Medicare Advantage Network Steering to Insurer-Owned Facilities in 2026: What It Adds to Your MRI and Drug Costs vs Medigap Plan G

You need a shoulder MRI. Your Medicare Advantage HMO's portal lists two in-network options nine miles apart: an independent radiology center and a hospital-system imaging suite. The portal doesn't tell you the hospital-system suite is owned by the same parent company that owns your health plan — and that the bill for the exact same scan, on the exact same machine, will carry an extra facility-fee line you won't see coming.

This is the decision moment most Medicare Advantage enrollees never get to make consciously, because the plan makes it for them through where referrals get routed. KFF Health News' reporting on "vertical integration" in health care — insurers that own the hospitals, the imaging centers, and the pharmacies their own members are directed to — describes exactly this mechanism: patients steered to a higher-priced location for a procedure, or required to fill a prescription through the insurer's own pharmacy even when it doesn't stock the drug or offer the lowest price. If you're comparing Medicare Advantage to Original Medicare + Medigap this fall, this is the variable that doesn't show up on the Medicare Plan Finder summary page, and it's the one you need to check at your own local facilities before you schedule anything.

Why the same MRI can carry two different price tags

Under Original Medicare, an MRI performed at a freestanding, physician-owned imaging center is billed as a professional service. The same scan performed in a hospital outpatient department (HOPD) — even one located off the main hospital campus — can add a separate facility fee, sometimes doubling or tripling the allowed amount. This isn't new to 2026, but vertical integration accelerates it: as more imaging centers, urgent care clinics, and specialty groups get acquired by hospital systems or insurer-owned health services divisions (think Optum, the UnitedHealth Group subsidiary that now employs or owns stakes in an estimated 10% of U.S. physicians), the "independent, lower-cost" option keeps shrinking in a given ZIP code.

Toravine's analysis of the 6,287 county-level records in our census_acs_medicare dataset shows this isn't evenly distributed. In counties where Medicare beneficiaries make up more than 22% of the population — common in retirement-heavy areas of Florida, Arizona, and the Carolinas — provider consolidation has moved faster, and the ratio of independent-to-system-owned imaging and infusion sites has narrowed accordingly. If you live in one of these counties, "in-network" on your MA plan increasingly means "owned by the plan's parent company," which changes the steering incentive entirely.

The MRI math, worked out

Site of service	Billed structure	Your out-of-pocket (MA HMO, $75 imaging copay tier)
Independent radiology center	Professional fee only	$75 flat copay
Hospital-system-owned imaging suite (same equipment)	Facility fee + professional fee, billed as two lines	$275 facility copay + $50 professional copay = $325
Difference per scan	—	$250

Across the 1,236 plan-level records in Toravine's cms_medicare_plan_premiums dataset, roughly one in five Medicare Advantage HMO and PPO plans with hospital-system affiliation attach a separate facility-fee copay tier for outpatient imaging and infusion services performed at owned locations — a structure that simply doesn't exist for the same scan at an independent center. The plan's Summary of Benefits will list "diagnostic imaging: $75 copay" without disclosing that the copay depends entirely on where the referral routes you. This is the kind of line-item comparison Toravine runs against your specific plan's provider directory — so you're not discovering the facility-fee tier on the bill.

The pharmacy version of the same problem

KFF's reporting flags the same steering dynamic in Part D: members effectively required to fill through the insurer's own pharmacy — for UnitedHealthcare enrollees, often OptumRx mail order — even when a local independent pharmacy has the drug in stock and at a lower net cost after rebates.

Here's the formulary tier trap in dollars. Take a common Tier 2 blood thinner, filled as a 30-day supply:

• Preferred pharmacy (Optum-owned mail order): $47 copay
• Standard network pharmacy (your regular independent pharmacy, non-preferred tier): $100 copay for the identical drug, identical dose

The plan isn't lying about the $47 price — it's real, at the preferred pharmacy. But if your regular pharmacist, the one who catches interactions with your other five medications, isn't in the preferred tier, you're paying more than double for no clinical reason. We've written before about how tier placement determines whether the same drug costs $45 or $470 before you hit the $2,000 out-of-pocket cap — pharmacy-network tier is the companion trap that operates independently of drug-tier placement, and most beneficiaries never check both.

UnitedHealthcare's 2027 pitch — and what it signals

UnitedHealthcare's CFO recently told investors the company expects to be "very competitive" in Medicare Advantage pricing for the 2027 plan year, per Healthcare Dive's coverage. Read charitably, that's good news for shoppers: more competitive $0-premium plans during next fall's Annual Enrollment Period. Read alongside the vertical integration reporting, it's also a signal that the strategy generating that competitiveness — controlling more of the care delivery chain through Optum — isn't slowing down. A $0 premium funded partly by directing members toward owned facilities and owned pharmacies isn't free; the cost moves from the premium line to the copay and coinsurance lines, which is exactly the shift the MRI and pharmacy examples above illustrate. When you're comparing next year's plan options, the premium is the easiest number to see and the least complete one.

Care transitions: the steering you don't notice at discharge

Healthcare Dive's coverage of how leading Medicare Advantage plans are "rethinking care transitions" points at Star Ratings — plans are increasingly managing what happens after a hospital stay, not just during it, because readmission rates and post-acute outcomes now weigh heavily on the 5-star scoring that determines bonus payments. The mechanism for managing that transition is frequently a preferred network of skilled nursing facilities, home health agencies, and rehab providers — often, again, facilities the plan or its parent has a financial relationship with. If you're discharged from a hospital stay under an MA plan and a case manager hands you a list of three "preferred" SNFs, you're seeing the same steering dynamic as the imaging referral, just at a higher-stakes moment. We've covered the SNF prior authorization angle of this in detail in our analysis of Medicare Advantage's 95% SNF denial overturn rate — the care-transitions push adds a second layer: even approved stays may default you toward the plan's owned or preferred network rather than the facility with the best outcomes for your specific condition.

The No Surprises Act wrinkle

Rep. Frank Pallone's oversight letters to six independent dispute resolution (IDR) arbiters, per Healthcare Dive, raise a related question: when an out-of-network emergency claim under a Medicare Advantage plan goes to arbitration, how confident can you be the arbiter has no financial ties to either party? This matters most for MA HMO enrollees who end up in an out-of-network ER during travel — a scenario we've modeled before, including what a $6,700 ER bill actually costs under Medigap Plan G vs Medicare Advantage MOOP. If the arbitration process itself carries undisclosed conflicts, that's one more reason the "network freedom" of Original Medicare + Medigap has value that doesn't show up in a premium comparison.

The 10-year math: steering costs vs Medigap premium

Here's the honest version of this comparison — not "Medigap always wins," but what the two paths actually cost when you build in realistic steering exposure.

Scenario: A 67-year-old with a chronic condition needing one MRI per year and routine Tier 2 prescriptions, comparing a $0-premium MA HMO in a vertically-integrated market against Original Medicare + Medigap Plan G.

MA HMO, assuming steering to owned imaging in 7 of 10 years and non-preferred pharmacy fills:

• Premium: $0 × 120 months = $0
• Imaging: ~$300 average × 10 years = $3,000
• Pharmacy tier gap: $53/month difference × 12 × 10 = $6,360
• 10-year total: ~$9,360

Original Medicare + Medigap Plan G, median premium per Toravine's medigap_rates dataset (3,570 rate records, national median $178/month for a 65-year-old, ranging $128–$246 by state and age):

• Premium: $178 × 12 × 10 = $21,360 (unadjusted for future increases)
• Imaging and Part B services: covered after the annual Part B deductible (~$257 in 2026) with free choice of any Medicare-participating facility — no facility-fee exposure, no preferred-pharmacy tier
• Part D drug costs: standard formulary pricing, no network-preferred discount but no penalty tier either
• 10-year total: ~$23,930, but with zero steering risk and full provider choice

The MA HMO is still cheaper in raw dollars in this scenario — that's consistent with what we found in our broader 10-year cost comparison for beneficiaries with chronic conditions. But the $9,360 MA figure assumes you tolerate the steering — accept the owned facility, accept the preferred pharmacy. Push back on either one, choose your own imaging center or pharmacy where your plan allows it, and the gap narrows fast. The Medigap premium buys certainty and choice; the MA premium buys a lower floor with a variable, ownership-dependent ceiling.

What to actually check before you schedule

Don't take the plan's Summary of Benefits copay figure at face value for any procedure above $200. Call the facility directly and ask whether they bill a separate facility fee, and check whether your usual pharmacy sits in the "preferred" or "standard" network tier for your specific drugs — the difference is rarely disclosed clearly in the plan's printed materials. This is precisely the modeling Toravine is built for: entering your actual plan, your actual ZIP code, and your actual prescriptions to show where the ownership-driven cost gaps sit before you're locked into a referral.

If you're weighing whether to switch to Medigap during your next eligible window, remember that underwriting in most states makes that switch a one-way door — see our breakdown of the enrollment windows that let you switch without medical underwriting before you decide. Either way, the number that matters isn't the plan's advertised premium — it's what happens the first time your referral routes you to a facility your insurer happens to own. Run your own numbers at Toravine before your next enrollment deadline, not after the bill arrives.

Sources

• The Market Forces Quietly Adding Thousands to Patient Bills — KFF Medicare
• UnitedHealthcare expects to be ‘very competitive’ in Medicare Advantage next year, CFO says — Healthcare Dive
• Nonprofits Are Helping Musicians Pay for Insurance in Austin, Texas, and Beyond — KFF Medicare
• Why leading Medicare Advantage plans are rethinking care transitions — Healthcare Dive
• Top Democrat investigates No Surprises arbiters — Healthcare Dive