You’ve seen why Medicare Advantage is changing and what risks are rising. This third installment of the “Medicare reality check series gets practical: it helps you identify the most common Medicare Advantage coverage gaps — the fine print areas that can lead to unexpected costs.
On the surface, Medicare Advantage (MA) plans appear to ensure comprehensive health care coverage. When you compare Medicare Advantage vs original Medicare, you learn that Medicare Advantage provides the benefits of original Medicare Parts A and B and generally includes coverage for prescription drugs, vision, dental, and hearing. It all usually comes at lower monthly premiums than original Medicare and can offer added perks, too. But are some MA plans too good to be true?
An AARP study reports a quarter of new Medicare Advantage beneficiaries received surprise bills after enrolling, leaving them confused about their coverage. These plans are changing, and a growing number of people are citing dissatisfaction. Erin Bueltel, Director of Product Solutions for Wellabe, says it’s more important now to know your Medicare Advantage coverage gaps to protect both your health and retirement savings.
Coverage gaps in insurance plans refer to areas where policies fall short of what they pay for the care you need. While MA plans are generally believed to be “all-inclusive” — and Bueltel says they can be in some areas — they do have coverage gaps. She names inadequate health care provider networks as a big Medicare Advantage coverage gap today.
Hospitals and medical practices are dropping MA plans due to contract disputes, which include issues with reimbursements and prior authorization requirements. Physicians say the latter are creating administrative headaches and delays in providing service, which can also be detrimental to you, the patient. The process threatens your abilities to receive timely care and to protect your finances from out-of-pocket expenses due to being out-of-network.
This sheds light on another misconception of MA plans that could impact your bank account — that they’re cheap or free, due to $0 premiums. But they’re often neither. Also, unlike original Medicare, MA plans aren’t standard. Because they’re offered by private insurance companies, they vary in the benefits they provide. Therefore, you’ll need to review these plans carefully to determine which is best for you. Then, you’ll want to review your plan again each year to make sure new coverage gaps haven’t appeared.
You’ll want to be aware of any Medicare Advantage limitations related to:
If your MA plan includes benefits for dental, vision, and hearing, you will want to know what exactly they cover. While some provide more comprehensive coverage, others may only include routine visits. For example, your Medicare Advantage plan may pay for dental cleanings but may not pay toward tooth extractions or fillings. Each of these services costs a few hundred dollars or more, meaning you may one day face significant out-of-pocket expenses.
Most Medicare Advantage plans include prescription drug coverage, known as Medicare Part D. For years, Part D was notorious for its coverage gap — known as the “donut hole” — which was eliminated at the start of 2025. In its place, a new out-of-pocket maximum was implemented by the federal government to help older adults with high drug costs. For 2026, you’ll be responsible for $2,100 out of pocket before Part D pays for your prescription drugs.
How quickly you reach that amount, if you reach it, will depend on your insurer since it determines which drugs they cover. Each Part D drug plan has a list of drugs it covers, known as a “formulary,” and their costs. The drugs are grouped into tiers based on their costs (i.e., a higher tier contains drugs that cost more than those in the lower tiers). This means your medications may or may not be covered by a plan, and their prices may differ across MA plans.
When you need inpatient rehabilitation, MA plans must provide the same benefits of original Medicare for a stay in a skilled nursing facility. To be eligible, your plan may require a qualifying inpatient hospital stay, among other criteria. If you meet the conditions, you should receive benefits for up to 100 days for a stay in a skilled nursing facility. But you’ll be responsible for some costs, including copayments, starting on day 21. Depending on your specific MA plan, you may receive other benefits for this type of care, but you may also face different out-of-pocket costs, such as copayments for days 1 to 20.
Your stay in a hospital is another area MA plans must match original Medicare benefits at a minimum. But Medicare Advantage copayments can be coverage gaps.
“MA plans can generate a lot in out-of-pocket expense through high copays before coverage begins,” Bueltel says. “If you’re admitted into the hospital, you can expect to pay up to $400 a day for the first 6 days prior to your MA plan kicking in. If you’re in the hospital for 3 to 4 days, there can be extensive out-of-pocket costs.”
If travel is part of your retirement plans, you should know that your Medicare Advantage coverage while on international travel is likely little to none. Medicare Advantage plans are required to provide the same benefits outside the United States as original Medicare. This means they may provide some coverage in Canada when you’re traveling to or from Alaska and experience a medical emergency. They may also offer benefits if, while in the U.S., the closest hospital that can assist with your illness or injury is outside the U.S. It’s worth noting that MA plans do have flexibility to provide added coverage, so it’s important to ask the insurer what they cover abroad, if that’s important to you.
Medicare Advantage plans are known for their low premiums, but you may be responsible for paying many expenses out of pocket — and they can accumulate quickly.
You could be responsible for high copays or growing deductibles — in 2025, the average Medicare Advantage deductible doubled. Bueltel says that more MA plan providers are going to Health Maintenance Organization (HMO) plans, which have slimmer networks of providers than Preferred Provider Organization (PPO) plans. That means, if you have an HMO plan, you’ll want to really know your network of providers. Network limits may cause you to pay out-of-network prices to see your preferred provider. Fortunately, these plans have out-of-pocket maximums, although they’re high. For 2026, these amounts are $9,250 (in-network) and $13,900 (out-of-network).
Continue to “Part 4 — Your 2026 Medicare Advantage survival guide: Questions to ask + how to fill coverage gaps” to walk through the exact questions to ask about your plan and learn how supplemental coverage can help fill key gaps.
Ready to speak to an agent? Call 866-739-8143 or request a free quote.
View the entire “Medicare reality check” series >
Photo credit: iStock
Wellabe offers life and supplemental health insurance plans to help you prepare for good days and bad. We’ll always be here to empower you to be well — well prepared and well protected.
