The Problem With Medicare Advantage Plans In NJ

Medicare Advantage plans are often presented as a convenient, cost-effective way to simplify healthcare coverage.

Commercials and brochures make them sound like a one-stop solution—promising low premiums, bundled services, and extra benefits. For many, it sounds ideal. But behind the marketing, many seniors discover that these plans can be more complicated, more restrictive, and sometimes more expensive than expected.

At Seawind Health Advocacy Group, Board-Certified Patient Advocate Stephanie “Stevie” Kiziukiewicz works closely with individuals and families in Ocean and Monmouth County, New Jersey. To help them understand their coverage and avoid hidden pitfalls. By shedding light on how Medicare Advantage plans really operate, Stevie empowers her clients to make informed choices that protect both their health and finances, offering care coordination and support in the region.

Why Medicare Advantage Plans Sound So Good

On the surface, Medicare Advantage (MA) plans seem like a streamlined solution. They bundle hospital, medical, and prescription coverage into one plan, often with added perks like dental, vision, or fitness programs. Medicare Advantage plans can offer different benefits compared to Original Medicare, and these benefits can vary from plan to plan. The monthly premium is a regular fee paid for coverage, and some plans may have a low or even zero monthly premium. Many advertise a low premium, giving the impression of affordability and convenience.

Most people are attracted to these plans because of the perceived simplicity and potential cost savings. It’s easy to see the appeal—especially for people managing multiple medications or juggling complex medical needs. The idea of having everything under one roof feels comforting. For some, these plans work just fine, especially when they stay healthy and rarely need specialized care.

But as many New Jersey residents have discovered, the real experience of using Medicare Advantage often looks different once care needs become more serious. What seems simple at enrollment can become frustrating and restrictive over time.

Types of Medicare Advantage Plans

Medicare Advantage plans, also known as Medicare Part C, come in several forms to match different lifestyles and healthcare needs. Each plan type offers a different balance of cost, flexibility, and provider access. Understanding how these options work will help you choose coverage that aligns with your health priorities and financial comfort.

Health Maintenance Organization (HMO)

HMO plans are the most common type of Medicare Advantage coverage. They require you to receive care from a specific network of doctors, hospitals, and specialists. You’ll usually need to choose a primary care physician who coordinates your treatment and provides referrals when you need to see a specialist.

HMO plans often feature lower monthly premiums and predictable out-of-pocket costs, which makes them appealing to many retirees. However, they can feel restrictive if your preferred doctors or hospitals are outside the network. Generally, out-of-network care is only covered in emergencies.

Preferred Provider Organization (PPO)

If flexibility matters most, a PPO plan might be a better fit. PPOs allow you to see any healthcare provider, but you’ll save money by staying within the plan’s preferred network. Out-of-network care is covered but at a higher cost.

PPO plans work well for people who travel frequently, divide their time between states, or prefer not to rely on referrals for specialist visits. The tradeoff is typically higher premiums or cost-sharing compared to HMOs.

Private Fee-for-Service (PFFS)

Private Fee-for-Service plans give you more control over your care. You can see any provider who agrees to the plan’s payment terms and accepts its conditions for treatment. Some PFFS plans have networks, while others do not, so it’s essential to confirm with your doctors and hospitals that they accept the plan before enrolling.

PFFS plans can be appealing for those who want freedom of choice, but they can also be unpredictable. Coverage may vary depending on where you live or which providers are willing to participate.

Special Needs Plans (SNPs)

Special Needs Plans are tailored to specific populations—such as people with certain chronic conditions, those living in long-term care facilities, or individuals eligible for both Medicare and Medicaid. These plans customize their benefits, provider networks, and prescription coverage to meet the needs of their members.

SNPs can offer significant advantages if you qualify, including access to coordinated care teams and specialized drug formularies designed for your specific diagnosis or situation.

Medicare Savings Account (MSA)

MSA plans combine a high-deductible health plan with a medical savings account that you can use to pay for healthcare costs. Funds are deposited into your account each year, and you can use them for qualified medical expenses.

However, MSA plans do not include prescription drug coverage, so you’ll need to enroll in a separate Medicare Part D plan if you require medications. These plans tend to appeal to individuals who are healthy, financially organized, and comfortable managing their own healthcare spending.

Added Benefits and Coverage Differences

Most Medicare Advantage plans include prescription drug coverage, and many go beyond what Original Medicare offers. Extra benefits often include dental, vision, hearing aids, wellness programs, and even transportation or fitness perks. Some also provide preventive services like annual physicals, lab tests, and screenings—often with little or no copayment.

While these added benefits sound appealing, it’s important to weigh them against possible limitations on provider access and requirements for prior authorization or referrals.

What to Consider Before You Enroll

When comparing plans, look closely at the provider network, monthly premiums, cost-sharing amounts, and maximum out-of-pocket limits. In rural areas of New Jersey, provider networks can be smaller, so confirm that your preferred doctors, hospitals, and specialists are included.

Keep in mind that Medicare Advantage differs from Original Medicare. While it may offer more bundled benefits, it often comes with stricter rules about where you can receive care and which doctors you can see.

Before enrolling, review each plan’s Evidence of Coverage and Summary of Benefits carefully. Consulting with a Board-Certified Patient Advocate or licensed insurance professional—like those at Seawind Health Advocacy Group—can help you understand how each plan fits your medical and financial situation. You can also use the official Medicare.gov comparison tool to review plans available in your area.

Finding the Right Fit for Your Needs

Choosing the right Medicare Advantage plan isn’t just about the lowest premium. It’s about finding coverage that truly supports your health goals and lifestyle. By taking time to understand your options and how each plan type works, you’ll be better equipped to select coverage that offers the right balance of cost, convenience, and care quality.

If you need guidance in evaluating Medicare Advantage plans in New Jersey, Seawind Health Advocacy Group can help. Patient advocate Stevie Kiziukiewicz provides personalized assistance to ensure your coverage choices align with your medical needs, financial goals, and peace of mind.

The Hidden Drawbacks of Medicare Advantage Plans

One of the most significant problems with Medicare Advantage is restricted access to doctors and hospitals. Each plan has its own network, and going outside that network can lead to higher bills—or no coverage at all. Coverage and costs are determined by the plan’s network, so if your preferred doctors or hospitals are not included, you may face higher expenses or limited access to care. For someone who travels between states or relies on a trusted specialist, that’s a serious limitation.

a patient being consulted about healthcare who needs a patient advocate

These network rules can create difficult situations for patients dealing with chronic illnesses or sudden diagnoses. Imagine needing treatment from a leading cardiac or cancer center only to learn your plan won’t cover it because the facility is out of network. That’s a reality many Medicare Advantage members face.

Another growing concern is that some hospitals in New Jersey and across the country are stopping acceptance of Medicare Advantage plans altogether. Lower reimbursement rates and complicated approval processes make participation less appealing for providers. As a result, patients find themselves losing access to high-quality hospitals or specialty care centers.

Stevie Kiziukiewicz explains it clearly: “Patients often enroll in a Medicare Advantage plan thinking they’re covered, but later find themselves denied care or facing large out-of-pocket costs. It’s heartbreaking because these issues usually surface when someone is already sick and under stress.”

Understanding the Financial Side

At first glance, Medicare Advantage plans seem like they save money—low or even zero-dollar premiums can be enticing. However, these savings are often offset by unexpected copays, copayments, coinsurance, and coverage gaps. Some Medicare Advantage plans have their own deductibles, which can add to your overall costs. Even if your Medicare Advantage plan has a low or zero premium, you are still responsible for the Medicare Part B premium (b premium). Medicare Advantage plans include Part B coverage, but costs for Part B—including part b premiums—still apply. The Part B premium is set by the federal government and may be higher for high-income individuals.

Every time a patient visits a specialist, needs lab work, or receives therapy, costs can add up quickly. And since each plan sets its own rules for prior authorizations and referrals, coverage isn’t always as straightforward as it seems. Patients often discover too late that “covered” doesn’t mean “fully paid.”

Traditional Medicare, in contrast, allows patients to see any doctor who accepts Medicare—without the same network restrictions—and often offers clearer, more predictable out-of-pocket costs.

A patient advocate can review your Medicare plan in detail, explain what is and isn’t covered, and help determine if switching to traditional Medicare might provide better long-term value.

How Medicare Advantage Plans Put Profit Before Patients

Behind the scenes, Medicare Advantage plans are run by private insurance companies that receive payments from the federal government for each enrolled member. This structure means that every covered service affects the plan’s profit margin. The more care a patient receives, the more it costs the insurer—so there’s a built-in incentive to limit access and delay approvals.

This financial model can lead to practices that directly impact patient care:

Requiring prior authorization before covering necessary tests or treatments
Denying claims for care outside of narrow provider networks
Encouraging patients to use lower-cost options even when not medically ideal

While these cost-control measures are legal, they often frustrate patients who expect their Medicare Advantage plan to provide seamless access to care. The result can be delayed treatment, denied claims, and unnecessary stress for families already managing serious health issues.

For patients with chronic conditions—like heart disease, COPD, cancer, or dementia—these delays can have serious consequences. By contrast, traditional Medicare is generally more flexible, allowing providers to make care decisions based on medical need rather than plan approval.

The Growing Trend of Patients Leaving Medicare Advantage

More and more seniors are choosing to leave Medicare Advantage plans and return to traditional Medicare. Many do so after encountering barriers to care, high out-of-pocket expenses, or limited provider options.

One of the biggest motivators for switching back is the freedom to choose doctors and specialists without network restrictions. Under traditional Medicare, patients can see nearly any provider who accepts Medicare nationwide. That flexibility becomes critical for individuals who need specialized care or second opinions.

Others make the switch after realizing that the added “benefits” of Medicare Advantage—such as gym memberships or limited dental coverage—don’t outweigh the limitations when they actually need medical attention. In many cases, the simplicity of traditional Medicare, combined with a Medigap supplement, provides far greater stability and peace of mind.

Why Many Hospitals Are Saying “No” to Medicare Advantage

A concerning trend across the country, including here in New Jersey, is the increasing number of hospitals declining to accept Medicare Advantage plans. Hospitals cite delayed payments, denied claims, and administrative burdens as major challenges. For patients, this means fewer options for care—sometimes even having to travel long distances for covered services.

These systemic issues reinforce what patient advocates like Stevie have seen firsthand: Medicare Advantage often prioritizes insurer profit margins over patient well-being. Families who rely on these plans can find themselves caught in a cycle of denials, appeals, and uncertainty at a time when they need support, not stress.

How a Patient Advocate Can Help

Choosing between Medicare Advantage and traditional Medicare can feel confusing. A Board-Certified Patient Advocate like Stevie Kiziukiewicz can simplify the process by offering independent, personalized guidance.

Stevie helps clients:

Compare coverage options under Medicare Advantage and traditional Medicare
Identify potential coverage gaps and hidden costs
Navigate appeals and claim disputes
Evaluate whether their preferred doctors and hospitals are included in their plan

As a Certified Dementia Practitioner and experienced healthcare advocate, Stevie understands how these choices affect not just patients but their families as well. Her approach combines compassion with deep knowledge of the healthcare system, helping clients make decisions that safeguard both their care and their financial stability.

If you’re reviewing your Medicare options or struggling with a current plan, contact Seawind Health Advocacy Group for an unbiased review and professional guidance.

Making an Informed Choice About Your Medicare Coverage

Medicare Advantage plans may look attractive, but the fine print often tells another story. For many people, the restricted networks, unpredictable costs, and profit-driven policies outweigh the advertised benefits. Traditional Medicare, while less flashy, tends to offer broader access and greater transparency.

Eligibility for a Medicare Advantage plan depends on living within the plan’s service area. While routine care may be limited to network providers, emergency and urgent care are covered even when traveling within the U.S. Additionally, some Medicare Advantage plans require a referral from your primary care doctor to see a specialist.

Ultimately, the best choice depends on your unique health needs, financial situation, and priorities. Understanding the differences between these plans—and the real-world impact on your care—can prevent frustration and protect your health in the long run.

At Seawind Health Advocacy Group, Stevie Kiziukiewicz believes every patient deserves clear information and compassionate support when making healthcare decisions. She helps New Jersey residents navigate Medicare with confidence and peace of mind, ensuring that the focus stays where it belongs—on quality care, not confusing coverage.

If you or a loved one are weighing Medicare Advantage vs. traditional Medicare in New Jersey, reach out to Seawind Health Advocacy Group today. A single conversation can help you avoid hidden costs, understand your options, and secure the coverage that truly meets your needs.