Do Medicare Advantage Plans Frequently Deny Care That Would Be Covered by Original Medicare?
Two Enrollment Periods, One Critical Decision — Don’t Make the Wrong One
As the Original Medicare Open Enrollment (October 15 – December 7) period winds down for the year, you may still be contemplating whether to switch from Original Medicare to a cheaper Medicare Advantage Plan. My general advice is don’t.
There are two important annual Medicare open enrollment periods during which you can switch from Original Medicare to a cheaper Medicare Advantage or, if you’re already on a Medicare Advantage Plan, switch to a different Medicare Advantage (MA) plan:
1. Annual Election Period (AEP): October 15 – December 7
This is the main open enrollment window each year, and it’s available to everyone with Medicare — whether you’re on Original Medicare or a Medicare Advantage (MA) plan.
During this primary AEP, you can:
• Switch from Original Medicare to a Medicare Advantage plan.
• Switch from one Medicare Advantage plan to another.
• Drop Medicare Advantage and return to Original Medicare (with or without a Part D plan), keeping in mind you may not be able to qualify for a Medicare Supplement / Medigap plan because of medical underwriting.
• Join, switch, or drop a Part D prescription drug plan
Any changes made during AEP take effect on January 1 of the following year.
2. Medicare Advantage Open Enrollment Period (MA-OEP): January 1 – March 31
This second window is a more limited opportunity to make changes after the plan year begins, especially for those who experience unexpected issues with their new plan. This period is intended to allow individuals enrolled in an MA plan to make changes if they are dissatisfied with their plan early in the year.
It’s only available to people who are already enrolled in a Medicare Advantage plan as of January 1.
During the MA-OEP, you can:
• Switch from one Medicare Advantage plan to another.
• Drop Medicare Advantage and return to Original Medicare (with or without Part D), BUT WITH A MAJOR WARNING about medical underwriting if you want to get a Medicare Supplement policy. You can return to Original Medicare during MA-OEP. But if you also want to buy a Medicare Supplement (Medigap) plan, you may face medical underwriting.
Unless you qualify for a guaranteed issue right, Medicare Supplement insurers in most states can:
- Deny coverage;
- Impose waiting periods for pre-existing conditions; and
- Charge higher premiums based on health.
The guaranteed issue protection usually applies only in two specific situations:
- You’re within your 6-month Medigap Open Enrollment Period (starts when you first enroll in Medicare Part B); or
- You qualify due to special circumstances (e.g., your MA plan is leaving your service area).
You cannot:
- Join a Medicare Advantage plan if you’re currently on Original Medicare.
- Make changes to standalone Part D drug plans (unless you’re also leaving an MA plan).
Changes made during MA-OEP take effect the first day of the following month.
If you’re currently on Original Medicare and considering switching to Medicare Advantage, your deadline is December 7. After that, you’re locked out until next October — unless you qualify for a Special Enrollment Period.
If you’re already on a Medicare Advantage plan, you can still make one change between January 1 and March 31 — but only to another MA plan or back to Original Medicare.
Why So Many People Regret Medicare Advantage
Medicare Advantage plans are heavily marketed — some as “zero premium” or “extra benefit” options. But a growing number of beneficiaries and policymakers are sounding the alarm about what’s not advertised.
A 2025 Senate investigation found that many MA plans operate within a “secretive maze” of broker kickbacks, misleading marketing, narrow networks, and outrageous service denials. The report documents how some unscrupulous agents are incentivized to enroll seniors in specific plans — regardless of whether those plans are actually the best fit.
Here’s what you need to know before locking yourself into a Medicare Advantage plan for 2026.
If You’re on Original Medicare and Thinking of Switching: Know the Tradeoffs
• Freedom vs. networks. Original Medicare is accepted by nearly all doctors and hospitals nationwide. MA plans restrict you to a network, often local, and may deny coverage if you go out of network.
• No preauthorization. Original Medicare does not require prior approval for most services. MA plans often require preauthorization, which can delay or block care.
• MA denials based on cost management. MA plans have a financial incentive to deny or restrict high-cost care. Original Medicare does not operate under a managed care model.
• No “lock-in” problems. Once you switch to MA, returning to Original Medicare may not be easy. You may lose guaranteed access to a Medigap policy — especially if you’ve been in an MA plan more than a year.
Whatever Happened to Prior Authorization Reform?
Back in 2018, the nation’s largest health insurance industry groups made a public pledge: they would reduce prior authorization burdens. Doctors, hospitals, and patients were promised that insurers would simplify the process, approve care faster, and use prior authorization only when truly necessary.
Seven years later, those promises remain largely unfulfilled.
According to a November 2025 investigation by the Associated Press, not only have many of those commitments been abandoned or ignored, but in some areas, insurers have actually increased their reliance on prior authorization — further delaying care, denying treatment, and endangering lives.
What Is Prior Authorization, and Why Does It Matter?
Prior authorization (PA) is a cost-control tool used by health insurers. Before certain treatments, scans, surgeries, or medications are approved, doctors must submit detailed paperwork and wait for insurer approval — sometimes for days or even weeks.
When used sparingly, prior authorization can prevent unnecessary care. But in reality, it often:
• Delays urgent treatment.
• Denies medically necessary care.
• Creates administrative chaos for providers.
• Causes dangerous gaps in medication access.
• Adds stress and confusion for patients.
In one tragic case cited by the AP, a woman’s heart procedure was delayed by prior authorization, and she died while still waiting for approval.
Insurers Promised Reform. What Happened?
In 2018, five major trade groups — including America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association — signed a joint statement pledging to improve the PA process. They promised to:
• Cut down on the number of services requiring PA.
• Speed up decisions.
• Reduce paperwork.
• Improve transparency around denials.
• Expand use of electronic approvals.
But as the AP investigation reveals, many of those goals were quietly abandoned, and the initial pledge has disappeared from some organizations’ websites altogether.
In fact, prior authorization has become more deeply entrenched — especially in Medicare Advantage plans and state Medicaid managed care programs.
Medicare Advantage: A Red Tape Trap for Seniors
As we have explained in many previous articles, Medicare Advantage (MA) plans often look better on paper than they perform in practice. One of the biggest issues? Prior authorization.
The US Department of Health and Human Services Inspector General reported in 2022 that 13 percent of denied MA claims would have been covered by traditional Medicare.
In short:
• Traditional Medicare generally doesn’t use PA.
• MA plans often require PA for high-cost services.
• Patients are frequently denied or delayed.
• Appeals can take weeks — or longer.
• Many seniors don’t realize the risk when they enroll.
If you’re considering MA, it’s essential to understand that the coverage isn’t always there when you need it.
Doctors Are Drowning in Paperwork
The AP article also quotes physicians who describe PA as a “time-wasting treadmill.” Doctors must:
• Navigate different PA portals for different insurers.
• Repeat submissions for the same treatments.
• Fight denials with lengthy appeal processes.
• Divert staff time to administrative work instead of patient care.
Many smaller practices have been forced to hire full-time staff just to manage PA submissions — a hidden cost passed on to patients.
What’s Being Done?
There have been some limited steps toward reform:
• CMS issued new rules in 2023 requiring faster response times and public reporting of PA metrics.
• Some state legislatures have enacted laws limiting PA for chronic conditions or requiring auto-renewal.
• Congress introduced bills to limit PA in Medicare Advantage, but most have stalled.
Meanwhile, major insurers and their lobbying groups continue to claim that PA is necessary to reduce fraud and control costs — even as patient harm from delays and denials increases.
What Can You Do?
If you’ve been impacted by prior authorization:
• Appeal the decision — and keep all documentation.
• Ask your doctor to request an expedited review if the delay could cause harm.
• File a complaint with your state insurance commissioner.
• During open enrollment, review your plan’s prior authorization practices — especially if you’re in Medicare Advantage.
• Consider switching to Original Medicare with a Medicare Supplement plan, which generally avoids Prior Authorization entirely.
If You’re Already on a Medicare Advantage Plan: Read the Fine Print
• Did your provider leave the network? Networks change every year. Your doctor, specialist, or hospital may no longer be covered in 2026.
• Higher out-of-pocket costs than you expected? Many plans have co-pays and coinsurance that exceed what you’d pay with Original Medicare plus a Medigap plan.
• Care denied or delayed? The US Department of Health and Human Services has documented how MA plans frequently deny medically necessary care — care that would otherwise be covered under Original Medicare.
• Still healthy? That might change. MA plans often work well for people who are healthy. But if your health declines, those same restrictions can become costly and dangerous.
• Worried about possibly winding up in a nursing home? — Every nursing home has only certain MA plans that are “in network” with that nursing home, meaning that the nursing home doctor can get paid. For example, Kaiser Permanente, one of the biggest and most popular MA plans in the DMV, is notorious for only having a small handful of nursing homes that are “in network” with Kaiser Permanente, so if you have a Kaiser Permanente MA plan, your choice of rehab facilities and nursing homes will be drastically smaller than if you had a different MA plan such as Humana, UnitedHealthcare, Anthem, or Aetna. The good news is that if you ever wind up in a nursing home, that creates an automatic and continuing open enrollment period to switch to a different MA plan. But that flexibility is most often stymied by the fact that you can’t get into an out of network nursing home in the first place.
What Can You Do Now?
If have a Medicare Advantage plan that you’re unhappy with, or unsure about switching from Original Medicare, here’s your roadmap:
• By December 7: Anyone can join, drop, or switch MA plans — or return to Original Medicare. This is your best opportunity to re-evaluate.
• Between January 1 and March 31: If you’re already in an MA plan, you can make one more change — either to another MA plan or back to Original Medicare. You can’t use this period to join a MA plan if you’re not already in one.
• Add a Medigap plan: If switching to Original Medicare, act quickly to apply for Medigap. Outside of your one-time guaranteed issue window, you may be subject to medical underwriting.
We Can Help You Think Through the Consequences
As Elder Law attorneys, we work with clients every day who face real consequences from Medicare Advantage plan decisions. Whether it’s denied (or terminated too soon) rehab coverage, a surprise out-of-network bill, or a need for long-term care (which Medicare does not cover), we’ve seen the fallout.
We’ll help you:
• Compare MA vs. Original Medicare + Medigap
• Understand long-term care implications
• Protect your assets from future nursing home costs• Avoid being trapped in a plan that doesn’t meet your needs
Don’t wait. The December 7 deadline is approaching fast — and once it passes, you may not have another chance until next year.
Related Reading:
• Key Changes Coming to Medicare in 2026
• What Are the Differences Between the Medicare Supplement Plans — and Should You Switch from Plan F to Plan G?• Nearly Half of QMBs Are Wrongly Billed — Are You One of Them?
• Virginia’s New Medicare Supplement Birthday Rule: No Health Questions Once a Year!
• Customers Are Being Misled by Marketers Into Signing Up for Certain Private Medicare Advantage Plans• The Darker Side of Medicare Advantage Plans
Don’t wait for a crisis. Educate yourself, talk with those you trust, and work with a knowledgeable attorney here at the Farr Law Firm to make your decisions official.
