For many Medicare beneficiaries, deciding between Original Medicare and a Medicare Advantage plan can be confusing. Over 60% of people with Medicare are enrolled in Medicare Advantage plans, as an alternative to Original Medicare. However, Medicare Advantage plans are not right for everyone. There are some key disadvantages of Medicare Advantage plans to consider.

What is Medicare Advantage?

Medicare Advantage, also known as Medicare Part C, refers to private insurance plans that contract with Medicare to provide Medicare benefits. Medicare Advantage plans include:

  • HMO plans
  • PPO plans
  • Private Fee-for-Service Plans
  • Special Needs Plans

These medicare plans must cover medically-necessary services Original Medicare covers, but  plan may offer extra benefits Original Medicare doesn’t cover like dental, vision, hearing, transportation, and more.

Pros of Medicare Advantage Plan

There are many advantages to Medicare Advantage plans that make them attractive, such as:

All-In-One Coverage

Medicare Advantage plans may bundle Medicare Part A, Part B, and often Part D prescription drug coverage into one plan. This can be more convenient than juggling multiple plans under Original Medicare.

Extra Benefits

Many Medicare Advantage plans include routine dental, vision, hearing exams, gym memberships, transportation services, and other benefits not covered by Original Medicare alone. These extra perks appeal to many enrollees.

Out-of-Pocket Limits

Unlike traditional Medicare, most Medicare Advantage plans have an annual limit on your out-of-pocket costs for covered medical services. Once you hit that limit, the plan pays 100% of covered costs for the rest of the year.

Lower Premiums

Some Medicare Advantage plans have a $0 monthly premium, or they may reimburse part of your Medicare Part B premium. This can mean lower costs than Original Medicare.

Disadvantages of Medicare Advantage to Consider

While Medicare Advantage offers advantages, there are also some key disadvantages to these plans that make Original Medicare a better option for many beneficiaries:

Limited Provider Network

Most Medicare Advantage plans have a network of doctors, specialists, and hospitals you are limited to. If you want to see providers outside the network, you’ll pay more or the care won’t be covered.

Prior Authorization Requirements

To enroll in a Medicare advantage plan requires you get prior authorization before receiving certain services and seeing specialists. This extra paperwork and delays in care frustrate many enrollees.

Drug Formulary Restrictions

If your Medicare Advantage plan includes prescription drug coverage, it will have a formulary that excludes some medications or covers them at a higher cost-share. This can mean higher drug costs.

Lack of Medicare Supplement Option

You cannot purchase a Medigap plan to supplement gaps in Medicare Advantage. Many enrollees miss the flexibility of pairing Original Medicare with a Medigap plan.

Coverage Disruptions When Traveling

Your Medicare Advantage plan’s network and coverage does not extend beyond your plan’s service area. This can limit access to care when traveling outside your home region.

Plan Availability Varies by Location

Where you live greatly impacts what Medicare Advantage plan options are available to you. Rural residents may have access to few (if any) Medicare Advantage plans.

Medicare Advantage Nightmares

Reports of billing issues, coverage denials, and poor customer service from some private Medicare Advantage insurers can make enrollees wish they had stuck with Original Medicare.

Who Might Prefer Original Medicare?

While Medicare Advantage appeals to many beneficiaries, Original Medicare tends to be the best option for:

  • Beneficiaries who travel frequently or live part of the year outside their plan’s service area. Original Medicare covers you nationwide.
  • Rural residents with few Medicare Advantage plans available in their county.
  • Retirees who want access to the broader provider network Original Medicare offers.
  • Enrollees willing to pay higher premiums for the flexibility to see any doctor or hospital that accepts Medicare.
  • Those who want robust prescription drug coverage through a stand-alone Part D plan with few restrictions.
  • Beneficiaries with complex health conditions who require access to specialists and want to avoid delays in care due to prior authorization requirements.
  • Individuals who want the option to supplement gaps in Original Medicare with a Medigap policy.
  • Seniors happy with their current doctors and uneasy about network limitations under Medicare Advantage.
  • Medicare pays better in some instances. You want to search the benefits that original medicare offers.

Key Differences: Medicare Advantage vs Original Medicare

When evaluating Medicare Advantage compared to Original Medicare, here are some of the key differences to weigh:

Medicare Advantage

  • Offered by private insurers
  • Bundles Medicare Part A and part B, and often D
  • Restricted provider network
  • Extra benefits not covered by Original Medicare
  • Out-of-pocket spending limits
  • Monthly premiums vary or may be $0
  • Typically need referrals to see specialists
  • Coverage area restrictions

Original Medicare

  • Run by federal government
  • Need to add Part D plan for drug coverage
  • Freedom to choose any doctor/hospital that accepts Medicare
  • Must pay Medicare Part B premium (around $170/month in 2023)
  • No annual limit on out-of-pocket medical costs
  • original medicare and Medigap plan to reduce costs
  • No restrictions on seeing specialists
  • Covers you anywhere in the U.S.

How to Decide: Medicare Advantage or Original Medicare?

When deciding whether Medicare Advantage or Original Medicare is better for you, consider these tips:

  • Make sure your preferred doctors accept the plans you are considering.
  • Compare premiums, deductibles, and total out-of-pocket costs.
  • Evaluate extra benefits offered by the Medicare Advantage plans in your area.
  • Ask how the plans handle referrals to specialists.
  • Consider the convenience of all-in-one coverage vs the flexibility of Original Medicare.
  • Think about your expected health needs and travel plans for the upcoming year.
  • Speak to a broker or call Medicare to discuss your specific situation.
  • as medicare advantage enrollees, check Medicare Advantage plan ratings on Medicare’s website.

When you consider pros and cons of medicare advantage vs original medicare you make better choices. So if you’re eligible for Medicare, sign up for medicare as soon as possible.

Can You Switch from Medicare Advantage Back to Original Medicare?

One appealing aspect of Medicare Advantage plans is that you can switch back to Original Medicare during Medicare’s annual enrollment period each fall. So if you find Medicare Advantage isn’t right for you, you can return to Original Medicare the following year.

You can also switch from Medicare Advantage back to Original Medicare outside of the enrollment period if you qualify for a Special Enrollment Period due to certain circumstances like moving out of your plan’s service area.

Weigh the Pros and Cons of medicare advantage plans Carefully

Medicare Advantage offers appealing benefits, but also comes with some significant drawbacks to consider. Weigh the pros and cons and talk to a Medicare expert to decide if the restrictions of Medicare Advantage are worth it for the perks these plans provide over Original Medicare. Many seniors find Original Medicare plus a Medigap plan offers better flexibility and freedom for their health needs.

We’re Here to Help

You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at American Entitlements a Call at (469) 814-0289. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.


Why do some people say that medicare advantage plans are bad?

One of the biggest downsides to medicare advantage plans is their high premium costs and potential lack of coverage if you need to see a provider that doesn’t accept medicare. Many people find that original medicare plus a medicare supplement, also called medicare part b and supplement, works better for their needs.

What are some reasons why medicare advantage plans often don’t cover benefits that original medicare covers?

Medicare advantage plans are allowed to limit coverage of benefits that original medicare doesn’t cover, like some prescription drugs. If you need these extra benefits that original medicare doesn’t ordinarily pay for, a medicare advantage plan may not be the best choice and original medicare plus a medigap plan would likely suit your needs better.

If I’m unhappy with my medicare advantage plan, can I switch to original medicare?

Yes, medicare beneficiaries can switch from a medicare advantage plan to original medicare during the annual enrollment period each year. Make sure to also sign up for a prescription drug plan and get a medicare supplement if eligible. Switching back to original medicare and medigap coverage may alleviate complaints about medicare advantage plans.

What is the difference between medicare and medicare advantage plans?

Medicare includes medicare parts a and b for hospital and medical coverage. Medicare advantage plans, also called medicare part c, are offered by private insurers and often include prescription drug coverage. They provide the same benefits as original medicare but are sometimes limited to certain providers.

What is the monthly medicare part b premium for original medicare versus medicare advantage plans?

While original medicare has standard monthly part b premiums set by the centers for medicare and medicaid, premiums for medicare advantage plans can vary greatly by plan and region. Make sure to compare specific medicare advantage premiums to the part b premium to understand your total costs.

What types of medicare advantage plans are available and which is right for me?

There are several types like HMOs, PPOs and PFFS plans that differ in coverage details. Consider your providers, medications and willingness to switch doctors when deciding whether a medicare advantage plan or original medicare plus a medigap plan is best for your situation.

What is the biggest disadvantage of medicare advantage plans compared to original medicare?

For many people, the biggest disadvantage of medicare advantage plans is more limited provider choice since not all doctors/facilities take part in every medicare advantage network. Original medicare offers more flexibility to see any doctor that accepts medicare.

Can I switch from a medicare advantage plan back to original medicare if I don’t like the coverage?

Yes, during the annual open enrollment period, new medicare beneficiaries who are unhappy with their medicare advantage insurance have the option to switch back to original medicare coverage and pay their monthly medicare part b premium instead of the medicare advantage plan premium.

What is the chief difference between medicare advantage plans and original medicare plus medigap?

While both provide comprehensive medical coverage, the main difference is that original medicare plus a medigap plan like medicare part b and supplement covers all gaps that medicare advantage may limit. Original medicare has more provider flexibility too but medigap plans have additional out-of-pocket costs.

What percentage of medicare advantage enrollees would switch to original medicare if given the choice?

Research shows nearly half of all medicare advantage enrollees don’t actually prefer their medicare advantage plan and would switch to original medicare if they better understood the options. Speaking to a specialist can help decide whether a medicare advantage plan or original medicare is the best candidate.

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