What is the trap of Medicare Advantage plans?

Question

Larry Dalton · Accepted Answer

It's important to understand that Medicare Advantage is not the same as traditional Medicare. Medicare Advantage is a type of group insurance plan created by an insurance company that adheres to Medicare guidelines to serve beneficiaries. Although some Medicare Advantage plans may have a zero monthly premium, they often come with various other cost factors that can arise when using the coverage. Here are some key points to consider when switching to a Medicare Advantage plan:

1. Some individuals may encounter difficulties when trying to switch back to traditional Medicare after enrolling in a Medicare Advantage plan, particularly due to their health conditions.
2. Medicare Advantage plans operate within provider networks, such as PPO and HMO networks.
3. Approximately 50 to 70% of surgeries or other therapies may require prior approval.
4. Coverage is subject to specific geographic areas, and you may need to obtain approval for services outside those areas.
5. Under Medicare Advantage, your out-of-pocket costs for one year of service could be significantly higher than with traditional Medicare combined with Medigap, especially if you have serious health conditions.
6. Medicare Advantage programs must be renewed each year, and the plans are subject to change annually.

Tony Capraro III · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/what-is-the-trap-of-medicare-advantage-plans#tony-capraro

Tasha Riggs · Answer

There is no Trap. Medicare advantages have to cover the exam same things as Medicare. It is a law. Medicare advantage is a Guarantee issue and gave give you extra benefits that Medicare supplements can not.  Medicare supplemental is only medical. 
Medicare Advantage can have coverage for Dental, Vision , hearing, Over the counter and healthy foods if you qualify.

Lauryn Ivey · Answer

I don’t believe there is a trap. If your agent has done their job and explained how they work and also explained your other options then you can make a truly educated decision based on your specific needs.

Answered by Lauryn Ivey on June 3, 2025

Broker Licensed in AL

Answered by Lauryn Ivey Medicare Insurance Agent

Hope Suhr · Answer

The trap of a Medicare Advantage plan is that it’s an HMO plan, and you have to get prior authorization for a specialist. However, the cost is minimal. If zero out-of-pocket.
That’s the benefit of having the Medicare advantage HMO plan, along with all of the other benefits that come along with dental, vision, hearing, chiropractic, acupuncture, over-the-counter benefits, so on and so forth.

Lance Stanley · Answer

The Medicare trap refers to the difficulty beneficiaries can sometime face when going back to original Medicare because they may or may not be able to qualify for a Medicare supplement based on their health.

Answered by Lance Stanley on June 9, 2025

Broker Licensed in FL, AL, GA, MS & TX

Answered by Lance Stanley Medicare Insurance Agent

Yasmine Lopez · Answer

Medicare Advantage can look like the easy choice — low or $0 premiums, bundled extras — but there are some serious tradeoffs that you may not realize until it’s too late.

Your doctor or hospital could disappear from your plan.
Provider networks are renegotiated every 1–3 years. That top-rated hospital or specialist you rely on? They could be out-of-network next year, and you’re left scrambling. If you live with a chronic condition, this can be devastating.

Chronic illness can drain your wallet.
If you're diagnosed with cancer, autoimmune disease, or need infusions or specialty drugs, you could hit the plan’s maximum out-of-pocket — up to $8,000+ per year  depending on the plan — with no cap over time. And that's every single year.

You might lose your chance to find cost relief once you have a chronic illness.
Many people don’t realize you can’t just switch to a Medicare Supplement plan anytime. If your health changes and you now have pre-existing conditions, you can be denied a Supplement — and stuck in Advantage with higher long-term costs and fewer choices.

Bottom line: Medicare Advantage works for many — but it’s not risk-free. If staying in control of your care, costs, and providers matters to you, we need to talk through all the options first to understand the tradeoffs and your risk tolerance.

Steve Thurmond · Answer

There isn't a "Trap" with Medicare Advantage Plans, per se, but on more than one occasion I've come across individuals that find themselves stuck in their Medicare Advantage Plan as they are unable to pass underwriting guidelines in order to move back to Original Medicare (Red/White/Blue Card) paired with a Medicare Supplemental Plan that covers the other 20% that Original Medicare does NOT cover.

In most states, you can only enroll into a Medicare Supplemental Plan WITHOUT having to go through underwriting during your initial, 6-month, Medicare Supplemental Plan 'Open Enrollment' window that coincides with the starting of your Medicare Pat B (Medical) coverage effective date. 

Once that 6-month window closes, you can still change to ANY available Medicare Supplemental Plan available to you in your market at ANY time for ANY reason, BUT you are then beholden to underwriting guidelines (in most states) and you can be declined by the Medicare Supplemental Plan carrier that you're applying with if they deem you too high-risk to cover.

So, a common thing I run into is; someone starts out with a Medicare Advantage plan because they're attracted to the low (or $0) monthly premium and the extra benefits ("Advantages") that come with these Managed Care plans. Everything is fine until they get sick or start to deal with a serious or chronic health condition. They then experience ongoing copays and coinsurance costs which they are responsible for (up to their particular plan's Maximum Out of Pocket) and realize they are paying MORE for the low-monthly-cost Medicare Advantage Plan than they would be if they ha 100% coverage between original Medicare and a Medicare Supplemental plan that costs them a higher monthly premium.

There is no one-size fits all and there is quite a bit of nuance that can vary drastically, but generally speaking, if you can afford a Medicare Supplemental Plan, it will give you the better coverage long-term as you age and your risk profile increases.

Steven Bleicher · Answer

Prior authorization! This has nothing to do with your doctor or your agent but with your insurance company. There have been a greater # of insurance firms that now will question whether a less expensive treatment for your malady may be used instead of the first one prescribed by your Primary Doctor. Moreover, you likely know that an Advantage plan has no monthly premium as it is subsidized by the Federal Govt. As a tradeoff to that, it does contain a fairly steep deductible which again, depending upon the State you live in and the policy of your insurance company, can be a burden for those with not much money. This is why it is essential to fully understand the differences between a Med. Supplement (with a premium) and a Med. Advantage plan. The cheapest premium does not always offer the best benefits!
Remember this: at 65, you're likely to be healthier than you will be in 5 or 10 years. So, just because you may run 3 miles a day, doesn't mean that you can keep that up when you're 75!

DeeDee Whitlock · Answer

There is not really a so called TRAP, just most agents are not CLEAR exactly how they work or check doctors client wants to have access to! Commissions are really good & there are too many agents who look at commissions & are NOT completely honest with clients or they flat out lie to them. Make sure you have a reputable local agent who has a history of great clients who recommend them!

Answered by DeeDee Whitlock on June 24, 2025

Broker Licensed in LA

Answered by DeeDee Whitlock Medicare Insurance Agent

Michael Crocker · Answer

I prefer to think of them as "holes" rather than "traps" because a "trap" implies that someone was deceived. I educate my clients on the potential "holes" in Medicare Advantage plans so that they are prepared for every eventuality. The first major hole is cancer treatment. A cancer diagnosis can result in months of expensive treatments and quickly eat up your maximum out of pocket (MOOP) on an MA plan. For this reason, I encourage all MA recipients to purchase an inexpensive cancer policy that will pay or help pay the out of pocket expenses of cancer treatment. The second major hole in MA plans is hospitalization; it is not unusual for MA plans to have $1k to $2K copays for multi-day hospital stays. I encourage clients to purchase inexpensive hospital indemnity plans for extra protection, just as with cancer plans.

Answered by Michael Crocker on April 18, 2025

Broker Licensed in SC

Answered by Michael Crocker Medicare Insurance Agent

Jo Gallo · Answer

Advantage Plans are not a “trap”. They are an alternative to original Medicare. However, they do require participants to spend a certain amount of money before they cover at 100%. For folks that do not want to pay monthly or folks who cannot afford Original Medicare, they are a good alternative. Think of an Advantage Plan asa pay as you use it plan. Please feel free to contact me - Advantage Plans need to meet your needs - you cannot just “pick one”. Jo Gallo - 848-226-6897

Answered by Jo Gallo on July 25, 2025

Broker Licensed in NJ, AZ, DE & 8 other states

Answered by Jo Gallo Medicare Insurance Agent

Mike Henry · Answer

Medicare advantage has many “traps”!  Many deductible for many things. Dr can quit the plan usually because of non payment. Companies have been known to quit doing business in various regions.

Suzanne Lamperti · Answer

They're restrictive on where and by who you can get care. You also need preauthorization for certain procedures. They are slow to pay out of network care.

Robert Remin · Answer

Robert Remin, Expert Medicare Plan Adviser, Certified by Medicare and the carriers I represent in NY, NJ, CT, and Fl. If you work with a professional lke me you will understand all the advantages and disadvantages of Advantage plans. There are no "traps."

Answered by Robert Remin on June 9, 2025

Agent Licensed in NY, CT, FL & NJ

Answered by Robert Remin Medicare Insurance Agent

Eizel Mere · Answer

There is a Network associated with every company that offers a Medicare Advantage Plan, once you pick one you abide by the network. Plans change every year, it is important to go over your plan every year to make sure it is still the best one for you.

Answered by Eizel Mere on April 9, 2025

Broker Licensed in FL

Answered by Eizel Mere Medicare Insurance Agent

Judi Norton · Answer

Once there is a serious health problem, you will be unable to go to a Medicare Supplement where you could have gone where you could get the best care independent of in-network and out-of-network than with Medicare Advantage Plans.

Answered by Judi Norton on April 9, 2025

Agent Licensed in NM

Answered by Judi Norton Medicare Insurance Agent

Wild Bill Anderson · Answer

Advantage plans are like any other purchase: know what you are getting, where you go to use it and what it costs.
We go through the important step of finding out what is important to you. Then we clearly explain the differences, the benefits, why people choose one vs the other and compare them to your priorities.
Many agents are not educated or appointed to provide you with many options. They try to fit you to the insurance company vs matching your needs with the plan the best aligns with them.

Robert Rowe · Answer

I wouldn’t say there’s necessarily a trap with Medicare Advantage plans. There is just more maintenance required for them including annual reviews of your doctor and hospital networks, plan changes with carrier and preparing for the costs of copays and relatively high Max Out Of Pockets.

Answered by Robert Rowe on May 25, 2025

Broker Licensed in MI

Answered by Robert Rowe Medicare Insurance Agent

Ellen Diehl · Answer

Initially when you sign up, you are lured in by the free dental and the free vision, etc. But when you actually need to access care, you’ll find that the advantage networks can sometimes be smaller and inaccessible of the doctors that you really want treating you. If you’ve got more questions, you can contact me at 770-712-9990 Ellen Diehl.

Answered by Ellen Diehl on April 9, 2025

Broker Licensed in GA

Answered by Ellen Diehl Medicare Insurance Agent

Babs Atwell · Answer

In my professional opinion, there is no "trap" with Medicare Advantage plans. MA plans are not a perfect fit for everyone, however they have definitely been a great fit for those who cannot afford or simply do not want a Medicare Supplement plan. This is why we always recommend working with a local broker who you trust, one who offers plans with many different companies for comparison.

Answered by Babs Atwell on May 1, 2025

Broker Licensed in OH

Answered by Babs Atwell Medicare Insurance Agent

Louanne Allison · Answer

The trap of Medicare Advantage plans is the hospital copays. These can range from $1800-$3000 for every hospital stay. I sell a Hospital Indemnity plan that is affordable and will cover this copay should it ever occur. Hospital Indemnity plans can provide peace of mind and its how I set myself up!!

Answered by Louanne Allison on April 14, 2025

Agent Licensed in MI, FL, IL & OH, TN, TX & UT

Answered by Louanne Allison Medicare Insurance Agent

Albert Smith · Answer

There isn't a trap! You need to understand how to use it for your HealthCare needs.

Hector Vazquez · Answer

Trap is such a negative question that I don't use it, but there are gaps in Medicare Advantage like less access to providers and the need for referrals in some HMO's and other things that make advantage plans less appealing to some people.

Answered by Hector Vazquez on May 1, 2025

Broker Licensed in FL & TX

Answered by Hector Vazquez Medicare Insurance Agent

Christine Itami · Answer

Clever marketing of the "fluff" or extra coverages, such as Dental, Vision, Hearing, and over the counter allowances attract the consumer to these plans. However, the Medicare coverage is micro-managed and there are Networks to stay within.

Answered by Christine Itami on April 9, 2025

Broker Licensed in AZ, FL, ID & 5 other states

Answered by Christine Itami Medicare Insurance Agent

What is the trap of Medicare Advantage plans?

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What is the trap of Medicare Advantage plans?

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