2021-09-12 Medicare DISADVANTAGE

Original Medicare is transparent, uniform, and simpler to follow than many Medicare Advantage plans. Some MA plans offer reduced coverage or limit benefits that decrease our healthcare security as we age. 


Medicare Advantage Plan coverage and limits are variable between plans and may not be obvious – buyer beware. Many Medicare Advantage (MA) private insurers do Cherry Picking (picking the healthy Seniors) and Lemon Dropping (not appealing to sicker Seniors whose conditions need more expensive care) with their advertising and barriers to getting care.

Medicare Advantage insurers advertise to seniors about benefits that would appeal to healthy seniors, like gym club memberships. Lemon-dropping creates barriers to care such as narrow networks, needing prior authorizations, excluding expensive drugs and specialists,  and charging unforeseen medical bills.  

If you switch from MA back to Medicare plus supplemental insurance, the private insurer does an actuarial evaluation of your health and may deny sicker seniors. Sometimes you can’t switch to original Medicare at all. 

The Complexity of MA Plans

Each company covers different things at different levels with different rules. Even if you WANT to research Medicare Advantage plans, you can’t get the data on which Medicare Advantage plans deny care for what conditions (i.e., cancer). The Inspector-General of the Department of Health and Human Services reports that our government gets incomplete or inaccurate data.

  • Report from the Inspector General at the Department of Health and Human Services (HHS) 9/2018

If you want to find out which MA plans deny care and at what rate, you can’t.

Medicare Advantage plans regularly deny claims. Only 1% of beneficiaries appeal a denied claim. However, when beneficiaries appeal, 75% of denials are reversed.

  • The report from the Inspector General at the Department of Health and Human Services (HHS) titled – Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials  09-25-2018 | Report (OEI-09-16-00410) 

Switching Plans

American’s need healthcare security that provides reliable medical coverage throughout life. If your medical needs change, your MA plan may not be a good fit. If you want to switch to original Medicare, it may be difficult. It is easier to get into a MA plan than Out (if you are healthy.) A low-cost MA plan is analogous to an adjustable-rate mortgage that offers seductive low payments earlier in life, but expenses balloon as we age.

Low-income seniors with high medical needs quit their MA plans and return to traditional Medicare  3-4 times more frequently than their counterparts with fewer medical needs.

  • Page 208 Medicare for All, A Citizen’s Guide by Doctors Abdul El-Sayed and Micah Johnson. 

Original reference:

  • David J. Meyers et al., “Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries,” JAMA, Internal Medicine 179, No 4 (April 1, 2019): 524-32, https://doi.org/10.1001/jamainternmed.2018.7639.


MA patients cost the government MORE than traditional Medicare patients. Medicare Payment Advisory Commission “Report to the Congress: Medicare Payment Policy,” March 2019. Medicare Advantage plans lower costs by cherry-picking,  lemon dropping, paying more for “sicker” patients that are relatively healthy, and exaggerating how sick their enrollees look on paper to get more payments from Medicare. 

  • Page 210 Medicare for All, A Citizen’s Guide by Doctors Abdul El-Sayed and Micah Johnson The lion’s share of those savings seems to be flowing to insurance companies, partly in the form of profits and administrative costs.

One estimate is MA’s spend 86% on medical care and 14% on profits and administrative costs. In contrast, traditional Medicare allocates nearly 98% of its budget on medical care. 

  • Page  207, Medicare for All, A Citizen’s Guide by Doctors Abdul El-Sayed and Micah Johnson. Original reference: Juliette Cubanski, Tricia Neuman, and Meredith Freed, “The Facts on Medicare Spending and Financing,” Kaiser Family Foundation, August 20, 2019, https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing

Bottom line: WE Taxpayers ARE GETTING RIPPED OFF By Private Insurance Companies.


Rather than promoting Medicare Advantage, we need to put our energy towards improving Original Medicare.  Improvements include: add dental, vision, and hearing benefits and preventative care, lower the eligibility age to 50, lower drug prices by allowing Medicare to negotiate drug prices,  and eliminate the “donut hole.” WE SUPPORT the $3.5 trillion Infrastructure Bill by Bernie Sanders and Pramila Jayapal to fix some of these issues!

  –  Cathy Blake, LPC