Key Takeaways

• Even the best-rated Medicare Advantage Plans can leave out crucial details that affect your long-term care, access, and out-of-pocket costs.

• Understanding CMS star ratings, prior authorization rules, network restrictions, and supplemental benefits is essential before choosing a plan.

What Makes a Plan the “Best” Isn’t Always What Matters Most

Medicare Advantage Plans are often marketed as all-in-one solutions that offer more than Original Medicare. While some do offer additional benefits and coordinated care, there’s a lot more to the story. When you hear about the “best” plans, you’re usually hearing about high star ratings, extra perks, or low premiums. But those factors alone don’t necessarily make a plan a good fit for your personal needs.

Understanding CMS Star Ratings

The Centers for Medicare & Medicaid Services (CMS) assigns star ratings to Medicare Advantage Plans annually, using a 5-star system. The rating reflects the plan’s quality in areas like:

• Customer service

• Member experience

• Managing chronic conditions

• Preventive services

• Complaints and performance improvements

In 2025, the CMS star rating continues to be a critical quality indicator. Plans that earn 4 stars or higher are considered above average. However, even a 5-star plan can fall short if its provider network is limited in your area or if it doesn’t cover your medications.

What You Might Not Hear About Provider Networks

Many Medicare Advantage Plans use managed care models such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). Each comes with network restrictions:

• HMOs typically require you to choose doctors within the network and get referrals for specialist visits.

• PPOs offer more flexibility but may charge more if you use out-of-network providers.

This means your favorite doctor or specialist may not be covered unless they are in the plan’s network. In rural or underserved areas, you may find networks particularly narrow.

Prior Authorization Requirements Are Often Overlooked

One of the most important but often downplayed features of Medicare Advantage Plans is the use of prior authorization. In 2025, most plans still require prior authorization for services like:

• MRIs and CT scans

• Skilled nursing facility care

• Home health services

• Durable medical equipment

While prior authorization is intended to control costs and prevent unnecessary procedures, it can also delay care and create administrative burdens. If you’re managing a chronic condition, this could become a barrier rather than a safeguard.

Supplemental Benefits Sound Good But Vary Widely

The added perks are often what make Medicare Advantage Plans attractive. These may include:

• Routine dental, vision, and hearing care

• Transportation to medical appointments

• Over-the-counter allowances

• Fitness memberships

But here’s the key issue: these benefits are not standardized. Two plans may offer “dental benefits,” but one might only cover cleanings and X-rays, while another could include crowns or dentures. You need to read the fine print.

Hidden Costs Behind the Marketing

While Medicare Advantage Plans typically limit your annual out-of-pocket expenses, those costs can still be substantial. In 2025:

• The maximum in-network out-of-pocket limit can go up to $9,350

• Combined in- and out-of-network maximums can reach $14,000 for PPOs

This cap excludes premiums for Part B and non-Medicare-covered services. If your plan requires frequent copayments for visits, therapies, or medications, your annual costs can quickly accumulate.

Coverage Changes Every Year

Medicare Advantage Plans are not static. They are renewed annually, and each year brings updates to:

• Monthly premiums

• Copayments and coinsurance amounts

• Deductibles

• Drug formularies (list of covered medications)

• Provider network

That’s why you receive an Annual Notice of Change (ANOC) each fall. It’s critical to review it closely to avoid surprises in the following year. Failing to do so may result in higher out-of-pocket costs or the loss of access to your preferred providers.

Prescription Drug Coverage Isn’t Always Comprehensive

Most Medicare Advantage Plans include Part D prescription drug coverage. However, not all formularies are the same. Medications can be placed in different tiers, affecting your copayments or coinsurance. Key issues to look for include:

• High-cost medications placed in specialty tiers

• Requirements for step therapy

• Quantity limits

You’ll want to make sure your medications are covered, and at a cost you can manage. Use the Medicare Plan Finder or speak with a licensed agent listed on this website to evaluate your options.

Star Ratings Can Fluctuate

Star ratings are updated each fall, based on data from the previous performance year. A plan rated 5 stars in 2024 could drop to 3.5 stars in 2025. Reasons for decline may include:

• Increased complaints

• Poor chronic disease management scores

• Declining member satisfaction

If you’re selecting a plan based on a past rating, verify the most current year’s rating before enrolling or renewing.

Emergency and Urgent Care May Be Covered Differently

One point often left out of Medicare Advantage marketing is how emergency and urgent care are handled out of your service area. While emergency care is covered regardless of location, follow-up services or hospital stays outside your network may not be.

This is particularly important if you travel frequently or spend part of the year in a different state. Some plans offer visitor or travel coverage, but others do not.

Medicare Advantage Is Not the Same as Medicare Supplement

A common misconception is that Medicare Advantage and Medigap (Medicare Supplement Insurance) can work together. They do not. You cannot enroll in both at the same time.

Medigap works only with Original Medicare, helping cover your Part A and Part B out-of-pocket costs. If you choose a Medicare Advantage Plan, you receive coverage through the private plan instead of Original Medicare.

Enrollment Periods Are Strict

You can only enroll in or change your Medicare Advantage Plan during certain periods:

• Initial Enrollment Period: Surrounding your 65th birthday

• Annual Enrollment Period: October 15 to December 7 each year

• Medicare Advantage Open Enrollment Period: January 1 to March 31

• Special Enrollment Periods: Triggered by life events such as moving or losing coverage

Missing these windows can lock you into a plan that may not suit your needs for up to a year. Make sure to mark your calendar and compare plans during the appropriate period.

Not All Benefits Are Utilized

In 2025, Medicare requires plans to issue a Mid-Year Enrollee Notification of Unused Supplemental Benefits. This is because many enrollees don’t take full advantage of what their plan offers. Reasons include:

• Unawareness of the benefit

• Difficulty accessing services

• Restrictions or caps that limit usefulness

Before enrolling, confirm whether the plan’s extra benefits align with services you actually use.

The Appeal of Convenience Can Be Misleading

One of the biggest selling points of Medicare Advantage Plans is that everything is bundled together: hospital, medical, and drug coverage, sometimes even dental and vision. While this sounds convenient, it also means:

• Fewer opportunities to customize

• One-size-fits-all networks and formularies

• More potential for prior authorization roadblocks

Bundling can simplify billing and paperwork, but it can also limit flexibility if your healthcare needs change.

Take Control of Your Decision

When considering a Medicare Advantage Plan in 2025, don’t stop at the headline features. Take the time to:

• Verify the most recent CMS star rating

• Check your preferred providers and hospitals in the network

• Review the plan’s drug formulary against your prescriptions

• Understand prior authorization requirements

• Evaluate the annual out-of-pocket cap and what counts toward it

• Review supplemental benefits to confirm they match your actual needs

What You Don’t See Can Cost You

Choosing a Medicare Advantage Plan isn’t just about finding the one with the most stars or the flashiest benefits. It’s about matching your unique health needs and budget with the right plan features. The details left out of brochures and commercials are often the ones that end up mattering most in the long run.

If you want help reviewing your options in detail, speak with a licensed agent listed on this website. They can walk you through the fine print and make sure your decision supports your health—not just for now, but for years to come.