Thanks for this, Chip, my friend. But I still don't know what the fuck I'm doing with my Medicare plan. And I have a Ph.D. I think they want us confused, on purpose.
Oh, there’s no shortage of confusion. What I hope people learn from this article is that Medicare Advantage is not the same thing as Medicare. MA is an alternative run by for-profit insurance companies. With that said, it’s an extremely enticing alternative for folks in tougher money situations because the premiums are quite low. So, I’m encouraging folks to make sure they receive care in-network and fully understand the implications of their plan because they can switch off and go back to regular Medicare. Like most the issues in America, greed is a primary culprit here. For profit groups are all about the bottom line so many of the MA providers have bad reputations which is why groups like The Iowa Clinic only now work with three MA provider plans. But, yes, it’s become a mammoth system that is extremely confusing. A single-payer system would be much better for the people.
Thanks much! Sorry, I shared my frustration. I read your advice again, and thank you very much for the clarity! It helped. So many of our interactions on these kinds of things are with people we don't know, and so it's hard to know whose interests they are representing. That's why this post is so important to me, because I know and trust you and your advice. We aren't always so lucky! So thanks again.
Thank you for the kind words and restack, Bob. This article is a departure from my beloved topic of music, but I feel compelled to share what I’m learning because the system is so complex and easily misinterpreted. This intelligent and empathetic dialogue from the likes of pharmacists, health insurance counselors and fellow citizens striving to make the best decisions in a convoluted program has been extremely insightful.
The cheap premiums often entice people. As a pharmacist, my perception is that these plans are rarely worth it. There are far too many unexpected surprises as you try to navigate the process of receiving healthcare. What you save in premiums you often pay for in surprises later.
Fair. I get some reasons weight loss drugs would not be covered, but as a whole weight loss is for medical reasons. Smoking cessation is for medical reasons, and there’s no reason that dental and vision are not covered under medical healthcare.
To be honest, I really don’t know if it has to do with a tier being omitted or not. In the unfortunate hustle and bustle of pharmacy, I am generally just trying to respond to the coverage issue and assisting the patient in getting the best help and support that they can. So, generally, I’m not looking at the reason, but I am aware of the additional nuances often related to these plans.
Generally, I see it in many different ways with what I call “hidden costs.“ These things offset the premium savings and it may be from items traditionally covered by Medicare, which are not covered by advantage plans or maybe by recipients going to providers who you think are Medicare providers (and are) but are not Medicare advantage providers. These situations leave you stuck paying more than expected or stuck with the entire bill. As far as prescription medications, yes, there are generally more restrictions and hoops to jump through in order to obtain coverage.
Guess I'll have to retain a lawyer to advise me before seeing a doctor. This is not a health care system, it's a system to monetize healthcare so that insurers who write clever policies can scrape a percentage off the top for their shareholders. Bob Leonard has it right - his confusion is a feature of insurers' business plans.
Yes, I agree with folks that’s it way too confusing. A single-payer system would be much better for people to understand. Many people think Medicare Advantage is Medicare. It’s not. The trend of health organizations opting out of accepting these plans will continue to increase as well so I fear many will think they are covered at certain places in 2026 to find out they’re not. If you’re on MA and use out-of-network care, the bill is likely to be outrageous. So, for those people planning to stay on MA plans, I sure hope they create an “in-network” plan of care and understand other implications of their plan like maximum out of pocket because those MOOPs are all going up this year too. So, if someone is on a plan now with very limited “in-network” choices and a scary MOOP they should look to switch in the first quarter of 2026 back to traditional Medicare or another MA plan that protects them better.
Factual and informative. The Nebraska Hospital Aasociation issued a 2025 statement about the negatives that Medicare Advantage plans inflict on rural hospitals. One thing I am amazed at is how many think Medicare is free. Taking time to learn about Medicare is imperative. I will say that when my job was eliminated, paying COBRA for health and dental covetsge was a pre-Medicare lesson and budget line item. I do appreciate those who help others navigate the Medicare moss.
Former health insurance educator here… there is another whole article that needs to be written based on your content and that is the statement to switch back to traditional Medicare. An individual who initially is eligible for Medicare or MA plans can in the first year switch from Advantage coverage back to traditional Medicare. Then it gets more difficult.
When I taught classes about health insurance coverage I would point out what an 80/20 coverage plan looked like with dollar examples of what you could expect to pay. ($15,000 knee replacement would cost you $3000 out of pocket and maybe the deductible for the year.) A lot of people have a robust employer plan that offered 90/10 coverage. ($1,500 +any yearly deductible) This was possible because the employer had a young healthy pool of members. They could see from the examples that financially it made sense to add a supplemental plan to cover the 20% not paid by traditional medicare and it’s limits on things like length of stay, etc. And that is the catch, insurance companies don’t have to accept you into the supplemental plans after an initial enrollment grace period. That is the other story. In some ways, once you enter the Advantage market you are locked in and can expect that as you age the coverage will diminish.
Thanks Joyce. Yes, with the MA switch period in the new year folks can switch back to Medicare or a new MA plan. You make a great point about the being accepted back on the other Med Supplements though because as we age and use more core it’s harder to get accepted on some of those plans. As a former health insurance educator, what’s your best advice knowing everyone has different situations especially those on fixed incomes? I fear too many people think MA and Medicare are the same thing without realizing MA is operated by for-profits because so are many of the Medicare supplements. Appreciate the feedback, thank you!
Your article included some of the info used to point out the differences; network of providers, pre-approval requirements, and if time allowed the differences in amounts paid and number of days. I did see that Medicare is including pre-approval for care in five states. 🙁 I would try to get individuals to think of health insurance premiums as building a trust with an insurance provider who over time would be stable and had a track record of giving reliable benefits. Advantage plans come and go, change benefit rules every year, have evidence of high rates of denied coverage. There are also valid sources that show they cost taxpayers more than traditional Medicare. If you can afford the premiums then be a wise consumer and don’t fall for $0 premiums because you don’t ever get something for nothing. If you have limited resources, I still see traditional Medicare as your best deal because of near universal acceptance and their ability to cap the charges providers can charge. (That’s another article, interactions between gap policies and Medicare in bill payment.)
During my working years, money was deducted from my paycheck to fund the Medicare program. A program established by the federal government because private insurance wouldn’t offer coverage to those 65 or older. So why would I now permit those tax deductions, ones I couldn’t opt out of, to be withdrawn from a social non-profit government(citizen) oversight account and handed over to an insurance company for an Advantage plan designed to generate profit?
It seems Medicare Advantage is great until you actually get sick. That’s when potential big problems arise. I was fortunate to be able to switch back to conventional Medicare with a medigap plan. It’s more expensive, but the peace of mind is worth it. Who wants to battle an insurance company when you’re sick?
Yes, this is why many of the health care providers won’t accept the plans too. Medicare with a supplement is more expensive but there’s more peace of mind for sure. I’m encouraging folks to better understand what they have. Many think Medicare Advantage is Medicare. It’s not. It’s an alternative run by for-profit companies. With that said, the lower (if any) premiums and other benefits are enticing to many people so I’m hopeful they will review the details and be ready.
Thank you for the deep dive on MA, Chip. I am glad the plan served Uncle Pete well, but people really do need to read the fine print. It is not for everyone.
So true Kathi. I want people to know Medicare Advantage is not Medicare. MA is provided by for-profit companies with enticing low premiums and other perks so they need to do their due diligence to fully understand their coverage.
MA plans are a dice toss. Good luck. Unfortunately,though, for those who bought Medicare supplements, there often comes a time when those premiums are so steep that a subscriber is forced to give up the supplement that truly was a better choice for them and instead has to accept the lesser upfront cost of some MA plan……and roll the dice. It’s kind of a no-win situation as all expenses rise. Fortunately, I’m still able to hang on to my good, though ridiculously increased for 2026, supplement plan. Imagine what this world would be like if we actually taxed billionaires and corporations appropriately. But I digress……
So true Marcy. It really puts people between a rock and hard place so many roll the dice. I’m not advocating MA plans but hoping to educate folks that they can still switch in the new year, to make sure their care is in-network, to know their maximum out of pocket and to understand that MA is not Medicare. MA is an alternative run by for-profit insurance companies. So if someone stays on MA in 2026 (which more than 250k Iowans will) to be prepared by knowing these answers before an issue arises.
In my opinion Medicare Advantage plans are a trap. Many of them offer Freebies and people don't pay attention to what they will have to pay themselves. You have done a good job of laying out what is covered, deductibles and such. The sales people are as bad as timeshare sellers.
Medicare supplements are expensive but are accepted anywhere that accepts regular Medicare nation wide. I like the peace of mind knowing I won't get hit with a bill of thousands of dollars.
And a "buyer beware" Mayo Clinic only accepts a very few specific Medicare Advantage plans and all has to be pre-authorized.
Yes, these are all great points. Often they say MA is for the “healthy” and “wealthy” meaning you don’t need it or can easily pay out of pocket if needed. $0 premium attracts a lot of people and most docs in Iowa still take so thousands will be utilizing again so I hope they can do so in an efficient way. Thanks Becky! Always great to hear from you and this is an important conversation people should have.
Yeah, that seems to be an issue for many folks. I need to do more research but there are some caveats when an MA plan drops someone. But the Medicare supplements do increase in price as people age and/or have more health issues being a risk.
I started working on healthcare for all when the Clinton administration was elected. We just never get the momentum we need to actually get there. The insurance companies are too powerful. The ACA was a start but did not address the costs of medical care. It was mostly a gift to insurance companies.
I started working on healthcare for all when the Clinton administration was elected. We just never get the momentum we need to actually get there. The insurance companies are too powerful. The ACA was a start but did not address the costs of medical care. It was mostly a gift to insurance companies.
Almost every issue in America can be traced back to money and profiteering. Mitt Romney is still wrong about corporations being people too. Corporations are designed to make profit, hence, the bizarre system we find ourselves in today. Regular folks are caught between two massive groups with incredible influence and power: medical orgs and insurance companies. ACA definitely a positive step creating more options for more people especially those of us self-employed and independent but it’s not a true single payer system by any stretch of the imagination.
Thanks for this, Chip, my friend. But I still don't know what the fuck I'm doing with my Medicare plan. And I have a Ph.D. I think they want us confused, on purpose.
Oh, there’s no shortage of confusion. What I hope people learn from this article is that Medicare Advantage is not the same thing as Medicare. MA is an alternative run by for-profit insurance companies. With that said, it’s an extremely enticing alternative for folks in tougher money situations because the premiums are quite low. So, I’m encouraging folks to make sure they receive care in-network and fully understand the implications of their plan because they can switch off and go back to regular Medicare. Like most the issues in America, greed is a primary culprit here. For profit groups are all about the bottom line so many of the MA providers have bad reputations which is why groups like The Iowa Clinic only now work with three MA provider plans. But, yes, it’s become a mammoth system that is extremely confusing. A single-payer system would be much better for the people.
Thanks much! Sorry, I shared my frustration. I read your advice again, and thank you very much for the clarity! It helped. So many of our interactions on these kinds of things are with people we don't know, and so it's hard to know whose interests they are representing. That's why this post is so important to me, because I know and trust you and your advice. We aren't always so lucky! So thanks again.
Thank you for the kind words and restack, Bob. This article is a departure from my beloved topic of music, but I feel compelled to share what I’m learning because the system is so complex and easily misinterpreted. This intelligent and empathetic dialogue from the likes of pharmacists, health insurance counselors and fellow citizens striving to make the best decisions in a convoluted program has been extremely insightful.
The cheap premiums often entice people. As a pharmacist, my perception is that these plans are rarely worth it. There are far too many unexpected surprises as you try to navigate the process of receiving healthcare. What you save in premiums you often pay for in surprises later.
Agreed. As a pharmacist, do you see more issues with drug reimbursements especially with some tiers being omitted?
Fair. I get some reasons weight loss drugs would not be covered, but as a whole weight loss is for medical reasons. Smoking cessation is for medical reasons, and there’s no reason that dental and vision are not covered under medical healthcare.
To be honest, I really don’t know if it has to do with a tier being omitted or not. In the unfortunate hustle and bustle of pharmacy, I am generally just trying to respond to the coverage issue and assisting the patient in getting the best help and support that they can. So, generally, I’m not looking at the reason, but I am aware of the additional nuances often related to these plans.
Interesting. The fancy weight loss drugs could likely help my guy in this story but have been way too expensive for us to find a way to make it work.
Generally, I see it in many different ways with what I call “hidden costs.“ These things offset the premium savings and it may be from items traditionally covered by Medicare, which are not covered by advantage plans or maybe by recipients going to providers who you think are Medicare providers (and are) but are not Medicare advantage providers. These situations leave you stuck paying more than expected or stuck with the entire bill. As far as prescription medications, yes, there are generally more restrictions and hoops to jump through in order to obtain coverage.
So many “hidden costs” that become found when needing care. Appreciate all the insights, Mike.
Guess I'll have to retain a lawyer to advise me before seeing a doctor. This is not a health care system, it's a system to monetize healthcare so that insurers who write clever policies can scrape a percentage off the top for their shareholders. Bob Leonard has it right - his confusion is a feature of insurers' business plans.
,
Yes, I agree with folks that’s it way too confusing. A single-payer system would be much better for people to understand. Many people think Medicare Advantage is Medicare. It’s not. The trend of health organizations opting out of accepting these plans will continue to increase as well so I fear many will think they are covered at certain places in 2026 to find out they’re not. If you’re on MA and use out-of-network care, the bill is likely to be outrageous. So, for those people planning to stay on MA plans, I sure hope they create an “in-network” plan of care and understand other implications of their plan like maximum out of pocket because those MOOPs are all going up this year too. So, if someone is on a plan now with very limited “in-network” choices and a scary MOOP they should look to switch in the first quarter of 2026 back to traditional Medicare or another MA plan that protects them better.
Factual and informative. The Nebraska Hospital Aasociation issued a 2025 statement about the negatives that Medicare Advantage plans inflict on rural hospitals. One thing I am amazed at is how many think Medicare is free. Taking time to learn about Medicare is imperative. I will say that when my job was eliminated, paying COBRA for health and dental covetsge was a pre-Medicare lesson and budget line item. I do appreciate those who help others navigate the Medicare moss.
Thank you, Mary. The plight of rural healthcare is a whole different powder keg. I appreciate you reading and sharing personal insights.
Good info indeed. John Oliver did a recent show on this very topic too. So much to take in...
I’m sure John’s was more entertaining. Huge topic with no shortage of nuances.
Former health insurance educator here… there is another whole article that needs to be written based on your content and that is the statement to switch back to traditional Medicare. An individual who initially is eligible for Medicare or MA plans can in the first year switch from Advantage coverage back to traditional Medicare. Then it gets more difficult.
When I taught classes about health insurance coverage I would point out what an 80/20 coverage plan looked like with dollar examples of what you could expect to pay. ($15,000 knee replacement would cost you $3000 out of pocket and maybe the deductible for the year.) A lot of people have a robust employer plan that offered 90/10 coverage. ($1,500 +any yearly deductible) This was possible because the employer had a young healthy pool of members. They could see from the examples that financially it made sense to add a supplemental plan to cover the 20% not paid by traditional medicare and it’s limits on things like length of stay, etc. And that is the catch, insurance companies don’t have to accept you into the supplemental plans after an initial enrollment grace period. That is the other story. In some ways, once you enter the Advantage market you are locked in and can expect that as you age the coverage will diminish.
Thanks Joyce. Yes, with the MA switch period in the new year folks can switch back to Medicare or a new MA plan. You make a great point about the being accepted back on the other Med Supplements though because as we age and use more core it’s harder to get accepted on some of those plans. As a former health insurance educator, what’s your best advice knowing everyone has different situations especially those on fixed incomes? I fear too many people think MA and Medicare are the same thing without realizing MA is operated by for-profits because so are many of the Medicare supplements. Appreciate the feedback, thank you!
Your article included some of the info used to point out the differences; network of providers, pre-approval requirements, and if time allowed the differences in amounts paid and number of days. I did see that Medicare is including pre-approval for care in five states. 🙁 I would try to get individuals to think of health insurance premiums as building a trust with an insurance provider who over time would be stable and had a track record of giving reliable benefits. Advantage plans come and go, change benefit rules every year, have evidence of high rates of denied coverage. There are also valid sources that show they cost taxpayers more than traditional Medicare. If you can afford the premiums then be a wise consumer and don’t fall for $0 premiums because you don’t ever get something for nothing. If you have limited resources, I still see traditional Medicare as your best deal because of near universal acceptance and their ability to cap the charges providers can charge. (That’s another article, interactions between gap policies and Medicare in bill payment.)
Thanks Joyce. Terrific insights.
During my working years, money was deducted from my paycheck to fund the Medicare program. A program established by the federal government because private insurance wouldn’t offer coverage to those 65 or older. So why would I now permit those tax deductions, ones I couldn’t opt out of, to be withdrawn from a social non-profit government(citizen) oversight account and handed over to an insurance company for an Advantage plan designed to generate profit?
It seems Medicare Advantage is great until you actually get sick. That’s when potential big problems arise. I was fortunate to be able to switch back to conventional Medicare with a medigap plan. It’s more expensive, but the peace of mind is worth it. Who wants to battle an insurance company when you’re sick?
Yes, this is why many of the health care providers won’t accept the plans too. Medicare with a supplement is more expensive but there’s more peace of mind for sure. I’m encouraging folks to better understand what they have. Many think Medicare Advantage is Medicare. It’s not. It’s an alternative run by for-profit companies. With that said, the lower (if any) premiums and other benefits are enticing to many people so I’m hopeful they will review the details and be ready.
Thank you for the deep dive on MA, Chip. I am glad the plan served Uncle Pete well, but people really do need to read the fine print. It is not for everyone.
So true Kathi. I want people to know Medicare Advantage is not Medicare. MA is provided by for-profit companies with enticing low premiums and other perks so they need to do their due diligence to fully understand their coverage.
Thanks, Chip. I think for profit healthcare is an absolutely immoral business model.
It sure is letting a lot of people down.
MA plans are a dice toss. Good luck. Unfortunately,though, for those who bought Medicare supplements, there often comes a time when those premiums are so steep that a subscriber is forced to give up the supplement that truly was a better choice for them and instead has to accept the lesser upfront cost of some MA plan……and roll the dice. It’s kind of a no-win situation as all expenses rise. Fortunately, I’m still able to hang on to my good, though ridiculously increased for 2026, supplement plan. Imagine what this world would be like if we actually taxed billionaires and corporations appropriately. But I digress……
So true Marcy. It really puts people between a rock and hard place so many roll the dice. I’m not advocating MA plans but hoping to educate folks that they can still switch in the new year, to make sure their care is in-network, to know their maximum out of pocket and to understand that MA is not Medicare. MA is an alternative run by for-profit insurance companies. So if someone stays on MA in 2026 (which more than 250k Iowans will) to be prepared by knowing these answers before an issue arises.
Knowledge is power.
Amen. But with everything changing all the time, it is hard to maintain that accurate knowledge.
True that, Chip. The incessant barrage of info— accurate, suspect, and downright false — is a real brain smoother. Battle on.
In my opinion Medicare Advantage plans are a trap. Many of them offer Freebies and people don't pay attention to what they will have to pay themselves. You have done a good job of laying out what is covered, deductibles and such. The sales people are as bad as timeshare sellers.
Medicare supplements are expensive but are accepted anywhere that accepts regular Medicare nation wide. I like the peace of mind knowing I won't get hit with a bill of thousands of dollars.
And a "buyer beware" Mayo Clinic only accepts a very few specific Medicare Advantage plans and all has to be pre-authorized.
Yes, these are all great points. Often they say MA is for the “healthy” and “wealthy” meaning you don’t need it or can easily pay out of pocket if needed. $0 premium attracts a lot of people and most docs in Iowa still take so thousands will be utilizing again so I hope they can do so in an efficient way. Thanks Becky! Always great to hear from you and this is an important conversation people should have.
Thanks Chip that was very informative. I have Atena and so far all my drs are in network.
Glad you found it informative and your docs are in-network, Jill. All the best.
someone told me if you switch back to medicare your preexisting conditions may not be covered?
Yeah, that seems to be an issue for many folks. I need to do more research but there are some caveats when an MA plan drops someone. But the Medicare supplements do increase in price as people age and/or have more health issues being a risk.
Healthcare for all. Healthcare should be a universal right.
That would sure simplify things.
I started working on healthcare for all when the Clinton administration was elected. We just never get the momentum we need to actually get there. The insurance companies are too powerful. The ACA was a start but did not address the costs of medical care. It was mostly a gift to insurance companies.
I started working on healthcare for all when the Clinton administration was elected. We just never get the momentum we need to actually get there. The insurance companies are too powerful. The ACA was a start but did not address the costs of medical care. It was mostly a gift to insurance companies.
Almost every issue in America can be traced back to money and profiteering. Mitt Romney is still wrong about corporations being people too. Corporations are designed to make profit, hence, the bizarre system we find ourselves in today. Regular folks are caught between two massive groups with incredible influence and power: medical orgs and insurance companies. ACA definitely a positive step creating more options for more people especially those of us self-employed and independent but it’s not a true single payer system by any stretch of the imagination.