Weighing the Pros and Cons of Medicare Advantage

Medicare Advantage (Part C) is an alternative to original Medicare offered by private, Medicare-approved insurance companies. Its advantages include an annual out-of-pocket limit for covered medical care and extra benefits offered by many plans, such as dental and vision coverage. Potential drawbacks range from restrictive provider networks and prior authorization requirements to high out-of-pocket costs. 

Medicare Advantage can be a great choice for getting more from your Medicare benefits. But it’s not right for everyone. In this article, we’ll explain how Medicare Advantage works—and walk you through the pros and cons of this comprehensive coverage option.

What's the difference between original Medicare (Parts A and B) and Medicare Advantage?

Original Medicare covers basic health care services like hospital stays (Part A) and doctor visits (Part B). To expand coverage to include prescription drugs, original Medicare can be combined with a Medicare Part D plan. Some people also add a Medigap plan (supplemental coverage) to cover the out-of-pocket costs of original Medicare, like deductibles and copayments.

A Medicare Advantage plan is another way to receive your Part A and Part B coverage. This is a privately managed alternative to original Medicare covers all the services of original Medicare, and usually includes Part D coverage as well.

“In most cases, you’ll need to use health care providers who participate in the plan’s network; however, some [Medicare Advantage] plans offer non-emergency coverage out-of-network, but typically at a higher cost,” Ryan Ramsey, a Medicare expert and NCOA Associate Director of Health Coverage and Benefits, told Medical News Today. “These plans may also offer additional extra benefits like vision, dental, or fitness and wellness benefits that are not covered by Medicare.”

What is the benefit of having a Medicare Advantage plan?

There are five key advantages to choosing a Medicare Advantage plan compared to original Medicare only:

1. Lower costs. With both types of plans, you must pay the monthly Part B premium ($202.90 in 2026, projected to increase to $209.50 in 2027 according to the 2026 Medicare Trustees Report). But Medicare Advantage premiums are often less expensive (sometimes $0) compared to original Medicare combined with a Medigap policy. In 2026, the estimated average monthly Medicare Advantage premium is $14.00—this is projected to drop to $12.00 in 2027. 
   
   What's more, Medicare Advantage plans have a maximum out-of-pocket spending limit for each policy period. In 2026, this cap is $9,250 for approved services (but some plans set lower limits); in 2027, this cap will increase to $9,850. Once the cap is reached, no additional payments are required for covered services for the rest of the year. Original Medicare does not offer an out-of-pocket maximum, so your expenses could be much higher.
2. Similar to employer health insurance. If you're leaving a job where health insurance was offered in the form of an HMO plan, a Medicare Advantage plan will look similar. Deductibles, co-insurance, drug coverage, and physician networks are all part of the package.
3. One plan instead of several. A Medicare Advantage plan is an “all in one” system. Often, you have only one insurance card to keep track of, not three. Some people prefer to deal with one plan versus the separate plans of original Medicare, Part D, and Medigap.
4. More coordinated care. HMO Medicare Advantage plans require you to have a primary care physician (PCP). They are the “gatekeeper” for all your care, responsible for making sure your team collaborates with other medical professionals on your treatment. For people with complicated health conditions, this kind of coordinated effort can be valuable.
5. Additional benefits (not covered by original Medicare). Medicare Advantage plans often include prescription drug coverage, plus vision, hearing, and dental benefits—all of which are not part of original Medicare. In some cases, an additional premium may be required, but that is not true for all plans. Most Medicare Advantage plans also offer non-medical benefits as well, such as nutrition counseling, meal and grocery delivery, transportation access, and falls prevention aids. But it’s worth noting that due to a variety of factors, many plans are scaling back or eliminating these extra benefits for the 2027 coverage year.

What are the disadvantages of a Medicare Advantage plan?

There are four key disadvantages of choosing a Medicare Advantage plan versus original Medicare:

1. Getting coverage for procedures can be more complicated. Since managed care plans aim to keep health care costs within budget, they try to prevent overuse through various means—such as “prior authorization” requirements for surgery, home health care, hospital stays, and medical equipment. Doctors often must provide additional proof of necessity for a service before the plan will pay.
2. Billing before you receive treatment. With Medicare Advantage, copayments are paid prior to treatment. For multiple physician visits, there may be several copayments required upfront before you can see a doctor or receive care. In contrast, if you have original Medicare plus Medigap, you would owe a 20% coinsurance (billed after the service) that would be covered by your Medigap policy.
3. Less freedom in choosing health care providers. With original Medicare, you can see any physician who accepts Medicare, which gives you access to providers and major medical centers nationwide. In contrast, Medicare Advantage plans are more restrictive in terms of provider networks. A network is a list of doctors, hospitals, and/or pharmacies that negotiate prices with insurance companies. In some areas, it can be difficult to find a local doctor or hospital that works with Medicare Advantage. And if you visit a doctor or a hospital that isn’t “in-network,” you will pay higher out-of-pocket costs.
4. Less compatible with other forms of retiree coverage. There are also some limitations in how Medicare Advantage works with other types of retiree coverage. For example, people with TRICARE for Life need to enroll in original Medicare (versus Medicare Advantage) in order to keep their TRICARE coverage. Prior to enrolling in a Medicare Advantage plan, be sure to find out how it will work with other retiree coverage you have.

Switching from Medicare Advantage to original Medicare

Switching between a Medicare Advantage plan and original Medicare is allowed once a year—during the annual Medicare Open Enrollment period from Oct. 15-Dec. 7. During this time, anyone with Medicare Advantage can switch to original Medicare.

In most states, anyone enrolled in a Medicare Advantage plan for more than one year is not likely to be able to enroll in a Medigap policy. If enrollment is possible, there may be additional guidelines to meet. Staying on a Medicare Advantage plan for more than one year—and then trying to switch to original Medicare—may result in limited (or nonexistent) Medigap choices. That's why it's important to take the time to read and discuss these options with a licensed Medicare benefits adviser.

Medicare Advantage in 2027: What’s changing? 

Medicare Advantage plans may change their premiums, copays, annual out-of-pocket limits, provider networks, drug formularies, and extra benefits for the 2027 coverage year. Some plans are reducing benefits like dental and vision coverage or leaving certain service areas entirely. 

Ramsey points out that these changes can’t be attributed to a single factor: “Some stem from federal policy and payment decisions, while others come from insurers deciding which plans to offer and where,” he explained. “The biggest takeaway for older adults is that these updates can impact much more than your monthly premium. They may affect what you pay at office visits, which doctors and hospitals you can use, whether your prescriptions are covered, and which extra benefits you receive. Even a plan with a low premium could leave you with higher copays or a higher annual out-of-pocket limit. Read your Annual Notice of Change to see what your coverage looks like for the coming year, and don’t be afraid to explore new options during Open Enrollment.”

Medicare's Open Enrollment period runs from Oct. 15 through Dec. 7 each year. The annual Medicare Advantage Open Enrollment period runs from Jan. 1–March 31. Learn more about when you can make changes to your Medicare Advantage plan.

Where's the best place to get advice on Medicare?

The good news is there are several ways to get expert Medicare guidance from people who know the program inside and out. We’ve outlined some options below.

State Health Insurance Assistance Programs (SHIPs)

SHIPs offer free, impartial, and personalized insurance counseling and assistance to Medicare-eligible older adults, their families, and caregivers. They do not sell insurance products of any kind. These programs are available in all 50 states, Puerto Rico, Guam, D.C., and the U.S. Virgin Islands.

A certified SHIP counselor can help you:

• Learn the basics of Medicare, including who is eligible
• Review your options for health and/or prescription drug coverage
• Understand Medicare out-of-pocket costs as well as programs that can help you pay for these costs
• Ensure your rights are protected under Medicare
• Refer you to other agencies for additional help, if needed

These trained volunteers can also help you deal with Medicare billing problems and complaints about medical care or treatment. Find your local SHIP office here or call 1-877-839-2675.

Medicare Support Hotline

Available 24/7, Medicare's 1-800-MEDICARE (1-800-633-4227) Support Hotline can help you with your Medicare questions and concerns. You can also visit the Medicare.gov website to start a live chat. TTY users should call 1-877-486-2048.