‘Kugunda kwenikweni’: kutsiriza dongosolo la inshuwaransi yaumoyo ya anthu opuma pantchito | WIBQ Talking Station

Champaign County, Illinois (WCIA) – “Ndikuwona ngati uku ndi kumenya kwenikweni kwa aphunzitsi,” mphunzitsi wopuma wa Paxton-Buckley-Luda Vicki Judd adayankha nkhani Lolemba kuti Aetna Medicare Advantage ikhala njira yokhayo ya inshuwaransi yazaumoyo. pafupifupi 140,000 ogwira ntchito m’boma Anapuma pantchito kwa zaka zisanu kapena kuposerapo. Ndi zotsatira zomwe akuluakulu ku Champaign ndi zigawo zozungulira akhala akuchita mantha kwa miyezi ingapo.

United HealthCare, kampani yomwe m’mbuyomu idagwira PPO yomwe Aetna adzalowa pa Januware 1, yachita apilo chigamulo chomwe bungwe la Illinois Central Management Services (CMS) linapanga mu Julayi. Ofesi yayikulu yogula zinthu m’boma idakana ziwonetserozi, ndipo CMS idatsimikiza Lachisanu kumapeto.

M’mbuyomu, panali makampani angapo oti opuma pantchito aboma asankhe, koma awa akuyembekezeka kutha kumapeto kwa chaka. Aetna adzakhala yekhayo inshuwaransi pambuyo pogulitsa boma pa dongosolo la PPO (Preferred Provider Organisation) lomwe kampaniyo sinaperekepo kale ku Illinois.

Oimira ochokera ku Aetna ndi boma anali ndi chidaliro kuti ndondomeko yomwe ikubwerayi idzatha kupereka chithandizo chokwanira cha madokotala malinga ndi malamulo a federal network adequacy.

Mamembala ena apano a Aetna anali okayikira kwambiri.

“Ndiye ndidakali wokhumudwa,” Good adayamba kuyankhulana Lolemba m’mawa. “Sizimakupatsani mwayi uliwonse wachitetezo.”

Tinakumana koyamba ndi mphunzitsi wopuma pantchito mu March. Kwa zaka zambiri, wakhala akulembetsa mu Total Retiree Advantage Illinois Medicare Advantage (TRAIL MAPD) ​​Prescription Drug Program. Zabwino pamalingaliro apano a Aetna omwe adapanga mgwirizano ndi boma la Medicare HMO.

Iye wakhala akuvutika kuti apeze madokotala ambiri omwe angapangidwe pansi pa ndondomeko yake kuyambira kumayambiriro kwa chaka chino pamene mapulani a Aetna Medicare anasiya kuvomerezedwa ku Carle Health maofesi mkati mwa ola la Champaign, kuphatikizapo maukonde a madokotala oposa 500.

“Ndikuda nkhawa ndi Aetna,” adatero. “Amapangitsa kuti ziwoneke ngati ali ndi anthu onsewa kuti atithandize, madokotala onsewa omwe angathe kutithandiza. Komabe, pamene mukuyesera kupeza chinachake, sichikuwoneka ngati chikuwoneka pamwamba.”

Masiku ano, Judd akufufuza kufunikira kwa maopaleshoni angapo a manja a carpal tunnel, kuphatikiza m’malo mwake. Zonse zomwe zili pamwambazi zimafuna dokotala wa opaleshoni yamanja, mtundu wina wa katswiri wa mafupa.

“[My primary care doctor] Iye anati, “Ndikudziwa zabwino za Carl, koma simungathe kupita ku Carl chifukwa, mukudziwa, chifukwa muli ndi Aetna,” anafotokoza. “Ndiye akunditumiza ku Springfield.”

Pakadali pano, Good adati adalumikizana ndi Aetna kuti awone ngati pali njira zina zapafupi. Woimirayo adamutumizira pa foni mndandanda wa madokotala 27.

Atatu oyambirira anali akatswiri amtundu wolakwika, katswiri wa msana, katswiri wa chiuno ndi mawondo, ndipo winayo anali kuthana ndi mapewa ndi mawondo okha.

“Kenako 1, 2, 3, 4, 5 otsatirawa adanditumizira anali No Appointment Clinics, ndi Christie’s No Appointment Clinics,” anapitiriza.

“Sindikuganiza kuti ndikufuna kupita kuchipatala popanda nthawi yokafuna katswiri wamanja.”

Zina zonsezo zinali za mayina ofanana kapena obwerezabwereza.

ku Aetna akubwera Dongosolo la Medicare PPO liyenera, mwamalingaliro, kubwera ndi zosankha zambiri kuposa dongosolo la Medicare HMO lomwe mukugwira ntchito. Chifukwa cha kuchotsedwa kwa federal, dongosolo la PPO-ESA (kapena Extended Service Area) limalola odwala kuti awone madotolo ena omwe ali kunja kwa intaneti pamlingo wapaintaneti. ngati Ofesi ya dokotala kapena chipatala Sankhani kukawona wodwala uyu.

Woimira Carle Health – ‘wotsogolera’ wapakati pa Illinois komanso wogwira ntchito yofunika kwambiri pagulu la anthu opuma pantchito ku Champaign County – adati Lolemba mochedwa kuti Carle Foundation Hospital ku Urbana ndi Carle Physician Group (awa 500+ doctors)) akuwunikabe “kuthekera kwawo kuthandiza mamembala omwe ali muofesi yogula zinthu,” kutchulanso zandalama komanso “kudikirira chilengezo chamgwirizano wa olipira boma.”

Woimira Aetna adayankha Lachisanu, “Ngati wothandizira kunja kwa intaneti ali wokonzeka kuwona membala ndipo ali woyenera kulandira malipiro a Medicare, Aetna adzalipira 100% ya Medicare yovomerezeka ya ntchito zophimbidwa,” ponena kuti “membalayo lipirani wolembetsa mu-network” mosasamala kanthu za zomwe wopereka chithandizo amalipiritsa kuchokera kunja kwa netiweki.

Wothandizira inshuwaransi wa CVS adapempha Carle Health kuti “akhalebe ndi chidwi pa thanzi ndi moyo wa anthu opuma pantchito ku Illinois popitiliza kuwawona akudwala monga momwe amachitira lero.”

Mkulu wa mauthenga a Carle adatcha CMS ndi maganizo a Aetna kuti madokotala a Carle “ayenera” kukhalapo mofanana ndi momwe adakhalira opuma pantchito mu ndondomeko ya United HealthCare PPO ya United States inali “yofalikira komanso yosocheretsa.”

“Ife tikumvetsa zimenezo ngati Membala omwe akufunsidwa akuwoneka ndi wothandizira kunja kwa intaneti, ndipo mtengo kwa membala udzakhala wofanana ngati akuwona wothandizira pa intaneti. Koma, izi zimatengera momwe kampani ya inshuwaransi imathandizira pa intaneti. ”

“Ndizomvetsa chisoni kuti anthu m’madera mwathu adayikidwa ndikuyikidwa m’malo omwe amayenera kupeza wothandizira kunja kapena kutuluka m’deralo chifukwa cha kuwonekera kwa PPO komanso kuchepa kwa makontrakitala. othandizira,” imelo yomwe idawerengedwa kuchokera kwa woimira Carl idachedwa Lolemba.

Chipatala cha Carle Foundation ndi Carle Physician Group alibe mapangano ndi mapulani aliwonse a Medicare Advantage, kuphatikiza dongosolo la United HealthCare lomwe likuchita ndi boma pano. Aetna Medicare anali chip chaposachedwa kwambiri. Chifukwa cha kuchotsedwa kwa boma komwe kwatchulidwa pamwambapa, Karl adasankha kuvomereza mapulani a inshuwaransi ya Medicare Advantage. Pakadali pano, izi zikuphatikiza dongosolo la United HealthCare Group la PPO, lomwe limalemba anthu opuma pantchito opitilira 100,000.

“Monga ma inshuwaransi opereka chithandizo akuchulukirachulukira kuthana nawo, zomwe zimapangitsa kuti zikhale zokwera mtengo kwa opereka chithandizo, kupanga ma hoops ambiri owongolera kuti adumphire, ndikukana kulipira ntchito zomwe zaperekedwa, opereka chithandizo m’dziko lonselo akuwunikanso omwe amalumikizana nawo komanso ngati atero, Carle Health Communications idatero poyankha funso loti chifukwa chiyani gulu lothandizira komanso othandizira sachita mgwirizano ndi mapulani a Medicare Advantage.

Sipanakhalepo yankho kuchokera kwa Aetna ponena za chikhalidwe cha zokambirana za mgwirizano ndi Carle Health, koma kampaniyo imati ndi yotseguka kuti aganizirenso zokambiranazo.

“Ndinkaganizira kwambiri zosinthira ku United Health[Care], “Anatero Hassan. “Zowona, tsopano palibe njira yochitira United Health. Ndi njira ya Aetna basi, ndipo ikuwoneka ngati wodzilamulira kwa ine. “

Kudula njira ya HMO kwa opuma pantchito kungayambitse vuto lalamulo ku CMS. Mgwirizano wa boma ndi AFSCME Board 31 – mutu wa Illinois wa American Federation of State, County, and Municipal Employees – makamaka akuti “boma lidzapitiriza kupereka kulembetsa kwa HMO.” Kaya izi zikufikira anthu opuma pantchito sizikudziwika bwino kuchokera ku imelo yochokera ku AFSCME poyankha mafunso amgwirizano.

“Zotsatira za pulogalamu ya inshuwaransi yaumoyo wa anthu opuma pantchito zalembedwa m’mapangano athu onse ndipo ziyenera kukwaniritsidwa chaka chomwe chikubwera cha 2023,” atero a Martha Merrill, Director of Research and Employee Benefits ku AFSCME Council 31.

Koma Chifukwa chiyani? Kodi CMS yadula zosankha? Chifukwa 90 peresenti ya olembetsa amasankha kale dongosolo la PPO, malinga ndi Kathy Kwiatkowski, wachiwiri kwa director of communications and information ku CMS.

Otsala 10 peresenti omwe adalembetsa muzosankha za HMO ndi anthu pafupifupi 20,000.

Aetna adapatsanso boma ndalama zokwana $0 pa nthawi yoyamba ya mgwirizano wazaka zisanu, Kwiatkowski adatchulapo pothandizira njira imodzi.

Sizikuwoneka ngati opuma pantchito kapena antchito adzalandira $ 0 umafunika. Ngakhale dongosololi lidzabweretsa “kuchepetsa kwakukulu” kwa zopereka za opuma pantchito ndi odalira, Kwiatkowski anatero.

Kwa ambiri omwe adapuma pantchito omwe adayimba, kutumiza maimelo ndi kutumiza mauthenga a WCIA 3 News, sizokhudza ndalama. Ndi za kusunga madotolo omwe adawakhulupirira pa nthawi yovuta m’miyoyo yawo kuti alandire chithandizo chamankhwala.

“Sindinapange ndalama zambiri pamene ndinkaphunzira, koma ndinkaphunzira chifukwa ndinkakonda. Ndipo mbali ya maphunziro, ndinkadziwa nthawi zonse kuti padzakhala penshoni kwa ine, ndipo ndidzalandira chithandizo chamankhwala, ” Adatero Judd akufotokoza mwachidule mantha ndi zokhumudwitsa zomwe zidatsala.

“Ndipo tsopano akungonyalanyaza malonjezo awo kwa ife, mukudziwa, zomwe atipatse tikapuma pantchito.”

Ena opanga malamulo aboma nawonso adadodometsedwa ndi ndondomekoyi, kuphatikiza wapampando wa COGFA, Senator Dave Koehler, (D) yemwe adati Lolemba kuti opuma pantchito akuyenera kukhala ndi zosankha.

Senator Koehler adati CMS ikuyenera kupereka mgwirizano watsopano wa opanga malamulo ku Government Prediction and Accountability Commission, koma msonkhanowu sukuyembekezeka mpaka masika, mochedwa kwambiri kuti asinthe.

Kohler adati udindo wa COGVA ndi upangiri wokha. CMS ikhoza “kuvomereza kapena kusiya” upangiri.

Koehler, atamva kuti mafunso a atolankhani komanso nkhawa za anthu opuma pantchito sizinayankhidwe, adalemba kalata ku bungwe la boma mu Seputembala akufunsa, mwa zina, “Kodi CMS idasankha bwanji kulumikizidwa koyenera pa netiweki ‘panthawi yoyitanitsa TRAIL MAPD?

CMS yayankha molembera kwa omwe akufunafuna pempholi (RFP) kuti awonetse kutsata miyezo yokhazikitsidwa ndi akuluakulu oyenerera, Federal Center for Medicare and Medicaid Services.

Ngati malipoti athu am’mbuyomu ndi mndandanda wa maopaleshoni amanja ku Vicki Good ndi ziwonetsero, kutsimikizira kodziyimira pawokha kwa ma network operekedwa ndi kampani ya inshuwaransi kunavumbula zolakwika zambiri.

CMS sinayankhe pomwe atolankhani a Target 3 adafunsa mwachindunji ngati kutsimikizira kodziyimira pawokha kunali gawo la ndondomekoyi.

Kulembetsa kotseguka kwa opuma pantchito m’boma kwabwezeredwa mpaka Novembara 1 kuyambira tsiku lodziwika bwino la Okutobala 1. Dongosolo latsopanoli liyamba kugwira ntchito kwa olembetsa pa Januware 1.

Kuyankhulana kokhudza kusintha kwa MAPD PPO kudzayamba mkati mwa masabata awiri otsatirawa, ndi umboni wotseguka wa chisankho cha kulembetsa kutumizidwa kumapeto kwa October. Mamembala adzalandiranso mafoni achindunji kuchokera ku Aetna, Medicare Center, ndi Medicaid Services. Illinois itulutsa mauthenga angapo kwa anthu opuma pantchito, kufotokoza zosintha, kuphatikizapo maimelo olengeza kunyumba, makalata, maimelo, ndi masemina aumwini panthawi yolembetsa.

Kwiatkowski adalongosola kuti mgwirizano wa Aetna umayenda kwa zaka zosachepera zisanu “ndi ndalama zotsimikizika za $ 0 kwa nthawi yoyamba.” “Pali zaka 5 zomwe mungasankhe kuti mukonzenso.”

Anthu amene apuma pantchito m’boma satenga nawo mbali popanga zisankho zomwe zakhala zikudandauliranso miyezi ingapo yapitayi.

Kulankhulana ndi opanga malamulo a boma kudzera pa foni kapena imelo ndiyo njira yakomweko yogawana madandaulo.

Madandaulo a Medicare pano amaperekedwa ku American Centers for Medicare ndi Medicaid.

United HealthCare sinayankhe pempho loti afotokozere momwe lipoti ilili.

TNkhani yake yasinthidwa kuti imveketse kuti Karl Foundation Hospital ndi Karl Physicians Group osalandira zina Mapulani a Medicare Advantage, komabe osapanga mgwirizano Ndi chilichonse.

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