Medicare Advantage - Don't do it

[Salida]

This is a timely thread. About half of Medicare eligible recipients are on Advantage Plans. Advantage plans are increasingly administered by large insurers like United Healthcare, Kaiser Permanente, CVS, BCBS, etc.

The government pays insurers to assume the full risk of providing all care for that patient for an inclusive amount. This payment varies by patient, provider and locality. Just as Medicare advantage plan costs vary by the same factors.

Medicare Advantage costs the government more than traditional Medicare for covering the same beneficiary. So it will see more scrutiny as time goes on.

As underlying costs increase, Advantage Plan participants will continue to see increasing out-of-pocket expenses and deductibles.

I chose traditional Medicare because we have two homes and it was impossible to find in network providers in both locations.

There are now Advantage plans that claim portability, so that would have made my decision much harder.

 

[amper42]

I asked my AI this question:
Is there data that shows whether retirees do better on a medicare advantage plan versus straight Medicare with a secondary that covers everything not covered by Medicare and offers drug coverage. Compare based on expense, benefits, having to deal with pre-authorization, denial of services and any other criteria that would be important.

Below is the AI response:
Most retirees are satisfied with both Medicare Advantage (MA) and Original Medicare paired with Medigap (secondary insurance) plus Part D prescription coverage, but there are important trade-offs based on cost, benefits, access, and ease of use that can make one better suited for an individual’s needs.

Out of Pocket Expenses

• Medicare Advantage plans have an annual in-network out-of-pocket maximum, capped at $9,350 in 2025, and often offer lower premiums (average $17 per month in 2025), sometimes $0, but you still have copays and coinsurance until you hit the cap.
• Traditional Medicare with a Medigap policy typically has much higher monthly premiums ($44–$400+ per month), but covers nearly all costs for Medicare-approved services (except prescription drugs), making costs more predictable as you pay mostly premiums rather than unpredictable copays.
• Both options cap annual out-of-pocket prescription drug (Part D) costs at $2,000 in 2025 due to the Inflation Reduction Act.

Benefits and Access

• Medicare Advantage plans may include non-medical benefits like dental, vision, hearing, transportation, and wellness, but you are restricted to in-network providers (with limited exceptions) and may need referrals for specialists.
• Medigap lets you see any provider who accepts Medicare nationwide without referrals and can offer limited overseas emergency coverage. However, standard Medigap doesn’t cover dental, vision, or hearing by default.
• Drug coverage is built into most Medicare Advantage plans, while Medigap users must buy a separate Part D plan.

Pre-authorization and Service Denials

• Pre-authorization is a major drawback for Medicare Advantage users: in 2023, 6.4% of prior authorization requests (over 3 million out of nearly 50 million) were denied, and only about 12% of these denials were appealed.
• Original Medicare with Medigap very rarely requires pre-authorization (except some rare situations like durable medical equipment), so service denials and barriers to care are far less common.

Other Important Criteria

• Medigap policies may not be as easy to purchase or switch into after your first Medicare enrollment period—premiums can be much higher or coverage denied outright due to health history in most states.
• Medicare Advantage allows you to switch plans or return to Original Medicare during annual enrollment periods.
• Satisfaction rates are high with both options: a 2025 survey found 87% satisfaction among both groups.
• Medigap is typically more portable—ideal for retirees who travel extensively within the U.S., while MA users must use local networks.

Summary Comparison Table

	Med.Advantage	Medicare + Secondary
Monthly Premiums	$0–$17+ avg. (2025)	$44–$400+ (Medigap), Part D extra
Annual Max Out-of-Pocket (medical)	$9,350 limit (in-network)	No cap, but almost all costs covered with Medigap
Drug Coverage (Part D)	Usually included	Separate plan required
Network Restrictions	Yes (local, in-network)	No (any Medicare provider nationwide)
Service Denials/Pre-Auth	Common (6.4% denied in 2023)	Rare, almost never
Additional Benefits	Dental, vision, extras	Rare, some plans limited
Portability (Travel)	Limited	Nationwide (plus some foreign travel)
Satisfaction Rate	87% (2025 survey)	87% (2025 survey)

Takeaway​

• Choose Medicare Advantage if you want low premiums, prefer bundled extras, are willing to use a network, and can handle more plan management and potential pre-authorization.
• Choose Original Medicare with Medigap and Part D if you want nationwide access, highly predictable costs, minimal hassle for care approvals, and don’t mind higher premiums or managing a separate prescription plan.
• Both options require careful comparison of local plan details and individual health usage patterns; satisfaction is high in both groups, but decision hinges on whether you value lower monthly costs and extras (MA) or greatest flexibility and predictability (Medigap).

Each option presents clear trade-offs, so consider your budget, health needs, travel habits, and aversion to denied claims or pre-authorization before deciding.

 

[RDoc]

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

Certainly that's all true, but we are secure in our position as the most expensive.

 

[Soandso]

… we are secure in our position as the most expensive.

Below is a graphic showing how medical insurance company stock valuations increased from 2010 to some date in early (the seventh?) Nov. 2025 week since the "Affordable Care Act" (ACA) was signed into law (March 2010) by the President at that time. It seems that the ACA has been very relevant to their value. This despite how in this time period of 2025 to market close 07 Nov. 2025 (year to date data) the United Health Group company's stock price is down almost 36%, Cigna stock is down almost 4%, Molina stock is down almost 47%, Centene stock is down almost 38%, Elevance (Anthem) stock is down about 13% and then Humana stock price is only down about 1/4%; Aetna is now a part of CVS' holdings so my free stock app has no entries for Aetna.

 

[Soniclife]

I had an upper endoscopy earlier this year, Charges to insurance were something like $18,000 for an outpatient procedure that took 15-20 minutes. I had to pay $1800 out of pocket in copays.

That seems really expensive, I just googled what that procedure would cost privately in the UK and it's about £1500, similar to your copay. Is there an explanation for why it's so different, it is a simple procedure.

 

[Soandso]

… that procedure would cost privately in the UK and it's about £1500, similar to your copay….

The situation where some USA medical insurance plan's colonoscopy coverage requires co-pays are apparently for "bowel prep" (separate insurance medical coded services) and not the actual diagnostic viewing procedure. My assumption is the cost of the preferred anesthesia drug itself (see below reference to Medicare Part D drug coverage) the USA pay scale of monitoring anesthesiologist's honorarium are what makes any preparatory ("prep") steps costly.

[The below shown snipped does not parse MedAdvantage so am only anecdotally mentioning that my specific MedAdvantage plan approved colonoscopy 10 years ago there was $0.00 co-pay and ideally shall be likewise for 2026. For what it may matter with most MedAdvantage plan(s) Medicare Part D drug coverage is included at no extra charge; while those on traditional (regular) Medicare and/or Med.Supplement plans must choose to buy a monthly premium Part D drug insurance.]

Below relevant screen shot is from author Claire Wallace's June 20, 2025 article in the on-line issue of Becket's ASC Review. [Note: in text ''ACA'' stands for the Affordable Care Act law enacted popularly referred to as "Obamacare".]

 

[Soniclife]

The situation where some USA medical insurance plan's colonoscopy coverage requires co-pays are apparently for "bowel prep"

Upper endoscopy goes in the other end, no bowel prep required. Not that bowl prep should cost much.

 

[JustJones]

The situation where some USA medical insurance plan's colonoscopy coverage requires co-pays are apparently for "bowel prep" (a separate insurance medical coded service) and not the actual diagnostic procedure. [For my particular MedAdvantage plan approved colonoscopy 10 years ago there was $0.00 co-pay and ideally shall be likewise for 2026.]

Below relevant screen shot is from author Claire Wallace's June 20, 2025 article in the on-line issue of Becket's ASC Review. [Note: in text ''ACA'' stands for the Affordable Care Act law enacted popularly referred to as "Obamacare".]

View attachment 489661

What does any of this have to do with an upper GI?

 

[Soandso]

What does any of this have to do with an upper GI?

My mistake I hadn't picked up on the precise diagnostic procedure and discussed another.

 

[Soandso]

Upper endoscopy goes in the other end …

Thank you for correctly pointing out my mistaken procedure.

Editing to include the following:

Here are the Center for Medicare Services procedural codes specific to upper gastrointestinal endoscopy. Usually more than one billing code is submitted to a medical insurance plan. The up-thread mentioned costly bill for one upper GI testing session doesn't indicate its coded breakdown.

 

[amper42]

Upper endoscopy goes in the other end, no bowel prep required. Not that bowl prep should cost much.

With Standard Medicare + Medigap Endoscopy or colonoscopy procedures are absolutely FREE. Same with any other procedure or doctor visit. No copay, no deductible, no extra fees. It costs a bit more for Medigap coverage but when you need care there are no questions about fees. It takes any thought of expenses totally out of the equation and instead you focus on staying healthy and getting proper care.

I find this very helpful as when you need a procedure or a hospital emergency visit there are lots of fees from different vendors that come into play. The facility is one charge. The doctor another. Plus, the anesthesiologist and labs can add up. Paying nothing for any of these bills plus being able to choose the best facility anywhere is the USA to get it done is absolutely wonderful.

 

[Soandso]

With Standard Medicare + Medigap Endoscopy or colonoscopy procedures are absolutely FREE.……

Yes, similarly I had a simple endoscopy going to the duodenum performed on me twice about 6 years ago and my MedAdvantage plan covered those with $0.00 co-payments from me. Ideally now-a -days for the same procedure should I need it my Med.Advantage plan might likewise have either no or a minimal co-payment.

Far bellow screen shot describes the 2024 breakdown of the basic upper GI endoscopic basic services' billing components. [For 2016 there may be approximately another 16% cost increases above whatever amounts the 2025 related billing codes is.] Bear in mind that if during the procedure an issue is discovered prompting some non-basic care then there'll be additional service codes added.

The time involved including the procedural room usage in the USA is apparently 1/2 hour.

 

[JustJones]

Hospitals are dropping Medicare Advantage plans left and right - Becker's Hospital Review | Healthcare News & Analysis

Hospitals nationwide are dropping Medicare Advantage plans due to excessive prior authorization denial rates and slow payments from insurers. Scripps and St. Ch

www.beckershospitalreview.com

 

[Beave]

That seems really expensive, I just googled what that procedure would cost privately in the UK and it's about £1500, similar to your copay. Is there an explanation for why it's so different, it is a simple procedure.

I did leave out a little key info. It was more than an upper endoscopy, as they went into the duodenum as well, and they used propofol for anesthesia instead of the more common "twilight sedation" of fentanyl & versed. Still, it was a 15-20 minute procedure. And the charges were way, way higher than when I last had the same procedure done just three years ago. I've had several of these done over the years, and this one was charged way more than ever before.

 

[Beave]

OK, I have to apologize for a mistake. I just reviewed all the EOBs again. They charged insurance somewhere between $9k and $10k, not $18k. My copays and coinsurance were a little over $1800.

Procedure code was 44361, and charges associated with that were the lowest of all the charges.

Anesthesia alone charged over $2k. There were two identical charges for around $1060 each for anesthesia. When I questioned this, I was told there was an anesthesiologist and his nurse present during the procedure, so there was a charge for each one being there.

The biggest set of charges were facility fees (hospital, and just like with the MRI, the only place the insurance would allow me to have the procedure done).

 

[Soandso]

…Procedure code was 44361…

Looked up code 44361 and see it's when the endoscopic procedural purpose includes "allowing" the context of biopsy(s). Aside from the procedure and anesthesia charges it sounds likely there were additional "charges associated" with the medical services involved. Quite likely the actual excision of internal tissue (single or plural?), analysis of the tissue (s) and the medical specialist who requested the biopsy's later office consultation about results all had billing codes adding to the final cost.

[The Med.Advantage plan I am enrolled in has paid for several biopsies and all the relevant associated coded medical services. So far my co-pay share has been $0.00 although I recall the insurance didn't pay the full seemingly high amounts originally billed.]

 

[Beave]

Pathology charges for biopsy review were the lowest of all the charges (around $400). Then procedure itself next lowest. Then anesthesia quite a bit higher than either at $2100 total (again, for 15-20 minutes). Then all the hospital facility fees made up the bulk of the charges at about $6k of the $9k total charges.

 

[Audionaut]

Interesting
I am insured with the German statutory health insurance provider Techniker Krankenkasse and pay the maximum rate.
This is currently €940.40, or €11,284.80 per year.
My wife and my daughter, who is a student, are automatically covered by what is known as family insurance.
Most of it is free of charge.
For medication, you have to pay a minimum of €5 and a maximum of €10 per prescription.
Dental costs are free, except for dentures, which are only covered at 60%.
To ensure that my family and I are fully covered, I pay an additional €150 per month for supplementary insurance.
That's about €1,100 per month for health insurance, which is mandatory in Germany.
There is also private health insurance, which offers better benefits, but is often very unfavorable in old age.

 

[amper42]

Pathology charges for biopsy review were the lowest of all the charges (around $400). Then procedure itself next lowest. Then anesthesia quite a bit higher than either at $2100 total (again, for 15-20 minutes). Then all the hospital facility fees made up the bulk of the charges at about $6k of the $9k total charges.

In the USA, these procedures are billed high too ( in the $9,000 range). But, when Medicare applies its negotiated rate it's usually about 20% of the original billed fee. It always amazed me how the only customers paying the original higher medical fees were those that did not have health insurance. And in most cases, the people that couldn't afford health insurance also can't afford bills that are 500% higher than what is considered an acceptable payment for Medicare.

I asked a doctor about this once. He said we bill at the highest possible rate knowing it will be reduced to the contracted amount. I asked what about those that don't have insurance? He said in some cases they can ask for a cash discount if negotiated in advance, but it's less certain after service is rendered. Apparently, going without health insurance simply targets the person for the highest possible medical rate available. It's a crazy USA health system rigged to snare those without health coverage.

I can't imagine this being acceptable in any other commercial sale. Imagine if you want to buy a new set of speakers and they are 5x as much if you don't pay $1,000 a month to join a "Speaker Exchange Club" first. But getting the membership was a bit difficult and hard to set up and you might have to qualify with an exam. No one would tolerate this rule and antitrust would be all over it. But since the government is involved it's ok?

 

[Power Pop 23]

My 'conventional' supplement plan to Medicare has a high annual deductible.

I regard the supplement plan more as 'protection' against filing for personal bankruptcy due to medical bills than health insurance.