Key Takeaways

• Not all highly rated Medicare Advantage plans will suit your healthcare needs or financial situation, even if they appear to be among the “best.”

• Understanding how plan features like CMS ratings, provider networks, and out-of-pocket costs actually function is essential before making a choice.

Why Some of the Best Medicare Advantage Plans Don’t Fit Everyone

You might be told that certain Medicare Advantage plans are the best available, often based on national rankings or high CMS star ratings. While these rankings can be helpful, they don’t always reflect how well a plan will serve your specific needs.

The Centers for Medicare & Medicaid Services (CMS) uses a 5-star rating system to evaluate plans based on multiple performance metrics such as quality of care, member satisfaction, and access to services. But even a 5-star plan can become problematic if it doesn’t cover your preferred doctors, includes surprise costs, or limits access to services you use often.

Understanding What CMS Ratings Really Measure

A high CMS rating can give you a general idea of how a Medicare Advantage plan performs. Ratings are calculated annually and consider:

• Preventive services and chronic condition management

• Customer service performance

• Member complaints and disenrollment rates

• Medication safety and adherence

However, these ratings are averaged across the entire plan’s service area and might not reflect your local experience. A plan with excellent ratings nationwide may perform poorly in your specific region.

What “Best” Might Mean in Marketing vs. Reality

Marketing often focuses on the extras: dental, vision, hearing, and fitness benefits. While these features can be valuable, they might come with conditions that reduce their usefulness. For instance, routine dental care could be limited to specific providers, or vision coverage might only apply to basic services.

What seems like a strong benefit package on paper may not be accessible or relevant depending on where you live or your personal health needs.

The Trade-Off Between Premiums and Coverage

Some Medicare Advantage plans advertise lower monthly premiums or extra perks. But they may have higher costs in other areas, such as:

• Specialist visit copayments

• Tiered drug formularies that favor generics

• Higher deductibles for hospital care

Even though premiums are one of the first features people look at, they rarely tell the full story. In 2025, out-of-pocket maximums can reach as high as $9,350 for in-network services, making cost-sharing terms far more important than the premium alone.

Network Size and Access to Care

Many highly rated plans operate with restricted provider networks. You might find that your plan excludes:

• Your primary care physician or specialists

• Local hospitals or clinics

• Preferred pharmacies

Out-of-network care usually comes with higher costs or may not be covered at all. This matters significantly if you travel, spend part of the year in another state, or have complex medical needs that require consistent specialist access.

Prior Authorization Requirements

Another factor that can reduce a plan’s real-world usefulness is how it handles prior authorizations. Some plans require multiple layers of approval before you can:

• Get advanced imaging tests like MRIs

• Begin physical therapy

• Fill certain prescriptions

These steps can delay care and add administrative burdens, especially if you’re managing multiple conditions. Even a highly rated plan can fall short if it routinely denies or delays necessary services.

Drug Coverage That Looks Good on Paper

Part D drug coverage within Medicare Advantage plans varies widely. Many include coverage for generic drugs with low copays, but coverage for brand-name or specialty drugs may be limited. Some issues to consider:

• Formularies can change annually

• Medications may require step therapy or prior approval

• Higher-tier drugs might come with steep coinsurance rates

In 2025, while the new $2,000 cap on out-of-pocket drug costs under Medicare Part D helps, some Medicare Advantage plans may still have cost structures that delay reaching that cap, depending on how drugs are tiered.

Regional Availability vs. National Ratings

Medicare Advantage plans are not uniform across the country. Plan availability, benefits, and costs can vary drastically by ZIP code. A top-rated plan in one region may not even be offered in your area, or its local network and benefits may differ substantially.

You need to check your specific county-level offerings and not rely solely on national reviews or generalized comparisons.

Medicare Advantage Plan Changes Every Year

Each year during the Annual Enrollment Period (October 15 to December 7), plans can make adjustments, including:

• Premium increases

• Copayment changes

• Formulary revisions

• Dropping or adding providers

The Annual Notice of Change (ANOC) gives you a preview of these updates. Comparing these changes annually is essential, even if you’re currently satisfied with your plan.

Hidden Costs in Supplemental Benefits

Supplemental benefits are a hallmark of Medicare Advantage marketing. However, even in high-rated plans, these can involve:

• Annual or usage caps on dental and vision

• Limited access to transportation or home support services

• Reimbursement-only structures requiring you to pay upfront and file claims

It’s easy to assume these extras are as comprehensive as traditional Medicare add-ons, but in practice, they may come with numerous restrictions.

Plan Types Matter Too

There are different types of Medicare Advantage plans, such as:

• Health Maintenance Organizations (HMOs)

• Preferred Provider Organizations (PPOs)

• Special Needs Plans (SNPs)

Each has different implications for network flexibility, out-of-network costs, and how care is coordinated. Even the best-rated HMOs may not suit someone who needs more provider choice or out-of-area coverage.

How Enrollment Timing Affects Your Options

Your ability to switch or join plans is limited to specific enrollment periods:

• Initial Enrollment Period: 7 months around your 65th birthday

• Annual Enrollment Period: October 15 to December 7

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

Missing these windows means you could be locked into a plan that doesn’t meet your needs for the rest of the year.

Star Ratings Aren’t Personal Ratings

A plan may have earned five stars for how it performs in general, but that doesn’t mean it will perform well for you. For instance, CMS ratings won’t reveal:

• Wait times for appointments in your area

• Access to specialists in your network

• How well your prescriptions are covered

These are personal factors that require a more detailed review beyond what star ratings can provide.

Compare Beyond the Headlines

If you’re relying on headlines, TV commercials, or top-10 lists, you’re only seeing part of the story. To make the right choice, you should:

• Read the plan’s Evidence of Coverage (EOC)

• Compare in-network provider lists

• Examine the drug formulary in detail

• Confirm what benefits actually cost and cover

Plans that look alike on the surface may be quite different in how they function day to day.

Choosing What Works for You in 2025

This year, you have access to enhanced protections and benefit caps, such as the $2,000 annual out-of-pocket cap on Part D drugs. But you still need to balance that with the rest of your healthcare needs, including:

• How often you see doctors or specialists

• Whether you travel frequently

• What medications you rely on

There is no such thing as a universally “best” Medicare Advantage plan. Your ideal option depends on aligning your personal health profile with the structure of the plan.

Finding the Right Fit Starts With the Right Questions

Instead of asking which plan is best overall, ask:

• Does this plan include my doctors and hospitals?

• Are my prescriptions fully covered?

• What are my total expected yearly costs?

• How easily can I get the care I need?

If you’re uncertain, a licensed agent listed on this website can help you evaluate your options based on your health, your ZIP code, and your budget. Making a fully informed choice is the best protection against future surprises.