Actually the Shands web site says that a patient who shows up with nothing but a boatload of cash will get a 45% discount on their bill.

My wife and I opted out of the villages system because they would no longer accept medicare and our BC/BS plan F supplement insurances.
We reviewed our choices with someone on the staff that should know (will not divulge who for obvious reasons) and was told if you can afford those coverage's KEEP THEM!

wow...

Choice? Choice you say? Well, I guess so, but only within the parameters of take it or leave it. Soooo, by pure definition, that's right, I guess, but.......

When I first heard about what TV was doing, by imposing the limitations of only one insurance choice for Medicare-age residents, I could not believe it. I remember asking some guy in a vendor booth at Brownwood the same question, 3 different ways. Basically, my question was, and still is, "Is this for real?"

There are those who claim to be so in the know about the business plans of TV and have the need, for whatever reason, to cling to their defense, even to the point of condescension, as if those of us who dare to question are pizzants. So let's expand the talk about business plans......pizzant though I may be.......

I always thought the basic business concept of TV was to build a place where regular people could have a very nice lifestyle in retirement. Obviously, that concept has been successful, even beyond what could have been imagined in the beginning.

But.......among those retirees who chose to buy in TV, there are many who have retired from the military or from state or federal or municipal jobs or big corporations -- jobs that provided reasonably priced or no-cost health insurance for retirees. Those people worked for a lot of years for good retiree benefits and planned their retirement budgets with the knowledge that healthcare costs were covered.

I feel pretty certain that none of those retirees, who helped to build TV into a huge success, could ever have imagined that the rug would be pulled out from under them by a business decision that smacks of never enough, never ever enough.........

The convenience, or even the possibility, of accessibility is often a very big deal as we age. Now that Medicare-age Villagers have to scramble for outside doctors or give up excellent insurance, accessibility can become more of a factor, especially considering the lack of publicly available transportation. (Anybody remember house calls?)

I have thought from the beginning that this TV insurance business decision was contradictory to the basic business concept of lifestyle in retirement that I thought was TV. TV has made things hard for a lot of people who bought in and made the place such a big success. I think there are many among us who have a perfect right to their ire.

And now, back to the survey. It will be interesting to see where it goes.


Addendum: There is information out there now that says as of 2020, the Plan F Supplement to Medicare will no longer be available unless you already have it. So there we have another possible factor to consider for those who might have given up that one and could be rethinking.

Where do you see that on their website?

Financial Assistance | Patient & Visitor Guide | UF Health Jacksonville | University of Florida Health

"Uninsured patients who are not eligible for financial assistance under this policy may be eligible for a self-pay discount of 45% off gross charges. Any self-pay or financial assistance discount applied will be reversed if insurance, TPL, a settlement and/or other miscellaneous source is identified"

The key word in the above is "uninsured patients". Medicare is insurance regardless of your secondary coverage.

You make an excellent point. I never said the choices offered were wonderful, just that you HAD a choice. If you are convicted as a serial murderer in Utah, you have the choice of death by hanging, death by firing squad, and death by electrocution. Not very appealing, but nevertheless, a CHOICE.

There was no "condescension" intended, nor are you considered a "pizzant". Anyone can have an opinion as to the meaning of life, or who was our best president, or who makes the best pizza. But if you argue that the pizzeria serves predominantly Ethiopian food, it is no longer an opinion, it is simply factual wrong. If someone points out that this is wrong, it is not "condescension" , it is just setting the facts straight. It doesn't make anyone a "pizzant", just wrong regarding one specific issue. There are specific issues that I have been wrong on as well. I am not the enemy of those who felt slighted by TVH insurance change, just trying to shed some rational light on the subject.

Right but the question was about a person with nothing but boatload of money.

In any case my guess is that they are just trying to prevent double dipping... where your insurance company direct pays you a $1000 for a procedure because that is what the bill said but Shands ends up charging you only $600 after the discount you get when you pay it.

Web sites are usually not a good place to get the real details about things like this. It really something that would require talking with Shands to figure out.

In any case a Medicare Advantage plan has to cover any procedure that is covered by regular Medicare. So if your surgeon was the only one in the area who was qualified to do your procedure (and from what GE said it sounds like that may have been the case) UHC MA would have figure out a way to get him and the hospital paid.

I think you may be confusing TVRH (The Villages Regional Hospital) with TVH (The Villages Health) the group of physician practices in various locations around TV. They are not related organizations.


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DB---how does a provider, a hospital, and the insurer deal with reimbursement on an out of network referral????

I always loved patients with cash!

Having said that, most hospitals will first try to negotiate with the insurer to reach an equitable agreement. This might look something like 80% of the usual and customary fee paid by the insurer and the remainder as an out of pocket by the patient.

It would be extremely unusual for a hospital to completely turn down a sincere effort by an insurer to cover an out of network patient. In fact most health plans have a summary document which explains to a patient what % of a bill they can expect to pay as an out of pocket fee. And that % is always greater then what a patient would pay if they had stayed in network.


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I don't think that matter, as far as Shands is concerned, someone with UHC TV MA is uninsured. Let's see what DB has to say, he is the real expert on these type of referrals. All I can say is that I have made hundreds of out of network referrals, had 100% of them approved, and never had a patient give me feedback that they spent big bucks as a result.

Remember, UHC is an insurance company. They never lose. They look at their overhead, look at the cost of paying claims, look at their investment income then set a premium. What I've generally found is that any resistance comes from someone relatively low on the food chain that is guarding the insurer's money as if it were their own. Once you get to a higher level, you get a more reasonable response.

A hospital would rather receive some payment than receive nothing. But, this assumes the care is delivered in an emergent situation. I doubt Shands would provide a significantly reduced payment for an elective procedure. However, even in an elective situation one can usually negotiate a firm price.

Cosmetic procedures come to mind. Many hospitals that perform these procedures have developed (with the docs) a package price which includes combined hospital and physician fees.


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Now IF there is no provider in network that does the same procedure, and IF it is considered medically necessary to have that specific procedure, don't they cover it as though it were in network?

Did my post # 91 above answer you? If not I'll take a crack at it again. So many posts I'm having trouble keeping up!


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Yes, but the patient typically is still expected to pay a larger out of pocket fee by the insurer, since the insurer will almost always pay the out of network providers more than in-network providers. The former has no contract and the latter does, hence the difference in treatment.


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I guess the big question that people, including myself, would like to know is whether the UHC MA plan $4400(option 1) or $1900(option 2) maximum annual out of pocket expense still applies if the costs were incurred as a result of an approved out of network referral. (I assume if you just go without approval, you're on your own)

Don't know how many ways I can say the same thing. 🤔
1. Shands does not accept the Advantage Plan with or without an out of network approval.
2. Shands does not accept cash payments from an insured person.

The Medicare site says that an Advantage plan has to cover any procedure that traditional Medicare does.

"Medicare Advantage Plans must cover all of the services that Original Medicare covers. ...."

That's pretty unequivocal. If MA didn't work that way it seems like they would really be pretty iffy.

It also says

"The plan can choose not to cover the costs of services that aren't medically necessary under Medicare. If you're not sure whether a service is covered, check with your provider before you get the service."

The kinda' implies that UHC must pay for medically necessary services.

But the people who manage web site content are typically not the ones who write rules. But it seems like full Original Medicare coverage is what was intended for MA...

Medicare Advantage Plans cover all Medicare services | Medicare.gov

BTW UHC MA allowed my wife go out of network for some small services (~800.00) just because the in network provider was inconvenient to go to. Covered 100% after co-pay.

I believe you are correct. The key, as you note, is that the out of network referral is approved by the insurer and/or referring practice. It should work just as it would in a similar circumstance if an HMO referred a patient to a non network provider.


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Was the co-pay greater than or the same as if she had stayed in-network? Interested as a point for personal education?


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The same.

I was surprised. We literally told UHC that 45 min was to far to go when there was a provider in the bubble (well, The Villages) 15 min away. Took just two days to get it approved, no questions, no hassles.

The Villages Health - Survey
 

I could not find evidence of either point on the Shands website, but I did find the following information:

"1) Most health insurance companies, as well as Medicare, pay UF Health directly. Any portion of your hospitalization or care not covered by insurance will be your responsibility.

2) Coordination of Benefits (COB)
Coordination of Benefits, referred to as COB, is a term used by insurance companies when you are covered under two or more insurance policies. This usually happens when both husband and wife are listed on each other’s insurance policies, or when both parents carry their children on their individual policies, or when there is eligibility under two federal programs. This also can occur when you are involved in a motor vehicle accident and have medical insurance and automobile insurance. Most insurance companies have COB provisions that determine who is the primary payer when medical expenses are incurred. This prevents duplicate payments. COB priority must be identified at admission to comply with insurance guidelines. Your insurance may request a completed COB form before paying a claim and every attempt will be made to notify you if this occurs. The hospital cannot provide this information to your insurance company. You must resolve this issue with your insurance carrier for the claim to be paid.

3) Medicare
UF Health Shands Hospital and the University of Florida are approved Medicare providers. All services billed to Medicare follow federal guidelines and procedures. Medicare has a Coordination of Benefits clause. At the time of service you will be asked to answer questions to help determine the primary insurance carrier paying for your visit. This is referred to as an MSP Questionnaire and is required by federal law. Your assistance in providing accurate information will allow us to bill the correct insurance company. Medicare deductibles and co-insurance are covered by your secondary insurance. If you do not have secondary insurance you will be asked to pay these amounts or establish a payment plan. If you are unable to pay these amounts, we will help you determine if you qualify for a state-funded program."


Most hospitals will provide a list of insurances they accept, or the General type of information I found and noted above.

It would be very unusual for a major teaching hospital to NOT take MA plans. Teaching hospitals need educational material (I.e., patients) for Med students, residents, faculty and researcher.

I've run two, and know Shands well, but times change I guess.



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Interesting! That's good for patients though. Thanks.


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Besides being in or out of the TVH, do our amenity fees contribute to the maintenance and upkeep of the TVH medical facilities ?

Examples of being given " the boot ":
1. You are a major in the USAF with a family and have been up for promotion for Lt. Colonel two times and did not make the cut. You have served 20 years. Your next posting is a weather station in Northern Greenland for the next 36 months, if you do not retire. You have been given the " boot ".
2. You are a 50 year old Vice President of Advertising of a company headquartered in Dallas with a fat expense account recently acquired by a much larger one. You are offered a position in Missoula Montana as part the restructuring program managing a training program for high school drop outs or an early retirement package. You have been given the " boot ".
3. You use The Village Health model for your primary medical care and are told if you do not change your perfectly good insurance plan, which was perfectly acceptable when they first solicited you to be a patient, to one in which you have no interest whatsoever, you will have to find a new primary care physician. You have been given "the "boot ".

In each instance you had a choice as has been pointed out numerous times. It does not change the fact that a size 14 has just connected with your nether region.

Fascinating. In each instance you precisely laid out the available CHOICES, then proceeded to characterize it as being given "the boot", or no choice. Somewhere between getting from point A to point B you took an unscheduled left turn.

1) You can go to Greenland or retire----YOUR CHOICE
2) You can go to Montana or retire------YOUR CHOICE
3) You can change docs or insurance----YOUR CHOICE

Is there some new, secret definition of the word choice in the dictionary now that I am unaware of? Or is this common core vocabulary? Or maybe just fuzzy logic?

OhioBuckeye
 

I never heard of that because my heart Dr. is right accoss 441/27 from TVH & he wants to put a stent in a bypass artery & he wants to do it in Leesburg, only because if there's any emergency that comes up while doing the stent the TV hospital isn't equip to handle it & personally I wouldn't want to be there if I had a heart attack or my heart stopped like it did when I had my heart bypass. If you want to let TVH work on you in a case like this go ahead. I've had to many people tell me TVH isn't the best place to be in an emergency. Leesburg I was told was the 5th best heart hospital in FL. TVH isn't even mentioned, I like life to much. TVH has lost a lot of Drs. Again just my opinion!

Thanks for the pdf.. Those of us who leave TV for the summer months won't receive this letter from VHS. We never received their "boot" letter either. Had to find out from our supplemental insurance company that we had been released from their care. VHS sends all their written communication via third class mail that isn't forwarded by USPS. Not the best way to reach out to your present and past customers. But it is what it is.
While we loved our doctor and NP at Santa Barbara, I've already written to the heads of VHS to express my opinions prior to the boot. There were so many other ways they could have handled this situation - but chose not to... So be it.
Thankfully, there are many other great doctors and groups in the area to fill the gap. I won't be returning to VHS even if they decided to reverse their decision to not use my supplemental - which is also from United Healthcare..

OhioBuckeye
 

You know the first time I ever set foot in TVH, with someone playing the piano, I thought, WOW what a classy hospital. So I'm just wondering if the ones that see the inside of TVH are new residents here & just see the piano playing & how nicely the hall ways look are making their opinions about the care before really be admitted. When I first moved here I asked people about TVH that lived here 10 to 20 yrs. & most of them said it was just SO-SO. They might be able to put a stent in or a catheterization, but the real heart issues are actual heart surgery. Someone told me they do 5,000 stents a yr. so like most Dr. that only work out of 1 hospital will want to do stents before you actually have open heart. Again I'm only hearing old residents & they say go to Leesburg or Ocala for heart surgery.

OhioBuckeye, I just want to point out that this thread is about a survey which will be sent by TVH - The Villages Health, which provides services by primary care physicians.

All of your observations are about TVRH - The Villages Regional Hospital.

These two businesses are separate and have different ownership, administration and staff.

It looks like they learned their lesson, ours was preprinted in the stamp area "Presorted FIRST class US postage paid, Ocala, FL, permit #100", so you should get it forwarded, if you do not, I would complain to the post office.

It should be noted that being given choices and being screwed are not mutually exclusive.

Thanks for the info. We will look for it in our forwarded mail and report in if it should come our way. I'm not holding my breath -

Okay, not quite a " Sophie's Choice " situation. Perhaps more of a Cornelian Dilemma. I got the " Cornelization " from Villages Health just does not sound as good as the " boot " though.

Looks like we just found the common ground that we agree upon:beer3::beer3::beer3:

I don't want to make light of the choice VH gave a lot of their patients. But, as GE says, it's just a choice even though VH handled presenting the choice poorly. But it's a choice my wife an I have been given a number of times before we came to the Villages and how it is presented doesn't make it any less stressful.

I don't think the survey is being done because VH is thinking about moving away from Meidcare Advantage only. My guess, pure speculation actually, is that when they started VH based on the patient centered medical home concept they didn't realize that it wouldn't be viable based on orignal medicare. Once they finally did realize that they had to drop original medicare patients who didn't switch to MA.

And, more speculation, once they did realize this they hemmed and hawed and denied to themselves that they had a problem until at the last minute they had to executed a poorly planned transition to MA only.

And, as GE noted, doctors and insurance companies do this kind of thing all the time. All the management of VH are physicans who in the past had probably dropped or been dropped by insurance companies. There might be a few patients that gave them heartburn when that happened but they had survived that before.

Any yet more speculation... the survey is being done by VH because the heartburn was more than they expected and they wanted to know why. Any good company wants to do a post mortum, i.e. understand why, a process they used didn't work as expected.

I think the problem they had was that never clearly explained the patient centered medical home. That is they never gave a non-academic, non-conceptual explanation in terms of the practical benefits to patients, like same day appointments, hospitalists, the practical value of a PHP + team vs. a fee for service physician and so on.

To potential patients is was just another medical practice and all they had over other medical practices in the area was a nicer looking building. Why would anyone give up original medicare for that?

For my wife and I the transition to UHC MA actually was no big deal, but that's probably because of our life experience with health insurance.

In past 40 or so years before we came to the Villages the seemingly annual "Pick your health insurance event" we and a lot of other people go through due to employment changes or company policy changes or mergers and out of business events was always stressful and seemed to always resulted in less choices and more costs.

In that time we were given the "change your doc or change your insurance" choice 3 or 4 times. If the doc was our PCP we changed our insurance even if it cost more or had less options. If it was one of the specialists we saw we changed our doc.

Originally our insurance covered virtually any procedure from virtually any provider in the country. After a number of these "choice events" my wife had a serious medical problem but our coverage by then had restricted our choices and she couldn't go to the specialist she wanted. That was stressful but in the end the results turned out great and I doubt we could have found a specialist better that the one we ended up with from the insurance company's network. Over the years the limited selection of specialists never was an issue... maybe that is why we didn't view the limited network of UHC MA as a problem.

I thought most people have gone though the "change your insurance or change your doc" choice a number of times before coming to the Villages, but maybe that is not the case. I know we have some close friends who worked for a large utility for their entire working careers and we envied their health coverage and it's continuity. But most people we knew were in the same boat as us.

And one last piece of speculation, maybe wild speculation. I think VH's patient centered medical home and the change to MA only will be very successful. In fact... this is the wild part... at some point in the next 3 to 5 years all new patients of VH will have to switch to UHC MA. Yup, no under 65 patients any more except those that were "grandfathered in". The survey is going to help VH better explain what it is they are selling to make it attractive to potential patients. And until other practices in the area start patient centered medical homes new Villagers will be waiting in line to join.

DH and I received ours yesterday in PA.

My husband chose to remain in a job for 42 years knowing full well that the tradeoff in his lower salary allowed us to retire with benefits which would more than compensate us. One of those benefits was our current healthcare which is far, far superior to Medicare Advantage. To those of you who claim patients that refused to change their insurance to MA made a choice to do so should remember the promises The Villages made. It was published in their newspaper, The Daily Sun, that their healthcare would replicate that of a "Marcus Welby" philosophy. From what I remember from long, long ago, Marcus Welby was not only professional, he was an extremely thoughtful, knowledgeable physician who cared more about his patients than the almighty dollar. IMO The Villages didn't treat their patients with a caring attitude. First, they informed patients that although the healthcare was changing they would grandfather those people that already were being cared for by the VH. Again, I will say I for one am looking forward to a mutually, positive outcome of the "survey".