Key Takeaways

• Many of the most financially impactful details in a Medicare plan are hidden in plain sight—like prior authorization rules, cost-sharing structures, and network limitations.

• Reviewing your Medicare plan annually and consulting with a licensed agent listed on this website can help you avoid costly mistakes that aren’t obvious at first glance.

The Small Print in Medicare Plans Can Cost You Big

When you enroll in Medicare, it can feel like a major milestone. You’ve crossed an age threshold and stepped into a new chapter of your healthcare. But what often goes unnoticed is how many critical details in your Medicare plan can slip through the cracks—and result in out-of-pocket costs you didn’t see coming.

These overlooked aspects aren’t buried because they’re secret. They’re buried because most people don’t think to look. In 2025, with changes in coverage, rising healthcare expenses, and more complex plan designs, it’s more important than ever to examine your coverage beyond the obvious.

What Prior Authorization Really Means for You

You may assume that once you’re enrolled in a Medicare plan, your doctor’s recommendations are all that matter. Unfortunately, that’s not always the case. Many services require prior authorization—a process that demands approval from your insurance plan before treatment begins.

If you skip this step or are unaware it exists, you could be left paying the full cost of a procedure. Prior authorization is especially common for:

• Advanced imaging (like MRIs or CT scans)

• Durable medical equipment

• Certain outpatient surgeries

• Extended skilled nursing care

Check your plan’s Evidence of Coverage (EOC) to see which services require this approval. In 2025, delays due to prior authorization rules continue to be a leading reason beneficiaries postpone necessary care.

In-Network Doesn’t Always Mean Nearby

Medicare Advantage plans are often network-based, meaning you pay less if you use doctors and facilities in the plan’s network. But being in-network doesn’t always mean being convenient.

In rural areas or even suburban regions, the nearest in-network specialist might be hours away. And while you might have access to a nearby hospital, it may not contract with your Medicare plan. Always verify:

• Your preferred doctor is still in-network in 2025

• Hospitals and emergency care centers are covered

• Referrals are not needed for every type of specialist

This is a crucial step each Open Enrollment period, which runs annually from October 15 through December 7.

The True Cost of Copayments and Coinsurance

Many people assume once premiums are paid, the rest is predictable. That’s not the case. In 2025, you still face copayments and coinsurance for services under both Original Medicare and Medicare Advantage.

For example:

• Part B services often require a 20% coinsurance after the annual deductible of $257 is met

• Outpatient surgery or specialist visits may have flat copayments ranging from $30 to $60 or more under some Advantage plans

• Emergency care visits could exceed $100

Even routine services can become expensive when frequent. Review your Summary of Benefits for exact figures. The combination of frequency and cost-sharing is where most unexpected expenses occur.

Prescription Drug Costs Can Spiral Without You Noticing

Prescription coverage under Medicare Part D (or through a Medicare Advantage plan with drug benefits) involves multiple phases, and each has its own cost-sharing structure. As of 2025:

• The annual deductible may be as high as $590

• After that, you enter the initial coverage phase, where you pay coinsurance or copays

• Once you reach $2,000 in out-of-pocket drug costs, you transition into the catastrophic coverage phase where your plan covers 100% of covered drug costs

However, not all drugs are covered equally. Tier levels, prior authorization, step therapy, and formulary changes can make your medications far more expensive than expected. Always check:

• The plan’s drug formulary (preferred drug list)

• Tier placement for your prescriptions

• Restrictions like quantity limits or required step therapy

Travel Limitations with Certain Medicare Plans

Are you planning to travel within the U.S. or spend time in another state? Your Medicare plan might not travel with you. Original Medicare (Parts A and B) allows nationwide provider access, but most Medicare Advantage plans do not.

Advantage plans typically require:

• Use of network providers for non-emergency services

• Approval for out-of-area care, even for routine needs

• Coverage limits for extended stays outside your plan’s service area

In 2025, more plans offer limited travel benefits, but restrictions remain. If you’re a snowbird or frequent traveler, confirm that your plan supports multi-state care or consider alternatives that don’t restrict provider access.

Enrollment Timing Still Catches People Off Guard

Your Medicare coverage doesn’t begin automatically unless you’re already receiving Social Security benefits. Missing your Initial Enrollment Period—which spans 7 months around your 65th birthday (3 before, your birth month, and 3 after)—can result in late enrollment penalties.

In 2025:

• The General Enrollment Period runs January 1 to March 31, with coverage starting the month after enrollment

• Medicare Advantage Open Enrollment runs from January 1 to March 31 if you need to switch plans

• Annual Open Enrollment (October 15 to December 7) allows plan changes for the following year

Failing to act during the right window could lock you into a plan—or keep you without full coverage—for months.

Emergency and Urgent Care Rules Vary More Than You Think

Emergency care is covered by most Medicare Advantage plans regardless of network. But urgent care isn’t always as straightforward.

Before assuming a clinic is covered:

• Confirm whether the provider is part of your plan’s urgent care network

• Understand your cost-sharing, which may be higher than expected

• Check if the visit requires follow-up approval for additional care

This applies both inside and outside your plan’s service area. Out-of-network urgent care could result in partial or no reimbursement depending on the situation.

Extra Benefits Sound Great—But Aren’t Guaranteed

Many Medicare Advantage plans promote added benefits like dental, vision, hearing, or over-the-counter (OTC) allowances. In 2025, these benefits are common but not universal—and more importantly, not standardized.

Plans differ in:

• Benefit frequency (e.g., annual dental cleanings vs. semiannual)

• Reimbursement limits (some have caps as low as $100 per year)

• Covered services and networks for these benefits

If you’re counting on these extras, make sure they meet your needs and aren’t just promotional perks with limited value.

MOOP Doesn’t Mean Unlimited Coverage

Medicare Advantage plans include a Maximum Out-of-Pocket (MOOP) limit, which is the most you’ll pay in a year for covered services. For 2025:

• The maximum MOOP for in-network services is $9,350

• For combined in-network and out-of-network services, the limit is $14,000

This limit protects you from catastrophic costs—but only for covered services. Dental, vision, or non-covered prescriptions may not count toward this total. Also, the MOOP resets each calendar year.

Reevaluate Your Plan Every Year

Your health, prescriptions, and provider preferences change—and so do Medicare plans. In 2025, plans may change formularies, drop doctors from networks, increase cost-sharing, or reduce benefits.

Even if your plan worked well last year, don’t assume it still does. Each fall during the Open Enrollment period, review:

• The Annual Notice of Change (ANOC)

• Updated plan documents, including drug lists and provider directories

• Potential new plans with better value or broader coverage

Ignoring these updates is one of the most common—and expensive—mistakes Medicare enrollees make.

Don’t Let the Details Derail Your Medicare

When it comes to Medicare, the devil is truly in the details. Each benefit, rule, and cost-sharing arrangement can impact your healthcare experience and your wallet. Overlooking even one of these plan details in 2025 could lead to higher costs or denied care.

To get the coverage that truly works for your health needs and financial goals, speak with a licensed agent listed on this website. They can walk you through your options, help you avoid the most common pitfalls, and ensure you’re confident in your Medicare decisions for the year ahead.