Key Takeaways

• Medicare Advantage plans may look affordable up front, but many enrollees face unexpected restrictions or rising costs as the year progresses.

• You can’t switch plans freely mid-year unless you qualify for a Special Enrollment Period, which means unpleasant surprises can’t always be fixed quickly.

The First Few Months Can Be Misleading

When you first enroll in a Medicare Advantage plan, everything can appear to be in your favor. Premiums seem low. Extras like dental or vision are included. And the plan brochures tend to highlight savings and convenience. But these perks are just the surface. As the months go by, many enrollees discover that what seemed affordable or even generous comes with trade-offs they didn’t anticipate.

In 2025, Medicare Advantage remains a popular option, but that doesn’t mean it’s always the right one. Especially once you’re locked into a plan after the Annual Enrollment Period (October 15 to December 7), changing your mind is not as simple as you might think.

You May Need Prior Authorization—Often

One of the biggest frustrations reported by Medicare Advantage enrollees is the need for prior authorization. That means your plan must approve certain tests, procedures, or services before you can actually receive them. This can apply to things like:

• MRIs or CT scans

• Hospital stays

• Physical therapy

• Outpatient surgeries

And the list goes on. Even if your doctor says it’s necessary, the plan might delay or deny it. In 2025, plans are required to process prior authorization requests within seven calendar days for non-urgent services. But in a health crisis, even a few days can feel like too long.

Provider Networks Aren’t as Broad as They Seem

When you enrolled, you may have checked that your primary care doctor was in the network. But what about specialists? What if you need a second opinion? Or if you travel?

Medicare Advantage plans use provider networks—groups of hospitals and doctors who agree to the plan’s terms. If you go outside that network, you could end up with:

• Much higher out-of-pocket costs

• Denied claims

• No coverage at all unless it’s an emergency

In 2025, plans are expected to keep their directories updated, but errors can still occur. And some enrollees don’t realize until it’s too late that a specialist they were referred to doesn’t accept their plan.

Mid-Year Health Changes Can Lead to Cost Surprises

Health conditions can change at any time. Maybe you didn’t need to see a cardiologist when you first enrolled, but now you do. Or your prescriptions have increased in cost or complexity.

Medicare Advantage plans have fixed formularies (lists of covered drugs), and not all medications are covered the same way. Mid-year, if your medication changes or you need a new treatment, you might find:

• Your drug isn’t covered at all

• It’s placed in a high-cost tier

• You need prior authorization for it

• You must try a cheaper drug first (step therapy)

These restrictions can result in unexpected expenses or treatment delays.

You Can’t Always Just Switch Plans

After March 31, most Medicare Advantage enrollees are locked into their plans for the rest of the year. Unless you qualify for a Special Enrollment Period (SEP), you’ll have to wait until the next Open Enrollment Period.

Qualifying events for a SEP include:

• Moving to a new address that isn’t in your plan’s service area

• Losing other health coverage

• Moving into or out of a nursing facility

• Gaining or losing Medicaid eligibility

Without one of these situations, your only chance to make a change is between October 15 and December 7 each year. That means mid-year surprises—whether it’s a doctor leaving the network, a denied claim, or a high-cost medication—can’t always be corrected right away.

Supplemental Benefits Can Disappear or Underperform

Medicare Advantage plans love to advertise their extras—gym memberships, dental care, vision exams, hearing aids. But in practice, these benefits may come with:

• Dollar caps (like a $500 annual dental limit)

• Limited provider networks for dental or vision

• Long wait times for appointments

• Coverage that doesn’t include follow-up care or procedures

By mid-year, many enrollees realize they haven’t used some of the extras or that using them involved more out-of-pocket costs than expected. And while new rules in 2025 require plans to notify members mid-year about unused supplemental benefits, this doesn’t change their value or usability.

Emergency Coverage Outside Your Area Can Be Limited

Medicare Advantage plans generally cover emergencies anywhere in the U.S. But what qualifies as an “emergency” can vary. If you’re traveling and need urgent but non-emergency care, you may face steep bills.

Plans are not required to cover routine or follow-up care outside their service area. So if you spend extended time in another state—for example, during the summer or winter months—you might be out of luck.

In 2025, some plans offer national networks or visitor coverage, but not all do. It’s something that should be clarified before enrollment—yet it’s often discovered too late.

The Annual Out-of-Pocket Limit Isn’t Always Reassuring

Unlike Original Medicare, Medicare Advantage plans include an annual out-of-pocket (OOP) maximum. In 2025, that limit is $9,350 for in-network care and $14,000 for combined in- and out-of-network care. This sounds like a safety net, but there’s a catch:

• You have to reach that amount before the plan pays 100%

• Many services still involve copays and coinsurance along the way

• The OOP max doesn’t include monthly premiums or non-covered services

So even with a cap in place, a serious health issue can still leave you with substantial costs mid-year. And if you have a PPO plan that includes out-of-network coverage, those expenses can add up fast.

Your Primary Care Doctor Might Leave the Plan

Doctors and medical groups change affiliations. They may drop a Medicare Advantage contract mid-year for various reasons. If your doctor leaves the network, you’ll usually be required to:

• Find a new in-network doctor

• Get new referrals for specialists

• Start from scratch with care coordination

This isn’t always predictable, and it can interrupt your treatment plans. Unless your situation qualifies you for a SEP, you won’t be able to switch plans just because your doctor left.

Telehealth and Digital Tools May Be Limited

Many Medicare Advantage plans advertise virtual care options. But telehealth access can vary widely depending on the plan’s contracts. Some limitations include:

• Certain specialties not available

• Limited hours for virtual visits

• Restrictions on prescribing medications via telehealth

Even in 2025, not all plans offer the same level of digital access. So if you expected 24/7 virtual care or wide-ranging online services, you might find the reality doesn’t match the promise.

Enrollment Timing Can Leave You Stuck With the Wrong Plan

By the time you notice your plan isn’t working for you, it might be too late. After March 31, your options for switching are narrow. And even the Annual Enrollment Period doesn’t offer immediate relief—it takes effect the following January.

So if your issues surface in April, May, or June, you could be stuck with:

• A doctor network you can’t use

• Costs you didn’t anticipate

• Limitations you didn’t know about

This highlights why it’s critical to evaluate plans carefully before enrollment, not just based on upfront perks.

Why This Matters for Your Peace of Mind

Health coverage isn’t just about cost—it’s about confidence and continuity. Medicare Advantage plans can offer great value to some, but they are not without risk. When you’re healthy, everything may seem fine. But mid-year is when many discover that cost savings often come with strings attached.

If you value freedom to choose providers, consistent coverage wherever you go, and fewer authorization hurdles, a different Medicare path may suit you better.

Consider All the Moving Parts Before You Enroll

Choosing a Medicare Advantage plan is not just about comparing premiums or counting dental visits. It’s about anticipating what could change—and what can’t be changed quickly if your health needs shift mid-year.

If you want help reviewing your options or understanding what your current plan actually covers, reach out to a licensed agent listed on this website. You don’t have to make this decision alone.