By Mike Miligi | Michael M Insurance Services, Brightwaters, NY
If you spend any time on Facebook, in a diner booth, or at a senior center around Annual Enrollment, you’ll hear it: Medicare Advantage plans are a scam. I know someone who got denied care. You lose your freedom. Some of that is fair. Some of it is half the story. And almost none of it is unique to Medicare Advantage — most of these same complaints exist with employer plans, Marketplace plans, and pretty much every form of managed health insurance in the country.
That doesn’t mean the complaints are wrong. It means they deserve a straight, specific answer instead of a slogan. So let’s go through the four I hear most often — networks, prior authorizations, out-of-pocket maximums, and travel flexibility — and look at what’s actually true, what’s exaggerated, and what it means for your specific decision.
First, a Quick Refresher: Not All Medicare Advantage Plans Work the Same Way
Before we get into the four complaints, it helps to understand that Medicare Advantage isn’t one plan design — it’s several, and a lot of these complaints depend heavily on which type you’re actually enrolled in.
| Plan Type | Network Rule | Referrals Needed | Out-of-Network Coverage | Typical Premium |
|---|---|---|---|---|
| HMO (Health Maintenance Organization) | In-network only, except emergencies | Usually yes | Not covered, except emergencies | Lowest |
| PPO (Preferred Provider Organization) | In or out-of-network | No | Covered, at higher cost-share | Moderate |
| HMO-POS (HMO Point-of-Service) | Mostly in-network, with limited exceptions | Usually yes | Covered for specific services only, at higher cost | Low–Moderate |
| PFFS (Private Fee-for-Service) | Set by the plan on a service-by-service basis, not a fixed network | No | Varies by provider agreement | Varies |
The reason this table matters for everything that follows: an HMO and a PPO can produce two completely different experiences with the same complaint. An HMO member who wants to see an out-of-network specialist and a PPO member doing the same thing are living under different rules entirely — so Medicare Advantage restricts you is really a question of which Medicare Advantage plan you’re enrolled in.
Complaint : You're Stuck With a Network of Doctors and Hospitals
This is the most common complaint, and it’s real — Medicare Advantage plans do use provider networks. If your cardiologist or hospital system isn’t contracted with your plan, you may need to switch providers or pay more to see them out-of-network, depending on plan type.
Here’s the context that usually gets left out: every form of health insurance in America uses networks, except Original Medicare itself. Your former employer’s PPO had a network. A Marketplace plan has a network. Even Medicare Supplement plans, while they don’t restrict which Medicare-accepting doctor you see, don’t cover you at all if you drop them for a Medicare Advantage plan and want to switch back later without medical underwriting in most states.
The real issue isn’t “networks exist.” It’s whether your specific doctors and hospitals are in your specific plan’s network, at your specific address — and that changes every year, sometimes even mid-year. In 2026, for example, several Wellcare and Fidelis plans in Suffolk County lost their contract with Northwell Health, affecting coverage at facilities like Southside Hospital. That’s not a Medicare Advantage problem in general — that’s a this-plan, this-carrier, this-year problem, and it’s exactly the kind of thing that needs to be verified before you enroll, not after.
The fix isn’t avoiding Medicare Advantage. It’s verifying your network every single year, even if nothing about your health has changed — because the plan might have changed.
Complaint : They Make You Get Prior Authorization for Everything
Prior authorization means your plan requires approval before covering certain services — an MRI, a hospital admission, some specialist procedures, certain medications. People experience this as a hoop, and sometimes it is one. Delayed approvals can delay care, and that’s a legitimate frustration worth taking seriously.
What often gets missed is that prior authorization isn’t a Medicare Advantage invention — it’s standard across nearly all insurance, including many employer plans and Part D drug plans. Original Medicare actually uses prior authorization too, just for a narrower list of services. The difference with Medicare Advantage is that private carriers apply it more broadly, because they’re managing costs and utilization the way any insurer does.
CMS has also tightened the rules here. As of recent years, Medicare Advantage plans must follow national coverage decisions the same way Original Medicare does for many services, and denials can be appealed — with a real success rate for people who do appeal. That doesn’t erase the friction of prior auth, but it does mean it’s a manageable, appealable process rather than an arbitrary wall.
The practical takeaway: ask, before you enroll, how a plan handles prior authorization for the services you actually use regularly — not services you might theoretically need someday.
Complaint : The Out-of-Pocket Costs Are Higher Than I Expected
This one deserves a real answer, because it’s the complaint with the most truth in it. Compared to a Medicare Supplement plan — which can bring your out-of-pocket costs for covered services close to zero — a Medicare Advantage plan will generally expose you to more cost-sharing: copays for visits, coinsurance for some services, and a real (if capped) maximum out-of-pocket.
Here’s the number that matters: the federal Maximum Out-of-Pocket for Medicare Advantage plans is $9,250 in-network for 2026. That’s a meaningful amount of money if you have a bad health year. It’s also worth comparing to the alternative most people don’t think about: Original Medicare alone has no out-of-pocket maximum at all. Part B coinsurance is 20%, indefinitely, on however much care you need. Without a Supplement plan layered on top, Original Medicare’s worst case is actually worse than Medicare Advantage’s worst case — it’s just less visible because there’s no single number attached to it.
So the honest framing is: Medicare Advantage costs more out-of-pocket than a Supplement plan if you need a lot of care in a given year. It costs less out-of-pocket than Original Medicare alone in that same scenario. Which one matters to you depends on your budget for monthly premiums versus your tolerance for a larger, capped bill if your health takes a turn — not on which option is universally “cheaper.”
Complaint : You Lose the Freedom to Travel or See Any Doctor
This complaint is usually about HMOs specifically, and it’s fair as stated — an HMO Medicare Advantage plan generally expects you to get care within its network and service area, with true emergencies as the exception. If you spend winters in Florida, split time with family in another state, or simply want the option to walk into any doctor’s office nationwide, an HMO can feel restrictive.
But “Medicare Advantage” isn’t one plan type, and this is where the complaint often gets generalized further than it should. A PPO Medicare Advantage plan lets you see any Medicare-accepting provider, in or out of network, without a referral — you’ll pay more out-of-network, but you’re not locked out. Some Medicare Advantage plans also include visitor/travel programs that cover you for a set number of days a year outside your home area, even on an HMO.
The travel-flexibility complaint is really a plan-type complaint wearing a Medicare Advantage costume. If travel and provider freedom matter to you, that’s a conversation about HMO versus PPO versus a Medicare Supplement — not a reason to write off Medicare Advantage as a category.
So — Are the Complaints Wrong?
Not exactly. They’re real trade-offs, described as universal flaws. Networks, prior authorization, higher potential out-of-pocket costs, and reduced travel flexibility on some plan types are all genuinely part of how Medicare Advantage works. What’s missing from the version you hear at the diner is that:
- Networks and prior authorization exist across almost all insurance, not just Medicare Advantage.
- The out-of-pocket comparison depends entirely on what you’re comparing it to.
- The travel complaint is often a plan-type issue, not a Medicare Advantage issue.
None of that means Medicare Advantage is automatically right for you. It might not be. But some people don’t like it is a very different starting point than here’s specifically what wouldn’t work for my situation — and only one of those actually helps you make a decision.
The Framework I Use With Every Client
- Start with your doctors and hospitals — confirmed in-network for the specific plan, not just the general service area.
- Look at your actual medication list against the plan’s formulary and prior authorization requirements.
- Be honest about how much you travel, and choose HMO vs. PPO accordingly.
- Compare the realistic out-of-pocket exposure, not just the premium, against what you’d pay on Original Medicare alone or with a Supplement.
- Weigh all of that against the extra benefits — dental, vision, hearing, OTC allowances — that Original Medicare doesn’t offer at all.
Frequently Asked Questions
Do all Medicare Advantage plans have prior authorization requirements?
Most do for at least some services, though the specific list varies by carrier and plan. It’s worth asking directly which services on your plan require it before you enroll.
Is it true that Medicare Advantage plans can deny care that Original Medicare would cover?
Medicare Advantage plans are required to cover everything Original Medicare covers. Disputes are usually about process — prior authorization, documentation, or network status — rather than plans refusing to cover a Medicare-covered service outright. Denials can be appealed, and appeals succeed often enough to be worth pursuing.
If I travel a lot, should I avoid Medicare Advantage entirely?
Not necessarily — a PPO Medicare Advantage plan offers considerably more flexibility than an HMO, and some plans include specific travel benefits. It’s worth discussing your specific travel pattern rather than ruling out the whole category.
How do I know if my complaint about a Medicare Advantage plan is a Medicare Advantage issue or a specific-plan issue?
That’s usually the right question to start with, and it’s exactly what I help clients sort through — whether what they’ve heard applies to Medicare Advantage broadly or to one carrier, one plan type, or one plan year.
What's the actual difference between an HMO and a PPO Medicare Advantage plan?
An HMO requires you to stay in-network (except emergencies) and usually needs a referral to see a specialist, in exchange for a lower premium. A PPO lets you see any Medicare-accepting provider, in or out of network, without a referral — you’ll just pay more for care outside the network.
Can I switch from an HMO to a PPO if the network restrictions turn out to bother me?
Yes, but only during specific windows — the Annual Enrollment Period (Oct 15–Dec 7) or, if you’re already in a Medicare Advantage plan, the Medicare Advantage Open Enrollment Period (Jan 1–Mar 31). You can’t switch anytime you’d like outside of those periods without a qualifying life event.
Does a higher premium always mean a lower maximum out-of-pocket?
Not always, but there’s often a relationship between the two. It’s worth comparing the MOOP directly across plans rather than assuming premium alone tells you what your worst-case cost would be.
If I have a prior authorization denied, is that the end of it?
Do Special Needs Plans (SNPs) have the same complaints as standard Medicare Advantage plans?
Largely yes, since SNPs are still a form of Medicare Advantage with networks and often prior authorization — but they’re also tailored to specific chronic conditions or dual Medicare/Medicaid eligibility, so the benefit design is usually built around the population it serves.
Is Original Medicare really free of all these issues?
Not entirely. Original Medicare has no provider network and generally less prior authorization, but it also has no cap on your out-of-pocket costs and doesn’t include extra benefits like dental, vision, or hearing. It trades one set of trade-offs for another rather than avoiding trade-offs altogether.
Would a Medicare Supplement (Medigap) plan solve all four of these complaints?
It solves some of them. Supplement plans have no network and no Medicare Advantage-style prior authorization, and they bring your out-of-pocket costs close to zero. What they don’t include is the extra benefits — dental, vision, hearing, OTC allowances — that come bundled with most Medicare Advantage plans, and they typically carry a higher monthly premium.
Should I just pick the plan with the fewest of these four complaints?
Not necessarily — the right plan depends on how each of these four factors weighs against your specific doctors, medications, travel habits, and budget, not on which plan design has the shortest list of trade-offs on paper.
I'm Here to Help
I’ve been helping Seniors navigate Medicare for over 10 years, and I’m a Medicare beneficiary myself, so I’ve sat on both sides of this conversation. If you’ve heard something about Medicare Advantage that’s making you nervous, or you’re trying to figure out whether a complaint you’ve heard actually applies to your situation, call me. I’ll look at your specific doctors, medications, and priorities and give you a straight answer — including if the answer is that Medicare Advantage isn’t the right fit for you.
That conversation is always free.
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