Medicare (Dis)Advantage

Dec

2025

Dispatch RELEASE

Medicare (Dis)Advantage

Medicare is complex, so naturally various private entities have used numerous ploys to weasel their way in, seeking profit at the expense of senior citizens. One such ploy that is incredibly costly to seniors, both in terms of their wealth and their well-being, while being incredibly profitable to the private corporations that run them, are Medicare Advantage plans.

To understand the underlying scam, we first need a quick summary of Medicare. Coverage is divided into “parts.” Part A covers hospital stays while you are an inpatient in a hospital or in a skilled nursing home. There is no fee for Part A if you have paid Medicare taxes for 10 years. Part B covers outpatient services such as primary care visits, ER visits, vaccines, and lab work. Out of pocket costs for Part B are determined based on the federal government set amount for the year and the enrollee’s income. Part C includes the Medicare Advantage and Medigap plans. Rates and copays depend on the type of plan one has. Part D covers prescription drugs.

Medigap plans are sold and managed by private companies, but the federal government regulates the policies, what is covered, and what is not covered. You can enroll in a Medigap Medicare plan the first 6 months you are enrolled in Medicare. After this, you may be denied Medigap coverage or you may have to pay a higher premium based on your preexisting health conditions. Medigap plans are labeled A-D, F, G, and K-N. They are standard, the same letter offering the same benefits. You can see any health care provider you want. Medigap isn’t perfect, but for many seniors, it is far better than Medicare Advantage.

Have you ever seen an ad for a Medicare Advantage plan? I bet we all have. These ads should make alarm bells ring in our heads. The federal government pays Medicare Advantage plans a certain amount for care for each member on the plan. Medicare Advantage plans will cover Parts A and B and some drug coverage for this fee. They are managed by for-profit companies such as Blue Cross and Blue Shield, United Health Care, Aetna, and Humana. They offer lower monthly payments than Medigap, which on the surface seems appealing. They offer some vision and dental coverage which, again, seems like an “advantage.” Some even give a monthly stipend for groceries. However, as you can probably guess, this all just to lure people in. After all, the government pays them based on the number of enrollees. What Medicare Advantage plans do not have is good coverage. Sure, they might be reasonable if you are a healthy senior citizen that does not require much care. But if, like most seniors, you have chronic diseases, take a lot of medication, or need surgery, these are not the best plans for you.

But, of course, the private companies offering these Advantage plans are not content with the profit they get by tricking a bunch of people into switching from the good coverage of a Medigap plan to the lousy coverage of their plans. They always want more. So why not trick the federal government into paying them even more money for their enrollees? Yep, they found a way to do that too.

It makes use of something called “risk adjustment” that is intended to make sure the sicker enrollees of Medicare can get coverage. With this goal in mind, the federal government pays the Medicare Advantage insurers more money for sicker appearing people. But by now, you probably see the flaw in this logic. More money paid to insurers for enrollees that are sicker? Is there a way that for-profit health care insurers with a CEO and stockholders can use this? Hmmm. If only there was a way for the Medicare Advantage plans to make enrollees appear sicker than they really are....

Why, there is such a thing already in place! Health Risk Assessments (HRAs) can do just that. During an HRA, a plan representative may go to the Medicare Advantage enrollee’s house and give them a questionnaire. There might be a physical exam as well. Then voila, that person will receive new diagnoses codes that they do not currently have so that they look sicker on paper than they really are. It’s called upcoding. For these new diagnoses, seniors are often not given any treatment or follow-up care with their own primary care provider. And why wouldn’t their primary care provider diagnose these conditions if they really had them? Sometimes, it is not even a visit to the enrollee’s house. It may be a chart review of their medical record to upcode their health diagnosis. This could be done by a human with a medical background or AI.

A report was put out October 2024 by the HHS Office of Inspector General (OIG) titled “Medicare Advantage: Questionable Use of Health Risk Assessments To Drive Up Payments to Plans by Billions.” Some of the more frequent diagnoses used to drive the risk adjusted payments include secondary hyperaldosteronism, disorders of immunity, and substance use disorder. The OIG estimates there was an increase of $7.5 billion dollars in 2023 paid by the federal government to Medicare Advantage plans based on HRA’s while there was no increase in spending on the enrollees’ care with these new diagnoses.

Denying claims and requiring prior authorizations is another way Medicare Advantage plans harm seniors and rip us tax payors off. They refuse to pay for medications, surgery, or stays in a skilled nursing facility. My aunt is a prime example. She fell and fractured her hip. She had a few days stay in the hospital where her hip was repaired via surgery. She then went to a nursing home to receive physical therapy to learn to walk again. Traditionally, Medicare has paid for 20 days in a skilled nursing home after a hospitalization for therapy. My aunt got kicked out on day 10 by her United Health Care Medicare Advantage plan. At that point, she could not even walk alone from her bed to the bathroom, not even with a walker!

Medicare Advantage plans use the term “medical necessity.” United Health said it was not medically necessary for my aunt to stay in a nursing home any longer. I frantically called a separate denial company at 4:30 on a Friday afternoon to file an appeal. Guess what? It didn’t work. She was discharged from the nursing home anyway. And her family was left to pay the nursing home for the time while the appeal was being considered.

In 2024, Andrew Witty, the CEO of United Healthcare Group, made $26.3 million in compensation. And Andrew Witty is not the only executive at United Healthcare making the big bucks. Meanwhile, my aunt was not allowed to stay in the nursing home until she could walk safely to the bathroom. Andrew Witty is a modern-day robber baron. Under his leadership, United Health is harming seniors and stealing from taxpayers.

Now the Trump administration is rolling out a program called WISeR (Wasteful and Inappropriate Service Reduction). It will use AI to make prior authorization determinations for some services for traditional Medicare/Medigap. What could go possibly wrong?

Some hospitals are dropping Medicare Advantage plans due to poor reimbursements. Some health care organizations hire people to deal specifically with denials and prior authorizations. One would think the senior’s doctor know what is best for them, not some insurance company that puts profit before people. Medicare Advantage plans also control which health care facilities and treatment providers it’s members can see.

Whether you are a senior relying on Medicare now or you will be a senior in the future, your health care is being stolen by the for-profit machine of capitalistic America. Is our elected Congressman Morgan Griffith concerned with any of this? Based on his Facebook screeds blaming Virginians for the problems with our health care system, he certainly doesn’t seem to be. Vote Adam Murphy November 2026. He is concerned about both your access to and the cost of health care. And rather than blaming you, he will fight for you!

Your friend,

Rosemary Rox

Medicare (Dis)Advantage

Dispatch RELEASE — December 3rd, 2025 — Rosemary Rox