ku New Jersey, olemba malamulo aphatikizidwa, ndipo pali malamulo angapo omwe athandizidwa kuti athetse mavuto awo ndi kuwonekera momveka bwino momwe anthu operekera apatsidwira ntchito. Gawo la zipatala za boma linafika pawiri (mwachitsanzo, gawo losakondera) pansi pa makina opangidwa ndi Horizon BCBS a Omnia, ndipo sakumvetsetsa nazo.
Olemba malamulo ndi ogulitsa malonda akudandaula kuti zipatala mwa anthu omwe sali okondedwa omwe angakonde akhoza kuthetsa mavuto a zachuma chifukwa cha kuchepa kwa voliyumu ya voliyumu (popeza odwala amasankha chipatala chimodzi kuti agwiritse ntchito ndalama zochepa zomwe zili kunja) , ndipo izi zikhoza kuvulaza ogulitsa omwe amakhala pafupi ndi zipatala ziwirizi - makamaka pamene zipatala zomwe zili pambaliyi ndizipatala zotetezeka zomwe zimawona odwala ambiri omwe alibe ndalama komanso osalimbikitsidwa.