Medicare Advantage - Don't do it

[Soandso]

]

 

[Short38]

The administrative costs of Medicare and Social Security run roughly 2% of benefits administered. The administrative costs of private insurance plans of which Medicare Advantage is one form run about 12% of revenue.

There are staggering additional costs associated with private insurance plans placed on medical service providers which are related to tracking and billing dozens of insurance benefit plans and the cost of technology to manage billing and reporting. On top of that are the hours spent and psychological toll of patients battling insurance companies.

 

[xanalog]

Health care providers are like chameleons that morph into different organizational structures in very quick lock-step with the yearly, federal MA policy changes.
For example, I don't recall if "Urgent Care Centers" existed just a dozen years ago; now they are like 7-11s and everywhere.

Mid-October, I was sent an 8x8x8 box, addressed to me that I did not ask for.
Inside the box, there is a dealio to take a stool sample and send it back to some lab for colon cancer checks.
I had never requested this colon-test kit and neither had my primary care physician.
I've had 5 emails, 4 phone calls, 2 text messages from the testing outfit for use-instructions (although they are in the specimen/test box).
Today, my MA provider sent me a USPS letter offering me a $25 gift card for using the colon screening package before 2025/12/15.

Both my MA and this test lab may be complicit in gaming the Medicare Advantage system, but I already decided to poop on their scam... instead of pooping in their test tube.

 

[Sir Sanders Zingmore]

Health care providers are like chameleons that morph into different organizational structures in very quick lock-step with the yearly, federal MA policy changes.
For example, I don't recall if "Urgent Care Centers" existed just a dozen years ago; now they are like 7-11s and everywhere.

Mid-October, I was sent an 8x8x8 box, addressed to me that I did not ask for.
Inside the box, there is a dealio to take a stool sample and send it back to some lab for colon cancer checks.
I had never requested this colon-test kit and neither had my primary care physician.
I've had 5 emails, 4 phone calls, 2 text messages from the testing outfit for use-instructions (although they are in the specimen/test box).
Today, my MA provider sent me a USPS letter offering me a $25 gift card for using the colon screening package before 2025/12/15.

Both my MA and this test lab may be complicit in gaming the Medicare Advantage system, but I already decided to poop on their scam... instead of pooping in their test tube.

In Australia, everyone over 50 gets a bowel cancer screening test for free as part of our Medicare (that being the public health care system we have which still functions really well and hasn’t yet been fcuked up by being privatised).

 

[Bob from Florida]

During the COVID pandemic, hospitals has low census - compared to before COVID and after. There were periods of time and locations where they had a "large" number of COVID patients which were not as profitable as "normal" patients. People were afraid to go to the hospitals because of the "fear of COVID". As a result, both "urgent real needs hospital visits" and "unnecessary hospital visits" stopped occurring, until everyone "accepted" that COVID was going to "be around". This hurt some patients that needed to visit, while hurting healthcare revenue. Healthcare got a "taste" of reduced revenue when folks chose "not to go". I need to make sure folks understand that I am not trying to "minimize" COVID. The point is - the healthcare network is accustomed to lots of patients without true "medical necessity" using the system. This "use" results in medically unnecessary billings that help fuel the whole insurance / healthcare providers cash-flow model. Real reform at reducing costs and improving outcomes means the industry must accept only doing "medically necessary" treatments and getting the population to buy into healthier lifestyles. Both represent less profit, but what other choice is available? Steadily increasing healthcare spending for growth in profits is not sustainable.

 

[RDoc]

My wife and I have been on Medicare Advantage plans for almost 10 years and are totally happy with it. To be sure, we live in the Boston area and have never had a problem with finding providers. We've also never had an issue with coverage denial either.

 

[Soandso]

According to a voronoiapp~dot~com analysis utilizing USA Bureau of Labor Statistics data in the recent 12 month period from only the period of Sept. 2024 to Sept. 2025 they parsed the following percentages of increases within the USA of costs for:

Hospital services = up 5.8%
Health Insurance = up 4.1%
Medical Equipment/supplies = up 0.8%

 

[RDoc]

Health care providers are like chameleons that morph into different organizational structures in very quick lock-step with the yearly, federal MA policy changes.
For example, I don't recall if "Urgent Care Centers" existed just a dozen years ago; now they are like 7-11s and everywhere.

Mid-October, I was sent an 8x8x8 box, addressed to me that I did not ask for.
Inside the box, there is a dealio to take a stool sample and send it back to some lab for colon cancer checks.
I had never requested this colon-test kit and neither had my primary care physician.
I've had 5 emails, 4 phone calls, 2 text messages from the testing outfit for use-instructions (although they are in the specimen/test box).
Today, my MA provider sent me a USPS letter offering me a $25 gift card for using the colon screening package before 2025/12/15.

Both my MA and this test lab may be complicit in gaming the Medicare Advantage system, but I already decided to poop on their scam... instead of pooping in their test tube.

By "provider" do you mean your insurance company such as BCBS or your health care provider such as Partners Healthcare? We've not got that exam box, but have had repeated requests by our insurance company BCBSMA to have a home health exam separately from our PCP. I would suggest not doing it because IMHO this is the insurance company trying to assess your health status potentially to adjust your rates (even though that's probably illegal).

 

[Soandso]

I have an "Affordable" Care Act plan that costs $1300/month before subsidies and maybe $900/month after subsidies.

On the subject of insurance linked to A.C.A. "affordability" there's potential financial impact for 2026 enrollees. Below is a late Oct. 2025 screen shot from the "KFF" website which touts itself as an "independent source for health policy research …."

 

[amper42]

My secondary insurance which covers 100% of what Medicare A and B don't plus provides drug coverage is up $7 a month for 2026. I call that a win. Those on subsidized ACA plans seem to be the ones receiving HUGE HEALTH Insurance premium increases.

My guess is families whose Medical insurance sky rockets will be looking for ways to cut back or drop out entirely. That's not great for the impacted families or the industry.

 

[xanalog]

I cut, slash, poke, gouge myself with tools and often with some blood-letting.
Yesterday, I went to our local CVS drugstore to inquire about a tetanus jab.

It turned out it is fully covered under my MA and the jab of Boostrix also includes the diphtheria toxoid and a pertussis vaccine.
Whoa! Three for the price of zero!

Then, I was given a $10 store coupon for any $20 purchase.
I walked out of CVS store like I just robbed the place!

 

[MCH]

I know of UK for when my brother and family lived there. I was shocked how much begging/complaining they had to do to get an appointment for minor illnesses. Appointments were weeks and months in the future for what would be a few days for us.

Don't know about UK but I have lived in 4 eu countries so far and this is generally not true, and in some cases (I e. Germany) where doctors get paid directly by the social insurance, there is even a real risk of treatment beyond what is necessary.
What can be difficult to get is appointments with certain specialists, and that is normally because there aren't many.

 

[amper42]

I cut, slash, poke, gouge myself with tools and often with some blood-letting.
Yesterday, I went to our local CVS drugstore to inquire about a tetanus jab.

It turned out it is fully covered under my MA and the jab of Boostrix also includes the diphtheria toxoid and a pertussis vaccine.
Whoa! Three for the price of zero!

Then, I was given a $10 store coupon for any $20 purchase.
I walked out of CVS store like I just robbed the place!

Medicare covers all vaccinations, tetanus, shingles, pneumonia shots and such 100%. That's normal. You shouldn't feel like it's special treatment. It's expected as part of the monthly B premium and paying medicare taxes during working years. I know it's hard to believe you are actually entitled to services.

 

[Chrispy]

Medicare covers all vaccinations, tetanus, shingles, pneumonia shots and such 100%. That's normal. You shouldn't feel like it's special treatment. It's expected as part of the monthly B premium and paying medicare taxes during working years. I know it's hard to believe you are actually entitled to services.

It's a shame we need to view it in this regard at all....the health care system in the US is broken and corrupt

 

[Yuhasz01]

Medicare only manages your healthcare with traditional plans and supplement plans.

Advantage plans are not managed by Medicare. Commercial insurance firms have control of your healthcare issues. They should not use term Medicare: they are not.

 

[Alannn]

It's a shame we need to view it in this regard at all....the health care system in the US is broken and corrupt

Medicare Advantage works as designed. People brag about their free $10 coupon from their Advantage Plan. Not that many people die because their treatment approval got delayed by ungrounded denials. Most people do fine with their Advantage plan.

 

[Chrispy]

Medicare Advantage works as designed. People brag about their free $10 coupon from their Advantage Plan. Not that many people die because their treatment approval got delayed by ungrounded denials. Most people do fine with their Advantage plan.

That has little to do with the overall poor condition of the system overall was more my point. It's a ****** system here in the US

 

[Soandso]

…Advantage plans are not managed by Medicare.…

The curious structuring of how much money Medicare assigns to any Med.Advantage plan (based on the number of enrollees in an Med.Advantage plan) is that they are designed around Medicare's own statistics detailing how much money any one particular county (not State) spends on "traditional" (regular) Medicare. To this a formula is applied essentially estimating how much it's worth to Medicare to hand over all administration of any number of that county's individual recipients to accredited private companies' administration and let Med.Advantage plans do the extensive paper work.

Thus in counties which during the previous 12 month cycle (not a Jan. - Dec. period; more likely a Sept.- Oct. time period accounting) where Medicare hadn't spent an excessive amount on "traditional" (regular) Medicare the Med.Advantage plans in that same county can potentially get more money from Medicare for each of their Med.Advantage plans' enrollees. In contrast to this so-called benchmark funding calculation in those counties where "traditional" (regular) Medicare had spent relatively a lot of money there will be a lower amount given to Med.Advantage plans for each of their enrollees.

In other words: in the past any specific county's Med.Advantage plan stands to get from Medicare per enrollee as much as 115% or as little as 95% of the amount of money "traditional" (regular) Medicare determined had spent per person on average there. I suspect this might play out as a factor in why some people's Med.Advantage plan versus another person's Med.Advantage plan is more likely to initially deny authorization(s) for the same medical service(s); and then too is a factor in reversal(s) upon formal appeal(s).

Thus Medicare is in effect operating a "hedging" manipulation through Med.Advantage. Looking at it strategically in counties where it had cost them a lot Medicare gives Med.Advantage less than they (Medicare) had been paying out reducing their (Medicare's) cost exposure. To sweeten that deal there are also counties promising incentive to Med.Advantage plans with Medicare giving more (per plan enrollee) in the counties where they hadn't been paying the most per person.

[NOTE: I'm uncertain what the 2024 or 2025 nation-wide (let alone my county's) average amount of "traditional" (regular) Medicare's per person expenditure was - presumably regularly gets higher due to relevant inflation.]

 

[xanalog]

It's a shame we need to view it in this regard at all....the health care system in the US is broken and corrupt

[whataboutism?] If we are going to compare -in absence of a benchmark- which country would be nominated as the "best horse in the glue factor"?

It seems like I may have bet on the right horse, because I have nothing to complain about... either with respect to my health, or re: w/my health coverage.

 

[Soandso]

…The administrative costs of private insurance plans of which Medicare Advantage is one form run about 12%....

Which brings up the point that Medicare (technically C.M.S., the Center for Medicare Services) has a formal regulation that every year each Med.Advantage plan has to expend at least 85% of what Medicare promised to provide. Should the Med.Advantage plan operate in such a way that for 3 years in a row it's profitability was more than 15% of what Medicare fronted that plan then Med.Advantage should then (not yearly) rebate back to Medicare the excess % above the 15% profits.

Furthermore to keep Med.Advantage serving C.M.S. (Medicare) aims any time a particular Med.Advantage plan has been operating below 85% expenditure for 5 years in a row is deemed to be operating contrary to regulations. And Medicare reserves the right to completely immediately cancel that Med.Avantage plan. Incidentally, as for Med.Advantage plans operating 3 years in a row with more than 15% corporate profitability Medicare reserves the right to freeze that plan's approval to take in new enrollees.

It's been alluded to how Med.Advantage plans frequently included medical related services that traditional Medicare doesn't, including but not limited to usually drug 'Part D" coverage. These are essentially expenditures (ex: free transport to doctors, hearing aids, eye wear, dentistry, debit cards perks, chiropractic/acupuncture, etc.) which a specific Med.Advantage plan might offer to it's enrolled members because those extras were calculated (by the company) to keep that plan staying below the C.M.S. cut off of 15% corporate profitability. Thus Med.Advantage rarely rebates back to Medicare any significant "excess" profits, but re-directs the monetary value of what would otherwise have to be rebated into what the plan members' are offered as available "extras" not otherwise covered by "traditional" (regular) Medicare.

For 2026 my Med.Advantage plan is significantly cutting back on the "extra" benefits I've gotten before. Obviously the insurance bean counters have reviewed the last 3 (5?) years of corporate profit margins and determined the range of their profitability above C.M.S. (Medicare) 15% limit is in a declining trend. Thus the monetary value amount of "extra" benefits of my Med.Advantage plan will decrease next year while the insurer continues aiming for 15% profitability.