Time's Running Out: Why You Might Want to Switch Your Medicare Advantage Plan

Medicare Advantage plans have become increasingly popular, with more than half of Medicare enrollees opting for these private insurance alternatives. However, as the open enrollment period for 2025 approaches, many beneficiaries are finding that their Medicare Advantage plans aren't living up to the hype. High out-of-pocket costs, restricted provider networks, and claim denials are just a few of the issues that have left some seniors feeling dissatisfied and financially strained.



Take the case of Rose LaChapelle, whose 92-year-old mother, Vincentina Zarumba, found herself in a dire situation after contracting COVID-19. Zarumba's Medicare Advantage plan refused to pay for rehab facilities after multiple hospitalizations, leading to a rapid decline in her health. "Her Medicare Advantage insurance…refused to pay for her to go to a rehab facility after each hospitalization," LaChapelle recalls. "With each hospitalization, she grew weaker."

LaChapelle's story is not an isolated incident. A 2022 report by the U.S. Department of Health and Human Services (HHS) found that 13% of prior authorization requests in Medicare Advantage were denied, even though they met Medicare coverage rules. Additionally, 18% of payment denials for services already provided were later overturned when challenged, highlighting the frequency of wrongful denials.

But it's not just claim denials that are causing headaches for Medicare Advantage enrollees. High out-of-pocket costs are another major issue. While Medicare Advantage plans often have lower monthly premiums than Medigap (Medicare Supplement) policies, the real cost lies in out-of-pocket expenses. As of 2025, the maximum out-of-pocket limit for in-network services is $8,550, with even higher costs for out-of-network care. In contrast, Medigap policies often cover most or all of these expenses, significantly reducing out-of-pocket costs for beneficiaries.

Moreover, Medicare Advantage plans require copays for doctor visits, diagnostic tests, and specialist consultations—all of which can lead to unpredictable costs. Unlike Original Medicare, where a Medigap policy covers most out-of-pocket expenses, Medicare Advantage plans have high MOOP limits. This can result in beneficiaries facing potentially astronomical costs unless they can also enroll in a Medigap plan for an additional monthly premium.

The potential long-term financial implications for beneficiaries can be substantial. High out-of-pocket costs can lead to financial strain, especially for those on fixed incomes. The unpredictable nature of these costs can make it difficult for beneficiaries to budget effectively, leading to potential financial hardship. Additionally, the limited provider networks and prior authorization requirements can result in delays in care, which can have serious health consequences and further increase healthcare costs.

So, what can beneficiaries do if they're unhappy with their Medicare Advantage plan? The good news is that the open enrollment period for 2025 is just around the corner, running from October 15 to December 7. During this time, beneficiaries can switch to a different Medicare Advantage plan, enroll in Original Medicare with a Medigap policy, or make other changes to their coverage.

Before making a switch, it's important to evaluate your healthcare needs and budget. Consider the specific benefits and services provided by each plan, as well as the costs, provider networks, and quality of care. Online resources, such as the Medicare Plan Finder or State Medicaid websites, can provide valuable information on plan ratings and consumer reviews.

In conclusion, while Medicare Advantage plans may offer lower premiums, the high out-of-pocket costs and coverage limitations can result in significant financial burdens for beneficiaries in the long term. Original Medicare, supplemented with a Medigap policy, often provides more comprehensive coverage and lower out-of-pocket costs, making it a more financially stable option for many beneficiaries. If you're unhappy with your current Medicare Advantage plan, now is the time to explore your options and make a switch.