Medicare Advantage (MA) plans are often marketed as an affordable and simplified alternative to traditional Medicare, offering extra “value” such as dental or vision care, gym memberships, and even sometimes transportation. While the promise of lower premiums and extra benefits can be attractive, the reality for residents of assisted living communities is often far less favorable. Designed primarily for mostly healthy individuals, these plans rarely recognize the additional costs incurred for those who need higher levels of care, such as specialized services and medication management; as a result, financial responsibility gets shifted back to the resident and their family. More importantly, care can be impacted.

According to Medicare.org, hidden disadvantages include limited provider networks, prior authorization requirements that delay or obstruct access to care, higher out-of-pocket costs for those with chronic conditions, and restrictions on coverage that can result in surprise expenses. These shortcomings are particularly problematic for older adults who depend on coordinated pharmacy and medical support in assisted living.

A report from the Center for Medicare Advocacy echoes these concerns, documenting how Advantage plans are more likely than traditional Medicare to deny or delay medically necessary services. Narrow networks and coverage restrictions can further disrupt continuity of care, placing vulnerable residents at increased risk.

Hospitals and health systems across the country have also raised alarms. They report that Advantage plan denials and delays not only create frustration for families but also lead to worse outcomes for patients requiring timely intervention. For residents of assisted living, such delays can add complexity to an already fragile care environment.

For those with ongoing or complex medical needs, the risks are especially high. Individuals managing chronic conditions are more likely to encounter gaps in coverage, higher copays, and greater financial strain when enrolled in Medicare Advantage; a recent study of MA enrollees found that more than 40% had unmet communication and care coordination needs and an alarming 61% of those with three or more chronic conditions had not discussed care planning. Instead of simplifying care, these plans often create new barriers and unexpected costs for some of the most vulnerable older adults.

For assisted living communities, the result is increased stress for residents, unexpected financial burdens for families, and added challenges for staff working to ensure safe and reliable levels of care. While Medicare Advantage may appear to offer savings at first glance, the disadvantages can quickly outweigh the benefits, particularly in settings where consistent access to pharmacy services and specialized care is essential.