The Pros and Cons of Medicare Advantage Plans

Medicare Advantage Plans, also known as Part C plans, operate as private health care plans within the Medicare program and serve as alternatives to Original Medicare. These bundled policies can impose restrictions on which doctors and medical facilities members can use, require referrals or pre-authorization for certain care, and change their benefits, costs and provider networks annually.


When it comes to Medicare Advantage, cost is a big issue. Medicare Advantage plans offer monthly costs that are often less than Original Medicare — with the caveat that you pay more in copayments and out-of-pocket expenses each time you use medical services. The key is finding a plan that’s right for your budget and healthcare needs.

Most Medicare Advantage plans have a limit on how much you will pay in a year for care, known as an annual out-of-pocket maximum. This cap may apply to your deductible, copayments and coinsurance, or it could include the total cost of your premium and other benefits. In either case, it will protect you from unexpectedly high medical expenses in the future.

The cost of a Medicare Advantage plan depends on the type you choose. HMOs generally have lower monthly premiums, but you must stay within the plan’s network of doctors and hospitals. PPOs allow you to go out of network but at a higher cost. PFFS plans let you choose any doctor or hospital that accepts the insurance company’s payment terms and agrees to treat you. SNPs have a fixed monthly premium but also restrict you to the providers in the plan’s network.

If you need extra coverage such as dental, hearing or vision care, many Medicare Advantage plans provide these additional benefits at no extra charge. However, some plans may only offer these as add-ons or charge you an additional monthly fee.

If you want the best Medicare Advantage plan for you, look at all your options and compare the features of each. It may take some research, but if you spend some time, it’s possible to find a plan with a great star rating that offers the features you need at a price you can afford. There are even 5-star Medicare Advantage plans that cost $0 per month.


When choosing a Medicare Advantage plan, look at the coverage offered. This includes the plans deductibles and copays for different treatments, including the cost of specialist visits and MRIs. You should also check to see if your prescription drugs are included in the plan and compare drug prices.

Many Medicare Advantage Plans offer extra benefits to keep you healthy and save you money. They can include dental and vision care, gym memberships, non-emergency transportation and more. Some even offer free health screenings. These extras are not included in Original Medicare. If you’re interested in other plans, check out this mutual of omaha medicare supplement reivew!

Some people choose to enroll in Original Medicare plus a Medigap plan because they prefer the freedom of having access to Medicare’s nationwide network without restrictions. Others like the annual maximum out-of-pocket (MOOP) limit that comes with a Medicare Advantage plan, which helps them protect themselves from bankruptcy from excessive medical bills.

Another thing to consider is the number of providers in your area that are available in each Medicare Advantage plan’s network. Some Medicare Advantage plans have smaller networks than others. For example, HMO plans usually restrict you to only using doctors in their network, while PPO plans may allow you to go out-of-network for care but will typically charge you more if you do so.

In addition, some Medicare Advantage plans have limited service areas and require you to get a referral from your primary doctor before seeing a specialist. These restrictions can be frustrating for people who need specialized treatment.

Lastly, some Medicare Advantage plans do not cover some prescription medications or have a strict formulary that only covers certain brands of medication. If you have a prescription that is not on the list, your provider may refuse to fill it, which can be disruptive to your healthcare.

The good news is that the Centers for Medicare & Medicaid Services does a great job of weeding out sub-par Medicare Advantage plans by giving them a year to clean up their act or sanctioning them. In addition, the federal government offers a tool that allows you to compare Medicare Advantage plans in your area based on their star ratings, premiums, copayments and additional benefits.


While all Medicare Advantage Plans must cover the same basic benefits, it’s important to compare plans based on what they offer. For example, some plan options include extra benefits like vision and dental coverage, hearing aids, or fitness perks, like a gym membership. These add-ons can be of significant value for some, but they should be weighed carefully against the additional cost that these plans will require.

Another area of flexibility with Medicare Advantage plans is the size of their provider networks. The majority of Medicare Advantage plans limit enrollees to a select group of providers that have agreed to participate in the plan’s network, which can be limited either by county or by plan type (HMO, PPO, and PFFS). This restriction can make it difficult for some people to find a doctor who accepts their preferred insurance, and it can also create budgetary issues if their doctor decides to stop accepting new patients from the Medicare Advantage plan.

When choosing a Medicare Advantage Plan, it’s important to consider whether the plan’s network is large enough for your needs and to review how this network may change year-over-year. The size of a plan’s network is often based on the population of people in each county, which can change from year-to-year. The size of a plan’s provider network also differs between types of plans, as HMOs typically only provide coverage for services received from in-network providers, while PPOs generally allow for out-of-network services as well.

Some Medicare Advantage Plan enrollees are interested in the peace of mind that comes with knowing their medical costs will be capped each year. However, this is often a tradeoff for higher monthly premiums and limits on the freedom to choose a doctor. In many cases, people who want this level of control opt for Original Medicare plus a Medigap plan.


Medicare Advantage Plans are a convenient option for those who do not want to deal with the hassle of switching doctors, getting referrals and dealing with insurance companies. However, it’s important to weigh the pros and cons of these plans against your own health needs, finances and lifestyle.

The biggest drawback of Medicare Advantage Plans is that private insurers restrict your access to providers by limiting you to networks. Depending on the plan type, you may have to get a referral from your primary care doctor or other specialists to see certain providers, and you may be restricted to only choosing doctors that are in-network. Additionally, your doctors’ participation in a Medicare Advantage network can change year-to-year, so be sure to check with your doctor to find out if they plan on staying in the network next year.

Medicare Advantage plans typically offer extra benefits that Original Medicare does not, including dental, hearing and vision coverage. These extra benefits can be a great benefit for some Medicare enrollees, but they also add to your overall cost of the plan. The good news is that most Medicare Advantage plans provide these extras at little or no additional cost to their enrollees.

Some Medicare Advantage plans also have wellness programs that can help you stay healthy and reduce your medical expenses, such as fitness classes, discounted gym memberships and telehealth services. The benefit of these programs is that they can often be used in addition to other health-related services that are covered by your Medicare Advantage plan, such as annual wellness visits and preventative screenings.

If you’re a Medicare beneficiary with a chronic health condition, you should be aware that Medicare Advantage Plans can increase your costs over time due to their copays and deductibles. If you’re concerned about these extra costs, consider sticking with Original Medicare and purchasing a Medigap policy. Keep in mind that you can only buy a Medigap policy during the open enrollment period or during a Special Enrollment Period, and your monthly premium will be higher if you sign up for a policy later in life.