Why Some People Say Medicare Advantage Plans Are Bad: Prior Authorization, Networks and Getting Care

The short answer

People who criticize Medicare Advantage usually point to prior authorization, networks and plans leaving their area. These are trade-offs built into how the plans work, and they affect some people more than others.

Medicare Advantage plans are offered by private companies that Medicare approves and that follow Medicare's rules. They must cover almost all medically necessary services Original Medicare covers. In 2026, 55% of eligible people with Medicare were in one, KFF reports.

Whether the trade-offs work for you depends on your doctors, your drugs and how often you need care.

For the bigger picture, see what's changing in Medicare Advantage for 2027.

Prior authorization: approval before care

Prior authorization means your plan must approve a service, supply or drug before it pays for it. Almost every Medicare Advantage member is in a plan that uses it: 99% in 2026, according to KFF.

It's most common for hospital stays, skilled nursing facility stays and Part B drugs, which are often given in a doctor's office or clinic. Most members also need it for home health care. It's rarely needed for preventive care.

In 2024, Medicare Advantage insurers made nearly 53 million prior authorization decisions, KFF found:

• 4.1 million requests (7.7%) were denied in full or in part.

• Only 11.5% of those denials were appealed.

• 80.7% of appeals overturned the denial in full or in part.

Critics point to that overturn rate: a denial can delay care that's approved later. The data plans report to Medicare don't break denials down by service, so it's hard to see which care is denied most.

Original Medicare uses prior authorization for only a limited set of services. Since January 2026, a federal rule gives Medicare Advantage plans 7 calendar days to answer a standard prior authorization request, down from 14.

Networks and referrals

Most Medicare Advantage plans have a network: the doctors, hospitals and clinics the plan works with. For care that isn't an emergency or urgent, you may need to use doctors in the plan's network and service area. Some plans cover care outside the network, usually at a higher cost.

You may also need a referral, a written OK from your primary care doctor, to see a specialist. With Original Medicare, you can use any doctor or hospital that takes Medicare, anywhere in the U.S. You usually don't need a referral.

Networks can change from year to year. Before you choose a plan, check that your doctors and hospitals are in its directory, or call their offices to ask.

Plans leaving an area

Each year, insurance companies can decide to join or leave Medicare in an area. For 2027, more than 3 million people with Medicare Advantage must choose a new plan because theirs is leaving, CNN reports.

In some places, no Medicare Advantage plan with drug coverage is left. KFF estimates about 638,000 people in 193 counties will have none in 2027, up from 399,000 people in 123 counties in 2026.

If your plan is leaving, it should send you a notice. You then get a Special Enrollment Period, a time outside the usual dates when you can change coverage. You can join another plan or return to Original Medicare. In some cases, you also get a guaranteed right to buy a Medigap policy (supplemental insurance for Original Medicare). Check your exact dates on Medicare.gov.

What people like about Medicare Advantage

Many people pick Medicare Advantage for features Original Medicare doesn't have by itself:

• A yearly cost limit. Plans cap what you pay each year for covered Medicare services. Original Medicare has no yearly limit unless you add supplemental coverage.

• Drug coverage in the same plan. Most plans include Part D drug coverage, so you don't need a separate drug plan.

• Extra benefits. Plans may cover some vision, hearing and dental care that Original Medicare doesn't. In 2026, over 90% of members of individual plans had access to each, KFF found. What's covered, and how much, varies by plan.

• Lower premiums for many. In 2026, 75% of people in individual plans with drug coverage paid only the Part B premium, KFF found. Copays and other costs still apply.

What you can do if care gets harder

If your plan makes care harder to get, these steps can help:

1. Ask before you get care. You, your representative or your doctor can ask the plan whether it covers a service. This is called an organization determination.

2. Appeal a denial. You have 65 days from the date on the denial notice. For care you haven't received yet, the plan has 30 days to decide your appeal.

3. Ask for a fast appeal if waiting could harm your health. The plan then has 72 hours. Your doctor can ask for the appeal for you.

4. Know the next level. If the plan still says no, your appeal goes to an independent reviewer automatically.

5. Plan your renewals. A renewal is a new prescription for a medicine you already take. Request one before you run out, so an approval delay doesn't leave a gap.

6. Use telehealth. Video visits from home are covered under Medicare's expanded rules through December 31, 2027.

Is it worth weeks of waiting for a new network doctor to renew a medicine you've taken for years? A video visit can handle a renewal or a new health question while you sort out the rest. Doctronic accepts Medicare, and you can see a licensed doctor by video.

Where to compare plans

Doctronic isn't an insurance agent or broker and doesn't recommend plans. For free, unbiased help comparing them:

• Medicare.gov: the Medicare Plan Finder compares plans' costs, drug lists, doctors and star ratings.

• 1-800-MEDICARE (1-800-633-4227): Medicare's own help line.

• Your State Health Insurance Assistance Program (SHIP): free, one-on-one counseling.

Dates and costs for open enrollment for 2027 coverage are in our guide to Medicare open enrollment 2027.

Frequently Asked Questions

Are Medicare Advantage plans bad for everyone?

No. It depends on how you use care. People who see many specialists or travel often may notice the network and approval rules more than people who mostly see one local doctor.

Do Medicare Advantage plans cover emergencies outside the network?

Yes. Plans must cover emergency care, even from doctors and hospitals outside the network. They also cover urgent care you need while you're outside the plan's service area.

Can I leave Medicare Advantage if it isn't working for me?

Yes, at set times. During open enrollment, October 15 to December 7, you can return to Original Medicare. Medicare Advantage members can also change plans or return to Original Medicare between January 1 and March 31. A Medigap policy may cost more or be harder to get later, so check your rights first.

How do I find out if my plan's network or rules are changing?

Read your plan's Annual Notice of Change. Plans send it each fall, and it lists changes to costs, coverage, networks and service area that start in January.

Can I still see a doctor by video on a Medicare Advantage plan?

Yes. Medicare's expanded telehealth rules run through December 31, 2027, and your plan may cover more. Check its Evidence of Coverage, the document that lists what the plan covers and what you pay.

The Bottom Line

Before you choose or keep a plan, check its network and its prior authorization rules. Then check what you'd pay in a year. If a request is denied, appeal, and ask your doctor to help. Open enrollment ends December 7, 2026.