What’s wrong with “Medicare Advantage” plans?

Frame from a TV ad by a local agency that sells Medicare Advantage plans

At this time of year, ads hawking “Medicare Advantage” plans flood every possible media outlet, imploring seniors to call 1-800 numbers and contact their local insurance brokers for “free Medicare evaluations” where brokers can sign them up for Medicare Advantage (MA) plans, also called Part C plans, that offer premiums a bit lower than traditional Medicare and freebies like vision screenings, dental cleanings, gym memberships and a monthly allowance to spend on drugstore merchandise.

These plans definitely sound alluring, but don’t be fooled.

What seems like a good deal up front will likely be far more expensive in the long run because “Medicare Advantage” plans are not real Medicare plans. They are private insurance sold by for-profit insurance companies and they push subscribers into dealing with big bureaucracies that decide which doctors you can and can’t see, what care you can or can’t get, and that can deny you care for vague reasons if it isn’t in the companies’ best financial interests to pay for it.

In the words of my former colleague Wendell Potter, former Vice President of Corporate Communications for Cigna Health Insurance, who became a whistleblower against big insurance companies,, “Medicare Advantage” plans are neither Medicare nor an advantage. They’re a scam to keep people locked in the private, for-profit health insurance market where companies can continue to exploit them for years, even decades, to generate profits.

What’s so bad about Medicare Advantage plans?

“Medicare Advantage” (MA) plans were introduced 25 years ago on the theory that competition in the private insurance market would lead to better insurance and more efficiently-run plans. They mimic the private insurance many people have had for year in the workplace, with deductibles, copays and coinsurance.

MA plans are funded by the government, which pays private insurers a set amount for every person they enroll. The amount varies based on how healthy subscribers are, and the government pays higher rates to private insurers for the sicker subscribers.

Insurers must spend 85% of the money they get from the government on patient care. The other 15% is profit, so insurers have a built-in incentive to deny subscribers coverage to preserve their profits. Enticing seniors into purchasing MA plans early by offering them lower premiums and freebies while they are younger and relatively healthy, generates more profits for insurers in the long run. But as MA subscribers age and require more medical care, they increasingly face getting denied by their insurer for treatments and procedures they may need. This can force MA subscribers to have to go without care, or pay out of pocket for more of their own medical care. In addition, if the procedure or treatment your doctor recommends is denied by your “Medicare Advantage” insurer, you may have to go through a lengthy appeals process and risk having it denied again on appeal, or have your doctor devise a second choice care plan that may not be as good as the first, most highly-recommended course of treatment. In addition, the lower premiums MA plans advertise that lure them into these plans are often offset by the expense of copays and coinsurance.

What you need to know:

“Medicare Advantage” plans are private insurance plans that use the name “Medicare” to generate trust among seniors. They are NOT real Medicare plans. In fact, in 2023, House Rep. Mark Pocan (MN) introduced the “Save Medicare Act” (PDF) which would require these private plans to be called the “Alternative Private Health Plan Program” instead of using the confusing name “Medicare Advantage” plans.

But the bottom line is, if you buy into a “Medicare Advantage” plan, you are paying a private insurer to become a gatekeeper between you and your medical care.

TV 1-800 ad touting “free Medicare benefits Review” to recruit Medicare Advantage subscribers

MA plans restrict subscribers to closed networks of doctors and hospitals, called Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). These networks typically are limited and restricted to local areas, and can potentially block subscribers from getting the best care for a given condition. For example, if you are diagnosed with a rare form of cancer that can only be treated at a specialized national medical center like Mayo Clinic, Memorial Sloan Kettering in New York, or MD Anderson Cancer Center in Texas, but this medical center isn’t in your network, your Advantage plan can refuse to pay for the care you need. If you have an accident or get sick while outside of the state, and seek care at an urgent care clinic or an emergency room nearby, you could get stuck with thousands of dollars in medical bills if the doctor and medical facility you used were outside your network. Your MA plan won’t cover it.

MA plans also require doctors to get pre-approvals from insurers for many tests and treatments, and get pre-authorization for surgeries and procedures, so if you come down with a fast-moving illness and you need quick medical care, getting pre-approvals and pre-authorizations will needlessly delay your care and cost  precious time that could make a big difference in your medical outcome. Under MA plans, you usually need to get a referral from a primary care physician to see a specialist. MA plans can also put people in the position of having to battle an insurance company while they are sick or injured, to get the care they need.

Unlike Medicare Advantage, original Medicare does NOT have a profit motive, nor does it have gatekeepers

By contrast, original or “traditional” Medicare plans do not operate off a profit motive. Original Medicare is a government-run, fee-for-service program. Traditional Medicare’s only mandate is to “help the nation’s elderly meet their hospital, medical, and other healthcare costs.”(pdf)

Traditional Medicare subscribers can go to any doctor and facility in the country that accepts Medicare assignment (payment). In most cases, you won’t need a referral to see a specialist. No pre-authorization or pre-approval is required for tests, treatments or procedures you need. Original Medicare has less hassles and headaches and pays it’s portion of the Medicare-approved costs for your care easily, and whenever and wherever you need care. After you pay a reasonable annual deductible for the year, there are no further deductibles, copays or coinsurance to worry about.

Fraudulent billing and overcharging are pervasive

Another big problem with “Medicare Advantage” plans is that the corporate insurers that provide these plans have frequently engaged in fraudulent billing as a way to bilk the government out of more money.

Audits reveal Medicare Advantage plans typically overcharge the government by millions of dollars, at a rate of more than $1,000 per patient per year on average. Often companies add fraudulent billing codes for conditions patients don’t actually have, like chronic obstructive pulmonary disease (COPD), diabetes or cardiovascular disease, to make subscribers appear sicker to the government so they can collect more money while not actually providing services. The costs to American taxpayers of this fraudulent billing have skyrocketed over the past decade as more seniors are coerced into signing up for “Medicare Advantage” plans. This fraudulent added expense is also hastening the demise of Medicare overall, since costs of the program have increased greatly due to these private insurers’ malfeasance.

In October, 2022, the New York Times reported that 9 of the 10 biggest Medicare Advantage plan providers in the country have been accused of billing fraud. The federal government has sued four of the five biggest players in the national health insurance market — UnitedHealth, Humana, Elevance (formerly Anthem) and Kaiser — for fraudulently over-diagnosing subscribers so they can fraudulently charge the government more money.

So what should you do?

A 2021 survey found over half of people in America are confused by health insurance, so if you’re confused, you’re not alone.

Private insurers like customers to be confused or clueless, because it’s easier to manipulate a confused, clueless person into buying a plan that will benefit their company’s bottom line, even if it’s likely be detrimental to the subscriber in the long run.

Local TV ads try to get people who are already on traditional Medicare to switch to an MA plan

Medicare Advantage plans are fraught with problems like denials of care, fraudulent billing, difficulty in getting pre-approvals and pre-authorizations for tests, treatments and procedures, and bureaucratic obstacles like copays and coinsurance. Despite this, Medicare Advantage plans have been raking in record profits for private insurers while undermining original Medicare by unnecessarily raising program costs due to rampant fraudulent billing. At the same time, private insurers are putting the most vulnerable subscribers at risk by denying them care and subjecting them to bureaucratic obstacles to try to keep them from getting necessary treatments and procedures, especially if they are expensive.

So when you sign up for Medicare, don’t be fooled.

Be sure to sign up for traditional, government-operated Medicare, which pays 80% of medical costs. Get a supplemental plan to cover the remaining 20% the government doesn’t pay, and get a Plan D drug coverage plan, which you are required to have. At all costs, DO NOT sign up for a “Plan C” or a “Medicare Advantage” plan. If you’re already on a Medicare Advantage plan and want to get out of it, you can switch to original Medicare during the open enrollment period that runs from October 15 to December 7 of each year. After you sign up, your original Medicare plan will take effect on January 1 of the coming year. See an insurance broker to make this change, but be aware that the longer you stay on a Medicare Advantage plan and the more chronic illnesses you have, the higher the price will be for your supplemental coverage, which will make it more financially out of reach to switch.

Forgo the lure of the lower premiums and freebies up front in favor of signing up for a traditional Medicare plan. Traditional Medicare puts its beneficiaries’ interests — not profits — first. It will give you better, far simpler, more straightforward and user-friendly coverage that will be easier to understand, and that will be more reliable and affordable and less of a hassle in the long run.

If you have the time and want more information on why MA plans are bad, I suggest watching this 12 minute video (below) by a doctor that explains the problems with “Medicare Advantage” plans, and why people are better off avoiding them.

It’s well worth the time to watch it before you choose a plan. The doctor in the video talks fast and packs in a lot of information, but I guarantee you will understand everything he has written on the white board by the time he’s done:

 

  27 comments for “What’s wrong with “Medicare Advantage” plans?

  1. When my insurance through United Heath Care, R.M. Health Plans.. started offering me ‘gift cards’ for some preventive procedure, ‘why not’, I gave two away as Christmas Gifts to my Grandchildren. Something UP with that kind of insurance! And then I was insisted upon going to a dr. appointment several times for NO needing apparent reason, I finally asked the assistant I end up talking to “do the doctors need to do this to get government grants ?” yep! I am grateful for the coverage I have and have not changed it but the insurance run around taking up more than half of a quick appointment keeping up with the insurance requirement on stats got old. Being sent to one specialist after another on a never ending merry go round I finally said ‘I am through with doctors!” God is my M.D. The wear and tear of going to two or more appointments a week was too much stress in itself and being sent to yet another dr. to get one script filled took Three appointments!, then I get a monthly refill finally, and when I call in for refill, “you have to make an appointment to get this”. Done! Self care and good sleep with excellent nutritional practices and sunshine. Enough!

  2. Didn’t get around to it this year, but have written 2 letters to the Sentinel in past years about “Advantage”. The fake “Licensed Medicare Agent” and “Medicare Advisors” who have NO relationship to Medicare, and are nothing else than salespeople making commissions on selling policies from the insurance giants. The “you have to choose a Medicare plan” nonsense. The “you’ll owe 20% of the doctor bill” warning against real Medicare, conveniently ignoring that your copay is actually just 20% of the “Medicare approved amount” for a service – usually 1/2 or less than the actual billed amount. Example – primary care visit for me: Bill from doctor $329 – Medicare approved amount $131.65 – I paid $26.33, not $65.80. . And worst of all, the countless $ billions paid over the years in pure giveaway to the big insurers, as we all are paying significantly more of our taxed dollars for the continued overpayment to them out of the trust fund. AARP is particularly bad – usually the voice of protecting seniors, yet their lucrative $ relationship with United Healthcare has them pushing advantage plans themselves, rather than campaigning against the overpayment that is fleecing millions.

  3. Great summary, Wendell Potter has been a great advocate in this field. There is a great podcast about how to deal with insurance issues and it is called; “An Arm and a Leg”. It is entertaining and informative put out by Kaiser Health (not the hospital system).
    It is disgusting that these predatory companies are allowed to misrepresent and scam consumers as they do. They are draining Medicare and pocketing profits at a tremendous cost to the taxpayer. I cringe every time I hear the words “Medicare Advantage”. GOP generated hoax.

  4. Boy, why does insurance have to be so complicated. I’m on PERACare, where we don’t have any other options. It’s Medicare advantage, as I understand it. I haven’t had problems other than docs who don’t accept medicare (my plan). Yes, we need Medicare for all for lots of reasons

    • I had a choice of PERACare but I didn’t have the years of service to get a discount that made it affordable. I’m very satisfied with my gap plan and my Part D plan that covers my prescriptions with no monthly charge.

  5. Interesting perspective. Of course, being one person’s perspective, well .. you know the rest. I have a Humana Gold Advantage plan. I mistakenly forgot to pay my Plan B premium to Medicare and never received notice until several months after my Plan B was cancelled. Humana continued to pay the bills. I also enrolled my late mother into an Humana Gold plan several years before her death. I never had a single issue with doctors, pre-approvals etc … NOW .. my b/f has basic Medicare .. no Medigap. He’s had significant health issues – ugh – he now owes the 20%, which is upwards of $20,000.

    • I have to say Anne’s info is accurate. We have kept Medicare and have UHC plan F
      supplemental..worth it! In all years through now all but $400 for uncovered labs was paid. A bargain when you see the huge amounts paid out.

  6. Thank you so much for this on Medicare Advantage Plans. Another example of “If it seems too good to be true, it is NOT!

  7. The problem starts with Plan D, which covers medication, and you are required by the government to buy, otherwise you will get fined, so you need to find a private company who will cover it. “Medicare Advantage” covers Plan D. I understand that once you get it, you are giving them the power to administrate your government Medicare. The first year I got Humana Medicare Advantage, they told me it would cover some dental, which I really wanted, but it didn’t turn out to cover any dental at all. I tried to get rid of it the following year, but I didn’t find a company for Plan D, so I kept it. They do have different plans within the “Humana Medicare Advantage” plan. That second year, I was covered by them for some dental work. Now, it is accepted also at more places in the valley, so I’m not having problems with that. I have noticed that now I am also asked to show both my “Humana Medicare Advantage” card as well as my government Medicare card. That has worked well for me this year. I have to ask every time if the facility, like labs, is “in the network” for Humana Medicare Advantage. However, after I get lab work, or X-rays, some doctor I do not know sends a bill. From calling the lab and Humana, I found once that I didn’t have to pay for that. In another case, I had to, plus Humana said they didn’t authorize the last dental service, but my dentist said it was covered and it was paid for already. Definitely confusing. Since I am being asked to show my Medicare card together with my “Humana Medicare Advantage” every time, I should not have a problem should I have to see a doctor somewhere else in the country if I show them my government Medicare card, I think. Surly, you will be taken advantage of at any chance “they” have – maybe that’s where the name comes from. I havent’t decided if I want to keep it.

  8. Thank you Anne for posting this. All the more reason for Universal Healthcare in America. Medicare Advantage was George Bush’s and the Republican party’s first major attempt to privatize Medicare and give Billions of $’s to the insurance industry.

  9. Good explanation. I tell patients to avoid advantage plans like the plague. Question I have I why programs such as 60 minutes sell out to advantage plans ( united) In their last minute segment. Just sleazy.

  10. Thank goodness I’m a service connected Vietnam veteran. I get “free” medical care anywhere in the US. That’s what I’m told. I paid dearly for it 50 years ago.

  11. Thanks for addressing this Anne.
    I was asking this question a few years ago when my dr. sent a notice she would not accept an Advantage plan.
    In addition to being outside of Medicare with an Advantage plan I was told by relatives in the medical field they do not fairly reimburse medical bills and you might not get all the services you need.
    They have a long ways to go to prove to us the coverage will be adequate to our needs.

  12. My confusion came about from hearing that many doctors wouldn’t accept Medicare patients. I had friends who had to keep searching for doctors who would accept Medicare over patients with other types of insurance. I have no idea anymore whether this was a true or false assumption, but I went on to take Medicare Advantage with the belief that it would get me to basic care without having to search for that care. I would welcome clarification around this part of the issue.

    • My guess is that doctors listed in Medicare Advantage plan networks must accept Medicare Advantage plans that include them in their network. In any case, docs in these networks will have to spend a lot of their clinical time attempting to get pre-authorizations and pre-approvals for treatments, tests and procedures for their patients. These “Mother-may-I” plans probably are quite frustrating for them. Pre-authorizations, referrals, etc. and such “gatekeeping” functions are not requirements of original Medicare plans. What the doctor says the patient needs, real Medicare pays for. Period.

  13. Well said. I would only add that when you sign up for an advantage plan, it becomes your primary insurance.If you want to switch back, Medicare doesn’t have to accept you.

    • If you have a Medicare Advantage plan want to switch back, Medicare will accept you, but you might have trouble getting a Medigap plan to cover the 20% Medicare doesn’t pay, or you might have to pay more for a Medigap plan than if you had signed up for it when you first got on Medicare. This is because Medigap plans are still private insurance, and they screen for people who are in fairly good shape, without expensive chronic illnesses.

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