[golfinggrammy]

As a retired High School teacher who was very fond or research reports I decided to get my own answers before reading the back and forth drama on these past threads. I used my friend Google to get some answers and then I took some of my questions and your questions and met with a Villages Health employee at my center. I leaned so much and no my research hasn’t stopped here.

1. What is Medicare Advantage? “Medicare Part C plans are usually referred to as Medicare Advantage plans. These plans are offered by private insurance companies and allow you to get all the coverage Original Medicare (Parts A & B) offers, plus additional medical services all in a SINGLE plan. Many Medicare Advantage plans include prescription drug coverage, often for NO additional premium. And some plans also include extra benefits, such as routine vision, hearing, and dental care, wellness services and a nurse phoneline.”

2. Original Medicare vs. Medicare Advantage: Understanding the Difference
Original Medicare: “Medicare is federally administered health insurance providing health coverage to Americans above the age of 65 and other individuals who are eligible due to certain illnesses, disabilities or income level. Original Medicare consists of two parts, Medicare Part A and Medicare Part B. Medicare Part A provides coverage for hospital stays, inpatient procedures and some follow-up care in skilled nursing facilities. Medicare Part A is of no cost to the beneficiary as long as you or your spouse has made payroll contributions to Social Security for at least 10 years. Medicare Part B provides coverage for out-patient care including doctor’s office visits. Those who choose to take advantage of Medicare Part B will pay a premium. The premium is based on the yearly income of the beneficiary and is often deducted from their monthly Social Security benefits.”

Medicare Advantage: “Medicare Advantage is also known as Medicare Part C. Medicare Advantage is provided by private insurance companies and is designed to help cover medical costs that Medicare Parts A and B don’t cover. Some Medicare Advantage plans include prescription drug coverage at little or no additional cost. Because Medicare Advantage is provided by private insurers, these plans can vary in price and coverage. It’s a good idea to research your options to make sure you get the best plan and price for your needs. In order to enroll in Medicare Advantage you must first enroll in Medicare Parts A and B. You can only enroll in Original Medicare and Medicare Advantage plans during specific enrollment periods."

3. Are there different types of Medicare Advantage plans? There are Coordinated Care Plans (HMO, HMO POS, PPO, & SNP) and other plans (PFFS and MSA).

PS. United HealthCare Medicare Advantage offers several of these DIFFERENT plans.

4. Can you explain what Premium, Deductible, Copay, and Coinsurance are?
• Premium: This is a set amount that you pay to participate in the plan. Premiums are usually charged by the month.
• Deductible: A deductible is an amount that you have to pay before the plan will start helping you with your costs. Deductibles vary among plans and are often inversely related to premiums. For example, a high deductible plan may have a lower premium than a low-deductible plan.
• Copay: A copayment, or copay, is a fixed amount that you pay for a service or product at the time that you receive it. Copays are typically small amounts, like $5 or $10.
• Coinsurance: Coinsurance is when the cost is split between you and your plan on a percentage basis. For example, you pay 20% and the plan pays 80%.

5. What are the Medicare Advantage Plans that The Villages Health accepts?
• UnitedHealthcare® The Villages® MedicareComplete® (HMO) Plan 1
• UnitedHealthcare® The Villages® MedicareComplete® (HMO) Plan 2
• AARP® Medicare Complete Choice® (Regional PPO)
• AARP® Medicare Complete Choice® (HMO)
• United Healthcare® Medicare Advantage Dual Complete
* Found on the Villages Health webpage
**** Reread those plans! 5 different plans, some are HMO and some are PPO, two only have “The Villages” attached to it, – you have options****

6. My neighbor has Federal Blue Cross – is he being kicked out? “Every patient’s situation is different. We encourage them to contact their Patient Services Rep (PSR) at their care center so that they can review their insurance and options with them personally.”

7. My neighbor has been a patient for 11+ years, isn’t he grandfathered in? “There is no such thing as “grandfathered in”. We love having you as our patient and wish for you to remain our patient. We never promised or said you were grandfathered in. We have always stated that at this time we accept your insurance and at this time you can remain a patient – we never said what the future would hold. As you know healthcare and businesses are constantly changing. Therefore, change could happen in the future. Every healthcare facility in the country has to make and renew contracts with insurance companies to be in network with them. At any given time an insurance company can decide to drop a healthcare facility as can the healthcare facility chose to drop an insurance company. This isn’t the first time this has happened for The Villages Health – we once took Humana and Aetna and now we don’t.”

8. Why are you no longer accepting Medicare and Medicare Supplemental insurance? “These plans do not support our care model. The reason we are able to have smaller patient panel sizes, have longer visits, have onsite services (labs, x-rays, ekg’s, ect), is because of the relationship we have with Medicare Advantage.”

9. Why are you choosing to accept one insurer of Medicare Advantage? “We chose the company with one of the largest physician networks in Florida. We also chose one company which allows us to focus our efforts towards one set of quality standards and insurance requirements – this is what helped us receive 13 5-star ratings out of 15 with HEDIS.”

10. What is HEDIS? “HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis. Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts.”

11. There is a limited network – how will that help me? “Actually UHC has one of the largest physician networks available in Florida and the United Stated. I know I would rather be part of a network that is limited because that means that that physician has to meet requirements and standards to be a part of it. If anyone and everyone can be part of a network what kind of standards is that physician being held up to?” (that’s something to think about – I will be researching into this)

12. I heard you need a referral everywhere you go – is that true? “No. However the terms referral and authorization are sometimes confused. Most specialist now a days require a referral from a primary care physician no matter what insurance you carry. Some insurance companies require an authorization from that specialist before you are seen. I for one would like my doctor to refer me to someone because they know my medical history and they know the doctors around far better that Google. I don’t want to go to just anyone. Sending a referral also means that my doctor is keeping track of me and that also means that when I see that specialist he knows who sent me and he knows who to get in contact with if there is any questions. This is called coordination of care. Medicare advantage supports this type of care. You primary doctor and specialist are able to work as a team. They coordinate any procedures, medications, and any emergency care you might need. If you self-refer you are responsible for coordinating this stuff. You are the middle person in the hospital to tell your cardiologist that your primary doctor increased your medication and then your primary doctor decreased it. Wouldn’t you like to feel comfortable enough to know that your doctors can communicate and come up with a plan together? In a fee for service world this care is not possible – Original Medicare does not support this or back this up. The patient is responsible and if I’m unconscious then who has my back – not Medicare!”

13. My neighbor has Tricare – are you kicking him out? “Every patient’s situation is different. We encourage them to contact their Patient Services Rep (PSR) at their care center so that they can review their insurance and options with them personally.”

I also asked the front desk person this question and she informed me that there is a way for Tricare Medicare Age patients to combine it with Medicare Advantage and still keep all your Tricare benefits. She gave me a card with a lady named Vicki Garrick on it and her number is 352-249-6538.

14. Can I travel outside of The Villages with this Medicare Advantage? Absolutely, they have one of the largest networks in Florida. They also offer PASSPORT benefits which mean if you are a snowbird you can call in and let them know you will be traveling and chose a doctor up north. Or if you need emergency care in the Bahamas you would be covered. You should meet with a rep and discuss your options.

15. Who can I talk to for more information on these plans that you accept? You can stop by any of the Care Centers and meet with a local rep. They will get to know you one on one, learn about your medical history, see what doctors you see and what medications you take, and see if a plan will benefit you. They will let you know if you’re better off with your current plan or better off changing. There are also Medicare Stores on each of the squares.

I understand you are all frustrated and confused – as was I. Change is very hard to deal with sometimes, especially at our age! But the world around us is constantly changing and just because we are retired men and woman living in a beautiful environment doesn’t mean we won’t ever have to deal with real world stuff. When you bought your homes you were INFORMED not PROMISED an awesome healthcare system and to be a part of Americas Healthiest Hometown. The Villages Health is still an awesome healthcare system and is what is keeping us a part of Americas Healthiest Hometown. They are simply choosing to make a decision to not accept an insurance that doesn’t support the care model and doesn’t allow them to keep their patients’ healthy – again this has been done before and not just by The Villages Health. I encourage each and every one of you to do your OWN research and not just listen to your friend at the pool or on the golf course. We are all different, we all have different insurance plans, different health backgrounds, we take different medications, we travel to different parts of the world, we worked for different companies, and we all see different specialist. This means that these plans might work for some and not for others. You might have the best insurance now and that’s good for you but that doesn’t mean your neighbor has the same. Do your own research, meet with the Patient Service Rep at your care center, go make an appointment with a local agent at a care center or the square stores. Then after you find out the information you need and you get your answers then make your decision. Don’t make an irrational decision now because you’re confused or upset. The insurance change will take place January of 2017. That means we have till open enrollment (October-December) to make a decision. So plan accordingly!