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The health care industry is organized by insurance companies. For physicians to be able to receive any payment from an HMO/PPO or medical advantage insurance company they must be a member of that plan. Insurance plans limit which doctors can be a member, mostly to control cost. So when your doctor says that you must be a member of a certain plan - it is probably because she or he is not an authorized physician. Of course, a person can pay a physician directly - but that would be costly. It is important every open period for medicare to assure that your providers continue to be a member of the plan. If keeping your physician is important than you will need to change your plan. Of course there may be a trade-off on cost and benefits. There are agencies that can help you do this analysis.
Ms. Randall is right. It's not just Medicare. I wanted to keep my PCP but she didn't accept the insurance I had. I didn't see her for a year.. The following year, I went to her website and made sure she accepted the plan before I signed up,for it. There was no real forcing or demanding, it's just the way it is. If you want to continue seeing a certain doctor, you need to sign up for a plan they accept or change doctors.
Health care in the US is basically a closed system with access available to the consumer AND also the providers as per whatever insurance payor they have.
Reg - for you what probably as happened is that the Village has entered a negotiated payment agreement with United as a member or preferred provider. So the doctors, therapist, hospitals, etc. at village are all affiliated providers with united and have accepted to be paid at whatever rate United has set to be market rates for your area.
Your doc may do private pay alongside being with United.....it will be quite a bit of $ if your just used to only doing a copay. But please keep in mind that even if you do private pay say for your internist, if your internist writes orders for tests or that you need a consult with a cardiologist....that the lab & cardiologist have too entered an agreement with United. Thats why its considered a "closed" system. So your private pay costs could be huge and you may have to pay up front before you even see the MD.
If your very rural or small town / city, the options for care will be very very limited. So may need to travel to a big city where there is a health science center affliated with a medical school to find providers who take all the various insurance payors and have benefits staff who know how to bill & code for each insurance carrier.
The only solution imho is universal single payor health insurance......which seems to be beyond the current political will to ever happen in the US. Think carefully when you vote in November as to whomever you are voting for would be supportive of universal health care system.
Medicare Advantage Plans are different from Medicare in that they have Net-works. Some Doctors refuse to join a Net-work but will join others. I'm not sure for the reasons, But with that kind of attitude you may want to find another doctor
Reg, you probably signed some acknowledgements and other forms when you signed up with Village Health. And probably buried somewhere in size 2 font in those contracts are the rights to restrict your medical providers.
Unless you can't live without your doctor find one in your plan, you can either call or go online to your Medicare advantage insurance plan and find a doctor in your plan.
MsRandall is right on with her answer. Doctors cannot force you to take any certain plan, but since they can only accept patients who have certain plans, they can say that you would have to go to a provider under the plan you have. That's one reason we switched to the regular Medicare because as Garden Artist says, you can go to any doctor - as long as they accept Medicare. Some doctors are opting out of seeing Medicare patients at all now because of all of the restrictions placed on them, telling them what they can and can't do with their patients, and paying them very little for what services they will pay for. And with regular Medicare, you can often choose what specialists to go to without having to have a referral - as long as that particular specialist's office doesn't have their own rule about needing a referral to see them.
Some people are recommending "just" changing physician. but if you or your family member is dealing with chronic illnesses/ disabilities and you have a physician you like and who is doing a great job; it seems to me that keeping that physician might be a significant priority. Part of being able to do a good job is the physician knowing the patient, I don't you can easily replace the value of a longer history with a good physician.
Again, Ms Randall, you're right. That's why I didn't see my doctor for a year. It all boils down to finances. If money is no object and Reg can continue on with the physicians they have on board, that's wonderful. However, in my case, I could never afford the out-of-pocket costs to keep my doctor. As it is, my lousy insurance coverage and high deductible that I have now still preclude me from visiting specialists and having surgery that would make my life easier and less painful. Sometimes it's just a lose-lose situation.
regfallin: The real issue is that you are under the "umbrella" of The Villages (Florida) jurisdiction. Now that I've had some time to get back to my laptop, I see that "The Villages" in Florida is an active retirement community. Perhaps when you signed on with this "active retirement community" they did dictate what medical plans they accepted in the larger Medicare supplemental plans scheme of things. I don't know, but the first thing I would do if I were you is to go to your property manager or to look at your contract.
MsRandall: My Medicare and Medicare Supplemental was set up pro bono by an insurance agent who came to the house a few years back. He reviewed which doctors I saw and I signed up for Medicare Supplemental Plan F. In this case, the OP resides in an active retirement community, which may have some bearing on it. The only time I have ever had to ask a doctor "do you accept Medicare patients?" is to by GYN and that was a yes.
Igloo: I agree on your comment that The Villages active retirement community has already established what their residents' Medicare Supplemental Plan will be.
Some Docs will try to sign up and be a provider for whatever insurance plans one has...that means, they must apply to each insurer, to be one of their providers; that can be a confusing, complicated, arduous process. Other Docs offices just select some of the more popular plans, sign up to provide for them, and don't even consider trying to access other Plans. One Glitch to signing up to be a Provider: Plans can tell a Doc "we've got too many of your specialty now, so you have to wait and try applying next year"...the Doc is stalled-off until that approval goes through...or they give up. If your Doc won't apply to be a Provider for your Plan [ask their business office, or whoever staff handles insurance], your only choices that I know of, would be to change your insurance plan, or find a Doc who accepts the Plan you have. Be aware: Advantage Plans lock-up your Medicare, and these have about a 30-mile radius from their offices/facilities, beyond which you cannot get coverage, unless it's a bona fide emergency, seen in an emergency room, wherever you are traveling in the USA...and even then, they can refuse to cover the medical bills. If you travel, the Supplemental Plans will travel with you, usually [some don't]. Example: I signed onto a Group Health Medicare Advantage Plan [Advantage Plans are often HMO's], as it's something I could afford. But, there were other outside providers I'd like covered. None of the outside providers can bill my Medicare, as long as it is locked into the Advantage Plan. So, other providers have gone through lengthy, confusing paperwork to become an authorized Provider for Group Health Advantage Plans ...and must apply separately for other Plans under the Group Health umbrella.. One of them was told the Plan already had too many of that specialty, therefore she had to wait and re-apply next year. The other one took many months to get through the tangled application processes, but finally got approved.
Another thing might modify what one chooses to do: Insurers break data down to Counties. Some counties are very poor. In poor counties, Insurers think they reimburse disproportionately high, therefore, refuse to sell Plans in those poor counties. However, breaking data down per County, allows Insurers to tweak the system to allow them to not cover as much. [Allows 'artifact' data, not real data] Grays Harbor County, WA, is one of those. I'm sure there are many across the Country. This makes finding good coverage difficult at best, with few plans to choose from, of any kind, if one resides in a poor county. Bottom line: States should mandate that insurers must only break their data down Per State, not County level, as that skews coverage in favor of insurers, not patients and Docs. States can mandate Insurers cover certain things, or not be allowed to sell policies in that State...WA did that years ago, mandating insurers had to cover some alternatives, or not sell Policies in WA. Mandating date per State, not County, could cut out much confusion and problems related to Insurers not covering in poor Counties. And Insurers really won't like that at all. This will only happen if legislators are pushed, by voters, to do that.
Medicare Advantage plans are different than plain Medicare in that Advantage plans include a private insurance segment while Medicare is completely federal. The plain Medicare supplements must provide certain things to be considered viable for that Medicare plan. I’d be wary of any type of pressure to sign up for a particular plan. I'm not a Medicare expert but my guess would be that Advantage plans - like any private plans - may have more leeway in deciding who they cover. Plain Medicare (Plan F is the most expensive supplement but great since there are no co-pays) will supplement whatever Medicare covers as long as the facility takes Medicare. Advantage plans generally cover more things such as vision and sometimes dental but there are copays and you are dealing with a private insurer with more clout in the final page than with straight Medicare so you need to choose carefully. As was mentioned, doctors may have to sign up for providing care for each plan. I'm not sure how that works. All of the Medicare and Medicare Advantage choices can be complicated so making these choices is easier with someone who knows your state and federal laws as well as all of the possible plans. The problem is finding someone who can help but doesn't have something to gain by steering you toward a certain plan. There were some excellent answers here. As always, I learned just from reading. Thanks to this wonderful group of people. Carol
My understanding is he has to cover you for only 30 days after giving you notice Does he take ONLY ONE Medicare Supplemental or Advantage Group? IF he accepts insurance from other insurance payers & insists you change to a group that pays him better OR differently, THAT should be reported to AMA & state Medical Lisence Board!!
Some insurance plans pay $X per patient - period! If you need more visits & tests the Doctor/Group pays for it. Call your State Insurance Office and State's Attorney. They can find out if your doctor is in one of these 'prepaid' or pay per patient plans. If so, making his 'high resourse' patients change is a breach of contract with the insurance company that he contracted aith and got paid by It is also illegal and the States Attorney will check into how many other victims there are. Also call your State Senator ( not US Senate), and they can and will help you if something is fishy. Believe me a letter ffom their office goes a long way, even if technically a law is not broken They can also file a complaint with the proper state licencing boards ( Doctors & Insurance) on your behalf
Ms Randall, relw ood, Mcskeech all correct. Beware, Doctors may be included on a supplemental plan list when you sign up in Oct-Dec. Then drop out of the plan ( referring to your existing doctor), or doctors may not take new patients at all, even though the list says they will
Many groups now have 'gag orders'. I had basic Medicare plus non-restricted Supplemental, but the prompt care doc would not give me a script for labs or PT, had to only send me to their group. I only foumd this out because I got insistant for answers Had bad experience with their PT group and wanted to go to one I liked a lot. This was not even my primary care doctor, but the group served 40% of our city.
Doctors on lists should not be allowed to drop during time patients are stuck in the group. That should be illegal.
If you are not in an HMO plan, or PPO, Corporations should not dictate limits on specilists, labs, etc to line their bottom line! If they do it. They should have to disclose it Instead they say,"Our scheduler will be calling you to set it up" or we wired the order over to lab X or hospital Y. Hope this helps?
regfallin: Again, I suggest you contact the manager at "The Villages," as that is where you say you live in Florida. On its website, I was able to locate "The Villages Health-Inventing a New Paradigm for Care." You should read it.
If you are eligible for Medicare, we want you to know that the only Medicare Advantage plans The Villages Health participates in are those offered by UnitedHealthcare®.
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) UnitedHealthcare® Medicare Advantage Dual Complete UnitedHealthcare® Group Medicare Advantage PPO
A side note--I know that AARP is managed by United Health Care.
I wish I had more time to tell you about my parent's Medicare HMO from United Healthcare the Villages. Used it at ORMC for a lengthy stay recently (all in-network) and UHC paid out what they said was due (less than $20,000). However, ORMC is now "balance billing" us the difference (over $400,000+). They say this is unlawful, but they are doing it and we're having to pay an attorney to fight it.
By proceeding, I agree that I understand the following disclosures:
I. How We Work in Washington.
Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services.
APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
II. How We Are Paid.
We do not charge you any fee – we are paid by the Participating Communities. Some Participating Communities pay us a percentage of the first month's standard rate for the rent and care services you select. We invoice these fees after the senior moves in.
III. When We Tour.
APFM tours certain Participating Communities in Washington (typically more in metropolitan areas than in rural areas.) During the 12 month period prior to December 31, 2017, we toured 86.2% of Participating Communities with capacity for 20 or more residents.
IV. No Obligation or Commitment.
You have no obligation to use or to continue to use our services. Because you pay no fee to us, you will never need to ask for a refund.
V. Complaints.
Please contact our Family Feedback Line at (866) 584-7340 or ConsumerFeedback@aplaceformom.com to report any complaint. Consumers have many avenues to address a dispute with any referral service company, including the right to file a complaint with the Attorney General's office at: Consumer Protection Division, 800 5th Avenue, Ste. 2000, Seattle, 98104 or 800-551-4636.
VI. No Waiver of Your Rights.
APFM does not (and may not) require or even ask consumers seeking senior housing or care services in Washington State to sign waivers of liability for losses of personal property or injury or to sign waivers of any rights established under law.
I agree that:
A.
I authorize A Place For Mom ("APFM") to collect certain personal and contact detail information, as well as relevant health care information about me or from me about the senior family member or relative I am assisting ("Senior Living Care Information").
B.
APFM may provide information to me electronically. My electronic signature on agreements and documents has the same effect as if I signed them in ink.
C.
APFM may send all communications to me electronically via e-mail or by access to an APFM web site.
D.
If I want a paper copy, I can print a copy of the Disclosures or download the Disclosures for my records.
E.
This E-Sign Acknowledgement and Authorization applies to these Disclosures and all future Disclosures related to APFM's services, unless I revoke my authorization. You may revoke this authorization in writing at any time (except where we have already disclosed information before receiving your revocation.) This authorization will expire after one year.
F.
You consent to APFM's reaching out to you using a phone system than can auto-dial numbers (we miss rotary phones, too!), but this consent is not required to use our service.
Reg - for you what probably as happened is that the Village has entered a negotiated payment agreement with United as a member or preferred provider. So the doctors, therapist, hospitals, etc. at village are all affiliated providers with united and have accepted to be paid at whatever rate United has set to be market rates for your area.
Your doc may do private pay alongside being with United.....it will be quite a bit of $ if your just used to only doing a copay. But please keep in mind that even if you do private pay say for your internist, if your internist writes orders for tests or that you need a consult with a cardiologist....that the lab & cardiologist have too entered an agreement with United. Thats why its considered a "closed" system. So your private pay costs could be huge and you may have to pay up front before you even see the MD.
If your very rural or small town / city, the options for care will be very very limited. So may need to travel to a big city where there is a health science center affliated with a medical school to find providers who take all the various insurance payors and have benefits staff who know how to bill & code for each insurance carrier.
The only solution imho is universal single payor health insurance......which seems to be beyond the current political will to ever happen in the US. Think carefully when you vote in November as to whomever you are voting for would be supportive of universal health care system.
Other Docs offices just select some of the more popular plans, sign up to provide for them, and don't even consider trying to access other Plans.
One Glitch to signing up to be a Provider:
Plans can tell a Doc "we've got too many of your specialty now, so you have to wait and try applying next year"...the Doc is stalled-off until that approval goes through...or they give up.
If your Doc won't apply to be a Provider for your Plan [ask their business office, or whoever staff handles insurance], your only choices that I know of, would be to change your insurance plan, or find a Doc who accepts the Plan you have.
Be aware: Advantage Plans lock-up your Medicare, and these have about a 30-mile radius from their offices/facilities, beyond which you cannot get coverage, unless it's a bona fide emergency, seen in an emergency room, wherever you are traveling in the USA...and even then, they can refuse to cover the medical bills.
If you travel, the Supplemental Plans will travel with you, usually [some don't].
Example:
I signed onto a Group Health Medicare Advantage Plan [Advantage Plans are often HMO's], as it's something I could afford. But, there were other outside providers I'd like covered.
None of the outside providers can bill my Medicare, as long as it is locked into the Advantage Plan.
So, other providers have gone through lengthy, confusing paperwork to become an authorized Provider for Group Health Advantage Plans
...and must apply separately for other Plans under the Group Health umbrella.. One of them was told the Plan already had too many of that specialty, therefore she had to wait and re-apply next year. The other one took many months to get through the tangled application processes, but finally got approved.
Insurers break data down to Counties.
Some counties are very poor. In poor counties, Insurers think they reimburse disproportionately high, therefore, refuse to sell Plans in those poor counties. However, breaking data down per County, allows Insurers to tweak the system to allow them to not cover as much. [Allows 'artifact' data, not real data]
Grays Harbor County, WA, is one of those.
I'm sure there are many across the Country.
This makes finding good coverage difficult at best, with few plans to choose from, of any kind, if one resides in a poor county.
Bottom line:
States should mandate that insurers must only break their data down Per State,
not County level, as that skews coverage in favor of insurers, not patients and Docs.
States can mandate Insurers cover certain things, or not be allowed to sell policies in that State...WA did that years ago, mandating insurers had to cover some alternatives, or not sell Policies in WA.
Mandating date per State, not County, could cut out much confusion and problems related to Insurers not covering in poor Counties. And Insurers really won't like that at all.
This will only happen if legislators are pushed, by voters, to do that.
The plain Medicare supplements must provide certain things to be considered viable for that Medicare plan. I’d be wary of any type of pressure to sign up for a particular plan.
I'm not a Medicare expert but my guess would be that Advantage plans - like any private plans - may have more leeway in deciding who they cover. Plain Medicare (Plan F is the most expensive supplement but great since there are no co-pays) will supplement whatever Medicare covers as long as the facility takes Medicare.
Advantage plans generally cover more things such as vision and sometimes dental but there are copays and you are dealing with a private insurer with more clout in the final page than with straight Medicare so you need to choose carefully. As was mentioned, doctors may have to sign up for providing care for each plan. I'm not sure how that works.
All of the Medicare and Medicare Advantage choices can be complicated so making these choices is easier with someone who knows your state and federal laws as well as all of the possible plans. The problem is finding someone who can help but doesn't have something to gain by steering you toward a certain plan.
There were some excellent answers here. As always, I learned just from reading.
Thanks to this wonderful group of people.
Carol
Does he take ONLY ONE Medicare Supplemental or Advantage Group?
IF he accepts insurance from other insurance payers & insists you change to a group that pays him better OR differently, THAT should be reported to AMA & state Medical Lisence Board!!
Some insurance plans pay $X per patient - period! If you need more visits & tests the Doctor/Group pays for it. Call your State Insurance Office and State's Attorney. They can find out if your doctor is in one of these 'prepaid' or pay per patient plans. If so, making his 'high resourse' patients change is a breach of contract with the insurance company that he contracted aith and got paid by
It is also illegal and the States Attorney will check into how many other victims there are. Also call your State Senator ( not US Senate), and they can and will help you if something is fishy. Believe me a letter ffom their office goes a long way, even if technically a law is not broken
They can also file a complaint with the proper state licencing boards ( Doctors & Insurance) on your behalf
Ms Randall, relw ood, Mcskeech all correct. Beware, Doctors may be included on a supplemental plan list when you sign up in Oct-Dec. Then drop out of the plan ( referring to your existing doctor), or doctors may not take new patients at all, even though the list says they will
Many groups now have 'gag orders'. I had basic Medicare plus non-restricted Supplemental, but the prompt care doc would not give me a script for labs or PT, had to only send me to their group. I only foumd this out because I got insistant for answers
Had bad experience with their PT group and wanted to go to one I liked a lot. This was not even my primary care doctor, but the group served 40% of our city.
Doctors on lists should not be allowed to drop during time patients are stuck in the group. That should be illegal.
If you are not in an HMO plan, or PPO, Corporations should not dictate limits on specilists, labs, etc to line their bottom line! If they do it. They should have to disclose it
Instead they say,"Our scheduler will be calling you to set it up" or we wired the order over to lab X or hospital Y.
Hope this helps?
The Villages Health is patient-centered, community based and primary-care driven.
If you are eligible for Medicare, we want you to know that the only Medicare Advantage plans The Villages Health participates in are those offered by UnitedHealthcare®.
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)
UnitedHealthcare® Medicare Advantage Dual Complete
UnitedHealthcare® Group Medicare Advantage PPO
A side note--I know that AARP is managed by United Health Care.