Why Medicare Advantage Plans Fall Short: Key Problems You Should Know

Medicare Advantage plans are frequently promoted as a budget-friendly option for seniors turning 65, and they do offer certain appealing features—particularly the annual cap on out-of-pocket costs that original Medicare doesn’t provide. However, Medicare Advantage plans come with significant limitations that often go overlooked until enrollees face them firsthand. Understanding these drawbacks is essential before committing to such a plan.

Network Restrictions Limit Your Doctor Choices

The most immediate challenge with Medicare Advantage plans relates to their network-based structure. Unlike original Medicare, which allows you to visit any provider that accepts Medicare, these plans restrict you to a specific network of doctors, hospitals, and pharmacies. Stepping outside this network can result in substantially higher costs or coverage denial altogether.

Even more problematic is the fluid nature of these networks. Provider rosters change annually, meaning a trusted physician you see this year might not be available next year. This instability forces beneficiaries into difficult situations: either you switch providers at inconvenient times, or you pay out-of-network rates to maintain continuity of care. For those with chronic conditions requiring ongoing specialist care, this uncertainty can be particularly disruptive.

Paying for Benefits You May Never Actually Access

Medicare Advantage plans frequently advertise supplemental benefits that original Medicare doesn’t cover—dental work, vision care, fitness programs, and meal delivery services. These features sound attractive on paper, but there’s a critical catch. Access to many of these benefits requires a documented medical diagnosis that justifies eligibility.

Consider meal delivery benefits: you might qualify if you have a condition like diabetes that benefits from dietary management. But if you don’t have such a diagnosis, you won’t be able to use these services despite paying for them through your plan premiums. Essentially, you’re funding benefits designed for a specific subset of enrollees, which means many beneficiaries pay for coverage they’ll never utilize. This hidden cost structure is rarely emphasized in promotional materials.

Prior Authorization Requirements Create Treatment Delays

According to data from the Kaiser Family Foundation, 99% of Medicare Advantage plan enrollees are in plans that require prior authorization for at least some services. This administrative requirement stands in sharp contrast to original Medicare, where prior authorization is typically not mandated.

The consequences extend beyond paperwork. Required authorizations can delay diagnostic tests, specialist referrals, and necessary treatments. In some cases, authorization denials—even when later overturned—create gaps in care that affect patient outcomes. The bureaucratic burden falls on both patients and healthcare providers, many of whom have begun to view Medicare Advantage’s approval processes as prohibitively cumbersome.

Hospital System Participation Issues Are Expanding

Perhaps most concerning is the growing reluctance of major hospital systems to participate in Medicare Advantage networks. Mayo Clinic dropped Medicare Advantage plans in several states during 2024, citing authorization denial rates and payment delays as primary concerns. More recently, Scripps Health terminated a significant portion of its Medicare Advantage contracts, affecting over 30,000 seniors in its service areas.

These exits represent a troubling trend: as Medicare Advantage programs face sustainability challenges, healthcare providers are voting with their feet. When major systems abandon Advantage networks, beneficiaries within those geographies have limited choices. They either need to accept a smaller provider network or switch plans entirely—neither option provides real flexibility.

Making an Informed Decision

Medicare Advantage plans can work for some seniors, particularly those in good health with limited specialist needs who value the annual out-of-pocket cap. However, the structural limitations of Medicare Advantage plans—network restrictions, benefit access barriers, authorization delays, and shrinking provider participation—make them a problematic choice for many others.

Before enrolling, thoroughly research plan ratings and local provider networks. Verify that your preferred doctors and hospitals actually participate. Understand which benefits you’ll realistically be able to access. And consider whether you have the flexibility to adapt if your preferred providers leave the network. Medicare Advantage plans may offer lower premiums, but the trade-offs in flexibility, access, and control warrant serious consideration.