Beware of Health Insurance Companies Bearing Gifts

Gainesville, Florida (Special to Informed Comment; Feature) – When it comes to Medicare Advantage,“beware of health insurance companies bearing gifts”, just like “beware of Greeks bearing gifts”, is a phrase that serves as a cautionary warning against trusting those who may have ulterior motives, particularly when they present seemingly generous health insurance policy offers. Everyone should be aware that not all offers of help or generosity are genuine and that one should critically and thoroughly assess the intentions and specifics behind such programs and policies. The idiom is particularly relevant in situations where aggressive sales agents of health insurance companies may present themselves as allies while harboring hidden marketing and sales agendas for Medicare Advantage.

After The Centers for Medicare and Medicaid Services (CMS) revealed that the number of Medicare beneficiary complaints about private sector marketing for Medicare Advantage (MA) plans more than doubled from 2020 to 2021. The Senate Finance Committee Majority Staff, Chairman Senator Ron Wyden,D-OR, launched an inquiry in August 2022, collected information on marketing complaints from 14 states and found evidence that beneficiaries are being inundated with aggressive marketing tactics as well as false and misleading information.

Senator Wyden’s U.S. Senate Committee on Finance report, “Deceptive Marketing Practices Flourish in Medicare Advantage “, outlines how marketing practices by private plans, their agents and brokers need to be reined in. These bad actors are trying to cash in by taking advantage of loopholes and loosened rules around marketing and enrollment to beneficiaries. Agressive health insurance agents badger seniors on the phone, confuse them on television, and inundate them with mountains of mail. A burgeoning number of marketing materials are fraudulent or deceptive, undermining beneficiary access to care and trust in the traditional Medicare program itself. Vulnerable seniors and people with disabilities have had their health plans changed without their consent by un-ethical sales agents.

MA and Part D health plans and their contractors are engaging in manipulative and aggressive sales practices that take advantage of vulnerable older adults and people living with disabilities. In its survey of state insurance commissioners, the National Association of Insurance Commissioners (NAIC) reports there has been an increase in complaints from seniors about false and misleading advertising and marketing of MA plans.

BRIEF HISTORY:

Our contempory phrase “beware of health insurance companies bearing gifts” has its roots in ancient history and literature, specifically in the context of the Trojan War, a legendary conflict between the Greeks and the Trojans. The phrase encapsulates the idea that gifts and benefits can often be deceptive and that one should be wary of those who offer them. Caution is always needed because most health insurance companies have hidden profiteering motives, even when they seem to offer something kind, generous or economical, just like the story of the Trojan Horse in Greek mythology, where the Greeks used a deceptive gift to infiltrate and conquer Troy.

Originating from the story of the Trojan War and the Trojan Horse episode In Virgil’s epic poem, the Aeneid, the Trojan priest Laocoön, warns his fellow Trojans not to trust the wooden horse left by the Greeks, saying, “Timeo Danaos et dona ferentes,” which translates to “I fear the Greeks, even when they bear gifts.” The Trojans, believing the horse to be a peace offering, brought it into their city, leading to their downfall when Greek soldiers hidden inside attacked by opening the city gate.

The phrase has been referenced in many literary works, speeches, and popular culture, serving as a reminder to remain vigilant and skeptical of those who may not have our best interests at heart. It has transcended its original context and is now used in a broader sense to caution against manipulation and deceit in various aspects of life, including selling Medicare Advantage health insurance policies, politics, business, and personal relationships.

The Trojan war, which is believed to have taken place around the 12th or 13th century BCE, is a central theme in Greek mythology and literature. The phrase “Beware of Greeks bearing gifts” refers to the strategy the Greeks used to infiltrate the city of Troy. Frustrated by a long, unsuccessful siege, the Greeks devised a plan to construct a massive wooden horse, known as the Trojan Horse. After hollowing out the horse and hiding a select group of their best warriors inside, the Greeks then left the horse at the gates of Troy as a supposed offering of peace, while the rest of the Greek army pretended to retreat. The Trojans, believing they had won the war, brought the horse into their city as a trophy. That night, while the Trojans celebrated their victory, the Greek warriors hidden inside the horse emerged, opened the gates for the rest of the Greek army and launched a surprise attack. This treachery led to the fall of Troy and is one of the most famous tales from the epic poems of Homer, particularly the “Aeneid” by Virgil and the “Iliad.”

Medicare Advantage was established during the Bill Clinton administration with the Balanced Budget Act of 1997, when Congress approved the program initially known as Medicare+Choice. It was later renamed Medicare Advantage (MA) in 2003.

Medicare Advantage history:

* 1965: Medicare was created to provide health coverage for older Americans.

* 1997: The Balanced Budget Act introduced Medicare+Choice; Congress allows for-profit private health plans to offer Medicare benefits.
* 2003: The program was renamed Medicare Advantage under the Medicare Prescription Drug, Improvement, and Modernization Act. This act also introduced Medicare Part D, which added prescription drug coverage.
* 2024, approximately 33.8 million people, or 55% of all Medicare recipients, were enrolled in Medicare Advantage plans.
* 2025, over 50% of Medicare beneficiaries now have for-profit corporations in charge of their care through Medicare Advantage (MA).

* 2025, health insurance companies continue to be paid handsomely for these plans, and much of that money goes to corporate profits instead of care.

* 2025, the companies running MA plans contnue seeking full take over of traditional Medicare , leaving patients with no option but to give their money to private insurers.

Congress has permitted a private, for-profit health insurance option that wraps around traditional Medicare. Medicare Advantage plans may fill some coverage gaps and offer a few alternative coverage options in an attempt to make them appear more attractive to the subscriber as compared to traditional Medicare. As a result, private health insurance companies can then exact large profit from U.S. citizens as Wall Street banks and investors who back Big Insurance, turnpng public money into a bonanza of private riches. High U.S, health insurance costs are the result of a political decision by Congress to essentially allow Big Insurance to do what they want and charge whatever they want.

WHAT IS MEDICARE ADVANTAGE?

Medicare Advantage is a program offering private health insurance industry plans as options to replace public traditional Medicare. Medicare Advantage plans differ from traditional Medicare in that they are paid with capitation (per member), they are required to limit enrollees’ out-of-pocket spending, and can offer extra benefits (e.g. gym memberships, $900 worth of groceries, dental benefits). They almost always offer prescription drug coverage and use a defined and often restricted network of providers that can require enrollees to pay more for out-of-network care. Managed Care/Utilization management techniques are used, such as prior authorization, and they can also fund special programs such as rewards for beneficiaries to encourage “healthy behaviors”. In reality, “Medicare Dis-Advantage” is a better, more accurate name for the programs however, as insurance companies push Congress to corporatize all of Medicare, yet keep the name for the purposes of marketing, deception, and confusion.

HOW MA PLANS DIFFER FROM TRADITIONAL MEDICARE:

* They are owned and operated by for-profit, private insurance corporations ans Wall Street investors.

* Unlike traditional Medicare, Medicare Advantage plans often refuse to pay for treatments and medications physicians prescribe.
* Unlike traditional Medicare, many physicians, other healthcare professionals, and hospitals will be off-limits to patients because Medicare Advantage companies create their own proprietary and often skimpy, managed care type “networks” of healthcare providers.
* If patients go out of network, they could then be on the hook for thousands of dollars out of their own pocket.

* Patients do not have free choice of their professionals and health care institutions. Medicare Advantage does not allow choices within the entire health care system.

* They likely will have to pay extra—often a lot extra—for some of those extra benefits.

MEDICARE ADVANTAGE PROFITEERING STATISTICS: (from Wendall Potter, HEATHCARE UN-covered)

1). big Insurance revenues and profits have increased by 300% and 287% respectively since 2012 due to explosive growth in the insurance companies’ pharmacy benefit management (PBM) businesses and the Medicare replacement plans called Medicare Advantage.

2). the for-profits now control more than 70% of the Medicare Advantage market.
In 2022, Big Insurance revenues reached $1.25 trillion and profits soared to $69.3 billion.
That’s a 300% increase in revenue and a 287% increase in profits from 2012, when revenue was $412.9 billion and profits were $24 billion.

3). big insurers’ revenues have grown dramatically over the past decade, the result of consolidation in the PBM business and taxpayer-supported Medicare and Medicaid programs.

4). what has changed dramatically over the decade is that the big insurers are now getting far more of their revenues from the pharmaceutical supply chain, Medicare, Medicaid and from taxpayers as they have moved aggressively into government programs. This is especially true of Humana, Centene, and Molina, which now get, respectively, 85%, 88%, and 94% of their health-plan revenues from government programs.

5). the two biggest drivers are their fast-growing pharmacy benefit managers (PBMs), the relatively new and little-known middleman between patients and pharmaceutical drug manufacturers, and the privately owned and operated Medicare replacement plans marketed as Medicare Advantage.

6). huge strides in privatizing both Medicare and Medicaid have been made. More than 90% of health-plan revenues at three of the health industry companies come from government programs as they continue to privatize both Medicare and Medicaid, through Medicare Advantage in particular. Enrollment in government-funded programs increased by 261% in 10 years.

7). Health advocate Wendall Potter found that the seven biggest publicly traded health insurance companies collectively made $71.3 billion in profits, up more than half a billion dollars from 2023.

BENEFICIARIES INUNDATED WITH PRIVATE SECTOR AGGRESSIVE MARKETING TACTICS:

With so much money to be made in MA, it’s not surprising that The Centers for Medicare and Medicaid Services (CMS) revealed that the number of Medicare beneficiary complaints about private sector marketing for Medicare Advantage (MA) plans more than doubled from 2020 to 2021. Senator Ron Wyden’s Senate Finance Committee Majority Staff launched an inquiry in August 2022, collected information on marketing complaints from 14 states and found evidence that beneficiaries are being inundated with aggressive marketing tactics as well as false and misleading information.

Each one of these vignettes represents documented instances of aggressive or deceptive MA and Part D marketing practices that was found to be widespread, not isolated events:

*** Seniors shopping at their local grocery store are approached by insurance agents and asked to switch their Medicare coverage or MA plan.

*** Insurance agents selling new MA plans tell seniors that their doctors are covered by the new plans. Seniors who switch plans find out months later that their doctor is actually out-of-network, and they have to pay out-of-pocket to visit their doctor.

*** Seniors receive mailers that look like official business from a Federal agency, yet the mailer is a marketing prompt from an MA plan or its agent or broker.

*** An insurance agent calls seniors 20 times a day, attempting to convince them to switch their Medicare coverage.

*** Widespread television advertisements with celebrities claim that seniors are missing out on benefits, including higher Social Security payments, in order to prompt seniors to call MA plan agent or broker hotlines.

EXAMPLES OF DECEPTION, ‘beware of health insurance companies bearibg gifts’ in action:

1). Fake “IRS Mailers” and “Official Mailers”

Mailers are designed to look like official notices coming from the Internal Revenue Service (IRS) or the Medicare Program. These mailers are both misleading and serve an important role in lead generation that allow TPMOs to get around many of the marketing prohibitions currently in law, per Section 103 of the Medicare Improvement for Patient and Providers Act (MIPPA) of 2008 that prohibits MA and Part D plans from conducting certain marketing activities, including cold calling. These mailers allow salesmen to skirt the rules because after the beneficiary initiates contact in response to an advertisement these prohibitions are no longer in place per CMS rules. Mailers framed as urgent that look like official notices from the IRS or other government entities serve the explicitly misleading purpose of prompting beneficiaries to “initiate contact,” so that MA marketing prohibitions can be circumvented. This loophole allows bad actors to inundate older Americans with unsolicited calls and other aggressive marketing.

2). Misleading Information about Provider Networks
False or misleading claims around in-network and out-of-network providers were reported and are of high concern because they have serious impacts on beneficiary health. In response to the March 2022 Advance Notice released by CMS, the National Organization for Rheumatology Management (NORM) submitted a letter describing the provision of incorrect information about MA plan provider networks. In its letter to CMS, NORM reported that “When researching MA plan options, beneficiaries are often told by MA plan enrollment representatives that there will be no disruption in their treatment, and they can continue seeing their current care providers. Some beneficiaries will contact their rheumatology practice for confirmation. The practice administrator can share whether the treating rheumatologist is “in-network,” whether the prescribed medications are on the plan’s formulary and/or subject to prior authorization or step therapy, or whether the patient would need to be “switched” to another option, as well as what their expected out-of-pocket costs would be, if they proceed with MA plan enrollment. Far too often, beneficiaries learn the information shared by the MA plan representative was incorrect.” The letter goes on to say, “practice administrators learn of a patient’s change in coverage at the time the patient requests an appointment (and the practice does not participate in the plan) or visits the pharmacy to request a refill (and learns they either need prior authorization or the medication is now cost-prohibitive). At that time, the damage has been done, as the patient is “stuck” with the new MA plan until the next open enrollment period…. In these situations, the patient’s care is severely disrupted solely as a result of misleading marketing tactics used by the plan to increase enrollment.”

3). The Missouri Department of Insurance detailed similar beneficiary stories in a letter stating:“A 94-year-old woman with dementia was sold a MA plan. The consumer lives in a rural area, and the hospital and providers she utilizes are not in-network with the plan chosen for her by the insurance salesperson. The plan did not allow for continuity of care for the consumer and forced her to obtain care (with the help of staff) miles away from her residence.”

Photo by mohamad azaam on Unsplash

4). Television/Internet:

Another example of misleading marketing is the Medicare Coverage Helpline television advertisement campaign, which first aired in 2018 and features former football star Broadway Joe Namath. In the ad, Mr. Namath says, “get what you deserve,” and “the benefit that adds money back to your Social Security check.” After numerous lawsuits, the ad was recently updated to comply with current CMS regulations. However, it still fails to mention basic information about the MA program, including that not all providers are in-network and was only recently updated to mention that benefits vary by zip code.

5). Television advertisements can be particularly effective at targeting Medicare beneficiaries. For example, the Missouri Department of Commerce and Insurance reported instances of consumers “reaching out to insurance agencies after seeing a television advertisement. For example, an elderly consumer in a long-term care facility and without the capacity to make her own decisions, called the number advertised on television. During the call she was switched from one plan to another.”

6). Oregon reported a case where a dual eligible Medicare beneficiary and Social Security Income recipient was enrolled in a plan without prescription drug coverage. The beneficiary reported that they “did not remember making any changes to his coverage; however, remembered seeing a TV advertisement and called about it. He said the plan representative mentioned getting $135 more in his Social Security check ([the beneficiary] wasn’t sure what that meant but it sounded good). [The beneficiary] already had the State of Oregon paying his Part B premium. [The beneficiary] was told he would have a gym membership and dental coverage (which he already has dental through his Medicaid benefit). The key issue is that he was not told by the MA-only plan phone agent that the plan does not cover Rx and does not include Part D.”

BUYER BEWARE:
Investigation shows a toxic pattern of false, misleading advertisements and fraudulent sales practices that go well beyond isolated incidents. Reports from state insurance departments and SHIPs confirm that vulnerable seniors are being flooded by plans utilizing subsidiaries, third-party organizations, and “bait-and-switch” tactics that evade existing Medicare rules on plan marketing and communications to beneficiaries. Unscrupulous actors appear to be taking advantage of the loosening of marketing regulations, which has ratcheted up confusion and pressure on beneficiaries as well as enrollment into different plans without their consent.

HOW TO DEAL WITH HEALTH INSURANCE COMPANIES BEARING GIFTS:

1). USE EXTREME CAUTION IF CALLING A TV HELPLINE . The Federal Medicare program does not advertise MA plans or benefits on television. These so-called helplines will connect you with an agent or broker. That agent or broker does not have to tell you about all of your options in the Medicare program, and does not have to ensure that your plan will meet your needs.

2). IF YOU THINK YOU HAVE BEEN ENROLLED IN A NEW PLAN THAT DOESN’T WORK FOR YOU, CALL 1-800-MEDICARE FOR HELP. Seniors and people living with disabilities can also get no-cost counseling from the local State Health Insurance Assistance Program (SHIP) or Senior Medicare Patrol (SMP) office. In some situations, you may be eligible for a special enrollment period to switch back into your original plan. During the first three months of the year, you can also change your enrollment.

3). BE CAREFUL WHAT YOU CLICK. Third-Party Marketing Organizations are using sneaky tactics to get your information and then sell your information to agents or brokers who can call you. When in doubt, don’t provide your information on unfamiliar websites or unfamiliar people. The Medicare Call Center (1-800-MEDICARE) and your local State Health Insurance Assistance Program (SHIP) office can help you understand your Medicare choices and enroll in a plan that will meet your needs.

4). JUST DON’T DO IT ! Do everything you can to stay with (or return) to traditional Medicare and buy a supplemental Medigap policy, because unfortunately, traditional Medicare has some big holes in it.

5). DENIAL: Medicare Advantage plans look good while you’re healthy. But when you get sick, odds are high they will deny you.

6). REMEMBER another important factor: The door will have been slammed behind you if you have been in Medicare Advantage for more than six months and then decide you want to return /re-enroll in traditional Medicare.

7). EXCEPTION: With the exception of four states in this country, if you’re in Medicare Advantage for more than six months and decide you want to go back, and then buy a supplemental coverage, the insurance companies that sells you supplemental coverage can turn you down for supplemental coverage..

8). PRE-EXISTING CONDITIONS: If they don’t like the look of your pre-existing conditions, they can also charge you a lot more money.

9). You need to make this decision in a six months enrollment timeframe if you are still fairly new to MA.

10). BASIC RECOMMENDATION: don’t even think about enrolling in Medicare Advantage in the first place!

11) CONTACT YOUR LEGISLATORS asking them to oppose and end Medicare Advantage plans immediately.

12). Most importantly, ask them to strongly support new legislation now filed in Congress, “The Medicare for All Act of 2025”

13). SPECIAL FYI NOTE ON M4A ACT-2025:

a). The Medicare for All Act of 2025, now filed in Congress, would provide health coverage to every U.S. resident—including comprehensive medical, dental, vision, mental health, and reproductive care—with no out-of-pocket costs, copays, or deductibles.
b). By eliminating waste and corporate profiteering in health care, the bill would save hundreds of billions annually that could be invested in actual health care, resulting in better, more equitable health outcomes.
c). By covering everyone without the copays, deductibles, and insurance networks that deter care and drive medical debt, M4A would achieve universal and comprehensive coverage, while assuring real choice of physician, mental health / health professional and hospital.
d). By eliminating profiteering and wasteful insurance bureaucracy (plus the administrative costs that bureaucracy inflicts on healthcare providers), it would — according to the Congressional Budget Office — free up $400 billion annually in funds that could pay for the cost of such coverage expansions and improvements.
e). Medicare-for-All could also effect a much needed shift in the ownership of care away from increasingly dominant private corporations to public ownership by Americans and their communities.

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