THE MOST COMMON SURPRISE'S WITH MEDICARE ADVANTAGE PLANS

Photo showing a shadow figure changing a Medicare Advantage Billboard to read "Medicare DisAdvantage"

Michael T. Braden January 29, 2026 Medicare Advantage

MEDICARE ADVANTAGE PLANS OFTEN HAVE HIGHER COSTS THAN YOU WERE TOLD BY AN AGENT

When you turn 64-1/2, your mailbox usually begins to overflow with flyers, postcards, brochures, and other advertising/marketing materials for Medicare plans. Many of these flyers promise $0 Premiums, a cornucopia of extras, and a bundle of extra benefits that seem too good to be true. While Medicare Advantage plans can offer an alternative to Original Medicare, they often can seem too good to be true, and once you get a bill, you realize that you are not getting what you thought you signed up for.

Understanding how these expenses are generated is the first step in protecting your savings in retirement. It is crucial that you take a deeper dive and look beyond the premium and understand the potential out-of-pocket expenses that can accumulate throughout the year. For those seeking predictable costs and peace of mind, Medicare Supplement plans often provide a more stable financial solution.

THE TRUTH HIDDEN IN MEDICARE ADVANTAGE PLANS

Surprise costs in Medicare Advantage plans generally arise because of how these plans are structured. Unlike Original Medicare, which is a fee-for-service program managed by the federal government, Medicare Advantage plans are managed care policies sold by private insurance companies.

These carriers agree to manage your care in exchange for a flat fee from Medicare. To make a profit, they often implement strict cost-control measures. This means they limit which doctors you can see and require approval for specific procedures. If you step outside their rules, even accidentally, you become responsible for a significant portion of the bill. This structural difference is the primary reason beneficiaries often face unexpected expenses, unlike the comprehensive coverage offered by Medigap plans.

NOBODY TOLD YOU ABOUT OUT-OF-NETWORK COSTS

One of the most significant financial shocks comes from receiving care outside of your plan’s network. Medicare Part C Plans (Medicare Advantage)typically operate as HMOs or PPOs, restricting you to a specific list of doctors and hospitals.

In an HMO, you generally have no coverage for non-emergency out-of-network care, meaning you must pay 100% of the cost. Even with a PPO, seeing a provider outside the network results in significantly higher copayments or coinsurance. This contrasts sharply with Medicare Supplement plans, which allow you to see any doctor in the United States who accepts Medicare, ensuring you are never penalized for choosing the best provider for your health needs.

THE REPROCUSSIONS FROM HAVING TO CHASE DOWN PRIOR AUTHORIZATIONS

Another hidden hurdle is the requirement for prior authorization. Before you can receive specific tests, surgeries, or therapies, your doctor must ask the insurance plan for permission.

If the plan denies the request or delays approval, you face a difficult choice: wait for the appeal process while your health suffers or pay for the treatment entirely out of pocket. These administrative barriers do not exist with Medicare Supplement plans, where medical necessity is determined by your doctor and Medicare, not an insurance company administrator looking to cut costs.

CO-PAYMENTS AND REFERRALS CAN ADD UP QUICKLY

While a zero-dollar premium sounds appealing, the “pay-as-you-go” model of Medicare Advantage can quickly become expensive. You will likely be charged a copayment for every single medical appointment.

Specialist visits are particularly prone to high copays, often ranging from $40 to $50 or more per visit. If you have a chronic condition that requires seeing a cardiologist, endocrinologist, or other specialists frequently, these copays add up rapidly. In comparison, a Medicare Supplement plan can cover these “gaps,” leaving you with little to no cost at the time of service.

UNFORESEEN CHANGES WITH PRESCRIPTION MEDICATIONS

Prescription drug coverage is often bundled into Medicare Advantage plans, but this convenience can backfire. Plans can change their formularies and the list of covered drugs every single year.

A medication that was in a low-cost tier one year might move to a higher tier the next, drastically increasing your copay. Furthermore, if your specific drug is removed from the formulary, you may have to pay the full retail price or go through a lengthy exception process.

NOT REALLY UNDERSTANDING YOUR MOOP

Marketing materials frequently highlight the Maximum Out-of-Pocket (MOOP) limit as a safety net. However, this safety net is often set much higher than many beneficiaries realize.

For 2026, the maximum out-of-pocket limit for in-network services can reach $9,250. This means you could potentially pay over nine thousand dollars in copays and coinsurance before the plan covers 100% of your costs. For many seniors, this amount is far beyond their means. Medicare Supplement plans typically result in far lower annual out-of-pocket expenses, providing proper financial protection.

LIMITS AND STRUCTURE OF THE EXTRA ADDED BENEFITS

The dental, vision, and hearing benefits touted by Medicare Advantage plans often come with strict limitations. The coverage is frequently capped at a low dollar amount, such as $1,000 or $1,500 per year, which does not cover major procedures like root canals, crowns, or high-quality hearing aids.

Additionally, these benefits are often restricted to a tiny network of dentists and optometrists. You may find that your preferred dentist does not accept the plan, rendering the benefit useless unless you switch providers.

URGENT CARE BILLING IS NOT THE HOSPITAL EMERGENCY ROOM

Finally, billing confusion between emergency room and urgent care visits can lead to expensive surprises. If you visit an emergency room for a condition the plan later deems “non-emergent,” the plan may downgrade your coverage, leaving you with a higher bill.

Conversely, if you go to an urgent care center that is out-of-network while traveling, you might not be covered at all. Medicare Supplement plans travel with you nationwide, providing consistent coverage whether you are at home or visiting grandchildren in another state.

PEACE OF MIND IS PART OF FEELING HEALTHY AND PROTECTED

Navigating the complexities of Medicare does not have to be a guessing game. While Medicare Advantage plans may initially appear attractive, the potential for surprise bills can disrupt your retirement budget. Medicare Supplement products offer a robust alternative, providing predictable costs, freedom of choice, and comprehensive coverage that lets you focus on your health rather than your wallet.