Key Takeaways

1. Carefully evaluating your healthcare needs and financial situation can help you choose a Medicare Advantage plan that aligns with your priorities.

2. Asking the right questions before enrolling ensures you avoid hidden costs, limited networks, or inadequate coverage.

Are You Clear About Your Healthcare Needs?

Before diving into plan options, take a moment to assess your current healthcare needs. Do you have any chronic conditions? How often do you visit specialists? Understanding your medical history and anticipated needs can guide you in choosing a plan with the right balance of benefits and costs. If you foresee needing frequent care, focus on plans that offer lower copayments and coinsurance for visits and treatments.

Think about preventive care as well—many Medicare Advantage plans include no-cost or low-cost screenings and wellness visits. If staying proactive about your health is a priority, you’ll want a plan that supports those efforts. Additionally, consider the frequency of emergency room or urgent care visits in your history, as these costs can vary significantly between plans.

Do You Need Additional Coverage Beyond Original Medicare?

Original Medicare covers hospital and medical care, but it doesn’t include certain services like vision, dental, or hearing. Many Medicare Advantage plans bundle these services into their offerings. Consider whether additional benefits like fitness memberships or transportation to medical appointments are important to you. Remember, not all plans offer the same extras, so prioritize what’s essential.

For instance, dental coverage may vary—some plans offer basic cleanings, while others include major procedures like crowns and dentures. If you wear glasses or hearing aids, you’ll want to confirm that your preferred plan covers these expenses adequately. Beyond that, consider lifestyle perks like wellness programs or caregiver support, which can make a big difference in your overall satisfaction with the plan.

How Does the Plan’s Network Fit Your Providers?

Medicare Advantage plans typically work within networks of healthcare providers. You’ll encounter Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). If you have a trusted doctor or specialist, confirm they’re in the plan’s network. If you’re open to switching providers, check if the plan’s network includes reputable options near you. Some plans may charge significantly higher costs if you seek care out-of-network, so double-check the details.

Don’t forget about hospital access—does the plan’s network include hospitals you’d feel comfortable using? Additionally, if telehealth services are important to you, confirm whether the plan includes virtual visits and whether those visits count as in-network care. Expanding access through telemedicine can be a valuable option, especially if you live in a rural or underserved area.

What Are the Plan’s Costs and Out-of-Pocket Limits?

Financial considerations are crucial when selecting a plan. Look beyond the monthly premium and examine the deductible, copayments, and coinsurance. Additionally, Medicare Advantage plans have an annual out-of-pocket maximum, which protects you from excessive expenses. In 2025, the maximum limit is $9,350 for in-network services and $14,000 for combined in-network and out-of-network services. Plans may offer lower caps, so it’s worth comparing.

Consider your budget and how often you’ll need medical care. A plan with lower upfront costs might work for someone with minimal health needs, but frequent doctor visits or prescriptions can quickly add up under plans with higher out-of-pocket costs. Remember to factor in unexpected costs, such as emergency care or hospital stays, and how the plan’s cost-sharing will impact you.

Are Your Prescription Drugs Covered?

Medicare Advantage plans often include prescription drug coverage (Part D), but formularies—the list of covered medications—can vary widely. Review the formulary to ensure it covers your prescriptions. Pay attention to costs, such as copayments, coinsurance, and tiered pricing for different drugs. If you’re prescribed a high-cost medication, check if the plan offers savings programs or alternatives to reduce your expenses.

In 2025, Medicare has introduced a $2,000 annual cap on out-of-pocket prescription drug costs, a significant improvement. However, you should still verify how the plan structures drug costs and whether any additional requirements, like prior authorization, apply. Don’t overlook generic drug options, which can save money, or mail-order pharmacy benefits that might simplify refills and reduce costs.

What Is the Plan’s Approach to Specialist Referrals?

Some Medicare Advantage plans, especially HMOs, require referrals to see specialists. This can be a barrier if you frequently need specialized care. If you prefer direct access to specialists without referral hoops, look for a PPO or a plan with more lenient policies. On the other hand, if you’re okay with working through a primary care physician for referrals, you may find more affordable plan options.

Another important factor is how the referral process is managed—does the plan make it easy to get referrals, or is it a cumbersome process? Delays in referrals can impact your ability to receive timely care. Evaluate the flexibility of the plan’s policies and how they align with your healthcare preferences.

Are There Geographical Limitations?

Medicare Advantage plans are regional, so your options and coverage will depend on where you live. If you travel frequently or split time between multiple states, make sure the plan offers coverage in those areas. Some plans provide emergency coverage outside their network area, but routine care might not be covered. Verify the plan’s flexibility if being mobile is part of your lifestyle.

For snowbirds or retirees who spend part of the year in a different location, national PPOs or plans with reciprocity agreements might be a better fit. Additionally, look into how the plan handles out-of-area urgent care or pharmacy benefits, ensuring you have access wherever you are.

How Easy Is It to Access Customer Support?

Strong customer service can make a significant difference in your experience with a Medicare Advantage plan. Look for plans with good reputations for resolving member issues and providing clear information. Check if the plan offers resources like a 24/7 nurse hotline or an easy-to-use online portal. Accessible and responsive support is invaluable when navigating healthcare questions or claims.

Beyond just contacting support, assess the resources available to you, such as educational webinars, help with managing chronic conditions, or personalized assistance from care coordinators. Plans with robust support systems can simplify your healthcare experience and provide peace of mind.

How to Stay Informed and Confident in Your Decision

Choosing the right Medicare Advantage plan requires research, reflection, and planning. By asking these eight key questions, you can clarify your priorities and identify a plan that fits your unique needs. Don’t rush the decision—take your time comparing plans, costs, and benefits. Staying informed and weighing all the factors ensures you select a plan that provides the coverage and peace of mind you deserve.