Beware of Medicare Advantage

The problems of Medicare Advantage (compared with traditional Medicare) are so severe that doctors are being warned about them. Insurance companies advertise Medicare Advantage aggressively. Since they are cheaper than traditional Medicare + Medigap and also cover services that traditional Medicare doesn’t (eyeglasses, hearing aids) many people sign up.

Should Doctors Warn Patients About the Downsides of Medicare Advantage Plans?

— Beneficiaries may not be aware of the plans’ limited networks or prior authorization rules

by Cheryl Clark, Contributing Writer, MedPage Today, December 8, 2022

If the doctor is not in that plan network, “they have absolutely no insurance coverage when they arrive,” Grisolia said. But even if the doctor is in the MA plan’s network, the MA plan required that the visit receive prior authorization, which wasn’t obtained.

This troublesome issue occurs more often these days as an increasing percentage of Medicare-eligible patients – now roughly 48% of 58 million beneficiaries – are enrolled in Medicare Advantage plans. Some doctors think they should go out of their way to alert their naïve patients to the downsides of these plans before they change their coverage.

The TV ads, he said, are “almost false advertising, because they make the plans sound like the best thing since sliced bread, that a retired person doesn’t have to pay anything. That’s great for outpatient visits when they go once or twice a year, but when they get sick and go into the hospital, they realize they don’t have coverage for that.” Generally, said Floyd, most of the doctors who take care of adults tell them that “if and when you go on Medicare, stick with the plain, regular Medicare system. Don’t take Medicare Advantage because it’s not going to give you the coverage you need if you get sick and have to be in the hospital.”… [end quote]

Fortunately, I was warned about this at a public lecture given by an insurance agency in my town.



I have to disagree. I have a no-extra-costs, MedAdvantage plan that served me well. Five years ago, I had medical and hospital cost totaling $250k. But my out-of-pocket costs ended up around $5k.

Additionally, while I was in care and my daughter was dealing with the administrators and presenting my insurance card, to a person, everyone she talked with said, “Don’t worry, Your Dad has excellent coverage.”

What people fail to realize is that medical insurance is just that, INSURANCE. It isn’t a “we-pay-for-every-little-thing plan”.

Yeah, if I hadn’'t had med insurance, I could have written a check and paid for everything two or three times over without a problem. But my coverage meant I didn’t have to compromise my assets. That’s the function of insurance. For paying a small annual prem, the catastrophic, unexpected, big stuff gets covered.

Even better, in the case of MedAdvantage plans, the prem is no more than what Medicare costs. The “downside” of such plans is that one has to pay for the ordinary, everyday, nickel-and-dime stuff. “Chef’s Choice,” I’d say. But nothing that merits “warnings”.




You can get very badly broadsided.

I am not any sort of expert on this. I come from a family of doctors and family friends as doctors. All of them are against these plans for the patient’s sake.

Remember when you say it was $5k out pocket it can be worse and there are people who can not afford the $5k.

The real problem is baby boomers who can not afford to retire some 50% of them can not afford a Medicare supplemental plan.

Anyone who can afford the supplemental plans is much better off going that route.

1 Like

Wendy, could you or someone else explain the difference between an Advantage PPO plan and a workplace PPO plan?

Workplace PPO’s have the same limitations/requirements as the Advantage plans as far as I can tell. I’ve lived with a workplace PPO most of my life.


1 Like

That is true with ANY health care insurance plan. I look at the online documentation to see if any proposed plan covers who I want to see.

Many of the plans in this area (metro Twin Cities–Minneapolis/St Paul, MN) cover 94% or so of ALL the doctors in the area.

So the issues come down to how high do you want extra coverages? I checked a couple plans some years ago: They were comparable, but had higher coverage on dental and/or vision, etc. But guess what? The premium INCREASE for the higher coverages was essentially the same as the increased coverages (i.e. $500 higher dental coverage meant about a $500 higher annual premium). So, TANSTAAFL. You pay one way OR you pay the other way–but YOU ALWAYS PAY.

1 Like

Different issue, but there’s a big sign in front of the pharmacy at Kroger saying something like “Starting in 2023 we will not be participating in Cigna/Managed Choice Program,” (I may have the company wrong, but at least they’re notifying people with enough time to change to another pharmacy, which I applaud.)

On the original topic, I am one of those with a Medicare Advantage plan (Humana, if you must know.) I have had multiple hospital procedures over the past several years (spinal spondylosis, spinal stenosis) including week-long stays in the hospital, and the bills came to roughly $0.00. Other than my usual insurance premiums, of course.

I have also had several procedures requiring an oral surgeon, and used a guy who is out-of-network but whom I trust, and those are multiple thousands of dollars each. My dental insurance is a joke, and barely pays the cost of a couple cleanings a year, so that one is a “pay me now or pay me later” thing.


I think I mentioned a couple weeks ago, a change I noticed in this year’s flood of TV advertising for MA plans during open enrollment.

A fixture of many of these ads is a series of people saying they “called” to see if they were eligible for an MA plan, or a plan that “adds money back to my Social Security check”.

The change I noticed in the ads this year was that, among that string of people saying they called, is one that says “I called to see if my doctor is still in my plan”, a subtle admission that the plans lay “out of network” traps for their clients.




You can’t have it both ways.

Either a person/family/household can afford $5k out-of-pocket medical expenses per yer, or they can’t. If they fall into the latter group, they are likely to be on the dole, and they won’t be paying their medical bills themselves, nor much of anything else. They’re “America’s Poor” (by choice as much by circumstance).

If they are part of the former group, then they have to make a bet --aka, a consumer choice-- between known higher monthly prems and --possibly-- lower out-of-pocket cost, or lower monthly prems and probably higher out-of-pocket costs. But what both need to consider is whether either path will cover the truly major things should they happen. That’s the only reason why having medical INSURANCE is a prudent bet.

How they pencil out the prem numbers for themselves is for them to determine. But I certainly wouldn’t depend on anyone associated with the medical profession to offer advice. That’s like asking the foxes to guard the hen house.

Now, answer me this question: Why isn’t healthcare in this country totally free? If the US can give nearly $100 billion this year alone to support its central European follies, why can’t it take care of its citizens at home through an aggressive outreach program that focuses on WELLNESS, not on fixing problems that should never have arisen in the first place?

If you want to be dismayed, compare how much is spent on medical care in the US versus how healthy the US population is in terms of thing like infant mortality, etc. The US healthcare system sucks compared to that of most other industrialized countries.



Because $100B is chump change compared to annual medical costs of multi-trillion $$$. Estimated LOW:

“In 2018, $3.7 trillion was spent on healthcare-related goods and services, 18% of the nation’s gross domestic product.”


Let me get this straight, there is a difference between Medicare Advantage, and Medicare supplement? How complex has the industry made this? In the words of Daffy Duck, “Shoot me now!”


That is right you cant in the current system have it both ways if you cant afford it. It is a misery for a lot of people.

You are preaching to the choir


Universal care would save us all money. That is why. Meaning the profit centers do not want to see a better less expensive system take their gravy train away.


Yup. Medicare supplemental coverage has been around for decades. The supplements can cover dental, vision, “silver sneaker” gym memberships. But the “JCs” saw all that money going from Medicare parts A and B going directly to the providers, and wanted to skim that cash flow too. So presto, Part C, aka Medicare Advantage, that funnels all the money through the hands of the “JCs” for skimming. No surprise that Part C was passed by the same regime that passed Part D, which was specifically written so all the money passed through the “JC’s” hands, people are required to buy it as soon as they go on Medicare,or pay a penalty later, and Medicare is prohibited from providing the benefit itself, so the “JCs” don’t need to compete with it. Shiny, isn’t it?



@bjurasz you need to understand the difference if you are anywhere near qualification for Medicare (which can be age 65 or younger if you are disabled).

Standard Medicare is administered by the U.S. government. Standard Medicare only covers 80% of charges from a doctor or hospital. Since medical costs can be astronomical the 20% that is not covered can be ruinous. To cover that 20%, Medicare insured people often buy a separate private policy from an insurance company to cover the 20%. This is called a “Medicare supplement” or “Medigap” insurance policy. (My grandmother taught me about this so it has been around for many years.)

Medicare Advantage is completely different from standard Medicare. Medicare Advantage is administered by insurance companies.

Medicare is so complex and has so many gotchas that a book has been written to describe it:

Get What’s Yours for Medicare: Maximize Your Coverage, Minimize Your Costs,

by Philip Moeller.

SHIBA, which is a state-sponsored advisory office, has trained volunteers who can explain the differences in plans. But they don’t provide information about the serious problems many Medicare Advantage patients have had from the insurance companies. Before making a decision, research this.



The best part about “big gummit” Medicare is there are no “networks”. Medicare will pay “any willing provider”. Last July, I tripped on an uneven sidewalk and took a lurid flop. Landed in the ER for a couple stitches. The hospital company that owns the ER was “in network” for the private insurance I had before I qualified for Medicare. But, apparently, the guy who stitched me up, in that ER, was an employee of a different company. “Big gummit” Medicare paid everyone. My outcome may have been significantly more expensive, to me, if I had still been on the private insurance, and the guy doing the stitching was not in the private company’s network.

Wendy talked about having private insurance to cover the deductables and copays of “big gummit” Medicare, but do those supplementary coverages pay “any willing provider”, like Medicare does, or do the supplements lay more “network” traps? I would not be surprised to see people paying for a supplement, land in the hospital, and have the supplement refuse to pay, because the hospital, or one or more people working in it, is not “in network”.



That is why the “no surprise billing” law was passed.


That is another point. If you move or have an emergency the advantage plan can be a problem cost wise. Might not be a surprise but still a problem.


Many years ago, heck, decades ago, when our first daughter was born, my wife pre-registered at a local hospital. That means that a few months before the birth, you give all your insurance info, and they begin the processing to get approvals, etc. Everything was approved. Then, after the baby was born, we receive a large bill from the anesthesiologist stating that it was “out of network” and not {fully} covered. After she recovered, my wife argued with the insurance company for over 18 months … because there was no possible way to “choose” an in-network anesthesiologist while giving birth, and that we pre-approved everything, including any ancillary services at that hospital. In the end, the insurance paid everything … and they had to pay the anesthesiologist at the full regular rate because they had no negotiated rate with that group of anesthesiologists.


If moving to a new location outside your existing health care plan means you will be doing the research needed to find a replacement plan that meets your needs at your new residence.

If traveling, then it would be dependent upon the coverage of your existing plan–and you may have purchased a separate policy to cover your gallivanting, wherever it took you.

1 Like

It is not that simple. You may be locked in for a year. You may not find a doctor in network that is worth a damn. Not all doctors are equal.

Also the other part of what I am saying is emergencies. Just because you are not surprised does not mean you have time for a choice. Again specialists in an emergency situation may be out of network.