WHY MEDICARE ADVANTAGE PLANS ARE BAD

Michael T. Braden March 24, 2026 MEDICARE ADVANTAGE

WHY MEDICARE ADVANTAGE PLANS ARE BAD

Picture of Braden Medicare Insurance's Poster: Why Some People Refer To Medicare Advantage as Medicare Dis-Advantage.

WHY PEOPLE REFER TO MEDICARE ADVANTAGE PLANS AS “MEDICARE DISADVANTAGE”

Picture of Braden Medicare Insurance's Poster For Medicare DIS-ADVANTAGE Plans

Almost one in three Medicare Advantage members experienced at least one prior authorization denial in 2024, according to CMS data, and millions more discovered mid-year that their preferred doctor or hospital had left their plan’s network. These situations are more common than many enrollees expect, and understanding them before you choose a plan can make a real difference.

Medicare Advantage (MA) plans are private insurance alternatives to Original Medicare, bundling hospital, medical, and often drug coverage into a single plan. Their appeal is understandable; many advertise $0 premiums, dental and vision benefits, and gym memberships. Enrollment has grown steadily, with MA now covering roughly half of all Medicare beneficiaries as of 2026.

But popularity doesn’t equal suitability. This article takes a clear-eyed look at why Medicare Advantage plans are bad for many seniors, particularly due to restricted provider networks, prior-authorization barriers, out-of-pocket costs, and year-to-year instability. Understanding these disadvantages before you enroll or re-evaluate your current plan can protect both your health and your finances.

Medicare Advantage plans can be frustrating due to their restricted networks, frequent prior-authorization denials, high cost-sharing, and annual benefit changes that disrupt continuity of care.

THE MOST COMMON ISSUES FOR THOSE WHO CHOOSE MEDICARE ADVANTAGE PLANS

• Most people like the extra benefits, but these benefits are a far cry from what was offered 3-4 years ago. It was common to find $3,000 of Dental Coverage; now it is hard to find anything over $1,000.

• Most Medicare beneficiaries are not told the truth by Medicare Advantage Agents.  For example, nearly all of the “Extra Benefit” coverage is divided by 4, so $1,000 is just $250 per quarter.  And to add insult to injury, most plans do not allow you to roll over unused amounts.

• Captured Agents (Agents who only work for one company) are not allowed to mention any plans that they are not contracted to sell.  So, most people never hear about any other plans from them.

• Medicare Advantage plans have strict Networks of Providers and Facilities that you must use.

• More and more Medicare Advantage members have had to put up with Denials for care and the need for prior authorizations.

• Medicare Advantage plans restrict which doctors and hospitals you can use, which can limit access to specialists and disrupt ongoing care relationships.

• Prior authorization requirements frequently delay or deny medically necessary treatments, creating barriers between you and the care your doctor recommends.

• The 2026 maximum out-of-pocket limit for MA plans is $9,250, a potentially significant financial exposure that many enrollees don’t anticipate when selecting a “$0 premium” plan.

  
  

BIGGEST GRIPES THAT SENIORS HAVE

WITH MEDICARE ADVANTAGE PLANS

Medicare Advantage plans are not inherently bad products. But they come with structural limitations that can create serious problems, especially for seniors managing chronic conditions or complex health needs. Five issues consistently surface as the most impactful.

1. Restrictive Provider Networks: Many plans limit you to a specific group of doctors and hospitals, potentially restricting your choice of care.

2. Prior Authorization Delays and Denials: Plans often require approval for services, which can delay or deny medically necessary treatments.

3. High Out-of-Pocket Costs: Despite low or $0 premiums, you may face significant copayments, coinsurance, and deductibles that add up.

4. Annual Plan Benefit Changes: Benefits, networks, and drug formularies can change every year, creating instability and uncertainty.

5. Referral Requirements: Many plans require a referral from a primary care physician before you can see a specialist, which slows access to care.

   
   

These aren’t abstract policy concerns. They show up as denied claims, delayed surgeries, unexpected bills, and phone calls with insurance representatives when you should be focused on recovery. In 2026, these disadvantages remain just as relevant as they were when MA plans first became widely adopted. Understanding each issue clearly helps you make a coverage decision based on reality, not marketing materials.

1. NETWORK, PROVIDER, AND GEOPGRAPHICAL LIMITATIONS

Medicare Advantage plans operate as HMOs or PPOs, which means your care is tied to a specific network of contracted doctors, hospitals, and specialists. Step outside that network, intentionally or in an emergency, and you may face dramatically higher costs or no coverage at all.

This can result in you being responsible for much higher costs for those Medicare beneficiaries who travel frequently, split time between two states, or live in rural areas where the network may include only a handful of providers. If your cardiologist or oncologist isn’t in the plan’s network, you either pay out-of-pocket or find a new doctor.

States like rural Montana, Wyoming, and parts of the South have seen ongoing complaints about thin MA networks, which make it genuinely difficult to access specialists. Even in suburban areas, a mid-year network change can leave you scrambling to find a new primary care physician. You can learn more about navigating Medicare Advantage networks before committing to a plan.

2. AUTHORIZATIONS, 2nd, 3^rd and 4^th OPINIONS, ADDITIONAL REASONS FOR DENAIAL OF CARE

Prior authorization is the process by which an MA plan must approve certain services, tests, or treatments before they’re covered. In theory, it controls costs. In practice, it can stand between you and the care your doctor has already determined you need.

A 2024 CMS audit found that Medicare Advantage plans denied millions of prior authorization requests that would have been approved under Original Medicare, often using clinical criteria stricter than CMS standards permit. Beneficiaries can appeal, but appeals take time, and time matters when you’re waiting for a cancer scan, a cardiac procedure, or a post-surgical rehabilitation placement.

The administrative burden on physicians is also substantial. Medical offices routinely spend hours each week on authorization paperwork, pulling staff away from direct patient care. For seniors, this translates into measurable delays that can affect diagnosis and treatment timelines.

3. CO-PAYMENTS AND OUT-OF-POCKET COSTS HAVE GOTTEN MUCH HIGHER

The “$0 premium” label on many MA plans captures attention, but it tells only part of the story. While you may pay nothing monthly beyond your Part B premium (currently $202.90 in 2026), you’ll still face copayments, coinsurance, and potentially separate deductibles every time you use care.

A hospital stay, a specialist visit, or a course of chemotherapy can trigger cost-sharing that adds up quickly. The 2026 maximum out-of-pocket limit for MA plans is $9,250. That’s the ceiling, meaning your actual exposure could reach that amount in a single plan year if you experience a serious illness or injury.

By contrast, someone with Original Medicare plus a comprehensive Medigap plan like Plan G would face a predictable annual deductible (currently $283 for Part B in 2026) with most other costs covered by their supplement. For someone with significant health needs, financial comparison often favors Medigap despite its monthly premium.

4. HAVING TO REVIEW DOCTORS, PLANS, AND CHANGES IN BENEFITS EVERY YEAR.

Medicare Advantage plans can change almost everything about themselves each year, including their premiums, cost-sharing, drug formularies, provider networks, and covered benefits. What worked well for you in 2025 may look very different in 2026.

Each fall, enrollees receive an Annual Notice of Change (ANOC) document outlining upcoming changes. Many people don’t read it carefully, or don’t realize a specific drug has been dropped from the formulary or a beloved specialist has left the network until they’re already mid-treatment.

This annual instability creates a real burden for seniors managing long-term conditions. Continuity of care, seeing the same doctors, staying on the same medications, following through on multi-year treatment plans, can be disrupted every January 1st. Review your Annual Notice of Change letter every fall without exception.

5. THE HEADACHES OF NEEDING PERMISSION TO SEE A SPECIALIST

HMO-based Medicare Advantage plans typically require you to choose a primary care physician (PCP) who must then provide a referral before you can see a specialist. This “gatekeeper” structure is designed to coordinate care, but in reality, it often slows down access to the specialists you actually need.

Under Original Medicare, you can generally see any Medicare-accepting specialist directly, no referral required. That freedom disappears under most HMO plans. If your PCP is booked up for three weeks, your specialist appointment is delayed by at least that long.

Consider a scenario: a senior notices a new symptom that warrants a neurology consultation. Under Original Medicare, they call the neurologist directly. Under an HMO, they wait for a PCP appointment, then for the referral to be processed, and then for the specialist appointment. For certain conditions, those extra weeks matter enormously.

DOCTORS DO NOT LIKE THE WAY MEDICARE ADVANTAGE PLANS MANAGE THEIR CARE, AND BROWBEAT THEM ABOUT THEIR FEES

Patient frustration with MA plans is well-documented. Less discussed, but equally important, is the frustration among physicians and medical staff who must operate within the system’s constraints every day.

Surveys of practicing physicians consistently show dissatisfaction with Medicare Advantage’s administrative requirements. Prior authorizations, complex billing rules, and restrictions on specialist referrals don’t just affect patients; they affect a doctor’s ability to practice medicine the way they were trained to.

Some practices have stopped accepting certain MA plans entirely, citing payment delays and administrative overhead that make participation financially unsustainable. This further shrinks the effective network for enrollees.

WHAT HAPPENS WHEN PRIOR AUTHORIZATIONS GET IN THE WAY OF CRITICAL HEALTH DECISIONS

When a physician orders a test or procedure, they’ve made a clinical judgment based on your symptoms, history, and medical evidence. Prior authorization inserts an insurer’s review process into that judgment, sometimes overriding it with a denial from a reviewer who has never examined you.

Medical offices in large health systems report dedicating multiple full-time staff members exclusively to prior authorization work. Independent practices, which often serve rural and underserved populations, frequently lack the resources to absorb this burden.

The downstream effects are real: delayed imaging, postponed procedures, and patients who abandon recommended care after navigating multiple denial cycles. These aren’t billing inconveniences; they’re clinical outcomes shaped by administrative processes.

LESS CARE FOR THOSE WHO NEED IT THE MOST DUE TO THE WAY MEDICARE ADVANTAGE PLANS ARE STRUCTURED

Understanding why MA plans are structured the way they are requires understanding how they’re paid. CMS pays each Medicare Advantage insurer a fixed monthly amount per enrollee, called a capitation payment, adjusted based on the enrollee’s health status through a process known as risk adjustment.

The risk adjustment model means insurers receive more money for sicker enrollees. This creates an incentive to thoroughly document diagnoses (a practice known as “upcoding” when taken to extremes) while simultaneously restricting services to keep actual costs below the capitation amount. The profit margin lives in that gap.

Critics argue this model fundamentally misaligns insurer incentives with patient care. The plan earns more when your conditions are documented as complex, but also profits when your care is limited. This financial structure explains many of the prior authorization denials and network restrictions that frustrate both patients and physicians.

MEDICARE INSTITUTED THEIR STAR-RATINGS SYSTEM FOR MEDICARE ADVANTAGE PLANS

Not all Medicare Advantage plans perform equally. CMS evaluates each plan annually using a Star Ratings System, scoring plans on a scale of 1 to 5 stars across dozens of quality measures. These measures include things like how well plans manage chronic conditions, how members rate their experience, how often care is delayed, and how the plan handles complaints and appeals. A 5-star plan represents consistently high performance. A 2-star or 3-star plan indicates documented problems with member experience and the quality of care.

Picture of Braden Medicare Insurances Poster of Medicare Star Ratings.

Before enrolling in any MA plan, check its star rating on Medicare. gov. A plan with low ratings isn’t just underperforming on paper; those ratings reflect real patterns of member dissatisfaction, denied care, and poor service that other enrollees have already experienced. You can also explore why Medicare Star Ratings matter when comparing your options.

NOTE:

Before the Annual Enrollment Period closes each year, pull up your plan’s Star Rating and read your ANOC document side by side. Look specifically for any changes to your drug formulary, provider network, or specialist copayments; these three areas account for most unpleasant surprises that hit in January. If anything has changed that affects your current doctors or medications, that’s your signal to compare alternatives during open enrollment rather than waiting until a problem forces your hand.

CMS IS RESPONSIBLE FOR OVERSEEING HOW MEDICARE ADVANTAGE PLANS OPERATE

CMS serves as the primary regulator of Medicare Advantage plans, setting standards that plans must meet to participate in the program and conducting audits to monitor compliance. In recent years, CMS has taken a notably sharper stance on MA plan behavior.

In 2024 and 2025, CMS audit reports documented widespread inappropriate denials of medically necessary care across multiple major MA carriers. CMS also tightened prior authorization rules, requiring plans to respond to certain authorization requests within defined timeframes and to use only CMS-approved clinical criteria when making decisions.

Consumer complaint data collected by CMS consistently show that MA plans generate higher complaint volumes than Original Medicare across categories such as coverage denials, billing disputes, and network access problems. These aren’t random outliers; they represent structural issues that regulatory oversight continues to work to address, with mixed success. Understanding your Medicare rights and protections is an important part of navigating any MA plan.

COMPARING ORIGINAL MEDICARE WITH MEDICARE ADVANTAGE (MEDICARE PART C)

For many seniors, particularly those with ongoing health conditions or those who value predictability, Original Medicare combined with a Medicare Supplement (Medigap) plan offers meaningful advantages over Medicare Advantage.

Original Medicare gives you access to any provider in the country who accepts Medicare, with no network restrictions and no referral requirements. Add a Medigap plan like Plan G, and most of your cost-sharing is covered, leaving you with highly predictable annual expenses. The tradeoff is a monthly Medigap premium, but for someone who uses their coverage regularly, that premium often costs less than the cumulative copayments and coinsurance of an MA plan.

The key question isn’t which structure is universally better; it’s which structure fits your specific health needs, preferred doctors, and financial situation.

HOW AND WHEN YOU CAN CHANGE/SWITCH PLANS

The Annual Enrollment Period (AEP) runs October 15 through December 7 each year and allows you to switch between MA plans or return to Original Medicare. The Medicare Advantage Open Enrollment Period (MA OEP) runs January 1 through March 31 and allows one switch per year for current MA enrollees.

Switching from Medicare Advantage back to Original Medicare is straightforward. The complication arises when you want to add Medigap coverage. Outside your initial Medigap Open Enrollment Period, which begins when you first enroll in Part B at age 65, insurers can require medical underwriting and deny coverage based on pre-existing conditions in most states.

This makes the decision to choose MA at 65 potentially irreversible for people who later develop health conditions and want to switch to Medigap. Working with an independent insurance agent who represents multiple carriers can help you think through these long-term implications before making your initial enrollment choice. Learn more about switching from Medicare Advantage to Medicare Supplement if you’re currently in an MA plan and considering a change.

PUTTING IN TIME TO RESEARCH AND UNDERSTANDING IF MEDICARE ADVANTAGE IS THE RIGHT OPTION FOR YOU

This article focused on the real disadvantages of Medicare Advantage, and those disadvantages are significant. But context matters. MA plans may still be a reasonable fit for some people, particularly those in good health, living in areas with networks, and working within a tight monthly budget.

The extra benefits that MA plans often include, such as dental, vision, hearing, and gym memberships, offer genuine value to people who would otherwise pay out of pocket for those services. Plans from major carriers like Humana, UnitedHealthcare, and Aetna vary considerably in quality by region, and some perform well on Star Ratings year after year. No one should ever join a Medicare Advantage plan based solely on a Gym Membership.

The most important questions to ask before enrolling in any MA plan are:

• Are my current doctors and specialists in-network?

• Are my current prescriptions on the formulary at an acceptable tier?

• What is the prior plan’s list for services I’m likely to need?

• What is the maximum out-of-pocket limit, and could I absorb that cost in a bad year?

• What is the plan’s Star Rating, and how has it trended over recent years?

  
  

We strongly believe that no one should enroll in a Medicare plan, of any type, without reviewing a licensed, independent agent who can compare actual options in your zip code. Independent agents work across multiple carriers and aren’t incentivized to steer you toward any single product.

PRIORITIZE YOUR HEALTH MORE THAN ONE YEAR AT A TIME

Medicare Advantage plans are heavily marketed, widely enrolled, and, for some people, genuinely useful. But the disadvantages are real, documented, and consequential. Restricted networks, prior-authorization barriers, out-of-pocket costs up to $9,250, and annual benefit instability can create serious problems, especially when your health needs are complex or unpredictable.

The most important thing you can do before choosing any Medicare plan is to look beyond the premium. Read both the Summary of Benefits (SOB) and the Evidence of Coverage (EOC) for each Medicare Advantage plan you may be considering.

We also recommend checking the Medicare Star Rating for each plan you are interested in. Verify that your doctors are in-network, and that all of your prescription medications are covered. Each plan must include at least two medications in each category of Medications, but it does not always cover your exact medication, especially if it is a brand name. Understand what prior authorization requirements apply to services you’re likely to need.

And think about what your situation might look like five years from now, not just this January. Choosing between Medicare Advantage and Original Medicare is a decision that deserves real attention and personalized guidance. Speak with a licensed, independent Medicare agent, not a captive representative for a single carrier, who can walk you through the actual options available in your area and help you choose coverage that fits both your health and your budget.

MEDICARE ADVANTAGE FAQ’S

Photo of Braden Medicare Insurance's FAQ Poster.

WHAT DO MEDICARE ADVANTAGE MEMBER COMPLAIN ABOUT THE MOST?

The most common complaints center on restrictive provider networks, frequent prior authorization denials for medically necessary care, high out-of-pocket costs, and annual changes to benefits and drug formularies. These issues often surface most acutely for enrollees managing serious or chronic health conditions. And believe it or not, since every Medicare Advantage plan is only good for one year, the highest amount of delays often happens in the last quarter of the year, as many companies believe that if they run out the clock, you may choose a different plan or a different carrier for the next year, and at the end of the day, they save money. It is sad, but this is a proven fact.

WHY DOCTORS, NURSES, AND HOSPITAL STAFF DISLIKE MEDICARE PART C (MEDICARE ADVANTAGE)?

Physicians frequently cite the heavy administrative burden of prior authorizations, payment delays, and restrictions on their ability to refer patients to specialists. Many doctors feel these requirements interfere directly with clinical decision-making and the quality of care they can deliver. In fact, the majority of healthcare professionals who decide to leave a Medicare Advantage plan do so because they feel the company focuses on the bottom line rather than the health and welfare of their patients.

CAN YOU GO BACK TO ORIGINAL MEDICARE AND DROP YOUR MEDICARE ADVANTAGE PLAN?

Yes, but the timing is critical. Returning to Original Medicare during the Annual Enrollment Period is straightforward, but adding a Medigap plan outside your initial open enrollment period typically requires passing medical underwriting. If you’ve developed health conditions since you first enrolled, you could be denied Medigap coverage or charged significantly higher premiums in most states. This is another reason to really focus on choosing the right plan during your IEP (Initial Enrollment Period).

WHY DO PEOPLE THINK MEDICARE ADVANTAGE PLANS ARE FREE?

No, Medicare Advantage Plans are not free. Everyone who enrolls in Medicare must pay their Medicare Part B Monthly Premium of $202.90. A $0 premium means you pay no additional monthly fee beyond your Part B premium, but you’re still responsible for all co-payments, coinsurance, and deductibles every time you use covered services. In a year of serious illness, those costs can add up to well into the thousands.

Every Medicare Advantage plan has an MOOP (Maximum Out-Of-Pocket) amount. If you reach that amount for either In-Network or Out-Of-Network services, your carrier will pay for everything for the remainder of the calendar year. The National average for MOOP in 2026 is $5,700 across all Medicare Advantage plans.

HOW COMPLYING WITH PRIOR AUTHORIZATION REQUESTS CAN HURT YOUR CARE?

Prior authorizations can easily delay or deny access to medically necessary tests, treatments, or specialist visits, sometimes for weeks. These delays aren’t administrative inconveniences; for conditions requiring timely intervention, they can directly affect health outcomes.

AM I COVERED IF I LEAVE THE COUNTY I LIVE IN?

Most MA plans cover only emergency or urgent care outside their defined service area. Routine care, specialist visits, and scheduled procedures are typically not covered when you’re traveling or spending extended time in a different location, a significant limitation for seniors who travel frequently or maintain residences in multiple states.

Typically, the only options you have if you are out of your Service Area (Your Service Area is generally the County you reside in) are either at an Urgent Care Facility or in a Hospital Emergency Room. But if you are admitted to the hospital, you will have to pay those costs out of pocket.

 WRAPPING THINGS UP

We hope this article was informative and helpful in your search for the best Medicare option for you and your family. Everyone is different, with different wants, needs, and desires for their Healthcare; this is especially important when enrolling in Medicare. This is why it is extremely important to start with the plan you want, not just for the here and now, but for all your tomorrows.

If you have any questions about Medicare and would like to speak with an independent Medicare Broker who is also a Certified Medicare Planner (CMP), please feel free to reach out to me anytime. You can reach me at mike@bradenmedicare.com, via our website at www.bradenmedicare.com, or by text or phone using (480) 225-1393.