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The Truth About Medicare Advantage Plans & Denials in 2025

Medicare Advantage plans have been marketed as a cost-effective alternative to Original Medicare. The reality in 2025 tells a different story. Denials for medical claims under these plans have increased ninefold in the last five years, according to recent findings from the U.S. Senate. If you’re enrolled in a Medicare Advantage plan—or considering one—it’s crucial to understand how these denials could impact your healthcare and finances.

The Rising Trend of Medicare Advantage Denials

According to an article published by Senate.org, Medicare Advantage plans have been under scrutiny due to a massive spike in claim denials. Many seniors are discovering too late that their Advantage plan doesn’t cover the care they expected.

Take, for example, a recent case: 

A senior couple, who originally had a Medicare Supplement plan, switched to a Medicare Advantage plan in 2019. They were both healthy, took no prescriptions, and assumed they wouldn’t need extensive coverage. However, in 2024, one of them required a knee replacement surgery costing $90,000. Their Medicare Advantage plan covered only $13,000, leaving them with a massive $77,000 medical bill.

This isn’t an isolated case—millions of claims are denied every year, even when prior authorization was given.

Why Are Medicare Advantage Plans Denying More Claims?

The main reason behind the rise in denials is that Medicare Advantage plans are privately managed. Unlike Original Medicare, where doctors determine medical necessity, private insurance companies now decide which treatments are “necessary”—often denying coverage for cost-saving reasons.

A 2023 report by the New York Times highlighted real-life cases where:

  • A woman in her 80s with a fractured femur, was denied skilled nursing facility care.
  • Doctors’ orders for critical treatments, were overturned by insurance companies.

These denials have sparked federal investigations into whether Medicare Advantage plans are unfairly restricting access to essential care.

What You Need to Consider Before Choosing a Medicare Advantage Plan

While Medicare Advantage plans often advertise lower premiums, they come with serious drawbacks, including:

  • Higher Out-of-Pocket Costs – You may face significant co-pays, deductibles, and uncovered expenses.
  • Restricted Doctor & Hospital Networks – If your doctor or hospital stops accepting Medicare Advantage, you may have limited options for care.
  • Prior Authorization Delays – Even if your doctor prescribes a treatment, the insurance company must approve it first—and they may deny it.
  • Coverage Gaps for Serious Illnesses – Many essential treatments (like infusions, skilled nursing care, and surgeries) face higher rates of denial.

What Can You Do?

If you’re currently on a Medicare Advantage plan, or thinking about switching, it’s essential to do your research. Here’s what you can do to protect yourself:

Call us today at (817)539-0626 for a free consultation on your Medicare options. Explore Medicare Supplement plans that offer more predictable costs and fewer restrictions on care.

Don’t wait until it’s too late—Medicare decisions can have a lasting impact on your health and finances. Stay informed and choose the best coverage for your needs.

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