Key Takeaways

• Medicare Advantage plans often come with limitations you may not fully understand until you try to use them—especially when it comes to provider networks, prior authorizations, and mid-year benefit changes.

• You can only switch out of Medicare Advantage during specific times of year, and returning to Original Medicare with a Medigap plan may not be guaranteed without medical underwriting.

Understanding What You Actually Signed Up For

Medicare Advantage plans are promoted as an all-in-one alternative to Original Medicare, bundling Parts A and B and often including Part D drug coverage. These plans can sound appealing because of their extra benefits and consolidated structure. However, what you discover after enrolling is often very different from what you expected.

While these plans are regulated by Medicare, they’re administered by private companies. That means each plan’s rules, costs, provider network, and coverage can vary. And those variations can have significant impacts on your healthcare experience—many of which you may not realize until a health issue arises.

You May Be Locked Into Limited Networks

Most Medicare Advantage plans operate as HMOs or PPOs. With an HMO, you’re generally restricted to a specific list of doctors and hospitals. If you go outside that network, your care may not be covered at all, except in emergencies.

With a PPO, you have more flexibility to see out-of-network providers, but you’ll often pay significantly more out of pocket. In either case, if your trusted physician doesn’t participate in the plan’s network, you may need to change providers or pay the full cost yourself.

And unlike Original Medicare, which is accepted nearly everywhere in the U.S., Advantage plans limit you to the network and rules of your specific plan—rules that can change annually.

Prior Authorization Can Be a Major Obstacle

Another detail you may not have anticipated is the need for prior authorization. This is when the plan requires you or your doctor to get approval before it agrees to cover certain procedures, tests, or medications.

In 2025, prior authorization remains one of the most common hurdles Medicare Advantage enrollees face. It can delay treatment, force you to try less effective therapies first, or even result in denied coverage. This layer of bureaucracy can be especially burdensome when you’re dealing with time-sensitive conditions.

Original Medicare, in contrast, typically doesn’t require prior authorizations for most services, giving you and your doctor more control over your care.

Out-of-Pocket Costs Aren’t Always as Predictable as You Think

Many people enroll in Medicare Advantage expecting predictable, capped costs. While it’s true that these plans have annual out-of-pocket maximums—currently up to $9,350 in-network for 2025—reaching that cap can be financially and emotionally draining.

You may face copayments or coinsurance for:

• Specialist visits

• Diagnostic imaging

• Outpatient surgery

• Hospital stays

• Prescription drugs (especially in the coverage gap phase)

And if you use out-of-network services in a PPO, your spending could exceed the in-network cap. You might also be surprised to find that your plan does not cover certain services you expected, or places limits on things like physical therapy or skilled nursing facility care.

Benefits Can Change Every Year

Every fall, Medicare Advantage plans send an Annual Notice of Change (ANOC) that outlines updates to premiums, copayments, covered drugs, and network providers. These changes go into effect on January 1 of the following year.

This means that the plan you signed up for last year may not offer the same value in 2025. You might find:

• Increased copays

• A smaller provider network

• Higher drug costs

• Reduced coverage for certain services

If you don’t review your ANOC carefully during the October–December Open Enrollment Period, you could remain in a plan that no longer fits your healthcare needs.

You Can’t Switch Anytime You Want

Medicare Advantage comes with strict timelines for making changes. The most common opportunities include:

• Open Enrollment Period: October 15 to December 7 each year. You can switch to another Advantage plan or return to Original Medicare.

• Medicare Advantage Open Enrollment Period: January 1 to March 31. If you’re already in an Advantage plan, you can switch to a different one or drop it and go back to Original Medicare.

Outside of these windows, changes are only allowed if you qualify for a Special Enrollment Period, such as moving out of your plan’s service area or losing other coverage.

These timing restrictions can be frustrating, especially if you have an urgent healthcare issue and discover your plan doesn’t meet your needs.

Returning to Original Medicare Isn’t Always Easy

While you can leave your Medicare Advantage plan and go back to Original Medicare during a valid enrollment period, getting a Medigap policy isn’t always simple.

Medigap plans are designed to cover the gaps in Original Medicare, such as deductibles, coinsurance, and copayments. However, unless you qualify for guaranteed issue rights (like during your initial Medicare enrollment or in limited special cases), you may have to undergo medical underwriting. That means the insurance company can:

• Deny you coverage

• Charge you a higher premium

• Impose waiting periods for pre-existing conditions

This is why many people realize too late that switching back isn’t seamless—and may not even be an option depending on their health.

Extra Benefits Aren’t Always Reliable

Medicare Advantage plans often advertise extra benefits such as:

• Vision and dental care

• Hearing aids

• Gym memberships

• Over-the-counter (OTC) allowances

These perks sound attractive, but they vary significantly between plans and can come with usage restrictions. For example:

• Dental coverage might only include cleanings and exams, not crowns or dentures

• Vision care may be limited to one eye exam and a basic frame allowance per year

• OTC allowances may require using a specific vendor or may not cover the items you need most

These benefits can disappear or change from year to year, and they shouldn’t be the sole reason to enroll in a Medicare Advantage plan.

Emergency and Travel Coverage May Be Limited

Another area where Advantage plans can disappoint is in emergency and travel coverage. If you travel frequently, even within the U.S., you may find that your plan doesn’t cover you outside your service area for anything but emergency care.

Original Medicare, paired with a Medigap plan, often provides broader national coverage. Some Medigap plans also offer limited foreign travel emergency coverage, which most Advantage plans do not.

If you’re someone who splits time between different states or enjoys frequent travel, this limitation can become a serious inconvenience.

The Annual Enrollment Process Can Be Overwhelming

Because Medicare Advantage plans vary so much, comparing options during the fall enrollment period can feel like a full-time job. You’ll need to assess:

• Which doctors are in-network

• What your drug formulary looks like

• What the copay structure is for different services

• How the plan’s benefits have changed year over year

This complexity leads many to stay in a plan out of inertia, even if it’s no longer the best choice. Without careful annual review, you could be settling for coverage that doesn’t match your current health status or needs.

Be Proactive About Reviewing Your Medicare Coverage

Medicare Advantage plans can work well for some people—but only if you fully understand what you’re getting into. The key to avoiding unwelcome surprises is to stay informed and revisit your coverage options every year.

Ask yourself:

• Has your health changed in the last year?

• Are your doctors still in-network?

• Are your prescriptions still covered?

• Have your out-of-pocket costs gone up?

If the answer to any of these is yes, it may be time to reevaluate your plan.

If You’re Second-Guessing Your Medicare Advantage Plan

Every year, countless enrollees discover that the Medicare Advantage plan they chose isn’t working for them. Whether it’s because of limited networks, unexpected costs, or denied services, the regrets often surface too late.

You don’t have to make the same mistake twice. During the next enrollment window, consider speaking with a licensed agent listed on this website. They can help you compare all your options, including Original Medicare with a Medigap policy, so you make a more informed choice that fits your healthcare needs now and in the future.