MEDICARE ADVANTAGE PLANS

When I first went on Medicare, I opted for the traditional plan (parts A, B, and D) because it was the plan a majority of seniors chose at that time (15 years ago). I spent literally no time investigating the benefits of an Advantage plan and have never considered it since. In recent years, I have heard a lot of seniors talk about how their Medicare plan had coverage for dental care as well as vision and hearing; benefits I don’t receive. I compared what they paid for premiums to what I paid and found they were paying less. That led me to investigate the advantages of an Advantage plan—pun intended. What I learned convinced me that many years ago I had made the right decision.

Medicare Advantage is also called Medicare Part C. These plans have become popular in recent years for reasons previously mentioned—lower premiums and additional benefits. But these perks don’t come without some strings attached, as I’ll outline later.

Original/Traditional Medicare is comprised of Parts A, B, and D. Part A covers 80% of the charges for inpatient hospital care, skilled nursing facilities, hospice care, and some home health services. The other 20% is covered by a Medicare supplemental insurance policy, which most people purchase. Part B is optional, but is almost always chosen, and covers doctor’s fees, outpatient care, home health care, and durable medical equipment such as hospital beds and wheelchairs. Supplemental Medicare policies are required to pay what Part B does not pay. Part D is the optional coverage for prescription drugs. Premiums for Part D and supplemental coverage are paid to individual companies writing the policies. Part A has no premium if you paid Medicare tax during your working years. Part B is paid by the government and individuals by deductions from monthly Social Security payments. 

With traditional Medicare, patients can see any doctor, anywhere, at any time. They can go to any hospital in any city, for any reason. If they have an MRI, or blood tests, they are not limited in where they can go to have the test nor do they have to obtain Medicare’s approval before it  can be scheduled. That approval is called prior authorization, and it’s a time-consuming process done by the ordering physician’s office staff. Traditional Medicare usually has no co-pays for doctor visits, and unlike Advantage plans, it doesn’t have coverage for dental care, vision or hearing problems, nor does it cover a gym membership.

Medicare Advantage plans cover hospital stays and doctor visits, just like traditional Medicare. At no extra cost, though, they also cover prescription drugs (like Part D), plus Advantage plans have additional benefits for vision, dental, and hearing care. There is no additional premium for these benefits. Premiums for Advantage plans are less and no Medigap, supplemental policy, is required to pay expenses Medicare doesn’t cover; thus the “advantage” patients get with Advantage plans. But these don’t come without limitations and restrictions.

Restrictions and limitations of Advantage plans are listed below:

1.  In most cases, you must see a physician enrolled in the plan network. You may have to change physicians or see a different specialist with an advantage plan.
2. Yes, you have vision, dental, and hearing coverage, but there may be restrictive spending limits for each of these benefits. You may be restricted to getting your glasses or hearing aids from a discount provider.
3. Before you can have an MRI of your arthritic knee, you must get prior authorization (or approval) from the plan to schedule it. “Over 90% [of Advantage plans] require prior authorization for services ranging from hospital stays to procedures to lab tests.”
4. Strict drug formularies (preferred, cheaper generic drugs) are “imposed” upon patients and you may be required to fail (not respond to treatment) on one drug before a stronger, more expensive drug can be prescribed.
5. If a patient has a chronic illness, they may be denied coverage by an Advantage plan. Advantage plans often enroll only healthier patients. 
6. Insurance brokers may receive higher commissions for enrolling patients in Advantage plans. Thus the incentive is toward selling those plans and “hiding some of the risks of enrolling.”
7. Advantage plans deny coverage to enrollees far more often than traditional Medicare. However, if one appeals the denial, there is a 75%-80% chance the denial will be reversed. The problem comes, though, when only 12% of denials are appealed. A patient should not just allow the private Advantage plan insurer’s denial to go unchallenged. 
8. Denials and limits on ancillary services (vision, dental, etc.) are a big part of how United Healthcare generated $9 Billion in profit the first quarter of 2025!

My bias is in the direction of traditional Medicare. I have lived with provider networks, prior authorizations, and restrictive formularies for forty years. Together, they frustrate and anger physicians and patients alike. If my experience tells me Dr. A is better at gall bladder surgery, he is the doctor I prefer to use. But if he’s not in the Advantage provider network, I must use Dr. B who may be less desirable. If I must prescribe lovastatin before I can prescribe rosuvastatin, a better statin, I waste six months to a year waiting to see if it lowers cholesterol to the target level. AND if I think a patient needs an MRI of her knee, I’m insulted having to justify the need for the test. Prior authorizations do nothing but delay procedures and waste a physician’s time. 

The old adage “you get what you pay for” is appropriate for Medicare Advantage plans. Yes, you have lower premiums, you get your vision and hearing checked, but in my opinion, the restrictions placed on these benefits outweigh the extra benefits. 

References: Feldman MA. Medicare Advantage Plans: Where’s the Advantage? Medscape  2025 June 4.