Medicare Advantage - Don't do it

[Soandso]

Not sure what you’re getting at here since they still take Medicare and Medigap plans which are subject to the same pressures. My take is the Mayo Clinic was tired of being stiffed by these Advantage plans.


This is not entirely true as there are exceptions. For instance you continue working past 65 and are covered by an employer plan you can join a supplement when you retire without penalty or higher premiums as my wife did.

I'm "getting at" since medical service costs have risen so fast that some providers, like Mayo Clinic, are no longer satisfied receiving the sum of money which Medicare and not Med.Advantage deems authorized for any specific coded service(s) provided. This is not a matter of stiffing a provider because they either can accept or opt out of accepting the Medicare coded payment amount since Med.Advantage plans only agree that their member plans (including co-pays) pay providers, like Mayo Clinic, what Medicare approves in U$.

Basically for each person enrolled in a Med.Advantage plan Medicare annually assigns a gross sum of money prorated to each Med.Advantage plan for duly administering that person's Medicare coverage paperwork. If after the year is up the person has utilized Medicare coded services in excess of that annual assigned amount then Med.Advantage must pay that out of it's profits. The flip side is if Med.Advantage has enough members who do not use more medical services than the total U$ Medicare pledged for all plan members then Med.Advantage still makes a profit.

I get statements from my Med.Advantage plan showing service provider, date rendered, amount provider bills, U$ amount Medicare approves for the coded service, amount Med.advantage paid for that service and if I might have any U$ sum to also pay. The combined amount of what I pay (rarely anything) plus the amount Med.Advantage pays always adds up to just the U$ amount Medicare itself legally approves for any coded service I had received from the billing provider.

Item:
Yes, working at Medicare age has the nuance you mention. I was retired at 65 so don't think about that.

 

[Alannn]

When investigating Medicare options, remember although it is federally administered, rules can vary from state to state. I'm glad to see this thread on ASR. Choosing health insurance is almost as important as choosing speakers. And certain future Medigap upgrades can require medical underwriting, which can lead to denial or higher premiums. It's not as simple as adding a subwoofer.

 

[kidprofessor]

My wife and I have had Medicare advantage ppo plans for a couple of years. Zero premium, reasonable annual out of pocket. Numerous medical procedures including surgeries. No need for approval to see a specialist. The insurance company has issued every authorization requested in a timely fashion.
When I compare this to the 24 to 25k we paid in household premiums before retiring it looks pretty good.

My pet peeve? Before the “affordable” care act our household premiums were 5 to 6k. A higher out of pocket than now, otherwise pretty much the same. A 400% increase in less than 7 years. Somehow I don’t recall that being mentioned when the law was enacted. In fact, I believe the opposite was promised.

It was well understood at the time ACA was passed that premiums would go up just as fast as before, but anything to avoid universal healthcare that every wealthy country has

 

[Petrushka]

I just have part B.

The hospital billed Medicare $50,000 for a surgery, and my part was $500. I don’t know how this works, but this kind of ratio has happened several times.

I paid about $250 for cataract surgery, plus $600 for eye drops. I don’t have prescription coverage.

 

[amper42]

I just have part B.

The hospital billed Medicare $50,000 for a surgery, and my part was $500. I don’t know how this works, but this kind of ratio has happened several times.

I paid about $250 for cataract surgery, plus $600 for eye drops. I don’t have prescription coverage.

While adding a supplement and drug plan can seem pricey I found things I had no grasp of when first signing up like regular shots for macular degeneration and other conditions can cost more than double the premiums. It's a crap shoot. If you self insure, it might work out. But, if one lives long enough they are likely to be introduced to new quality of life treatments that tend to be expensive.

 

[Somafunk]

I signed up for Medicare this year and specifically opted out of Advantage program for reasons mentioned. But I can see why people get it (like my brothers). My month payments currently with Plan N supplement is something like $500 a month! It is half of what it is currently with individual plan so I am not complaining. But coughing up $6,000 a year is not for everyone.

 

[JustJones]

Don't even try to understand US healthcare and insurance it's a morass. Same thing every year, bogging through the minefield of open enrollment. Are the same providers in my plan, are my medicines covered? How much will premiums and co pays increase ?

 

[Talisman]

As an Italian who benefits from the free national healthcare system, I always experience a certain degree of culture shock when I think that expensive health insurance is needed in America. The idea that someone who can't afford good insurance can't afford important medical care makes me very uncomfortable.

 

[Somafunk]

Don't even try to understand US healthcare and insurance it's a morass. Same thing every year, bogging through the minefield of open enrollment. Are the same providers in my plan, are my medicines covered? How much will premiums and co pays increase ?

I guess given my history with hospitals/healthcare - shattering 3 vertebrae/severe internal organ damage/punctured lungs/coma/30hrs surgery/6months hospital before I walked out at age 19, followed by my diagnosis of SPMS 7 years ago with all the medications/prescriptions (free of course) and complications that has brought that I’d be dead if I lived in the U.S.

As much as I rail against our NHS it hasn’t cost me anything really. Small things to be thankful for

 

[Petrushka]

While adding a supplement and drug plan can seem pricey I found things I had no grasp of when first signing up like regular shots for macular degeneration and other conditions can cost more than double the premiums. It's a crap shoot. If you self insure, it might work out. But, if one lives long enough they are likely to be introduced to new quality of life treatments that tend to be expensive.

Insurers are likely to resist paying for new and expensive treatments.

 

[JustJones]

This special time of year also brings the added benefit of between 5 and 10 phone calls a day, inundated TV advertising, internet and email advertising and plain old flyers in the mailbox. It's a bit mind boggling the amount of $$$ spent on selling health insurance. Audio is in the minor leagues by comparison.

 

[Soandso]

The hospital billed Medicare $50,000 for a surgery, and my part was $500. I don’t know how this works …

Hospitals are owned by corporations which have tax liability. Medicare sets the acceptable amount for any specific provided medical service(s) which the corporate insurance company(s) behind both Med. Advantage and Med.Supplement, as well as Medicare's own Part B, can pay to the billing entity (ex: your hospital). [Med.Supplement is getting that U$ amount from Medicare and then above that the Med.Supplement plan is using money enrollees paid as monthly premiums.]

Hospitals and incorporated group medical practices routinely bill for sums in excess of Medicare's approved payment schedule (ex: amount Medicare Part B covers). When they are paid an amount less than what they bill then at annual tax filing time the medical service provider (corporation) writes off the difference as a financial loss against earnings. The result is a reduction in their corporate tax amount due (I don't know if such paper losses can be carried over to other years to offset taxes to come).

Which gets us to the situation other commentators point to of some hospitals (and group medical practices I'll add) choosing to no longer accept Med.Advantage which only will pay what Medicare says is their approved U$ amount. Up until the last few calendar years the hospitals/groups were satisfied with the paper loss(es) they got compensating by using those eventually as tax write off(s). So why do hospital corporate owners no longer welcome the Med.Advantage tax loss leading strategy?

I propose several factors one being inflation driven hospital overhead operating costs (ex: electricity, disposable materials, facility insurance, maintenance/repairs, equipment replacement and non-medical staff salaries). Another confounder being their USA legal obligation to provide what has become increased levels of emergency room service (ex: more uninsured people with both legal and no legal residency using it for primary care necessitating more medical doctor/nurse hours) as well as USA law stipulating hospital admittance can not turn away anyone. In other words after the last several years given the USA's socio-economic conditions some hospitals' corporate accounts have so many losses to write off against their taxes they no longer obtain financial benefit from chalking up Med.Advantage paper losses once consider the hospital would incur real (not ledger entry) costs providing service(s) to a Med.Advantage patient.

 

[xanalog]

The 1986 cautious Ronald Reagan tale about

"The nine most terrifying words in the English language are 'I'm from the government and I'm here to help.'"

Still holds true but not as a political statement.

Our government is loath to run any program as a financially solvent responsible institution.
SocialSecurity, MediCare, ACA are all prime examples; as relevant to this thread.

We did our diligence:
Researching the various local MedicareAdvantage programs, based on our medical needs.
Selecting the optimal program/plan for one's particular needs is best done w/o the government's (or a comedian's) interference.
Finding the one that has an established (year-over-year) financial performance is worth it.
Investing in the company that you choose, is the clincher!

Our plan is a MedicareAdvantage HMO plan, but there are also some that are PPO.
In the last 6 years, we had AFIB, stroke, broken toe visits to ER.
Both of us do our yearly doctor visits, blood tests, vaccines, etc.
Our out of pocket has been zero; including RX and ERs.
Our locale is quite a competitive market; thus, even the authorizations are pre-processed w/o our involvement.
YMMV but we are fully satisfied with their service and their stock performance.

I paid about $250 for cataract surgery

ADD: That reminds me: I also had cataract post surgery red-laser zaps and green-laser zaps for glaucoma pressure reduction. both also at zero cost including prescription glasses.

 

[Martin]

Watched the video and like most of John Oliver's Last Week Tonight episodes it was very one-sided presenting the worst cases as indicative of the entire industry without presenting one iota of differing opinion. His shows all seem to paint the worst possible picture of whatever subject they're covering that week.

My mother and father had Medicare Advantage until they passed away at 68 in 2006 and 87 in 2021. My mother battled COPD and cancer and my father was healthy but battled cancer at the end. Their MA plans never denied service and paid 100% minus very reasonable deductibles.

I have had an Aetna health plan through work for the last 20+ years and love it except for the cost and deductibles. Still, my high deductible plan was much cheaper than paying the several hundreds of thousands of dollars of usage I've gotten out of the plan over the years. I just signed up for Aetna Medicare Select (HMO) that starts January 1st for $0 premium with a $3,300 annual deductible that includes drug, dental and vision coverage. All my doctors and local facilities are in-network.

I did the research on my own and chose the MA over plan G, part D, plus dental and vision coverage based upon past medical care and past experience with Aetna. As with any insurance there are good and bad. The trick is doing thorough research and choosing that plan that fits your personal needs best. And staying away from the hucksters advertising to "help" you. Oh, I and think living in Florida helps - if a doctor of medical facility wants to survive in this state they will be on as many insurers networks as possible.

Martin

 

[Sal1950]

As an Italian who benefits from the free national healthcare system, I always experience a certain degree of culture shock when I think that expensive health insurance is needed in America. The idea that someone who can't afford good insurance can't afford important medical care makes me very uncomfortable.

Nothing comes for free. Countries with national health care pay for it in higher taxes.
So far the majority of US citizens have supported the idea of some form of private healthcare, though seniors and the disabled get Medicare which covers some if not all costs.
Let's not get political here or the thread will be closed. This thread is for the discussion of US Medicare and it's Advantage options.

 

[amirm]

FYI my individual (non-medicare) premiums for this year were $1050 a month or about $13,000 a year! For next year, they were going to raise it to $1,280 or something like it for a total of $15,000! And this was for the lowest tier, bronze plan with terrible deductibles!

It is such a broken system.

 

[Doodski]

FYI my individual (non-medicare) premiums for this year were $1050 a month or about $13,000 a year! For next year, they were going to raise it to $1,280 or something like it for a total of $15,000! And this was for the lowest tier, bronze plan with terrible deductibles!

It is such a broken system.

WoW... @amirm that is not what I thought of the USA health care premiums/insurance at all. Just wow... i hope you are getting your money's worth and are well cared for.

 

[Petrushka]

I cannot do the math, but Medicare for everyone would be adequate, perhaps better than some countries that brag about their healthcare. I have no idea about the cost, but prices are so screwed up, there’s no way to figure it out.

 

[xanalog]

Don't blast me for asking an AI for assistance and a 'deep(er) search':

AI: As of early 2025, approximately 51–54% of eligible Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans, confirming the ~51% figure.

 

[Alannn]

@Martin, good points presenting the other side, from long ago and present. MA is often cheaper, and potentially satisfactory. Please don't miss the big news that lately MA has now become less profitable. Each year now, deny and delay MA tactics have become more mainstream. More and more now, the highest quality medical networks are not accepting MA. They cannot afford the overhead, and obstructions involved with getting MA to approve and pay promptly. MA may very well be great for you, but for sure it's more of a gamble. Although future medical needs often cannot be predicted, what we do know is the last 3 years MA has been on a downhill slide.