Medicare Advantage - Don't do it

[Power Pop 23]

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.

Agreed.

One well-to-do relative who was eligible for Medicare, opted to pay their primary physician an annual retainer fee - starting originally in the low five figures - in the late 1990's - to obtain quicker access to medical care.

 

[Somafunk]

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.

How is that affordable?, what about those who earn minimum wage?, on benefits etc or with life long illnesses or disability?.

Your monthly premiums are around 80% of my monthly disability benefits (once converted to £).

I read so much about poor sods who get hit with massive bills of hundreds of thousands of $ for medical costs, I’m on various MS forums and one in particular in the U.S - the bills some folk have posted are eye watering, especially for what I can access/get prescribed for free…..it’s not right in such an obscenely wealthy country with billionaires

 

[Sal1950]

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.

OMG, Amir after all your time and position at Microsoft you didn't come away with some sort of medical insurance?
I guess not but that sucks,
I really don't know what your getting for all that money, it better be red carpet.

How is that affordable?, what about those who earn minimum wage?, on benefits etc or with life long illnesses or disability?.

It's not ?
I had a trauma medical issue in Feb with Doc and 2 months of in-hospital bills adding up to over a $500,000.
I only have Medicare, no advantage plan, and at the end of the road I've only had to pay a little over $2,000 out of pocket.

 

[Somafunk]

It's not ?
I had a trauma medical issue in Feb with Doc and 2 months of in-hospital bills adding up to over a $500.000.
I only have Medicare, no advantage plan, and at the end of the road I've only had to pay a little over $2,000 out of pocket.

Ouch…hope you’re on the mend and out of the woods…..the only folk benefitting from such a scheme are not the patients

 

[Soandso]

… lately MA has now become less profitable.

My Med.Advantage changes for 2026 reflect the insurer's potentially diminished profitability over 2025. I'll still pay U$0.00 monthly premiums and get Medicare's drug Part D (not to be confused with any Med.Supplement Plan "D"). But here's some relevant changes obviously not in my financial favor.

Maximum out of pocket [pertains to only covered Medicare Part A & B services] was (2025) U$1,000 vs. U$4,000 in 2026. Inpatient Hospital copay was U$200/d just for days 1-4 vs. U$300/d just for days 1-7 [In-patient psychiatric hospital was U$150/d just for days 1-4 vs. U$300/d just for days 1-7.] And for the drug coverage (Part D) deductible was U$420 vs. U$615 [insulin and vaccines excluded] with the 6 drug "tier" stages in 2025 vs. 2026 relatively similar until the "catastrophic" stage paying U$0.00 for drugs. Prior-authorization circumstances before "may" have been required vs. not (2026). Routine acupuncture and/or chiropractic and/or podiatry and/or non-emergency medical transportation and/or quarterly over-the-counter allowance benefits (2025) are in all categories none for 2026. Intensive and/or regular cardiac rehabilitation sessions was $0.00 co-pay for either vs. U$65 2026for intensive and U$50 2026 for regular. Pulmonary rehab co-pay was U$0.00 vs. U$40 for 2026. Emergency services whether nationally or worldwide co-pay was U$140 vs. U$150 2026 for either national or Worldwide emergency. Supervised exercise therapy was U$0.00 vs. U$30 2026 copay. Routine eyewear was up to U$200 vs. U$100 in 2026. Hearing aids was up to U$1,000 per ear vs. up to U$350 2026 per ear. Routine dental was unlimited diagnostics vs. limited to 1 diagnostic every 2 years. Outpatient hospital observation depending on way entered was U$140-200 co-pay vs. U$150-200 in 2026. Partial hospitalization was U$130/d vs. U$175/d in 2026. And finally skilled nursing facility (Medicare covered admission) copay day 1-20 U$0.00 then copay day 21-30 U$214/d vs. 2026 copay day 1-20 U$0.00 then copay day 21-40 U$218/d. Remember this is my domicile based eligible Med.Advantage plan which could be different than one in a different town/city in my same county in my state.

At this point I'd like to add an observation about Med.Supplement with reference to 2025 plans. What follows is about my same Med.Advantage insurer's own Med.Supplement plan they called "High-Deductable" Plan "G" (there is also a regular deductible Med.Supplement Plan G).

In 2025 unlike my Med.Advantage plan maximum out-of-pocket liability of U$1,000 their Med. Supplement High-deductable Plan G maximum out of pocket liability was U$2,870. My Med.Advantage out-of-pocket going from U$1,000 to U$4,000 in 2026 leads one to wonder what that Med.Supplement plan's U$2,870 out-of-pocket might be set at for 2026.

We have Amir's up-thread description of his 2026 Med.Supplement plan N monthly premium payment amount but no cipher for that plan's maximum out-of-pocket. I'm inclined to think that just like Med.Advantage diminished profitability due to inflation and Medicare's legal diktats that Med.Supplement issuers have tweaked 2026 maximum out-of-pocket levels and probably upwards the monthly premiums which new 65 year old would pay than was the case for 2025.

 

[Petrushka]

The 1986 cautious Ronald Reagan tale about

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.


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.

I also had YAG treatment at no cost. Medicare pays nothing for glasses or for eye exams. Or for hearing.

This is because old people do not require glasses or hearing aids.

 

[RayDunzl]

I'm 72.

Had a melanoma removed from my back a month ago.

Large patch of skin, then some additional cuts to create a "rotational flap" to stretch skin to close the hole.

Took an hour or two for that and associated poking around to see if it spread anywhere, then went home about noon.

Prior to the surgery, I saw a detailed estimate from the Hospital.

$6,180.00

That's not bad.

No, wait...

$61,800

Wow. Ok, stuff is expensive.

My bad, I looked again:

$618,000.

I asked the Surgeon, he said he had to account for various possible outcomes prior to the surgery or the Insurer would make his life (or the Hospital's) even more difficult than it already does.

And the prices there are just what the Hospital would like to get, and not what they will get for each of the items that were performed.

I haven't seen the final tally yet.

So far I'm only out $150 and a 10x6cm patch of hide.

Had a Florida Blue Advantage plan, that dropped my PCP, and now have a UHC Advantage plan, so far, so good, by my estimation. Both well used without any real problems (yet).

I'm off to the TV to see who NYC will elect.

 

[Chrispy]

While I do have an advantage plan, don't really understand why it's particularly bad for my needs. Someone can summarize it?

 

[Alannn]

While I do have an advantage plan, don't really understand why it's particularly bad for my needs. Someone can summarize it?

Advantage plan means the insurance company controls your care, although they are required to mimic Medicare plan coverage, they use deny and delay to increase their profits.

Medigap supplement plan means your doctor controls your care with no games and time wasted with preapprovals which are not needed.

 

[Chrispy]

Advantage plan means the insurance company controls your care, although they are required to mimic Medicare plan coverage, they use deny and delay to increase their profits.

Medigap supplement plan means your doctor controls your care with no games and time wasted with preapprovals which are not needed.

Thanks. Do private doctors need to participate in Medicare or are they all forced to and to what extent?

 

[JustJones]

Do private doctors need to participate in Medicare

No

 

[Chrispy]

No

So they just always have reimbursement capability?

 

[JustJones]

So they just always have reimbursement capability?

Not sure what you’re asking. Private doctors do not have to participate in Medicare. I know a doctor who doesn't take insurance of any kind, cash only.

 

[Chrispy]

Not sure what you’re asking. Private doctors do not have to participate in Medicare. I know a doctor who doesn't take insurance of any kind, cash only.

Yes, that was my point, if you want the benefit of the program you need to participate in it, not just as a citizen but also as a medical provider. No point in having no coverage in this conversation unless that's the only alternative?

 

[amper42]

I also had YAG treatment at no cost. Medicare pays nothing for glasses or for eye exams. Or for hearing.

This is because old people do not require glasses or hearing aids.

Actually, it's more nuanced than that.
1. While Medicare might not pay for hearing aids it's not unusual for a supplement plan to add hearing aid coverage. And if you have a physical ear issue like a broken eardrum Medicare will cover it.
2. While Medicare doesn't cover glasses, they will cover an annual eye exam without eyeglass prescription should you have a medical issue like glaucoma or a mole (possible cancer) inside the eye or other eye issues.
Eye glasses and hearing aids have become a commodity that's typically pretty easy to source.

 

[xanalog]

Thanks. Do private doctors need to participate in Medicare or are they all forced to and to what extent?

Haven't 'private doctors' gone the way of the dodo bird for common folk, long ago? 1990s?
I am certain that there is not a single (private) doctor who can survive -or even attempt to- in a market ran by big health insurers.

OT: I hope those who are interested have already received a copy of the big fat "Medicare & You 2026" book, w/130 pages?
The booklet even provides "scores" for every MA, including their costs' breakdowns... like THD ratings ...

 

[amper42]

Thanks. Do private doctors need to participate in Medicare or are they all forced to and to what extent?

It's really hard to find a medical doctor who doesn't participate in Medicare except maybe Pediatrics. Not supporting Medicare as a doctor lessens your client base dramatically. You may find a few doctors that are concierge based doctors but it's pretty rare and I avoid them.

 

[amirm]

One well-to-do relative who was eligible for Medicare, opted to pay their primary physician an annual retainer fee - starting originally in the low five figures - in the late 1990's - to obtain quicker access to medical care.

You remind me that we are doing that as well as paying for Insurance! The office apparently was losing money. So to stay with our current doctor, both my wife and I had to sign up to this subscription plan. I think it is $300 a year or something like it per person.

It had a nice effect of a lot of patients leaving so appointments now are indeed quick! That wasn't a promised benefit but turned out that way.

 

[amper42]

You remind me that we are doing that as well as paying for Insurance! The office apparently was losing money. So to stay with our current doctor, both my wife and I had to sign up to this subscription plan. I think it is $300 a year or something like it per person.

It had a nice effect of a lot of patients leaving so appointments now are indeed quick! That wasn't a promised benefit but turned out that way.

Some doctors try this "extra fee" concierge service and have two tiers of service. But like you saw it can cause most of their patients to leave so the net result is not higher profit. It's usually established doctors who want less work and are nearing retirement or are also involved in drug trials as a secondary income stream. This income model is hard to sustain when the vast majority of great doctors accept insurance without extra fees.

 

[Alannn]

Agreed.

One well-to-do relative who was eligible for Medicare, opted to pay their primary physician an annual retainer fee - starting originally in the low five figures - in the late 1990's - to obtain quicker access to medical care.

Pay for quicker access. Works in the express lane, Disneyland, airport security, vip parking up front, why not health care too.