Key Takeaways

• Medicare Advantage plans can be appealing on the surface, but there are important trade-offs and restrictions that aren’t always disclosed in TV ads.

• Understanding how these plans work in real life helps you make informed decisions about your healthcare coverage and long-term financial planning.

What Medicare Advantage Plans Promise

Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. These plans are administered by private insurance companies and are approved by Medicare. They are required to provide at least the same level of coverage as Original Medicare (Part A and Part B), and most also include additional benefits.

Television commercials often highlight attractive features:

• Lower monthly premiums

• Extra benefits like dental, vision, and hearing

• Prescription drug coverage bundled into the plan

• Fitness memberships or over-the-counter allowances

All of this can sound ideal. But what you see in the ads doesn’t always match the reality.

What You Won’t Hear in the Ads

Behind the carefully selected testimonials and colorful visuals, there are restrictions that can significantly affect how and when you receive care.

1. Limited Provider Networks

One of the biggest differences between Original Medicare and Medicare Advantage is the network. Medicare Advantage plans typically require you to use a specific network of doctors, hospitals, and specialists.

• If you go out of network, the plan might not cover your care, or you may have to pay more.

• In rural areas or for specialized care, finding an in-network provider may be difficult.

• Changing doctors or accessing preferred specialists may not be as flexible as with Original Medicare.

2. Prior Authorization Requirements

Unlike Original Medicare, which rarely requires prior approval, most Medicare Advantage plans use prior authorization. This means you must get approval before receiving certain services.

• Prior authorization can delay care, especially for surgeries, diagnostic imaging, or specialist referrals.

• Some requests may be denied, even when recommended by your doctor.

• Appeals are possible, but the process can be time-consuming and frustrating.

3. Regional Plan Limitations

Medicare Advantage plans are not national. They are offered by region and vary depending on where you live.

• If you travel frequently or move seasonally (such as to another state in the winter), your plan may not cover out-of-area care.

• Emergency coverage is typically included nationwide, but routine care outside your region may not be.

• If you relocate permanently, you must switch to a plan in your new area, which could come with different costs or fewer benefits.

4. Cost Structure Confusion

While Medicare Advantage plans can offer lower premiums, that doesn’t mean lower costs overall.

• You still pay your Medicare Part B premium (standard $185/month in 2025).

• Copayments and coinsurance for services can add up quickly.

• Plans have annual out-of-pocket limits (up to $9,350 for in-network care in 2025), but those limits don’t include premiums or out-of-network expenses.

Some plans may include reduced cost-sharing if you also have Medicare Part B, but this varies. Without a clear understanding of how much each visit, test, or procedure will cost, budgeting becomes difficult.

5. Prescription Drug Coverage Isn’t Always Comprehensive

Most Medicare Advantage plans include Part D prescription drug coverage, but that doesn’t guarantee all your medications are covered.

• Each plan has its own formulary (list of covered drugs).

• Tiered pricing can make some medications much more expensive than others.

• Coverage rules like step therapy or quantity limits may apply.

And if you opt out of the plan’s drug coverage, you typically can’t join a standalone Part D plan unless you return to Original Medicare.

Enrollment Timelines and When to Switch

Medicare Advantage enrollment follows a strict schedule:

• Initial Enrollment Period: 7-month window around your 65th birthday.

• Annual Enrollment Period (AEP): October 15 to December 7 each year. You can switch, join, or drop a plan.

• Medicare Advantage Open Enrollment Period: January 1 to March 31. You can switch plans or return to Original Medicare.

Outside of these windows, you must qualify for a Special Enrollment Period, triggered by life changes like moving or losing employer coverage.

Switching isn’t always simple. For example:

• If you return to Original Medicare, you may need to apply for a Medigap (supplement) plan. In most states, there’s no guarantee of acceptance unless you’re within your initial enrollment period or qualify under specific rules.

• You might face underwriting, higher premiums, or denial due to pre-existing conditions.

Evaluating the Trade-Offs

When choosing between Medicare Advantage and Original Medicare with a supplement, consider more than just monthly premium costs. Evaluate your specific needs:

• How often do you see specialists?

• Do you want the freedom to see any doctor who accepts Medicare?

• Are you managing a chronic condition that may require ongoing or complex care?

• Do you travel often or live in more than one state each year?

Medicare Advantage may work well for some. But for others, the restrictions can outweigh the extra benefits.

Plan Changes Every Year

Medicare Advantage plans can change their benefits, provider networks, and drug coverage annually. That’s why you receive an Annual Notice of Change (ANOC) each September.

• You must review the ANOC to understand what is changing in your plan for the following year.

• Failing to do so may result in unexpected coverage gaps or higher costs starting January 1.

Even if your plan worked for you last year, it might not suit your needs this year.

What You Should Ask Before Enrolling

Before enrolling in or renewing a Medicare Advantage plan, ask these questions:

• Are my doctors and hospitals in-network?

• What are the copayments for common services I use?

• Is prior authorization required for key treatments?

• How much will my prescription drugs cost under this plan?

• What is the annual out-of-pocket maximum?

• Are dental, vision, and hearing services included—and to what extent?

Don’t rely on advertising alone. Speak with someone who understands the fine print.

Understanding What Works for You

There is no one-size-fits-all Medicare plan. What works for your neighbor may not work for you. While the added perks of Medicare Advantage plans are appealing, you must weigh those against limitations on choice, flexibility, and predictability.

For many people, the true value lies not in a free gym membership or dental cleaning, but in having access to the care you need, when and where you need it.

Know Your Options Before You Decide

Making the right Medicare choice is about understanding what you’re gaining—and what you might be giving up. Every option comes with benefits and trade-offs, and those trade-offs become more significant as your healthcare needs increase.

If you’re uncertain or want personalized advice, reach out to a licensed insurance agent listed on this website. They can walk you through your options and help you find a plan that fits your specific situation.