Disadvantages of Medicare Advantage

	Medicare	Medicare Advantage
Providers	Lets you see any doctor accepting Medicare, anywhere in the U.S.	Typically restricts you to in-network care
Care restrictions	Prior authorization and referrals not typically required	Preauthorizations and referrals are typically necessary
Out-of-pocket cost maximum limits	No	Yes, then you don’t pay any costs for covered care for the plan year
Prescription drug coverage	Must be added with a Part D plan	Typically included in MA plans
Extra benefits (such as vision, hearing, or dental coverage)	No	Most plans include at least some of this coverage
U.S. travel coverage	Yes, see any doctor accepting Medicare in the U.S.	Non-emergency care outside the plan’s coverage area is typically not covered
Compatible with Medigap plans to cover extra expenses	Yes	No

Original Medicare allows you to see any doctor or go to any hospital accepting Medicare, but you’ll pay 20% of every bill as coinsurance. The government provides Part A and Part B coverage, and you can buy a separate Part D (drug coverage) plan from a health insurance company.

Most beneficiaries also buy a Medigap plan, which helps pay expenses such as Medicare’s 20% coinsurance. It can also help pay for foreign emergency coverage. However, Medigap doesn’t offer dental, vision, and hearing coverage.

Medicare Supplement Plan G or N can offer good cost coverage for those on Original Medicare, noted Diane Omdahl, a Wisconsin-based nurse educator and cofounder of 65incorporated.com, which offers fee-based Medicare counseling. Omdahl serves people who are getting ready to enroll in Medicare and those hoping to make a Medicare change.

Medicare Advantage plans typically require you to visit providers within the plan’s network to get the lowest costs. You’ll likely find more doctors available to you with Original Medicare.

But most Medicare Advantage plans offer extra benefits, such as vision, dental, or hearing coverage or a free fitness club membership. The plans also limit how much you’ll have to pay out of pocket in a given year, with maximum out-of-pocket limits.

Medicare Advantage plans differ in coverage and costs, even those sponsored by the same insurance company. Some plans even have $0 premiums or $0 deductibles, though all require you to still pay your Part B premium. (Medicare Advantage plans are partially funded by Medicare, which is why costs are so low.) Finding the details requires combing through the fine print in your “Evidence of Coverage” document, which outlines exactly how your benefits work for each issue.

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Disadvantages of Medicare Advantage

Although Medicare Advantage’s low or $0 premiums, extra benefits, and all-inclusive nature may sound appealing, familiarize yourself with the downsides before enrolling.

Problems With Switching Later

“Most enrollees believe they can later easily get out of Medicare Advantage when they can’t,” Omdahl said.

If you try to switch from Medicare Advantage to Original Medicare with Medigap during Medicare open enrollment, you may find an unpleasant surprise. Because your guaranteed issue period has passed, you’ll have to undergo medical underwriting to get a Medigap plan to help cover extra expenses.

“I can’t tell you how many people call us at open enrollment and say nobody told them they’d have to go through underwriting or what that would entail, and say, ‘If only I’d known,'” said Omdahl.

She said three “magic states”—New York, Connecticut, and Massachusetts—offer underwriting-free Medigap enrollment outside the initial enrollment period.

More Restrictions

Your Medicare Advantage Plan may have more restrictions on your care that Original Medicare does not, including prior authorization and referral requirements.

Like 99% of Medicare Advantage enrollees, if you need a higher-cost service, you’ll have to get your plan’s approval for coverage first. These services could include inpatient hospital stays or chemotherapy for cancer treatment. The goal is to manage healthcare costs by preventing unnecessary services.

Preauthorizations often include vague terms such as “not medically necessary,” Omdahl said. This catch-all term could mean dozens of things—it’s the wrong service, the diagnosis doesn’t support the service, or the frequency of visits is inappropriate, for example.

Note

Original Medicare has few prior authorization requirements, which are mainly limited to mobility devices and surgeries that could be classified as either cosmetic or not medically necessary.

According to a KFF study, insurers denied 7.4% of Medicare Advantage prior authorization requests in 2022, a larger share than in previous years. Only around 10% of those denials were appealed. But of those that were, 83% had the denial overturned. This could indicate a potential headache for even the most tenacious MA enrollees—a system of annoying hoop-jumping.

Some plans are more likely to require preauthorization or overturned denials. According to the same KFF study, Humana had the most preauthorization requests per person and Kaiser Permanente had the fewest. Humana also had the lowest success rate for overturning a denial.

Omdahl has low hopes for new rules around preauthorizations. In 2025, Medicare Advantage plans must evaluate how prior authorization policies impact certain at-risk populations and publicly display analysis results on their websites.

Then starting in January 2026, insurers must respond to prior authorization requests in seven calendar days (shortened from 14) for standard cases and 72 hours for expedited cases.

“I don’t think it’s going to fix a darn thing,” she said. You’ll likely get denials faster, with more specifics on why the denial occurred, but the 2026 timelines for appeal are lacking.

“If you’re diagnosed with cancer, the new rule could still leave you waiting 72 hours for expedited determination and seven days for standard determination for prior authorization and end up waiting months in appeals,” Omdahl said.

Provider Network Limitations

With Medicare, you can see any provider who accepts Medicare assignment. That’s 98% of providers, according to the Centers for Medicare & Medicaid Services (CMS).

On the other hand, with Medicare Advantage, you’ll have a more limited set of providers to choose from. If you opt for an HMO plan, you’ll only be covered if you see in-network doctors (except in emergencies). A PPO will give you the option of seeking care out of network, but you’ll pay more for those services.

According to research from KFF, these networks can vary widely. Some narrower networks cover less than 30% of a county’s physicians. People who live in rural areas may have a harder time finding providers.

If you’re traveling, know that doctors aren’t under obligation to see MA patients in a network the doctor doesn’t contract with. So, you may see a doctor, but you’ll pay out of pocket if the doctor doesn’t work with your plan. “Many people didn’t realize it was an issue until they got a bill,” Omdahl said.

While MA plans can’t charge you more than 20% for in-network services, there are no limits on out-of-network cost-sharing. As an example, a KFF study found that about half of MA plan enrollees are charged between 30% and 100% for Part B medications (such as chemotherapy drugs) if administered by an out-of-network provider.

Due to the network limitations, you don’t have the same cost coverage if you need to see a specialist who isn’t covered by your plan. You also may have a harder time traveling outside your plan’s service area—if you’re a snowbird who travels to Florida every year, your care may not be covered.

Plans may only allow you to be seen by a specialist with a referral, limiting your ability to easily self-refer for a second or third opinion.

Plans in Flux

Medicare Advantage plans are also constantly in flux. “Now some are pulling out of counties, leaving people scurrying during open enrollment,” Omdahl said.

“You’ll notice that your drug costs and the formulary can change throughout the year, as could your provider network,” Omdahl said. “The plan must notify you about the changes.”

Be sure to read any notice your plan sends to learn how to find a new provider or plan. Some changes may allow you to qualify for a special enrollment period.

Limitations on Extra Benefits

Medicare Advantage benefits can sound appealing on brochures or TV commercials.

“The plans say ‘free dental, free vision,’ but don’t always explain the limits well,” Omdahl said, pointing to the average vision coverage limit of $160. This price is much less than what glasses cost.

Most dental plan enrollees face dollar limits on how much care is covered in a year, and most are in plans with a maximum cap of $1,000 or less, the Kaiser Family Foundation noted. Some are even in plans with caps as low as $100 to $500. According to the same report, it’s less common to find a plan that covers root canals or dentures.

Fitness benefits can come with restrictions, too. Omdahl noted the recent example of a fitness chain that only allows seniors with Medicare Advantage plans to visit during certain hours.

“With benefits, it’s unfortunate that there are so many choices that change every year. It’s overwhelming to understand all the rules up front,” she said—plus grasp how the rules might change or apply to you.

Overwhelming Choices

While choice is typically a good thing, 98% of Medicare beneficiaries will have 10 or more Medical Advantage health plans available in their area in 2025, including special needs plans (SNPs), according to a survey by CMS. The selection of other plans per county also remains robust, with an average of 34 non-SNP MA plans offering prescription drug coverage and 65 plans offering it across all MA plans (including SNPs).

“It takes time and can be overwhelming” to search for a good plan, Omdahl said. The Medicare plan finder lists Advantage plans in order of lowest drug costs. Then, it provides more details about each plan and a link to its website.

You must then go to the plan site to ensure your doctor is within the network. This is great if you love comparison shopping, but it can be challenging to sift through and read all the fine print outlined above.

Who Is Medicare Advantage Best For?

People Who Can’t Afford or Can’t Get Medigap

Medigap helps protect you from unexpected Original Medicare expenses but does come with an additional premium—along with premiums you’ll pay for Part B, and Part D if you choose to buy drug coverage. If you can’t afford Medigap coverage, a Medicare Advantage plan might be a good fit.

That’s particularly true if you missed your enrollment window to sign up for a Medigap plan and can no longer qualify for or afford a Medigap plan without medical underwriting.

If you don’t use healthcare services regularly, you could get a $0 premium plan, stash your monthly savings in an interest-bearing account and allow them to grow, earning returns for future medical costs. However, note that you no longer qualify to make health savings account (HSA) contributions after you enroll in Medicare, so you’ll need to use a high-yield savings account or some other savings vehicle.

Healthy People With Healthy Emergency Funds

Medicare Advantage may be a good fit for those with a monetary inheritance and no known family history of chronic conditions. You may be able to stash away savings on premiums and have money to cover costs up to the out-of-pocket maximum if the unexpected should strike.

“Many people say, ‘I want a lower premium, I never have medical issues and can afford the out-of-pocket maximum,” Omdahl said. “If they get sick, they most likely will hit the maximum limit.”

People With Health Conditions

Conversely, if you have a chronic health condition (such as diabetes), you may qualify for a tailored Chronic Condition SNP (C-SNP) Medicare Advantage plan with more robust benefits, such as transportation and meal service. There are currently 15 qualifying chronic conditions, including chronic lung disorders, mental health conditions, diabetes, and chronic heart failure.

Those With Coverage Fit

MA can also be a good fit if your preferred doctor, pharmacy, and hospital is within an existing Medicare Advantage network and you don’t plan to travel much within the U.S. during retirement. Some MA plans offer more robust, broader in-network coverage, the KFF study on robust plans noted, covering up to 70% of a county’s physicians. Finding these plans may take some research.

Medicare Advantage’s extra coverages—such as dental, vision, gym membership, and other coverage—attract many sign-ups, too. Just ensure you understand the limitations.

Who Is Medicare Advantage Not Best For?

If you have the means and time to shop for Part D and a Medigap plan (assuming you want this coverage), you may find more flexibility and cost coverage. Medicare Advantage may not be a good fit for you if you:

Prioritize flexibility and choice regarding doctor, specialist, and institutional coverage
Don’t want to worry about the need for frequent preauthorizations for high-cost care
Travel between two or more states frequently (such as a snowbird)
Have the funds to purchase a Medigap plan, which covers many Medicare costs and emergency care (up to a limit) when traveling internationally

How to Switch Back to Original Medicare

Switching back to Original Medicare comes with some important caveats, depending on how long it’s been since you were in Original Medicare.

If it’s been 12 or fewer months since you started with Medicare Advantage, you can switch back to your Medigap plan if it’s still available. But if it’s been longer or you never signed up for a Medigap plan, you may not qualify for one—or will need to pay more. Some states offer the opportunity to enroll in Medigap at any time.

Frequently Asked Questions (FAQs)

What Is a Preauthorization?

Preauthorization, or prior authorization, is your Medicare Advantage plan’s decision on covering your care. In short, your health provider submits information in advance to support a service, treatment, prescription, or equipment to increase the likelihood that the plan pays your claim. Your Medicare Advantage plan then decides whether that request meets the “medically necessary” requirement. It may not provide approval in some cases—such as if you would like to take Ozempic for weight loss. You can appeal the decision if your prior authorization is denied.

Why Do Insurance Companies Push Medicare Advantage Plans?

Insurance companies can profit from Medicare Advantage plans, although the plans aren’t necessarily always profitable for every company. In general, these plans encourage enrollment through extra benefits and maximum out-of-pocket limits that Original Medicare doesn’t offer.

How Much Does Medicare Advantage Cost?

The average Medicare Advantage premium is estimated to be $17 in 2025. However, don’t forget that you’ll also likely pay the Part B premium and out-of-pocket costs for deductibles, copays, and increased costs for any out-of-network care you get. These costs vary by plan. There’s also a certain cost for your time involved in preauthorization requests. However, it’s easier to understand the maximum you’d spend per year by reviewing the maximum out-of-pocket (MOOP) limit your plan lists.

How Much Does Original Medicare Cost?

Original Medicare’s costs include monthly premiums and out-of-pocket costs such as deductibles and copays or coinsurance. Ideally, your Original Medicare plan would involve buying Part A, Part B, Part D and a Medigap plan.

Let’s consider an estimate. Every month, you’d pay around $0 for Part A, $175 for Part B, $42 for Part D (the average for standalone Part D plans), and around $300 per month for a Medigap plan’s costs. That comes to $531 per month for a fully loaded Original Medicare plan. Your costs may be higher or lower depending on your chosen Medigap and Part D plans, and whether your income requires you to pay an extra fee on top of your Part B premium.

The Bottom Line

Do your research before you buy an MA plan. “One of the biggest disadvantages is when people get into a Medicare Advantage plan at age 65 for free benefits like dental cleanings and free glasses and have no health problems,” Omdahl said. “But the plan is supposed to take care of big medical issues at age 75 and 80, too, and people are surprised by their coverage later on.”

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Disadvantages of Medicare Advantage