Medicare 2026 Update Vid

[Jim Rogers]

You can buy whatever insurance you want and you can pay as much as you want for the fear of something that might potentially happen.

I love that word potential
-The “...central concern in the capitated payment model used in Medicare Advantage is the potential incentive for Medicare Advantage Organizations to deny beneficiary access to services and deny payments to providers in an attempt to increase profits"

Such a strange take on this discussion-- the whole point of insurance is to engage in risk-sharing agreements to mitigate potential catastrophic outcomes.

Whether one is discussing the potential outcomes that one is insuring against, or the potential reliability of the insurance successfully covering the risks that you have paid for, the whole discussion is about potentials.

It's inherent to the conversation, yet you seem to feel that it's superfluous?

Buy what you like. 50% of the country is in Advantage plans and less that 50% in Medigap plans.

According to the video in the OP, CMS estimates that the uptake rate of MA plans will fall below 50% in 2026.

I have experience with both Plan N and Plan D plus 3 years experience with two different Advantage plans. I know many people in both and all are happy, buy what you want. I or anyone I know has not had a negative experience with either one.

Once again, are those ratings based on the early years (when MA has true advantages), or later years (when the trouble starts)?

I just can't seem to get you to stay focused on that critical distinction, which is unfortunate because it's where I believe your analysis is critically flawed.

Rather than explaining why I'm wrong, you just argue the flawed analysis over and over again.

If you feel I am an advocate for Advantage plans, that is wonderful, they are a great value and my opinion is just as valid as yours if not more so.

You express opinions based on incomplete experience (you're in the early years of MA).

I try to contain my analysis to hard data taken from the perspective of a complete picture of the entire old-age health insurance landscape.

I don't consider those approaches to be equal in value.

If you think I would tell someone who wants to pay an extra $200 to $400 a month Each (or more) for a Medigap plan, in addition to paying extra for dentists and eye care that they are crazy you are wrong.
If you think I would tell someone who wants an Advantage plan and save a boatload of money they are crazy, you are wrong again.

That's great, but more pertinent to both this discussion and proper decision-making protocols regarding insurance purchases, what do you tell them about high-cost, later-year claim coverage denials with MA?

You seem to be debating with yourself. No sense going in circles. It would be a shame to see this thread shut down.
Cleary your fear says you should be in a Medigap plan, though you don't offer what you are in but that is ok, Medigap is for you.

No, I'm clearly debating with you, but you are not really engaging the debate. You're correct that there is no point in going in circles, but the key to breaking the circle is to engage the main deficiency in MA (later-year coverage) and stop changing the subject to how great MA in early-year coverage (which is the only experience you have had).

Ps, you mention over and over that the video in post #22 is accurate in your mind. Well I know it is. Yet for some reason you say those videos are a dime a dozen. So what is the point of that statement? The video HELPS people understand what is available to them. Yet you keep attacking it and my opinion.

I've explained it many times, but I'll do it again: I asked you why you gave such a ravingly positive review of a fairly standard Medicare plan explanation video because you present yourself as a very well-read student of Medicare and that video was simply nothing special.

You have basically confirmed that there was no real reason, so I maintain my conclusion that you are not all that well-read on the topic.

In BITOG terms, it would be like if someone claimed to be a huge expert on engine oil but posted a generic video (not incorrect, but very basic and nothing special about it) on how to read the viscosity rating of oil and started "raving" about how it was "FANTASTIC" and that they had NEVER EVER seen a better video on the topic. NEVER!

Would you be likely to conclude that the fact that they found such a simple video to be so great was undermining the supposed expertise the person claimed to have?

My previous posts made it very clear that I was not attacking the video, and I said it was helpful. My point is that your over the top reaction to it was telling, not that there was anything wrong with the video.

And to answer your other question-- I retired early and am not yet eligible for Medicare. But I will be in a few years, so doing my best to educate myself in order to make the most informed decision I can.

Also note that I don't rule out choosing MA. Being a "free-market capitalist" kind of guy, I'm attracted to the philosophy of it. I'm also pretty healthy, so the early cost savings might be a worthwhile tradeoff for me as there's a chance that my later-years will be medically uneventful.

If that were to be the case, then MA would be the best for me. So, I'm not an anti-MA ideologue by any stretch.

But I do think you are advocating for MA based on a badly flawed analysis, so every once in a while, I feel like presenting the opposing view.

 

[alarmguy]

I have a simple question about conventional Medicare with Medigap. After Medicare agrees to pay the 80% for some treatment, does the Medigap company ever have a leg to stand on and try to deny the 20%?

No, none, zero, zip

 

[thastinger]

My Wife is a director at our regional health care company that has both hospitals and sells health insurance. They stopped selling Medicare plans this year, it is a money loser, they were able to lower their rates for all other programs once they dropped Medicare. The health care side still accepts Medicare.

 

[alarmguy]

Yep that's the way it goes. Regarding being fortunate, if I had to live on my SS benefit, I'd die a slow and miserable death from starvation. Thank God my wife and I planned for the future.

Yeah and that is what SS is intended for. A supplement to your savings, not a replacement to live. However, like any program, it takes on a while new life and people expect more, like any government program.

 

[demarpaint]

Yeah and that is what SS is intended for. A supplement to your savings, not a replacement to live. However, like any program, it takes on a while new life and people expect more, like any government program.

That's what I was taught growing up and thankfully planned accordingly.

 

[alarmguy]

That's what I was taught growing up and thankfully planned accordingly.

I could have planned way better at a young age, that is for sure. I lived like I might not live the next day but I did live (im glad*L*).... Luckily though, I made up for it, sort of unknowingly at the time, it worked out well. I did acquire it through hard work in my late 30's.

 

[fantastic]

Humana left 3 states as an example. That's awful for some folks now. UHC didn't have referrals on one plan but for 2026 must get a referral for Specialty & some physical therapy. The often touted "Extra Benefits" are getting stripped or reduced.

They removed VBID from MA plans for 2026. That alone helped many with copays on their prescriptions. These videos are a stark reminder that things aren't getting any better. Popular medigap plans eliminated for new Medicare enrollees etc. a few years ago.

Only a matter of time before most HMO-POS plans require referral at this rate.

 

[Pablo]

Yep that's the way it goes. Regarding being fortunate, if I had to live on my SS benefit, I'd die a slow and miserable death from starvation. Thank God my wife and I planned for the future.

That is part of what I said and part of why I chose the high-deduct plan.

I mean top down rich buggers don't really need to deal with any of this.

 

[mk378]

No, none, zero, zip

That is the point that I'm leading to-- with A/B Medicare, the government is consulted first for the coverage decision (since the provider foremost wants the 80%), and then the insurance company has to abide by it. With C the insurance company has the first decision and they are free to decline it and force you to appeal to the government -- possibly more than once.

It's a very fundamental structural difference between the two plans, and C is "potentially" a lot worse for the consumer.

 

[Jim Rogers]

That is the point that I'm leading to-- with A/B Medicare, the government is consulted first for the coverage decision (since the provider foremost wants the 80%), and then the insurance company has to abide by it. With C the insurance company has the first decision and they are free to decline it and force you to appeal to the government -- possibly more than once.

It's a very fundamental structural difference between the two plans, and C is "potentially" a lot worse for the consumer.

Yep-- this is the fundamental difference between the fee-for-service model of traditional Medicare and the capitation model of Medicare Advantage (although, I don't believe the appeals are made to the government).

But just to echo what alarmguy always says (and is true), the denial rate for Advantage plans in the early years is pretty low, and most of the denials that do occur are because the requested treatment was truly not medically necessary. That's actually a good thing.

And also bear in mind that the automatic coverage of a traditional Medicare plan doesn't come without downsides-- you're paying significantly higher premiums for that "no questions asked" style of coverage.

So, alarmguy is not wrong when he makes the point that, early on, you're paying a lot for medical insurance coverage that is not going to be all that different from what you'd be getting from a much cheaper Advantage plan.

My difference with him is that he seems to ignore the fact that what is experienced in the early years is not necessarily what will be experienced in the later years. As the policy holder ages and the costs pile up, MA gets stingier and stingier about what they'll pay as those types of cost have the highest impact in their bottom line.

And another thing that I think many do not fully consider is the toll of those denials on other family members.

Take someone who is 90, they get a MA denial, appeal it successfully, and days later get another denial which also has to be appealed. Who has to deal with all that time and stress?

Usually, the ~90 year old spouse, who will not necessarily have the energy, mental capacity, or financial resources required to hire representation in an ongoing appeal situation.

This is one of the main points that keeps drawing me back to traditional Medicare, despite the high premium cost-- I really don't want my wife or kids to be stuck dealing with a stressful and time-consuming appeal process where they have to deal with the guilt of having my life in their hands with every decision they make.

I really don't want to be a burden to anyone in my final years, and I feel that if I have to pay high premiums to achieve that, then so be it.

To do otherwise is basically saying "I want to save a few bucks now, so I'll dump the later costs on my family in the form of the burden of them having to deal with my appeals and other administrative chores."

Not my style.

 

[alarmguy]

That is the point that I'm leading to-- with A/B Medicare, the government is consulted first for the coverage decision (since the provider foremost wants the 80%), and then the insurance company has to abide by it. With C the insurance company has the first decision and they are free to decline it and force you to appeal to the government -- possibly more than once.

It's a very fundamental structural difference between the two plans, and C is "potentially" a lot worse for the consumer.

They are not free to decline anything that Medicare approves. Before my ramblings continue I want to sincerely say good post from you.

You are correct about the fundamental structural difference.

I mean, all can go back-and-forth all day long. Hey if it’s worth it to somebody to pay $4000 a year plus the dentist and vision then by all means and take a Medigap plan.

If you want to save that money and at the very, very slightest risk of a denial and possibly have a procedure denied and be forced to go the extra step to log into your account and have Medicare review it that’s what you get in return saving of thousands of dollars each and every year.

Here is my question though how come through peoples working careers are they OK with their company insurance being able to deny them coverage but then all of a sudden they flip the tables around and complain that their advantage plan can? It just doesn’t make any sense, but I do understand there are people out there who have a fear of everything and for those people there’s nothing wrong if you want to spend the money Medigap is great.

I have had the equivalent of hundreds of thousands of dollars in medical expenses under my advantage plans and Medigap plan N
Nothing was ever denied.

And oh my gosh, a sibling of mine easily over a half $1 million. His advantage plan even approved him going to MUSC hours away for a procedure that was almost experimental on equipment that that institution was only one of two in the country that had it currently available.

Yet a simple procedure on my wife’s legs with her company health insurance was denied and they had to jump through hoops over a six month period to get it approved..

Years back my company plan denied an MRI on my prostate for possible cancer and made me wait six months.

Yet in my advantage plans where I have needed more medical services than my entire life put together nothing was even questioned.

So why do people seem to try to predict the future of what might happen to them in an advantage plan? I think the answer to that is social media. Even though their protections are far far greater through Medicare and advantage plans than their company health insurance for some reason all of a sudden they’re concerned.

I want to repeat Medigap is a great insurance plan to have. The advantage plan depending what state you are in right now are in a upheaval The reason for this is around 2021 government stopped giving the plans an annual increases so they had to cut costs and that led to less advantages, but still no premiums. In the last year, they started getting increases again.
Depending on what state you live in the maximum out-of-pocket on advantage plans is far above what I would accept. Some of them getting in the $10,000 plus range. If I go back to advantage next January, my out-of-pocket limit will be 3500 which is perfectly acceptable.

I do understand there are many types of people in this world. Some have a fear of everything and others will fight for what is theirs.

With an advantage plan, you have the backing of the US government if you were ever denied anything. The US government pays your advantage plan roughly $1000 a month.
The US government approves each and every plan offered to the public. Fully regulated
The US government requires advantage plans to cover everything Medicare covers.

So on the outside chance something is denied. There very well may be a reason for it like a mistake that your doctor made? Something didn’t quite fit the criteria? So it may get kicked back to that doctor for further clarification. If the doctor says no this is correct. You could always appeal to Medicare. Medicare well then decide if it fits their criteria for that specific procedure.

Quite honestly, I’d look at that as an extra step making sure doctors or at least my doctor isn’t doing something that’s not medically accepted.
I love my doctors, but we could start a whole thread on that too

Just to be clear besides all my rambling on, I think you’re 100% correct in the way you stated it and I’m not saying it’s not true. I am saying to me and 50% of America in these plans. It’s unfounded or better yet. The denial rate is better than your company health plan.

Social media makes a tiny little thing sound very big and it’s also somebody could get clicks and make their website or their media account popular. They really do control the thought process of a lot of Americans.
Oh, and let’s not even get started on the Youtubers.

That’s why the video in my post number 22. I thought it was so spot on. Very balanced.

 

[Jim Rogers]

They are not free to decline anything that Medicare approves.

False, and they do it all the time.

 

[alarmguy]

Humana left 3 states as an example. That's awful for some folks now. UHC didn't have referrals on one plan but for 2026 must get a referral for Specialty & some physical therapy. The often touted "Extra Benefits" are getting stripped or reduced.

They removed VBID from MA plans for 2026. That alone helped many with copays on their prescriptions. These videos are a stark reminder that things aren't getting any better. Popular medigap plans eliminated for new Medicare enrollees etc. a few years ago.

Only a matter of time before most HMO-POS plans require referral at this rate.

No Medigap plans have been eliminated.
Partially correct a number of years ago they closed off some plans to any new Medigap participants in those plans. But the existing people did not lose their plan.
However, almost a mirror image of new plans came out for new Medigap applications of which the gold standard is plan G currently as well as plan N

Post number 22 shows you everything is still available.

I’m not sure what it’s awful about Humana pulling out of three states. Plans are canceled all the time though nowadays a lot more being canceled because government stopped giving them increases for a period of three years.
But the question would be so what?

It kind of stinks, but those people are free to go back to medigap without underwriting/automatic approval. It’s kinda like a testament to how much people love their advantage plans, take it away and people don’t want to pay thousands of dollars more a year for a Medigap plan when they were getting an advantage plan for nothing more than the part B monthly premium.

Just for the record, I agree with you. I’m not thrilled either but government is clamping down on how much they’re willing to give these companies or better yet they didn’t give the companies an increase for three years and the first increase just came through in year four recently.

I’m going to be very upset if I’m forced to start paying for a Medigap plan sometime in the future, but I suspect being the increases to these companies have started back up it will be at a status quo now I hope. Lower cost states still have a pretty good selection of advantage plans.

Some of the states, just for the record that the advantage plans are pulling out of and plans being cut are because of additional state mandates over what the federal government requires in those particular states. New York is a prime example much written on it, but I don’t think appropriate in this forum other than to say New York State, along with a handful of others, requires companies to allow you to switch back-and-forth between Medigap and advantage plans further increasing their costs in some of these very high cost states.

Full disclosure, this is an example. I had an Aetna HMO plan in 2024. (previous years I was in UHC HMO plans) It was fantastic. Aetna even bought me three Pickleball paddles and an Apple Watch. they also in the last three months of 2024 paid for every single test without question. This included a PSMA PET scan, biopsies, consultations with local specialists and consultation with a panel of doctors up at Duke University cancer clinic, a 3 Hour drive from my home, my wife and I stayed in a hotel the night before. The three doctors, one from each of the respective fields spent the entire morning with both my wife and I just to consult with us on treatment options, to give you the caliper of the people. One of those doctors was the director of research at the cancer clinic all paid for by my Aetna HMO plan.
However, toward the end of 2024 I was notified that plan was being canceled so for the heck of it since at that point I knew I had cancer. I went into Medigap plan N for 2025.
2025 is almost over, my cancer treatments, mostly all successfully completed and at this point 80% sure I will go back to an advantage plan in 2026. I have a couple more weeks to make up my mind.

Maybe some of this will explain to others my zeal for advantage plans.

 

[Vil_Riker]

I have a simple question about conventional Medicare with Medigap. After Medicare agrees to pay the 80% for some treatment, does the Medigap company ever have a leg to stand on and try to deny the 20%?

They sometimes do but require the hospital to eat it.

 

[alarmguy]

@mk378
I think a good way to put it is. If a doctor or Medicare or anybody provides you with a medical service or procedure that is not approved they cannot go back to the patient for payment.

Glad that was brought up. I forgot all about it. Another fantastic built in Medicare safety net for seniors. The medical establishment has to verify coverage and payment. If they don’t get paid, they cannot go back to the patient because they did not do their job verifying everything.
The burden is completely on the medical establishment.

 

[mk378]

They are not free to decline anything that Medicare approves.

Actually, a C plan is. Medicare is not asked at all until after the insurance company denies the payment, and the patient or their representative has to make that request.

A Medigap plan is going to pay because there is a decision by Medicare has already approved. If they don't pay for whatever reason the patient is not financially responsible. Generally this is for serious "never never" hospital mistakes which though they were planned and proposed as medically necessary and approved treatments, they were done so improperly (e.g. operating on the left knee instead of the right one) that Medicare won't pay the hospital either.

 

[Jim Rogers]

They are not free to decline anything that Medicare approves.

False, happens every day.

I mean, all can go back-and-forth all day long. Hey if it’s worth it to somebody to pay $4000 a year plus the dentist and vision then by all means and take a Medigap plan.

Strawman argument.

If you want to save that money and at the very, very slightest risk of a denial and possibly have a procedure denied and be forced to go the extra step to log into your account and have Medicare review it that’s what you get in return saving of thousands of dollars each and every year.

Argument works in the early years, fails badly in the later years.

Here is my question though how come through peoples working careers are they OK with their company insurance being able to deny them coverage but then all of a sudden they flip the tables around and complain that their advantage plan can? It just doesn’t make any sense, but I do understand there are people out there who have a fear of everything and for those people there’s nothing wrong if you want to spend the money Medigap is great.

Red herring. People do complain about private plan denials-- all the time. But irrelevant to the MA debate as we're taking about end-of-life denials, something private plans don't cover.

I have had the equivalent of hundreds of thousands of dollars in medical expenses under my advantage plans and Medigap plan N
Nothing was ever denied.

And oh my gosh, a sibling of mine easily over a half $1 million. His advantage plan even approved him going to MUSC hours away for a procedure that was almost experimental on equipment that that institution was only one of two in the country that had it currently available.

Yet a simple procedure on my wife’s legs with her company health insurance was denied and they had to jump through hoops over a six month period to get it approved..

Years back my company plan denied an MRI on my prostate for possible cancer and made me wait six months.

Yet in my advantage plans where I have needed more medical services than my entire life put together nothing was even questioned.

Personal anecdotes that won't stand up to statistical analysis.

So why do people seem to try to predict the future of what might happen to them in an advantage plan? I think the answer to that is social media. Even though their protections are far far greater through Medicare and advantage plans than their company health insurance for some reason all of a sudden they’re concerned.

Not supported by evidence and irrelevant because the main sticking point is later-life care that private insurers do not deal with. Totally different situations.

I do understand there are many types of people in this world. Some have a fear of everything and others will fight for what is theirs.

Rational risk management based on a good understanding of all facts should not be written off as "a fear of everything."

With an advantage plan, you have the backing of the US government if you were ever denied anything. The US government pays your advantage plan roughly $1000 a month.

False. "Backing of the government" due to premium support has nothing to do with (and does not imply) that the government controls what a MA provider covers.

The US government approves each and every plan offered to the public. Fully regulated

False. Actuarial decisions on denial are left to the insurance companies. Thus not "fully regulated" in the sense that you imply.

The US government requires advantage plans to cover everything Medicare covers.

Again, false.

So on the outside chance something is denied. There very well may be a reason for it like a mistake that your doctor made? Something didn’t quite fit the criteria? So it may get kicked back to that doctor for further clarification. If the doctor says no this is correct. You could always appeal to Medicare. Medicare well then decide if it fits their criteria for that specific procedure.

This is UNBELIEVABLY incorrect!!

At no point-- absolutely NO POINT-- does traditional Medicare (CMS) directly mediate MA claim disputes.

Once you take an Advantage plan, CMS is out of the picture-- totally. Your left with mediation boards and Administrative Law Judges.

I'm a little stunned that you would say something this contrary to the facts.

Just to be clear besides all my rambling on, I think you’re 100% correct in the way you stated it and I’m not saying it’s not true. I am saying to me and 50% of America in these plans. It’s unfounded or better yet. The denial rate is better than your company health plan.

Red herring. Since private plans are not contracted by the government, they are far freer to unilaterally decide what they will cover. Thus, there is a broad range of denial rates-- the lowest denial-rate companies deny in the 2-5% range, the worst in the 15-30% range. MA denies in the 7.5% range.

However, the MA denial distributions are not level-- straight-up denials are near 20% for end-of-life claims, but more importantly, 2/3 of hospitals report significant delays in approvals, meaning the de facto denial rates are much higher.

But the main problem here is that no private providers cover later-year, end of life health events like Medicare (traditional or Advantage) does. Two completely different markets with completely different denial dynamics. So, the comparison is pointless (and thus a red herring).

Social media makes a tiny little thing sound very big and it’s also somebody could get clicks and make their website or their media account popular. They really do control the thought process of a lot of Americans.
Oh, and let’s not even get started on the Youtubers.

That’s why the video in my post number 22. I thought it was so spot on. Very balanced.

I don't know which of those sources you use to get your information, but I can tell you that you need to get better ones.

That analysis was a litany of misunderstandings and outright falsehoods!

 

[mk378]

At no point-- absolutely NO POINT-- does traditional Medicare (CMS) directly mediate MA claim disputes.

Once you take an Advantage plan, CMS is out of the picture-- totally. Your left with mediation boards and Administrative Law Judges.

Wow that's even worse than I thought.

 

[drfeelgood]

@mk378
I think a good way to put it is. If a doctor or Medicare or anybody provides you with a medical service or procedure that is not approved they cannot go back to the patient for payment.

Glad that was brought up. I forgot all about it. Another fantastic built in Medicare safety net for seniors. The medical establishment has to verify coverage and payment. If they don’t get paid, they cannot go back to the patient because they did not do their job verifying everything.
The burden is completely on the medical establishment.

This is not completely true. If the physician has the patient sign a form(such as ABN) ahead of time, indicating it is possible their insurance may deny payment or claim something is not medically necessary, then it is allowed to turn the cost of the service to the patient. Insurances such as MA plans routinely require prior authorizations for almost everything that I do for my patients, yet they make clear even that is "no guarantee of payment"

 

[Jim Rogers]

Wow that's even worse than I thought.

Yep. Here's the full dispute pathway for MA:

• Level 1–2: Internal reconsideration within the MA plan.
• Level 3: Independent Review Entity (IRE) (contracted by CMS but not operated by CMS).
• Level 4: Administrative Law Judge (ALJ).
• Level 5: Medicare Appeals Council.
• Level 6: Federal court.
• At no point does “traditional Medicare” (Original Medicare or CMS staff) directly decide the dispute.

What's the dispute pathway for traditional Medicare? There is none! If your doctor deems something to be medically necessary, you get it. End of discussion!

That's why the idea that "MA must cover everything that traditional Medicare covers" is technically true but actually misleading.

An analogy might be two restaurants, the Medicare Cafe and the MA Diner. The federal government requires that the menu for the MA Diner be exactly the same as the menu for the Medicare Cafe, and, sure enough, it is.

But here's the difference: walk into the Medicare Cafe, order from the menu, and you get it-- no questions asked.

Order the same thing at the MA Diner, and they have the ability to say, "No, we're not going to allow you to order that because it's pretty high calorie, you're a bit overweight, so that order is not the best decision. Sorry!

Would you really say those two dining experiences are the same, just because the menus are regulated to be identical?

The MA debates involve a great deal of subtlety and nuance, and despite what alarmguy always says, it's not just a simple, straightforward, easy to analyze, plain-ol' common sense decision.

I don't pretend to be an expert, and I could have made mistakes myself in my posts (corrections welcome!), but I also would never advise anyone that these decisions are simple and obvious.