Medicare Advantage Plans: What You Need to Know

The Medicare decision—Original Medicare or Medicare Advantage—seems straightforward at first. But this choice shapes nearly every healthcare interaction for years to come. What works brilliantly in one situation can create serious headaches in another.

Medicare Advantage plans (also called Medicare Part C) are everywhere. The advertisements make them sound appealing—extra benefits like dental and vision coverage, $0 premiums, even gym memberships. In fact, over half of Medicare beneficiaries now choose Medicare Advantage plans. But underneath those attractive features lie important trade-offs that deserve careful consideration.

Key Takeaways

1. Medicare Advantage plans bundle coverage into one convenient package but limit provider choices through network restrictions that can significantly impact where care is received.

   
   

2. Lower premiums often mean higher out-of-pocket costs when care is needed, with prior authorization requirements that delayed or denied millions of authorization requests.

   
   

3. Geographic flexibility becomes limited—these plans typically don't provide coverage outside their service area, which matters for those who travel or live in multiple locations.

   
   

What Medicare Advantage Plans Actually Are

Medicare Advantage is a different way to receive Medicare benefits. Instead of going directly through the federal government (Original Medicare), beneficiaries choose a private insurance company that contracts with Medicare to provide all Part A and Part B coverage, usually with Part D prescription drug coverage built in.

Before signing up, enrollment in Original Medicare Part A (hospital insurance) and Part B (medical insurance) is required. Major insurers include Aetna, Blue Cross Blue Shield, Cigna, Humana, Kaiser Permanente, and UnitedHealthcare. The average beneficiary can choose among dozens of different plans.

Most plans are either HMOs (Health Maintenance Organizations) or PPOs (Preferred Provider Organizations). The type matters significantly for how healthcare is experienced.

The Appealing Benefits

Lower Monthly Premiums

Many Medicare Advantage plans charge $0 in monthly premiums beyond the standard Medicare Part B premium ($185 per month in 2026). However, those $0 premium plans may have steep out-of-pocket costs requiring payment for diagnostic studies, hospitalizations, specialists, and outpatient care.

Out-of-Pocket Maximums Provide Protection

Unlike Original Medicare, which has no cap on costs, Medicare Advantage plans must include an annual out-of-pocket maximum. In 2026, this cap is $9,350 for in-network services and $14,000 for out-of-network care. Part D prescription drug coverage now includes a $2,000 annual out-of-pocket limit.

Extra Benefits Original Medicare Doesn't Cover

Most Medicare Advantage plans include dental coverage, vision care, and hearing aids—three areas where Original Medicare provides virtually nothing. However, these benefits often come with restrictions. Dental care may only cover one cleaning per year or be capped at $1,000 or less. Vision coverage averages about $160 annually.

Some plans also provide prepaid cards for medications, health supplies, bathroom safety devices, gym memberships, subsidized meals or groceries, and transportation assistance.

Coordinated Care and Better Preventive Services

Plans consolidate everything into a single card. Many assign a primary care physician who coordinates all care, improving communication among specialists. Research shows Medicare Advantage outperformed Original Medicare for preventive services like annual wellness visits, screenings, and flu vaccines, with lower hospital readmission rates.

Predictable Copayments

While Original Medicare charges 20% coinsurance for Part B services, most Medicare Advantage plans have flat-fee copays that are often lower and more predictable—though out-of-network costs are substantially higher.

The Significant Limitations

Network Restrictions Control Access

Most Medicare Advantage plans require using doctors and hospitals within the plan's network. Each plan has its own network, and members change annually. With HMO plans, going outside the network typically means paying the full cost except in emergencies. PPO plans allow out-of-network care but charge substantially more.

When specialists are needed, choices narrow significantly. Research found that about half of counties reviewed didn't have a single Medicare Advantage-participating psychiatrist, though more mental health providers can now enroll.

Prior Authorization Creates Delays and Denials

Plans can require prior authorization before covering certain services, procedures, or medications. This practice delayed or denied millions of authorization requests in recent years. U.S. Health and Human Services Inspector General reports found "widespread and persistent problems related to denials of care and payment."

Doctors must submit paperwork and wait for approval, sometimes resulting in denials for services physicians believe are appropriate. Prescription medications face similar scrutiny—plans might not cover current medications or require trying cheaper alternatives first.

New rules require Medicare Advantage plans to include health equity experts on utilization management committees and conduct annual analyses to identify disproportionate delays for enrollees with disabilities or limited income.

Delays in Seeing Doctors

Research found that 36% of Medicare Advantage beneficiaries waited more than a month for physician appointments, with 22% reporting the delay was caused by prior authorization approval.

Geographic Limitations

Most plans only provide coverage within a specific service area. When traveling outside that area, coverage becomes limited to emergency and urgent care. For those who split time between locations or frequently visit family in other states, this creates genuine complications.

Higher Costs When Care Is Needed

Those attractive low premiums come with trade-offs. Plans typically charge copayments for each doctor visit, test, procedure, or hospital stay. Hospital stays might cost several hundred dollars per day initially. These copays add up quickly during health crises, potentially reaching thousands before hitting the out-of-pocket maximum.

Annual Plan Changes

Insurance companies can modify plans each year—changing premiums, adjusting copays, modifying drug coverage, or altering provider networks. Trusted physicians might be in-network one year and out-of-network the next.

Difficulty Switching Back

When switching from Traditional Medicare to Medicare Advantage, the ability to buy a Medigap plan is lost. If returning to Original Medicare later, in most states Medigap enrollment could be denied due to pre-existing conditions. This makes the initial choice particularly important.

Making This Decision

Medicare Advantage plans work well for relatively healthy individuals who want extra benefits, don't mind network restrictions, primarily receive care in one area, and prefer lower monthly premiums even if it means higher costs when care is needed.

These plans become problematic for those managing complex health conditions needing regular specialist care, individuals with established physician relationships who might not be in-network, people who travel extensively, and those who value freedom to see any Medicare-accepting provider without referrals or authorization requirements.

Key Questions to Ask

Are all current doctors in the plan's network? Verify each one individually—networks vary significantly between plans.

Are preferred hospitals included? What would options be if complex surgery or extended hospitalization were needed?

Are current medications covered, and at what tier?

Is the out-of-pocket maximum (up to $9,350 in-network or $14,000 out-of-network) affordable if needed?

Is regular travel common? How would healthcare needs be managed outside the service area?

Does current employer or union coverage exist that might be affected?

What is the plan's star rating for quality and customer service?

Moving Forward With Confidence

The State Health Insurance Assistance Program (SHIP) provides free, unbiased Medicare counseling in every state. These trained counselors can review specific situations and help compare plans without selling anything. Find local SHIP programs through state Departments of Insurance or by calling Medicare at 1-800-MEDICARE.

Compare at least three plans carefully using Medicare's Plan Finder tool at Medicare.gov. This tool shows coverage, costs, and Medicare's star rating system for quality of care and customer service.

Medicare's Open Enrollment period runs October 15 to December 7. From January through March, switching between Medicare Advantage plans or returning to Original Medicare is possible.

Think carefully about priorities. Would lower monthly costs be preferred, or more provider flexibility? How much does keeping current doctors matter? These preferences should guide the decision.

The right Medicare coverage provides security, appropriate care access, and financial protection. By understanding what Medicare Advantage plans truly offer—and what they don't—an informed choice can be made about coverage that genuinely serves individual needs rather than just looking good in a brochure.

Start exploring options today, because informed decisions take time, and enrollment deadlines come faster than expected.