Medicare Advantage Pros and Cons

Medicare Advantage (MA) plans, also known as Medicare Part C, are an alternative way to get your Medicare coverage. Instead of Original Medicare (Parts A and B), you get your benefits through a private insurance company approved by Medicare.

These plans are heavily advertised, and you've probably seen commercials promising $0 premiums, dental coverage, and gym memberships. But are they really better than Original Medicare? Let's look at the honest pros and cons.

What Is Medicare Advantage?

Medicare Advantage plans are offered by private insurance companies like Humana, UnitedHealthcare, Aetna, and others. When you enroll in a Medicare Advantage plan:

• You're still in Medicare (you must have Parts A and B)
• Your MA plan provides all your Part A and Part B benefits
• Most plans include prescription drug coverage (Part D)
• Many plans add extra benefits like dental, vision, and hearing
• You typically use a network of doctors and hospitals

About half of all Medicare beneficiaries are now enrolled in Medicare Advantage plans. But popularity doesn't mean they're right for everyone.

The Pros of Medicare Advantage

1. Lower Monthly Premiums (Often $0)

Many Medicare Advantage plans have $0 monthly premiums beyond what you pay for Part B. This is a significant savings compared to Medigap policies, which can cost $150-$350+ per month.

2. Maximum Out-of-Pocket Limit

All Medicare Advantage plans must have a maximum out-of-pocket (MOOP) limit for covered services. In 2025, this limit can be no higher than $8,850 for in-network services. Once you reach this limit, the plan pays 100% for covered services.

Original Medicare has no such limit—without a Medigap policy, your costs could theoretically be unlimited.

3. Extra Benefits

Medicare Advantage plans often include benefits that Original Medicare doesn't cover:

• Dental coverage: Preventive and sometimes comprehensive dental
• Vision coverage: Eye exams, glasses, and contacts
• Hearing coverage: Hearing exams and hearing aids
• Fitness benefits: Gym memberships (like SilverSneakers)
• Over-the-counter allowances: Quarterly credits for OTC items
• Transportation: Rides to medical appointments
• Meal delivery: After hospital stays or for chronic conditions

4. Drug Coverage Included

Most Medicare Advantage plans include Part D prescription drug coverage. This means one plan, one card, one premium—simpler than managing separate Part D and Medigap policies.

5. Care Coordination

Many Medicare Advantage plans, especially HMOs, emphasize care coordination. You may get a primary care doctor who helps coordinate your care, which can lead to better health outcomes for some people.

6. Predictable Copays

With Medicare Advantage, you typically pay fixed copays for services. For example, $20 for a doctor visit or $300 for a hospital admission. This can make budgeting easier than Original Medicare's 20% coinsurance.

The Cons of Medicare Advantage

1. Network Restrictions

This is the biggest drawback for most people. Medicare Advantage plans use provider networks:

• HMO plans: You must use in-network providers (except emergencies). You need referrals to see specialists.
• PPO plans: You can see out-of-network providers but pay significantly more.

If your preferred doctor or hospital isn't in the plan's network, you may need to switch providers or pay much more.

2. Prior Authorization Requirements

Many Medicare Advantage plans require prior authorization for certain services, tests, and procedures. This means:

• The plan must approve a service before you can get it
• Approvals can be delayed or denied
• You may need to appeal denials
• Time-sensitive care can be complicated

Studies have shown that Medicare Advantage plans deny prior authorizations at higher rates than Original Medicare, sometimes for medically necessary care.

3. Higher Costs When You're Sick

While premiums are low, cost-sharing can add up quickly if you need significant medical care:

• Hospital stays often have daily copays ($300-$500/day)
• Specialist visits may cost $40-$75 each
• Surgeries and procedures have substantial copays
• Out-of-network care costs much more (or isn't covered at all)

If you have multiple chronic conditions or need frequent care, these costs can approach or reach the maximum out-of-pocket limit.

4. Geographic Limitations

Medicare Advantage plans only work in their service area. If you:

• Travel frequently
• Spend winters in another state (snowbirds)
• Move to a new area

You may lose coverage or need to find new providers. Original Medicare works anywhere in the United States that accepts Medicare.

5. Extra Benefits May Be Limited

Those advertised dental, vision, and hearing benefits often have significant limitations:

• Dental: May only cover preventive care, with low annual maximums ($500-$1,500) for comprehensive services
• Vision: May only cover one eye exam per year and basic frames
• Hearing: May have high copays for hearing aids

Read the fine print—these benefits may not be as valuable as they appear in advertisements.

6. Harder to Switch Back to Medigap

If you try Medicare Advantage and want to switch back to Original Medicare with a Medigap policy, you may face problems:

• You lose your guaranteed issue rights for Medigap after your initial enrollment period
• Insurance companies can deny you Medigap coverage based on health conditions
• If approved, premiums may be much higher due to health issues

7. Plan Changes Every Year

Medicare Advantage plans can change their benefits, networks, premiums, and cost-sharing every year. You must review your plan during each Annual Enrollment Period (October 15 - December 7) to make sure it still meets your needs.

Quick Pros and Cons Summary

Who Should Consider Medicare Advantage?

Medicare Advantage might be a good choice if you:

• Are generally healthy and don't use many medical services
• Want to minimize monthly expenses and can handle copays when needed
• Live in one place and don't travel extensively
• Are comfortable with network restrictions and your preferred doctors are in-network
• Value extra benefits like dental and vision coverage
• Prefer one plan that covers medical and drug benefits together
• Can't afford Medigap premiums on your budget

Who Should Avoid Medicare Advantage?

Medicare Advantage might not be right for you if you:

• Have complex health conditions requiring frequent specialist care
• Want complete freedom to see any doctor who accepts Medicare
• Travel frequently or split time between states
• Have established relationships with doctors who may not be in MA networks
• Want predictable costs and can afford Medigap premiums
• Are concerned about prior authorization delays for care
• Want the security of knowing you can always access Medigap later

Medicare Advantage vs Original Medicare

Can You Switch Later?

Switching FROM Medicare Advantage

You can leave Medicare Advantage and return to Original Medicare during:

• Annual Enrollment Period: October 15 - December 7 each year
• Medicare Advantage Open Enrollment Period: January 1 - March 31 (can switch to Original Medicare)

However, getting a Medigap policy after leaving Medicare Advantage is the challenge. In most states, you don't have guaranteed issue rights, meaning insurers can deny you or charge higher premiums based on your health.

Switching TO Medicare Advantage

You can join a Medicare Advantage plan during:

• Annual Enrollment Period: October 15 - December 7
• Initial Enrollment Period: When you first become eligible for Medicare
• Special Enrollment Periods: If you qualify (moving, losing coverage, etc.)

Medicare Advantage plans cannot deny you based on health conditions (except for End-Stage Renal Disease in most cases).

The Bottom Line

Medicare Advantage plans aren't inherently good or bad—they're a different way to get Medicare coverage with different trade-offs.

The best choice depends on your health, budget, lifestyle, and priorities. Consider speaking with an unbiased Medicare advisor who can help you evaluate your specific situation without pushing you toward one option or another.