July 21st 2023
By Ari Parker
Understand the risks and drawbacks associated with Medicare Advantage plans, learn what you need to know before you enroll, and get help comparing options.
By Ari Parker
Medicare Advantage (Medicare Part C) plans are an alternative to Original Medicare. They bundle Part A & Part B benefits and also often cover Part D benefits. Many of these plans have low or no additional premiums, but keep in mind you still need to pay your Part B premium if you switch to an Advantage plan.
You may have heard of a Medicare Advantage nightmare from a friend or family member. You may have even experienced one of these nightmares yourself. You also may have plenty of friends who are happy with their Medicare Advantage plans. Over half of eligible Medicare beneficiaries are enrolled in a Medicare Advantage plan. So, why do so many people say Medicare Advantage plans are bad?
Like individual healthcare needs, every Medicare Advantage plan is different. As a result, some of them have their own unique disadvantages. That said, there are some disadvantages shared by most (or all) Advantage plans.
On Original Medicare, you can see any doctor who accepts Medicare (which is about 90% of doctors across the US). Medicare Advantage plans, however, have provider networks. In some cases, you’ll have a higher share of costs when you see an out-of-network doctor. In other cases, you’re not covered at all if you go out of network.
This is particularly important if you travel a lot because Medicare Advantage plans generally don’t provide out-of-state coverage. You also need to be sure your doctor is covered on your specific plan if you need regular treatment from a specialist.
Unlike Original Medicare, Medicare Advantage plans do have out-of-pocket maximums. This protects you from astronomical costs in a year you may need more (or expensive) healthcare services. But when you compare out-of-pocket costs to those paid by Medigap enrollees, you might just faint.
Most Medigap plans don’t have an out-of-pocket max. This is because out-of-pocket costs are so limited that a maximum isn’t as necessary. On a Plan G, for example, once you’ve met your Part B deductible (which is $257 in 2025), you don’t owe anything else for covered services in that year.
Medicare Advantage plans can require plan holders to get prior authorization before receiving a service. If the service is not approved, then the plan won’t cover it. Original Medicare, on the other hand, does not have prior authorization requirements, making it easier (and faster) for Medicare beneficiaries to get the care they need.
80% of Medicare Advantage beneficiaries are on plans that require prior authorization for at least one covered service. Usually these requirements are placed on more expensive equipment and services, including durable medical equipment, Part B drugs, and inpatient hospital stays. On some plans, enrollees even need to get prior authorization for preventive services. With prior authorization denials on the rise, you should look into a specific Medicare Advantage plan’s rules around prior authorization before enrolling.
Medicare plan pricing, availability, networks, and benefits vary, which can make choosing the right plan challenging. What’s worse though is that if you find and enroll in a plan that covers your doctors and prescriptions, has a good cost structure, and has some extra benefits you like…that plan can change.
Plan changes aren’t always bad. Sometimes the changes don’t affect you, and in some cases they may add to your benefits. To be sure you’re always on the plan that provides the best value for your needs, you just need to review your plan and other options each year during the Medicare Open Enrollment Period, which lasts from October 15 - December 7.
One of the worst things about Medicare Advantage isn’t the plans themselves, but the advertising practices used to promote them. Many Medicare Advantage commercials rattle off a number of benefits, misleading consumers into thinking they can get all of these benefits with one plan. Many Medicare ads are also made to look like they’re coming from the government.
$0 premiums tied to Medicare Advantage plans are also often poorly explained and misunderstood. These plans are not free, although that’s often how it sounds. It’s true that many Advantage plans have $0 or very low premiums. What’s not often explained, however, is that Medicare Advantage enrollees still need to pay their Part B premium.
If you’re thinking about enrolling in a Medicare Advantage plan, there are a few things you should do before you make your final decision.
Original Medicare (Part A and Part B) has its downsides. It doesn’t pay about 20% of costs and there’s no out-of-pocket maximums. This means that if you need regular or expensive healthcare services, your costs could be astronomical. Original Medicare also doesn’t cover prescriptions, which we need more often as we age. You have two real options to get better coverage: Medicare Advantage or Medicare Supplement.
While Medicare Advantage plans replace Original Medicare, Medicare Supplement (also called Medigap) plans pair with Original Medicare. You also have an option to get a stand-alone prescription drug plan.
In a nutshell, Medigap plans help pay for the 20% of costs that Original Medicare doesn’t cover. There are ten types of Medigap plans labeled by letter. Plan G is often considered the best because it covers the most. After you meet your Part B deductible on a Plan G, you owe nothing else for Medicare-covered services that year.
Medicare Advantage premiums are lower than Medigap premiums. For those who need regular or expensive treatments, however, out-of-pocket costs may matter more, and Medigap out-of-pocket costs are generally much lower than those paid by Medicare Advantage enrollees. You may not need comprehensive coverage now, but none of us can know what the future holds.
One of the catches with Medigap plans is that you aren’t guaranteed acceptance into the plans outside of your Medigap Open Enrollment Period, which occurs during the first six months that you have Part B coverage. Outside of this period and a handful of other guaranteed issue periods, insurance companies can ask you questions about your health history and deny you coverage. What this means is that if you want a Supplement plan that doesn’t require prior authorizations, has no network limitations, and significantly reduces your out-of-pocket costs as you get older, you should enroll in a Medigap plan when you first sign up for Medicare.
What does the worst Medicare Advantage plan look like? The worst plan is unique to you, but would likely:
Have a high premium and/or high deductible
Have a network that doesn’t include your preferred doctors
Not cover your prescriptions
Require prior authorization for covered services
Have poor customer service
Even if you do thorough research, it’s good to talk to an advisor who knows the ins and outs of differences between Medicare Advantage and Medicare Supplement plans. One of our licensed Medicare Advisors can provide you with free advice and help you compare the pricing and benefits of specific Advantage and Supplement plans. Get started by scheduling a free consultation or giving us a call at (855) 900-CHAP.
If Medicare Advantage is your only or best option, then you should make sure to take the right steps to get the best Medicare Advantage plan for your specific situation. One of the ways that people end up with a bad Medicare Advantage plan is by skipping these steps.
Prepare to compare plans by jotting down details about these 3 Ps: Providers, prescriptions, and priorities.
Take note of each of the providers you prefer, including doctors, specialists, and pharmacies. In your notes, include details like their phone number and address. Next, have a list of the details of your prescriptions, including their names and your regular dosage. Finally, think through any priorities you have like wanting out-of-state coverage, saving money, or getting specific benefits.
Schedule a free consultation with one of our licensed Medicare Advisors to compare the plans available to you. You can also give us a call at at (855) 900-CHAP. We’ll take note of your healthcare needs and help you understand your options, choose the best plan, and enroll with confidence.
We’ll look at things like:
Premiums and out-of-pocket costs
Prescription coverage
Doctors in network
Extra benefits
Anything else you want to know about
Before we help you enroll, we’ll double check that all your healthcare needs are met. We’ll also check in with you later and help you set up any unused benefits, find doctors, and get the best pricing on your prescriptions.
We’ve all had buyer’s remorse. While you can’t exchange your Medicare Advantage plan any time, there are a couple times during the year that allow you to change your Medicare Advantage plan or switch back to Original Medicare.
Every year, Medicare has an Open Enrollment Period from October 15 - December 7. During this time, you can change from one Medicare Advantage plan to another. This allows you to get off of an Advantage plan that doesn’t fit your needs and find one that does. You also have the option to switch back to Original Medicare.
Even if you are happy with your Medicare Advantage plan, we encourage you to use the Medicare Open Enrollment Period to review any changes that have been made to your plan and compare your plan to others out there. In many cases, we find people are still on the best plan for their needs. In some cases though, we’re able to find a plan that provides additional benefits or saves beneficiaries money (sometimes thousands)!
The Medicare Advantage Open Enrollment Period occurs every year between January 1 - March 31. During this time, Medicare Advantage plan holders can:
Switch from one Medicare Advantage plan to another
Switch from Medicare Advantage to Original Medicare
So, if you ended up on a bad Medicare Advantage plan, you can use this time to find Medicare coverage that better fits your health and financial needs.
We recommend using your Medicare Advantage plan to see your doctor or fill a prescription early in the year. This helps many Medicare Advantage enrollees catch problems with their Medicare Advantage insurance plans when they can still fix things. Some common issues that arise with new Advantage plans include not having one of your preferred doctors in your network or one of your prescriptions covered. If you work with a Chapter Advisor, we’ll always double check that your plan covers your doctors and prescriptions.
There’s no one “worst” Medicare Advantage plan, and Advantage plans aren’t all bad. That said, it’s much more common to experience significant issues due to the variation between Advantage plans and the big disadvantages that come with most.
If you choose to enroll in a Medicare Advantage plan, the trick is to do your homework and work with a licensed Medicare Advisor who can compare all of the plans in your area against your healthcare needs. We’re here to help! Schedule a free consultation or give us a call at at (855) 900-CHAP.
