The Pros and Cons of Medicare Advantage Plans

Ever wondered about the intricacies of Medicare Advantage Plans? What makes them different from Original Medicare? How do they work?

What are the “pros and cons of Medicare Advantage Plans”? If you have pondered these questions, you are in the right place. This article aims to demystify Medicare Advantage Plans, helping you navigate the world of healthcare coverage with ease.


Key Takeaways

  • Medicare Advantage Plans offer comprehensive coverage with potential cost savings but may limit options for healthcare providers and require prior authorization.



  • Navigating enrollment requires knowledge of the process and deadlines when switching between plans or enrolling in one for the first time.

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Understanding Medicare Advantage Plans


The Pros and Cons of Medicare Advantage Plans, Understanding Medicare Advantage Plans


Medicare Advantage Plans, an alternative to Original Medicare, are provided by private insurance companies sanctioned by Medicare. They offer a comprehensive package, consolidating multiple aspects of healthcare coverage into one plan.

To be eligible for a Medicare Advantage Plan, you need to have Medicare Part A and Part B health insurance, and the plan must be available in your area.

These plans encompass all the benefits of Medicare Part A and B and often include Medicare Part D prescription drug coverage. With Medicare coverage, they also offer supplementary benefits such as:

  • regular dental care


  • eye exams


  • glasses


  • hearing aids


This provides an all-in-one solution for your healthcare needs.


How Medicare Advantage Plans Work

Medicare Advantage Plans amalgamate the hospital and medical coverage of traditional Medicare Parts A and B and may also encompass prescription drug coverage from Part D, thereby offering a comprehensive and convenient plan for beneficiaries.

This comprehensive coverage includes all the services covered by Medicare Part A and Part B, except clinical trials. Some Medicare Advantage Plans may also include prescription drug coverage and additional benefits, such as dental coverage.

However, keep in mind that many Medicare Advantage plans work with a restricted network of healthcare providers. This means your choice of doctors and hospitals may be limited.

If you choose a doctor who is not within the plan’s network, you may have to pay higher out-of-pocket expenses compared to using an in-network doctor.


Comparing Medicare Advantage to Original Medicare

Part A of Original Medicare provides coverage for hospital insurance. Part B covers medical insurance.

On the other hand, Medicare Advantage plans impose a yearly cap on the maximum amount that can be paid in the event of significant medical expenses, providing an additional layer of financial protection.

The two most prevalent types of Medicare Advantage plans are Health maintenance organizations (HMOs) and preferred provider organizations (PPOs).

An important distinction is that Medicare Advantage operates as an independent plan, combining all Medicare coverages, whereas Medicare Supplement plans, also known as Medigap plans, serve as supplementary additions to Original Medicare.

The Pros of Medicare Advantage Plans


The Pros and Cons of Medicare Advantage Plans, The Pros of Medicare Advantage Plans


Medicare Advantage Plans have distinct advantages. They offer bundled coverage which includes the same coverage as Medicare Part A, Part B, and often Part D, all in one comprehensive package.

This simplifies the healthcare experience for beneficiaries, as they only must deal with one plan instead of multiple.

Beyond this, most Medicare Advantage plans provide additional benefits such as:

  • Coverage for prescription drugs


  • Dental and vision care


  • Hearing aids


  • Fitness programs


  • Wellness programs


These plans provide comprehensive healthcare coverage that goes beyond Original Medicare. And for healthy individuals, these plans can offer potential cost savings due to lower premiums and out-of-pocket costs compared to Original Medicare.


Bundled Coverage


The Pros and Cons of Medicare Advantage Plans, The Cons of Medicare Advantage Plans


When we talk about bundled coverage in Medicare Advantage Plans, we refer to comprehensive coverage that encompasses hospital, medical, and drug benefits offered by a single insurance provider.

This means that instead of dealing with multiple plans or paying separate premiums for different coverage types, beneficiaries can oversee a single plan.

This consolidation of healthcare services includes:

  • Hospital stays


  • Doctor visits


  • Prescription drugs


  • Preventive care


It simplifies the healthcare experience for beneficiaries and makes it more convenient and streamlined.


Extra Benefits


The Pros and Cons of Medicare Advantage Plans,Extra Benefits


Medicare Advantage plans frequently incorporate supplementary benefits that are not encompassed by Original Medicare, such as dental, vision, or hearing care.

This means you can get coverage for services that you wouldn’t receive with Original Medicare, making Medicare Advantage a more comprehensive healthcare solution.

Supplementary benefits can provide access to various facilities like fitness center memberships, wellness programs, and preventive services. Some plans even cover alternative therapies like acupuncture or chiropractic care.

These programs are formulated to encourage a healthy and dynamic lifestyle among the plan members.


Potential Cost Savings

Numerous Medicare Advantage plans offer the benefit of no monthly premiums, and the potential for lower out-of-pocket costs compared to Original Medicare. This means that you could potentially save a significant amount of money if you’re a healthy individual who doesn’t require frequent medical attention.

However, the actual cost savings can vary depending on factors such as health status and healthcare utilization, supplemental coverage and the premiums associated with it, the benefits provided by the Medicare Advantage plan, and the Part B premiums determined by income level.

In 2024, the out-of-pocket limit for Medicare Advantage Plans is $8,300 for in-network services and $12,450 for out-of-network services.

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The Cons of Medicare Advantage Plans


The Pros and Cons of Medicare Advantage Plans, The Cons of Medicare Advantage Plans


While Medicare Advantage Plans offer many benefits, they have their downsides. For starters, most of these plan’s function with a restricted network of healthcare providers, thereby limiting the options available for doctors and hospitals.

This means if your preferred doctor is not within the plan’s network, you may have to pay higher out-of-pocket expenses.

Furthermore, Medicare Advantage Plans require prior authorization for certain medical treatments, which could potentially lead to delays.

Also, individuals with intricate healthcare needs may encounter elevated out-of-pocket expenses in Medicare Advantage Plans, particularly for services such as complex surgeries or prolonged hospital stays.


Limited Provider Networks

The limited provider networks in Medicare Advantage Plans have the following characteristics:

  • They are comprised of a specific group of doctors and hospitals


  • Beneficiaries are generally obligated to utilize these providers for their healthcare requirements


  • This can be restrictive and limit your choice of healthcare providers.


Contrastingly, Original Medicare permits beneficiaries to seek care from any provider that accepts Medicare, giving you more flexibility in choosing your healthcare providers.

If you receive care outside your network, the coverage and payment for that care may differ, with out-of-network care usually requiring out-of-pocket payment.


Prior Authorization Requirements

In Medicare Advantage Plans, the prior authorization requirements stipulate that individuals must obtain approval from the plan before undergoing specific tests or procedures.

This is implemented to verify the medical necessity of the services and their compliance with the plan’s coverage regulations.

However, the duration for obtaining prior authorization in Medicare Advantage Plans is not uniform and may vary among plans and insurers, potentially affecting the promptness of receiving covered services.

Around 6% of prior authorization requests get declined in Medicare Advantage Plans, possibly leading to delays or denial of access to specific healthcare services.


Higher Costs for Complex Healthcare Needs

Medicare Advantage plans typically entail elevated out-of-pocket costs for complex healthcare services due to the anticipation of enrollees incurring higher expenses for services not encompassed by Original Medicare.

This means that if you have a chronic condition or require specialized care, you may end up paying more out of pocket with a Medicare Advantage plan.

Some instances of intricate healthcare requirements that could potentially incur higher costs under Medicare Advantage Plans include:

  • Chronic conditions requiring specialized care


  • Complex surgeries


  • Intensive mental health therapy


  • Long-term care needs


  • Multiple chronic conditions needing comprehensive care


Therefore, for extensive medical needs, it is generally advisable to have Original Medicare combined with a Medigap plan.

Choosing the Right Medicare Advantage Plan


The Pros and Cons of Medicare Advantage Plans, Choosing the Right Medicare Advantage Plan

Choosing the right Medicare Advantage Plan involves assessing your health needs, comparing plan options, and considering factors such as network, benefits, and costs.

It’s important to understand the distinctions among the networks of Medicare Advantage Plans as HMOs generally have a more restricted network that necessitates choosing a primary care physician and obtaining referrals for specialists, whereas PPOs offer a wider selection of providers and the ability to consult out-of-network providers at an increased cost.

The cost of Medicare Advantage Plans fluctuates based on elements such as plan type, geographical location, and the extent of coverage. Premiums for these plans range from $0 to over $100 per month.

These plans also offer varied cost-sharing components, like co-payments, coinsurance, and deductibles. Therefore, it’s necessary to meticulously review each plan’s details for a comprehensive understanding of the financial implications.


Assessing Health Needs

In the assessment of health needs for Medicare Advantage Plans, it is important to consider factors such as:

  • Health status and health care utilization


  • Medicare Advantage plan benefits


  • Network of providers


  • Pre-authorization requirements


This means you need to evaluate your current health status, how frequently you use healthcare services, and what benefits you require from a plan.

Your current health condition can influence the selection of a Medicare Advantage Plan, as those with significant health issues may face undisclosed risks and potentially increased expenses.

Future health needs, such as expected changes in health status, anticipated healthcare usage, and the requirement for supplemental coverage should also be given due consideration.


Comparing Plan Options

The primary distinctions among various Medicare Advantage plans encompass:

  • Coverage


  • Network


  • Cost


  • Additional services


  • Prescription drug coverage


  • Referrals


This means that when comparing plans, you need to consider these factors to ensure you choose the plan that best suits your needs.

When comparing Medicare Advantage plans, consider the following factors:

  • Star ratings


  • Member complaints


  • Prescription drug coverage and cost


  • Network of healthcare providers


  • Specific benefits and coverage offered


  • Personal healthcare needs


Also, within Medicare Advantage plans, certain deductibles may apply, or there may be no deductible.

In 2024, the out-of-pocket limit for Medicare Advantage Plans is $8,300 for in-network services and $12,450 for out-of-network services.

Navigating Enrollment and Switching Plans

Navigating enrollment and switching plans requires understanding the enrollment process, deadlines, and potential challenges when switching between Medicare Advantage and Original Medicare.

To enroll in a Medicare Advantage plan, call us today at 1-833-641-4938.

Transitioning back to Original Medicare after the first year of enrollment in a Medicare Advantage Plan might pose difficulties, such as:

  • Securing a Medicare Supplement Insurance policy


  • Insurers may decline coverage or enforce a waiting period for pre-existing conditions


  • Leading to increased costs or coverage gaps for beneficiaries


Enrolling in a Medicare Advantage Plan

One must be enrolled in Medicare Parts A and B before being able to purchase a Medicare Advantage plan. The sequential steps for enrolling in a Medicare Advantage Plan are as follows:

  • Determine your Medicare eligibility


  • Enroll in Original Medicare (Part A and Part B)


  • Create your account


  • Apply online or by phone


The designated period for enrollment in a Medicare Advantage Plan is during the Annual Election Period (AEP), which takes place from October 15 to December 7 each year.

Furthermore, there is a 7-month period that commences 3 months before the month of turning 65 and concludes 3 months after that month, within which enrollment in a Medicare Advantage Plan is permissible.

Once enrolled, the plan will automatically renew unless changes are made during the Medicare Annual Enrollment Period.


Switching Plans

To change Medicare Advantage Plans, one can either contact 1-800-MEDICARE or reach out to their plan provider directly to initiate the transition. The annual Open Enrollment Period from January 1 to March 31 allows for this change to take place.

Before deciding to switch, consider comparing different plans by visiting their websites, examining the costs, coverage, and options available in your locality, and getting assistance from 1-800-MEDICARE if needed.

However, you should be aware of potential challenges such as restricted options for pre-existing conditions, waiting periods for specific benefits, the risk of being declined for a Medigap policy, and incompatibility between Medigap policies and Medicare Advantage Plans.


To conclude, Medicare Advantage Plans offer a comprehensive healthcare solution that consolidates multiple aspects of healthcare coverage into one plan. They provide numerous benefits but also have their downsides.

Choosing the right plan involves careful consideration of your health needs, comparing plan options, and understanding the enrollment process. Whether Medicare Advantage is right for you will depend on your healthcare requirements and circumstances.


Frequently Asked Questions


→  What is the biggest disadvantage of Medicare Advantage?

The biggest disadvantage of Medicare Advantage is that it often limits your choice of doctors and hospitals and may offer fewer coverage options than Original Medicare.

In addition, you may pay more for complex or expensive medical needs compared to Original Medicare and a Medigap plan.


  Why would you not choose a Medicare Advantage plan?

Because Medicare Advantage plans are known to have restrictive networks, potentially higher costs for out-of-network doctors, and usually no out-of-state coverage, you should not choose one.


→  Why is Medicare pushing Advantage plans?

Given that Medicare Advantage plans are often cheaper than a Medicare supplement and generate higher commissions for brokers, it is no surprise that Medicare has been pushing them in recent years.


  What are the advantages of Medicare Advantage Plans?

Medicare Advantage Plans offer numerous advantages, such as bundled coverage, extra benefits, and potential cost savings for healthy individuals, making them a valuable option for seniors.


 How do I choose the right Medicare Advantage Plan?

When choosing the right Medicare Advantage Plan, it is important to consider your health needs, compare plan options, and look at factors such as network, benefits, and costs.

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Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.