What are the downsides of a Medicare Advantage plan?

On the other hand, some reasons why you might choose Original Medicare over an Advantage plan include:

• Limited service providers: With popular Medicare Advantage plans like HMOs, you’re limited to in-network providers and pay more if you go out of network. Other plans offer more provider flexibility but often come with higher premiums and out-of-pocket costs.
• Prior authorization: Most Advantage plans require prior authorization, which can delay care. In 2021, over 35 million prior authorization requests were sent to Medicare Advantage plans. Original Medicare usually doesn’t require this, except in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington as of 2026
• Denials of service: A 2022 reportTrusted Source from the US Department of Health and Human Services Office of Inspector General (OIG) found that many Medicare Advantage plans denied necessary medical care, and many plans were found to deny payment to physicians for covered services.
• Complex plan offerings:Original Medicare provides nationwide coverage, while Medicare Advantage plans are limited to specific service areas. Medicare’s Find a Plan tool shows Advantage plan options by ZIP code, which may feel overwhelming, and if you move, your chosen plan may not be available.
• Different costs: Original Medicare charges a premium, deductible, and coinsurance for both parts A and B. The premium and deductibles is standardized across the United States. Advantage plans have variable out-of-pocket costs, depending on the specific plan, which may make it harder to predict how much you’ll spend on care.
• Medigap: When you’re enrolled in Original Medicare, you can purchase a Medigap plan that can help you pay your remaining out-of-pocket costs. However, you cannot use Medigap with Medicare Advantage plans.

How do you choose a Medicare Advantage plan?

Choosing the best Medicare Advantage plan for your needs can be complicated. There are many things to consider before you decide.

When you’re choosing a Medicare Advantage plan, ask yourself:

• How much did I spend on healthcare last year or the year before? This may help determine your budget – how much you can afford to spend on premiums and out-of-pocket costs. Some plans do offer $0 premiums and deductibles, but others may charge a few hundred dollars.
• What prescription drugs do I take or will I need? If you take medication, you’ll need to find an Advantage plan that includes prescription drug coverage or purchase a Part D plan. Be sure to search any plans’ drug lists (formulary) to confirm your medications are covered.
• What types of coverage do I need? Many Advantage plans include extra coverage for dental, vision, and hearing. You can contact carriers to see what their plans offer.
• What medical conditions do I have, and what are my long-term healthcare needs? More than 40% of Americans have chronic health conditions. You’ll also want to consider which plan best suits your long-term medical needs.
• Does my healthcare professional accept Medicare, or do they participate in an HMO network? If keeping your current healthcare professional is important to you, you will need to know what Medicare plans they accept or participate in.
• What is the CMS rating for the plans I’m considering? The Centers for Medicare & Medicaid Services (CMS) uses a Five-Star Rating System to measure the quality of care provided by Medicare Advantage and Part D plans. The CMS star rating measures things like management of chronic conditions, availability of care, member experience and complaints, customer service, drug pricing, and more. CMS releases its star ratings every year.

»Learn more:7 Best Medicare Advantage Plans

The takeaway

Medicare Advantage plans offer the same benefits as Original Medicare, along with additional benefits in many cases. Because these plans are privately managed, they offer convenient coverage, multiple plan options, and long-term savings.

But, some disadvantages also exist, including provider limitations, additional costs, and lack of coverage while traveling. Whether you choose Original Medicare or Medicare Advantage, it’s important to review your healthcare needs and Medicare options before choosing your coverage.