Key Takeaways

• Medicare Advantage plans are offered by private companies, but they operate within rules set by the federal government. You still receive your Medicare Part A and Part B benefits—just delivered differently.

• While these plans may include extra benefits not found in Original Medicare, limitations such as network restrictions, prior authorizations, and regional availability can significantly affect your healthcare experience.

Understanding the Structure Behind the Plans

Medicare is a federal program, but one of its biggest components—Medicare Advantage—is run by private companies. This unique structure leads to both opportunities and complications. You’re still part of Medicare, but your day-to-day care, costs, and choices may look very different compared to Original Medicare.

In 2025, more than half of all Medicare beneficiaries are enrolled in Medicare Advantage. These plans bundle your Part A (hospital) and Part B (medical) benefits, and usually include Part D (prescription drug coverage). But unlike Original Medicare, these plans aren’t uniform. Each one reflects the offerings and rules of the private company administering it.

What You Get—and What’s Different

Medicare Advantage plans are legally required to cover all services included in Part A and Part B. That’s non-negotiable. However, they often go further by offering additional benefits like:

• Dental, vision, and hearing care

• Wellness programs and gym memberships

• Transportation to medical appointments

• Over-the-counter health items

But those extras come with trade-offs. Unlike Original Medicare, which allows you to see almost any provider nationwide who accepts Medicare, Medicare Advantage typically relies on networks. This means:

• You may be required to see doctors within a specific service area

• Out-of-network care can be costly or not covered at all

• Prior authorizations may be needed for some services

A Federal Program in a Private Wrapper

What makes Medicare Advantage unique is its public-private hybrid nature. The government pays a fixed amount to private insurers for each enrollee. In return, these plans manage care and cost-sharing, but under federal guidelines.

As a result, the federal government still oversees:

• Plan quality through a star rating system (1 to 5 stars)

• Annual audits and compliance reviews

• Required benefits and limits on out-of-pocket expenses

But what’s not standardized are the:

• Monthly premiums (in addition to your Part B premium)

• Provider networks

• Drug formularies

• Out-of-pocket maximums

So while you are in a Medicare program, the experience you receive will be tailored by the private entity delivering it.

Regional Variability: Your ZIP Code Shapes Your Choices

In 2025, plan availability varies widely depending on where you live. Urban areas tend to offer dozens of Medicare Advantage options, while rural regions may have only a handful. This geographic gap affects:

• Number of providers participating in each plan

• Extra benefits offered

• Costs, including copayments and deductibles

This means two people with identical medical conditions might have entirely different Medicare experiences simply because they live in different counties.

What the Government Regulates—and What It Doesn’t

Here’s what the Centers for Medicare & Medicaid Services (CMS) mandates for all Medicare Advantage plans:

• Include all Medicare Part A and Part B benefits

• Cap out-of-pocket costs for in-network services (in 2025, this is $9,350 max)

• Offer annual enrollment periods

• Provide grievance and appeals processes

But CMS doesn’t regulate:

• Which doctors participate in a plan

• Which drugs are covered beyond the required minimum

• How much you pay in coinsurance for each service

• How restrictive prior authorization policies are

That flexibility allows private companies to innovate—but also means that your coverage experience can be complex and inconsistent.

Prior Authorizations: One of the Biggest Pain Points

Many Medicare Advantage plans require prior authorization for certain procedures, hospital stays, or even diagnostic imaging. This means you or your provider must get the plan’s approval before proceeding.

While prior authorization is intended to control unnecessary costs, it can lead to:

• Delays in care

• Additional paperwork for you and your doctor

• Denials that you must appeal

Original Medicare generally does not require this step, so switching from it to Medicare Advantage can feel like gaining more hurdles to access care.

Star Ratings and Quality Control

To help you compare options, the federal government assigns star ratings based on:

• Member satisfaction

• Management of chronic conditions

• Timely access to care

• Use of preventive services

Plans rated 4 stars or higher are generally considered high-performing. However, these ratings can change yearly, and what’s rated well today may not stay that way next year. That’s why reviewing your Annual Notice of Change every fall is important.

Enrollment Timing and How Long You’re Committed

When you choose a Medicare Advantage plan, you’re usually locked in for the calendar year unless you qualify for a Special Enrollment Period due to life events like moving or losing coverage.

The main opportunity to enroll or switch is:

• Medicare Open Enrollment: October 15 to December 7

Changes made during this time take effect January 1. Additionally, there’s a:

• Medicare Advantage Open Enrollment: January 1 to March 31

This allows you to switch to another Medicare Advantage plan or revert to Original Medicare. But you can only make one change during this period.

What If You Want to Go Back to Original Medicare?

Leaving Medicare Advantage is possible, but not always easy. If you return to Original Medicare after your first year, you might not be able to purchase a Medigap policy without medical underwriting unless you qualify for guaranteed issue rights.

This is especially important because Medigap helps cover the out-of-pocket costs that Original Medicare doesn’t pay. Not having this coverage could leave you exposed to higher expenses.

General Cost Expectations in 2025

While specifics vary widely by plan and region, here are general cost elements you should expect with Medicare Advantage in 2025:

• You still pay the standard Part B premium ($185/month)

• Many plans have additional monthly premiums (varies)

• Copays typically range from $20-$40 for primary care

• Specialist visits may cost $30-$60

• Emergency room visits may range from $100-$150

• Deductibles may apply and vary significantly

You are also subject to a maximum out-of-pocket limit, which caps what you’ll pay in total for covered services each year. For in-network care in 2025, this cannot exceed $9,350.

How These Plans Affect Prescription Drug Access

Most Medicare Advantage plans include Part D coverage. However, drug formularies—the list of covered medications—are unique to each plan. That means:

• Your medications may fall into different pricing tiers

• Prior authorization or step therapy may apply

• Not all pharmacies may be in-network

You should always verify that your prescriptions are covered and understand any restrictions before enrolling.

Supplemental Benefits: What’s New in 2025

In 2025, some Medicare Advantage plans are adjusting supplemental benefits based on usage patterns. Notably:

• Some plans are scaling back non-core benefits like OTC items and transportation

• A new mid-year notification will inform you of unused supplemental benefits

This change is aimed at improving benefit utilization, but it also means fewer extras for those not actively using them.

Your Medicare Experience Is a Direct Result of the Plan You Choose

Even though all Medicare Advantage plans must meet certain federal requirements, your real-world experience depends heavily on:

• The provider network

• Plan structure (HMO vs. PPO)

• Local availability

• Drug coverage policies

In short, Medicare Advantage is not a one-size-fits-all solution. It’s a custom experience delivered through a private filter, with all the flexibility and complications that come with that.

When Government Oversight Isn’t the Same as Government Consistency

The presence of federal rules may give you the impression of uniformity, but don’t mistake oversight for standardization. Medicare Advantage operates with wide latitude within federal parameters. That can create either a tailored fit—or major frustration.

It’s essential to evaluate plans annually, consider your medical needs and budget, and seek expert help.

If you need help comparing options, getting in touch with a licensed agent listed on this website can provide personalized assistance tailored to your situation.