Medicare Advantage sounds great – low premiums, extra benefits...
I got a call last month from my aunt. She’s 72, lives in Downers Grove, been with the same primary care physician for 15 years. She switched to a Medicare Advantage plan during open enrollment because the premium was $0 and they offered a grocery allowance. Sounded like a no-brainer. Then she went to schedule her annual physical. “We’re sorry, that doctor is not in our network for 2026.”
She called me, panicked. “Marcus, they said I can keep my doctor when I signed up. Now they say he’s out of network. What do I do?”
I’ve been hearing this a lot lately. Medicare Advantage plans are popular – about about 50% of Medicare beneficiaries are now in Advantage plans instead of Original Medicare. But networks are shrinking. Hospitals and doctors are dropping out of Advantage plans because of payment disputes. And seniors are getting caught in the middle.
So let me explain how Advantage networks work, why they’re changing, and what you can do about it – whether you’re already on Medicare or helping a parent figure out it.
Original Medicare – Part A (hospital) and Part B (medical) – is not a network plan. You can see any doctor or go to any hospital that accepts Medicare. That’s almost everywhere. You pay a monthly premium for Part B (about $174 in 2026, maybe more by now, higher if you have high income) and then coinsurance and deductibles. There’s no out-of-pocket maximum, which is why most people buy a Medigap supplement plan to cover the gaps.
Medicare Advantage – Part C – replaces Original Medicare. You still have to pay your Part B premium, plus an additional premium for the Advantage plan (often $0 or low). But now you’re in a private insurance plan with a network. HMO, PPO, or sometimes a special needs plan. You have co-pays for office visits, a maximum out-of-pocket, and extra benefits like dental, vision, hearing, and fitness. Sounds great – until you need care and find out your hospital is out of network.
The problem for 2026 is that many Illinois hospitals and health systems have renegotiated their contracts with Advantage plans. Some have walked away. I’ve seen news that a major Chicago health system dropped several UnitedHealthcare Advantage plans this year. Patients got letters saying “your doctor will still see you, but at a higher cost-sharing rate because they’re out of network.” That’s not a small thing. Out-of-network care in an Advantage PPO can cost 40-about 50% of the bill, with no out-of-pocket max on out-of-network services.
Someone I worked with – let’s call him Frank – had an Advantage PPO plan. He needed knee replacement surgery. His orthopedic surgeon was in-network. The hospital was in-network. But the anesthesiologist was out-of-network. Frank got a bill for about $3,200. His plan paid $0. He had to fight for six months. Eventually, the hospital wrote it off, but Frank almost had to take out a loan.
That’s the hidden trap. Even if you do everything right, someone in the chain might be out of network. In Original Medicare, that doesn’t happen – everyone who accepts Medicare is in network.
So how do you decide between Advantage and Original Medicare?
First, check your doctor and hospital. Before enrolling in any Advantage plan, call your doctor’s office and ask: “Are you in-network for [plan name] for 2026?” Don’t trust the plan’s online directory – those are often outdated. Call. Get a name. Write it down.
Second, think about your health needs. If you have a chronic condition that requires specialist visits or expensive treatments, Original Medicare plus Medigap might be a better fit. No networks, no prior authorizations, no surprise bills. If you’re healthy and rarely see doctors, Advantage can be a good deal – low premiums, free checkups, dental cleanings.
Third, consider your travel habits. Advantage plans usually don’t cover you outside your local area except for emergencies. If you snowbird to Florida or travel frequently, Original Medicare with a Medigap plan that has foreign travel coverage might be better.
Fourth, look at the out-of-pocket maximum. Advantage plans have a cap – in 2026, the maximum in-network out-of-pocket is around around $8,000 for HMOs, higher for PPOs. Original Medicare has no out-of-pocket max, which is why you need a Medigap plan. Medigap plans cost more in premium but give you predictable costs.
The Health Plan Comparator can help you see the total annual cost for different Medicare options.
Now, what if you’re already in an Advantage plan and your doctor leaves the network? You have options. During Medicare open enrollment (October 15 to December 7), you can switch to another Advantage plan that includes your doctor, or switch back to Original Medicare. If you switch to Original Medicare, you may need to buy a Medigap plan. But Medigap plans can medically underwrite you if you’re outside your initial enrollment period. That means they can charge you more or deny you based on pre-existing conditions. Some states have rules, but Illinois does not guarantee issue except in specific circumstances.
So if you have a pre-existing condition, switching from Advantage to Original Medicare plus Medigap could be expensive or impossible. That’s a trap. You need to decide wisely.
The Coverage Gap Calculator includes a section for health insurance gaps, including network restrictions.
My aunt – the one who called me – we ended up switching her back to Original Medicare during open enrollment. She bought a Medigap Plan N, which has a lower premium but requires small co-pays for office visits. She also bought a separate dental plan. Her total monthly cost went up by about about $80, but she kept her doctor. She told me “eighty bucks is worth not having to start over with a new doctor at my age.”
I think she made the right call.
So here’s your Medicare checklist for 2026.
One, decide between Advantage and Original Medicare based on your health needs and doctor preferences. If you want freedom and predictability, Original + Medigap. If you want low premiums and extra perks, Advantage.
Two, if you choose Advantage, verify networks directly with your providers. Don’t trust the directory.
Three, if you have a chronic condition or expect high medical costs, Original Medicare plus a Medigap plan is often safer.
Four, if you’re enrolling for the first time, consider your future health. You can switch from Advantage to Original later, but you may not be able to get a Medigap plan at a reasonable price. Choose carefully.
Five, use the tools. The Health Plan Comparator and Coverage Gap Calculator help you see real costs, not just premiums.
I know this is complicated. Medicare is the most confusing part of the insurance system – and that’s saying something. But the stakes are high. A wrong choice can cost you thousands or lock you out of seeing your trusted doctor.
Take your time. Read the plan’s Summary of Benefits. Call your doctor. Call a State Health Insurance Assistance Program counselor for free, unbiased advice. Don’t just pick the plan with the best mailer.
P.S. Frank – the one with the anesthesiologist bill – he switched to Original Medicare with a Medigap plan. He says he sleeps better knowing he won’t get surprise bills. “I pay more in premium, but I pay zero at the doctor. That’s worth it for me.”
By Marcus
