Medicare Advantage Nightmares: Be Informed
As Medicare agents with over 20 years of experience, we’ve seen so many get caught up in the downsides of Medicare Advantage (MA) plans.
While these plans are often marketed as cost-effective alternatives to Original Medicare, the reality is that many enrollees find themselves trapped in networks with limited access to care, facing unexpected denials, and struggling with out-of-pocket costs they never anticipated.
In this article, we’ll take a look at the biggest issues with Medicare Advantage and explore why so many beneficiaries end up regretting their decision. We’ll use:
- Real-world statistics
- News reports
- Firsthand cases
If you’re considering a Medicare Advantage plan (or already enrolled), you need to know the risks that insurers don’t advertise. Let’s start with network changes.
Network Changes and Limitations
Medicare Advantage enrollees are often blindsided by annual network changes that restrict access to trusted doctors, specialists, and hospitals.
Unlike Original Medicare, which allows beneficiaries to see any provider that accepts Medicare, Medicare Advantage plans operate within private insurer-controlled networks that are subject to frequent changes.
What does that mean?
This means that seniors can be left without access to essential healthcare providers, forcing them to either switch doctors or pay exorbitant out-of-network fees.
Why Do Networks Change?
Here are some of the top reasons that networks change:
- #1. Contract Disputes: insurers regularly renegotiate contracts with hospitals and doctors. If providers refuse to accept lower reimbursements, they may be dropped from the network.
- #2. Profit-Driven Adjustments: insurers narrow networks to steer patients toward lower-cost providers, limiting access to high-quality or specialized care.
- #3. Geographic Market Shifts: some insurers exit less profitable markets altogether, leaving enrollees scrambling to find new plans.
- #4. Annual Plan Overhauls: each year, MA plans restructure their networks as part of their business strategy, often without clearly notifying beneficiaries.
In a nutshell: Medicare Advantage insurers frequently alter their provider networks to cut costs and maximize profits.
Provider Network Instability
When a provider is removed from a Medicare Advantage network, it can create serious problems for enrollees, including:
Losing a trusted doctor: many seniors build long-term relationships with their doctors, and losing them can throw treatment plans off track.
Reduced access to specialists: for people with chronic conditions like cancer, heart disease, or diabetes, these changes can cause care delays and impact health outcomes.
Higher costs: if someone decides to stick with an out-of-network doctor, they might face steep bills or have their insurance claims denied.
Lack of communication: a lot of beneficiaries don’t even know about network changes until they show up for an appointment and find out their doctor isn’t covered anymore.
Real-World Cases
In 2024, Over 1 million Medicare Advantage enrollees lost access to their hospitals and doctors after major insurers dropped entire health systems from their networks.
Seniors in rural areas were particularly affected, as alternative providers were often not available within a reasonable distance.
Example Case #1. Oncology Patients Left Without Specialists
A retiree in Texas, who had been receiving oncology care under Medicare Advantage, was forced to find a new cancer specialist mid-treatment when her plan removed her oncologist from the network.
Her new provider had a three-month waitlist, delaying crucial chemotherapy treatments.
Example Case #2. Hospitals Cutting Ties with MA Plans
In 2024, several major health systems, including Aultman Health System in Ohio and Memorial Hermann Health System in Texas, terminated contracts with certain Medicare Advantage plans, affecting thousands of beneficiaries.
These hospitals cited excessive prior authorization requirements and delayed insurer payments as reasons for leaving..
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How to Stay Protected:
#1. Review your Annual Notice of Change (ANOC) each September/October to stay updated on network changes.
#2. Before re-enrolling, confirm your doctors will remain covered in the upcoming year.
#3. Alternatively, consider Original Medicare with Medigap for more provider flexibility nationwide.
Plan Changes During AEP
Each year, during the Annual Enrollment Period (AEP) from October 15 to December 7, Medicare Advantage plans can modify their benefits, premiums, and provider networks.
These changes can significantly impact enrollees, as insurers may adjust coverage options, introduce higher costs, or drop specific providers from their networks.
Many beneficiaries take to online forums, such as Reddit, to discuss the complexities of navigating these changes. Common concerns include:
- Unexpected increases in out-of-pocket costs
- The removal of key medications from formularies
- Loss of access to trusted healthcare providers
How to Prepare for AEP Changes
Be sure to review your Annual Notice of Change (ANOC), which is sent out every September. This document highlights any updates to your Medicare Advantage plan for the coming year.
Also, use Medicare’s Plan Finder tool or connect with one of our licensed agents to see if your current plan still fits your needs. Double-check that your doctors, hospitals, and medications will continue to be covered next year.
Joining online forums can also give you helpful tips for choosing the right plan.
Prior Authorizations (Delayed Care)
One of the most frustrating and dangerous aspects of Medicare Advantage is the requirement for prior authorization before receiving certain medical services or treatments.
- Studies show that 45% of Medicare Advantage plans require prior authorization for specialist visits.
While insurers claim this is meant to control costs and prevent unnecessary procedures, in practice, it often results in delays, denials, and even life-threatening consequences.
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Prior Authorizations:
A prior authorization is when an insurance company must approve a medical service before it is performed. This process is required for:
- Specialist visits
- Imaging services (MRIs, CT scans, PET scans, etc.)
- Surgeries and procedures
- Prescription medications
- Skilled nursing facility care
Unlike Original Medicare, which allows doctors to make medical decisions without interference, Medicare Advantage plans force providers to get approval from the insurer first, often resulting in dangerous delays.
Real-World Denial Cases
A report by the Office of Inspector General (OIG) highlighted cases where Medicare Advantage Organizations (MAOs) denied prior authorization requests for services that met Medicare coverage rules. Beneficiaries were denied advanced imaging services like MRIs, even though these services were deemed medically necessary under Medicare guidelines.
#1. Post-acute Care Denials
The Senate Permanent Subcommittee on Investigations found that major insurers, including UnitedHealthcare, Humana, and CVS, frequently denied prior authorization requests for post-acute care services.
These denials often created barriers to medically necessary treatments and rehabilitation, adversely affecting patient recovery.
#2. Increase in Denial Rates Over Time
Between 2019 and 2022, UnitedHealthcare’s denial rate for skilled nursing facility care prior authorizations increased significantly. In 2019, the denial rate was 8.7%, which rose to 22.7% by 2022.
This trend indicates a growing barrier for beneficiaries requiring post-acute care.
Here’s the reality. Prior authorizations = delayed or denied care. A 2024 Senate report found that Medicare Advantage insurers frequently delay or deny prior authorization requests for post-acute care services.
The denied requests force patients to undergo a lengthy appeals process—a process that most don’t have time for.
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What Can You Do?
If a service is denied, ask for a peer review so your doctor can talk directly to the insurer’s medical team. Don’t forget to appeal the decision, too—lots of denials get overturned during the appeal process, but it does take some persistence.
Plan Terminations
Medicare Advantage companies frequently make headlines for terminating plans, leaving thousands (sometimes millions) of beneficiaries scrambling for new coverage.
These plans are often promoted as stable, long-term solutions for seniors, but insurers only prioritize profits over consistency for policyholders. When financial pressures rise, plans can be cut, leaving enrollees to either search for new Medicare Advantage coverage or switch back to Original Medicare—usually at a significant personal cost.
Insurers justify these terminations by citing declining reimbursement rates from CMS, increasing medical costs, and regulatory compliance challenges.
However, the end result is the same: seniors lose their trusted providers, are forced into unfamiliar plans, or face unexpected out-of-pocket expenses.
Let’s look at some big-name companies that are cutting Medicare Advantage plans.
Aetna’s Medicare Advantage Cuts for 2025
Aetna, one of the largest Medicare Advantage providers, is set to terminate plans affecting as many as 420,000 beneficiaries across multiple states in 2025.
According to company executives, the decision is driven by financial pressures, with Aetna shifting its focus to profit margins over membership retention. Key impacted areas will include Florida (over 90K members), Texas, and California.
Aetna’s leadership acknowledged that some enrollees may need to find new coverage or transition back to Original Medicare, which could result in higher costs and reduced benefits for many.
Centene’s Exit from Medicare Advantage
Centene, a major player in the Medicare Advantage market, announced that nearly 40,000 enrollees will lose their coverage in 2025. This decision is largely due to lower-than-expected reimbursement rates from CMS, making it financially unviable to sustain operations in certain states.
States impacted by Centene’s exit:
- Alabama
- Massachusetts
- New Hampshire
- Rhode Island
- New Mexico
- Vermont (where Centene previously controlled 9% of the market)
Vermont enrollees, in particular, may struggle to find comparable replacement plans due to limited availability.
Cigna’s Reductions in Medicare Advantage Plans
Cigna is set to discontinue some Medicare Advantage plans in 2025, primarily impacting:
- Colorado
- Florida
- Illinois
- Missouri
- North Carolina
- Tennessee
- Texas
- Utah
This decision is attributed to high medical costs and shrinking reimbursement rates, making it unsustainable for Cigna to continue operations in these areas.
Approximately 6,000 enrollees in Florida will be directly affected, while beneficiaries in other states may see fewer plan options available.
Providers Dropping MA Networks
An increasing number of hospitals and health systems have been exiting Medicare Advantage networks, often due to delayed or denied payments, excessive administrative burdens from prior authorizations, low reimbursement rates, and frequent changes to plan policies.
There are facilities exiting MA networks all over the country, including:
When a hospital or major provider system opts out of a Medicare Advantage network, beneficiaries may suddenly find their trusted doctors or hospitals no longer covered, forcing them to either pay out-of-pocket or seek new providers within the network—often at the expense of continuity of care.
What Can You Do?
#1. Check your provider’s network status frequently: even if your hospital or doctor is in-network today, they may not be next year. Call your providers regularly to confirm they still accept your Medicare Advantage plan.
#2. Consider Original Medicare + Medigap: unlike Medicare Advantage, Original Medicare does not have network restrictions, allowing beneficiaries to see any provider that accepts Medicare nationwide.
#3. Stay alert for annual notices: Medicare Advantage plans send Annual Notice of Change (ANOC) letters each fall. Read them carefully to determine whether your healthcare providers will remain covered.
Next, let’s review why we believe that Medicare Supplement plans are an option worth considering.
Why We Love Medicare Supplement Plans
Considering all the pitfalls of Medicare Advantage—including network restrictions, denied claims, annual plan terminations, and increased out-of-pocket costs—a Medicare Supplement (Medigap) plan paired with Original Medicare is often a more stable, flexible, and cost-effective option.
Unlike Medicare Advantage, Medigap plans do not have provider networks. This means you can visit any doctor or specialist who accepts Medicare—without worrying about whether your provider will drop out next year.
Perks of Medigap Plans:
- No network restrictions: unlike MA plans, which limit you to specific providers, Medigap lets you see any Medicare-accepting provider nationwide.
- No prior authorizations: Medigap plans do not require insurer approval before you receive medical services.
- Predictable costs: Medigap plans cover many out-of-pocket expenses, such as deductibles and coinsurance.
- Guaranteed renewability: once enrolled, your Medigap plan cannot be canceled due to health conditions.
- Consistent coverage: unlike MA plans that change benefits annually, Medigap policies remain stable year after year.
Medigap Enrollment: Timing Is Important
One of the most critical factors when considering a Medicare Supplement plan is timing. Enrolling in a Medigap plan at the right time ensures you have access to the best rates and avoid potential coverage denials.
The best time to enroll in a Medigap plan is during your Medigap Open Enrollment Period, which begins the month you turn 65 and are enrolled in Medicare Part B. During this six-month window, insurers cannot deny you coverage or charge higher premiums due to pre-existing conditions.
If you wait to enroll in Medigap outside of your Open Enrollment Period, insurers can require medical underwriting, meaning they can deny coverage or increase rates based on your health status.
Important: If you attempt to switch from Medicare Advantage to Medigap later, you may find it difficult to qualify for a Medigap plan.
Why Switching Plans Isn’t Always Easy
Many beneficiaries assume that they can try Medicare Advantage and switch back to Original Medicare and add a Medigap policy whenever they want. However, they often discover a harsh reality: without guaranteed Medigap access, switching can be financially devastating. Let me explain a little further.
Medigap plans (Medicare Supplement insurance) help cover out-of-pocket costs that Original Medicare doesn’t, such as copays, deductibles, and coinsurance. The problem? Unlike Medicare Advantage, Medigap providers can deny you coverage or charge higher rates based on pre-existing conditions unless you enroll when first eligible.
Only four states—Connecticut, Massachusetts, Maine, and New York—require Medigap insurers to accept all applicants year-round. In most other states, if a Medicare Advantage enrollee tries to switch after their initial enrollment period, they may be denied coverage or forced to pay much higher premiums.
Real-World Scenario
Consider David, a retiree who originally enrolled in Medicare Advantage due to its lower premiums. Years later, after experiencing multiple coverage denials and network restrictions, he tried to switch back to Original Medicare.
However, when he applied for a Medigap plan, he was denied coverage due to his pre-existing heart condition.
Without Medigap, David faced 20% coinsurance on all outpatient care and significant out-of-pocket costs for hospital stays.
Medicare Advantage often looks appealing with its low or zero-dollar premiums, but many enrollees regret their choice when they realize how hard it is to switch.
Pro tip: Medigap plans are best purchased when first eligible for Medicare at age 65.
Bottom Line
Medicare Advantage plans continue to lure seniors with the promise of low premiums, additional benefits, and seemingly extensive provider networks.
The harsh reality is that Medicare Advantage plans can be unpredictable. There are annual changes to benefits and networks, hospitals dropping out due to administrative issues, and insurers like Aetna and Cigna exiting markets, leaving enrollees without coverage.
Patients also often face prior authorization delays, leading to care disruptions and increased health risks.
Medicare Advantage might seem like a good option, but for many, the downsides outweigh the benefits. These plans can work fine if you’re in good health with minimal medical needs, but for those who need regular or specialized care, they can be a nightmare.
If it’s within your budget, I would 100% recommend enrolling in a Medigap plan over a Medicare Advantage plan—this will save you headaches regarding prior authorizations, provider networks, and annual plan changes.
FAQs
- Why are so many Medicare Advantage plans being discontinued?
- What happens if my Medicare Advantage plan is discontinued?
- How does a Medicare Supplement (Medigap) plan offer better stability than Medicare Advantage?
- When is the best time to enroll in a Medicare Supplement (Medigap) plan?
- Can I switch from Medicare Advantage to Original Medicare with a Medigap plan at any time?
