BO HIM NHA KHOA

BSNK Anne-Marie Ha Nguyn

May 2010

 

Bc S Nha Khoa Anne-Marie Ha Nguyn chuyn tr bnh nܧu rng v ǥt implant (Periodontology & Implantology) tt nghip Baylor College of Dentistry nm 1990, c bng Master of Science v phn khoa nܧu rng ti University of Texas - San Antonio nm 1996 v Board Certified bi Hi American Board of Periodontology nm 1997, hin ang hnh ngh vng Ty Nam (Southwest) Houston. Nu c nhng thc mc lin quan ti nha khoa, xin lin lc hoc gi th v a ch vn phng 6666 Harwin Drive, Suite 650, Houston, Texas 77036. T: 713.917.0907. Copyright 2010 Anne-Marie H Nguyn, DDS, MS.

Trong thi bui kinh t kh khn hin ti vi con s hn 15 triu ngܩi M lm vo hon cnh tht nghip, nhiu ngܩi Vit Nam khp ni cng b nh hܪng bi s khng hong ny. Khi mt vic lm ri th hu ht mi ngܩi NJu ri vo tnh trng trm cm, suy t v lo lng v nhng khon tin chi tiu cho nh, xe, tin cho con n hc, tin bo him sc kho, v. v... Tt c chng ta NJu bit rng bo him sc khe rt quan trng trong ǩi sng. My thng trܧc, chnh ph Obama a ra d lut ci t bo him y t; nhng, cu hi l kt qu ca chng trnh ny s i v u v nh hܪng s nh th no khi lin quan ti ngnh nha khoa. Ti nܧc M, tin chi ph Nj c 1 b rng p Nj cܩi, nhai hoc n ni c th lm thm thng trm trng ti ngn khon ca mt gia nh. Mt tai nn xe c, mt cn bnh (ung th hm mt), bnh nܧu rng trm trng, hoc t gy rng c th tn ti tin ngn Nj sa li chic/hm rng ca mnh. Khi trong tnh trng ny, nhiu ngܩi lo tm kim v vn k Nj mua nhng hp ng bo him nha khoa cho chnh bn thn h hoc cho gia nh mt cch hi ht nhanh chng, m lm lc khng hiu r hoc khng nm chc nhng iu khon ܮc ghi r trong hp ng. Theo kinh nghim thu thp trong gn 20 nm hnh ngh, ti xin mn php gii thch nhng kin thc cn bn v bo him nha khoa.

Trܧc ht, Nj quyt nh chn la loi bo him no thch hp vi hon cnh ca chnh mnh, im chnh khng phi l nhn hng bo him no r hoc hng no cng ܮc, min c th thi! Chng ta ai cng c t nhiu kinh nghim khi i ph vi hng bo him cho xe, nh, c s thng mi, nhn th, sc khe v. v... Nu chng ta cng ngh rng hng bo him l 1 dch v thng mi Nj lm tin, em li li nhun cho h th c l s hiu d dng hn. H thu tin NJu ǥn v nghim ngt theo ng chu k. Nhng khi c chuyn g xy ra cn ti hng bo him phi trang tri hoc bi thܩng th i thi ... rt l nhc u v vt v! Bi th, y l vi cu hi chng ta nn suy ngh trܧc khi quyt nh chn la 1 hng bo him:

1.         Ti c quyn chn nha s ring cho ti hoc cho gia nh ܮc khng? Ging nh nhiu hng bo him y khoa sc khe, c vi hng bo him nha khoa gii hn chng ta phi ti nhng vn phng ܮc ch nh. Nu nha s chng ta a thch khng tham gia vo h thng ca hng bo him ch nh ny, d nhin ta phi tm phng k, ܩng li khc hoc phi tr thm tin Nj mua loi bo him c nhiu s la chn hn.

2.         Gia ti v nha s c quyn la chn phng cch cha tr tt nht cho ti khng? C vi hng bo him s gii hn hoc ngn cn cng vic cha tr tt nht hoc hn ch khon tin trang tri nhng cng vic lm trong vn phng nha khoa.

3.         Hp ng bo him bao gm nhng g? Mt bo him tt s bao gm cng vic khm rng, chp hnh X-ray, ch rng (teeth cleaning) mi nm 1 hoc 2 ln. Nhng cng vic khc nh nh rng, trm rng, rt ty, no rng, trng rng gi, gii phu nܧu rng thng thܩng ܮc chia ra 2 loi: cn bn (basic) hoc c bn (major) ty theo hp ng. Xin džc tip theo phn nh ngha dܧi.

4.         Ti c b gii hn khi lm hn vi vn phng nha s khng? Khi mua loi bo him r tin, mt s vn phng c th s gii hn thi gian Nj gp nhng bnh nhn . Th d: Vn phng A ch gp nhng bnh nhn c loi bo him XXX vo th t tun th 2 trong mi thng m thi. Nu nh vy th s rt bt tin cho ngܩi bnh v c th phi ch rt lu mi c ngy hn!

5.         Ti phi tr bao nhiu tin Nj mua ܮc bo him? a) Trܧc ht chnh mnh phi bit l s cn bao nhiu tin Nj sa rng v kh nng ti chnh ca gia nh c i th ܮc hay khng? b) Tnh trng rng v khoang ming c tt hay khng? c) V sinh rng ming c gi gn sch s, k lܫng khng? d) C thi quen nh nghin rng, nhai , ht thuc l, ngm thuc lo, x lܫi/mi? e) C quen i nha s thܩng xuyn khng?

Sau khi hiu s qua kin thc tng qut, chng ta nn džc k nhng iu khon ghi chp trong hp ng. Nu trong s lm c cung cp bo him nha khoa cho cng nhn, chng ta cng nn hi coi hng c bao nhiu loi bo him. V ty hng bo him, nhng cng vic bao gm (coverage) khc nhau ty theo hp ng (policy), hoc ty theo chng trnh (plan). Nhng hng cung cp bo him thܩng dng nhiu danh t chuyn khoa di dng kh hiu hoc ting lng Nj din t li ch, chng trnh, k hoch ca h Nj thu ht ܮc nhiu ngܩi! ng thi mt s iu khon gii hn thܩng ܮc xen ln vo nhng dng ch rt nh m t ngܩi džc k v ch ti!!!!

Bo him nha khoa cn bn bao gm nhng g? [Basic Dental Insurance Coverage-What is Included?]

Ni mt cch tng qut, bo him nha khoa ܮc chia thnh 3 phn:

1.       Bin php phng nga v chn bnh [Preventive & diagnostic dental care]: Hu ht mi hng bo him NJu bao gm cc tit mc nh: khm rng, ch rng, chp hnh X-ray, v nhng phng cch phng bnh su rng (nh lm sealants hoc p dng cht fluoride) v bnh nܧu rng. y l phn cn bn r tin v h khuyn khch bnh nhn nn i khm rng thܩng xuyn Nj phng bnh hu mong gim i phn chi ph cha tr. Thng thܩng hng bo him tr t 80 - 100% trong phn ny. Tt ht chng ta nn hi r vn phng iu l ny trܧc khi ly hn.

2.       Cha tr CN BN [Basic dental care]. Mc ny bao gm nhng vn NJ nh trm rng, nh rng, sa cha rng m. Ch cn bn rt kh hiu v c nhng cng vic ܮc cho l cn bn do hng bo him A quy nh nhng c th ܮc ǥt vo phn cng vic c bn (major dental care) do hng bo him B NJ ngh. S khc bit ln y l vn NJ ti chnh. Thng thܩng nhng mc cn bn ny hng bo him tr c th tr ti 80%. Th d: Gi tin nh rng trong vn phng nha s l $100 USD. Hng bo him A lit k l cng vic cn bn v s tr cho vn phng 80% ($80) v ngܩi bnh s tr 20% tin copayment ($20). Nhng nu hng bo him B nh ngha cng vic nh rng l c bn th c th ch tr 50% ($50) v ngܩi bnh phi tr 50% ($50). S khc bit ny s nh hܪng nhiu trn s tin copayment m ngܩi bnh bt buc phi tr cho vn phng nha s. Bi bnh nhn phi hiu r iu khon ny trܧc khi quyt nh lm cng vic g trong vn phng nha khoa, Nj trnh s ng ngng, gin di hoc hiu lm!

3.       Cha tr C BN [Major dental care]. Khng phi hng bo him no cng bao gm tit mc ny. Nhng cng vic c bn bao gm: gii phu nha khoa, rt ty rng, trng rng gi, v. v... y l nhng cng vic ܮc xem l ǡt tin nht! Phn ng, nhng hng bo him ch tr ti 50% cho phn ny m thi. Nu ngh k, chng ta thy r nhng cng vic cng ln hoc cng ǡt tin bao nhiu th hng bo him li cng tr ... t tin by nhiu!

nh ngha nhng danh t cn bn trong hp ng bo him:

1. Benefit Year: ngy thng hp ng bo him c hiu lc. Thng thܩng ܮc chia ra lm 2 lch:

Calendar Year: da theo nm lch 365 ngy. Th d: Hp ng bo him c hiu lc t ngy 1 thng 1, nm 2010 ti ngy 31 thng 12, nm 2010.

Fiscal Year: da theo nm ngn sch/nm ti chnh. Th d: Hp ng bo him c hiu lc t ngy 1 thng 4, nm 2009 cho ti ngy 31 thng 3, nm 2010. Nu nhng cng vic ta lm trܧc thng 4/2009, th d nhin bo him cha c hiu lc v ngܩi bnh phi chu ht khon tin chi ph.

2.        Claim: y l bn bo co vn phng nha s np cho hng bo him, lit k nhng cng vic lm cho bnh nhn trong ngy v khon tin chi ph Nj ܮc bi hon.

3.        Cleaning: (cn ܮc gi l ch prophylaxis) y l cng vic ch bng rng Nj ty sch nhng vt nh bn hoc cht ba dnh trn mt rng. Cng vic ny thng thܩng nm trong phn phng bnh (preventive); bo him c th tr ti 100% v bnh nhn c quyn lm 2 ln trong 1 nm. Khc hn vi cng vic no rng (scaling/root planning hoc deep cleaning) nm trong phn cn bn. Cng vic ny bo him ch tr ti 80% nhng bnh nhn c th b gii hn 1 ln/12 thng hoc 1 ln/24thng. Xin xem li bi No Rng (Xy Dng thng 12, 2008, trang 90-92).

4.        Co-payment: y l khon tin ܮc n nh r trong hp ng m ngܩi bnh nhn v hng bo him cng phi tr khi lm 1 cng vic no trong vn phng. Th d: tin trm rng trong vn phng l $100. Bo him tr 80% cho phn cn bn ny l: $80. Bnh nhn s phi tr 20% co-payment l $20.

5.        Covered charges: gi tin hng bo him qui nh trܧc cho nhng cng vic lm trong vn phng nha khoa. Th d: chi ph Nj rt ty/gn mu trong vn phng l $350. Nhng gi bo him qui nh l $250. Phn cn li l $100 bnh nhn phi chu trch nhim v tr cho vn phng. Phn ngha vi ch non-covered charges.

6.        Deductible: y l gi tin c nh (fixed amount) m ngܩi mua hp ng bo him ng tho thun phi ng ra trܧc khi bo him bt u tr cho nhng cng vic lm trong vn phng nha khoa. Trung bnh, tin deductible trong bo him nha khoa khong chng $25 - $100 cho mi nm.

7.        Dependent: bao gm nhng ngܩi hܪng bo him theo cng hp ng, nh v hoc chng v con ci.

8.        Exclusionary clause: iu khon ngn cn, hoc loi tr nhng cng vic lm cho bnh nhn. Th d: bnh nhn mt rng bn tay tri trܧc khi mua hp ng bo him th d nhin cng vic trng rng bn tay tri s khng ܮc bi thܩng.

9.        Explanation of Benefits (EOB): y l bn lit k, nu r chi tit nhng phn no hoc cng vic g bo him chp thun hoc khng trang tri v tr bao nhiu tin cho mi phn ܮc ghi nhn.

10.  Fee Schedule: bng l ph hng bo him lit k ra cho nhng vn phng nha s no nm trong h thng (in-network) phi theo. Th d: gi trong vn phng A (nm trong h thng) trm rng l $75. Gi bo him lit k ra ch tr $50. Trong trܩng hp ny bnh nhn khng cn phi tr khon tin sai bit $25. NHNG, nu i ti vn phng nm ngoi h thng (out-of-network), th d nhin ngܩi bnh phi tr s tin $25 cn li.

11.  Maximum benefit: y l khon tin ti a hng bo him dnh cho mi u ngܩi trong 1 nm. Ty hng bo him, gii hn khon tin khong t $1000 - $2000/mi ngܩi. S tin ny s t Ƕng bt u li vo mi nm (calendar vs. fiscal year, xin xem gii p trn). Nu ngܩi bnh khng s dng, th s mt khon tin trong nm; s tin s khng ܮc tch ly t nm ny qua nm khc ܮc.

12.  Missing tooth Clause: iu khon thiu rng. Bo him s khng tr khon tin trng rng nu ngܩi mua hp ng mt/thiu rng trܧc khi bo him c hiu lc.

13.  Network: In/Out of Network Dentists. H thng: Nha s nm trong h thng hoc ngoi h thng. Nu hng bo him ch nh ngܩi bnh phi i ti mt vn phng hoc trung tm trong h thng Nj cha tr rng, th bt buc ngܩi bnh phi tun theo. Nu bnh nhn t Ƕng i ti nhng nha s nm ngoi h thng, th d nhin bo him khng tr tin hoc tr t hn v bnh nhn s phi chu trch nhim cho tt c chi ph.

14.  Non-covered charges: iu khon v cc chi ph bo him khng tr.

15.  Premium: s tin n nh bnh nhn phi ng cho hng bo him mi thng.

16.  Replacement Clause: iu khon thay th. y l cch bo him gii hn thi gian Nj thay nhng b rng gi nh cu rng, b rng gi ton hm hoc bn phn hm. Thng thܩng thi gian thay th l 5 nm. Th d: ng A i lm b rng gi nm 2009. Vi thng sau, ng ri ro nh rt b b rng . Nu mun c ngay b rng khc, ng phi t mnh rt tin ti ra tr. Nu khng, th ng phi ch ti nm 2014 th bo him lc s tr mt phn s tin lm b rng ny cho ng!

17.  Treatment Plan: bn lit k k hoch cha tr bnh l

18.  Usual, Customary, and Reasonable Fee (UCR Fee): gi tin hܧng dn do hng bo him a ra. Gi chi ph ca vn phng t khng da trn nhng con s ny; y ch l khon tin ܮc d tnh trܧc ca hng bo him s tr cho vn phng m thi. Th d: Gi Nj ch rng trong VP Nha S XX l $75, nhng gi tin n nh ca hng bo him ch tr ti $58 thi. S tin $27 cn li l trch nhim ca ngܩi bnh tr cho VP.

19.  Waiting Period: y l thi gian bo him bt ch Ǯi trܧc khi hp ng c hiu lc. Th d: B B cn lm 1 chic mo rng v hp ng bo him c iu khon ch 12 thng c ngha l, 1) b t rt tin ti ra tr cho chic mo rng y v ng thi vn phi ng tin mi thng (premium) cho bo him, hay 2) b c th ch 12 thng sau khi bo him c hiu lc.

KT LU

N:

y l nhng kin thc cn bn, ph thng v NJ ti bo him nha khoa. Tc gi mong rng nhng chi tit ny s gip cho Ƕc gi hiu r thm Nj trnh s b ng khi phi s dng nhng dch v lin quan ti bo him. V gii hn trong khun kh trang bo, nn khng th no trnh by thm nhng vn NJ phc tp kh khn khi phi ng u vi hng bo him.

Da trn kinh nghim bn thn, vi im quan trng tc gi mun nu r v bo him:

          y l trch nhim ca chnh chng ta (l ngܩi mua bo him) Nj quen thuc v hiu r nhng iu khon qui nh trong hp ng.

          Ngܩi th k hoc cng tc vin trong nhng vn phng nha/y s ch lm vic khai giy t bo him Nj ǫ tn thi gi cho bnh nhn m thi. Cho d bo him tr hay khng tr, chnh chng ta phi t c trch nhim trn phn ny.

          S tin deductible v co-payment m bnh nhn phi tr cho vn phng l theo qui lut do hng bo him n nh. Khng vn phng nha/y s no c thm quyn quyt nh nhng khon tin ny.

          cho minh bch, chng ta nn xin v gi li nhng t bin lai t vn phng y/nha s ghi r v lit k nhng cng vic lm trong ngy khm/tr bnh cng vi gi tin trܧc khi ra v Nj sau ny c th so snh vi nhng giy t hng bo him s gi v cho mnh.

          Khi cn phi lm nhng cng vic i hi nhiu thi gian v tin bc, chng ta nn nh vn phng np n xin php hng bo him trܧc (Pre-Determination/Pre-Estimation) Nj bit r s tin bo him s tr cho vn phng v bnh nhn s phi chi bao nhiu tin trܧc khi khi s.

          Phn ng, nhn vin ca hng bo him ܮc hun luyn Nj khܧc t nhng n bi hon/khiu ni lin quan ljn khon tin ln, hoc h s i hi nhiu giy t Nj chng minh nhng cng vic lm trong vn phng nha s. Nu chng ta khng kin tr trong vn NJ khiu ni th phn thit thi s v mnh m thi.

          Chng ta ng nn c thi Ƕ dng dng, v trch nhim cho php nhng vn phng nha/y s c quyn mun khai g th khai. Hnh Ƕng ny s c hi cho chnh bn thn mnh v s vic c th hn ch nhng cng vic cha tr tht s cn lm trong tng lai. Hn na mnh v tnh to c hi cho ngܩi khc phm ti!

Anne-Marie Ha Nguyn, DDS, MS

Houston, Texas - May 2010