Key Takeaways

• Before enrolling in a Medicare Advantage plan in 2025, it’s essential to ask detailed questions about coverage, networks, costs, and limitations to avoid costly surprises.

• Medicare Advantage plans may include extra benefits not offered by Original Medicare, but these benefits often come with restrictions that may affect access or costs.

Understanding What You’re Signing Up For

Medicare Advantage, also known as Medicare Part C, remains a popular option for many in 2025. These plans offer an alternative to Original Medicare, often bundling additional services such as dental, vision, hearing, and prescription drug coverage. But popularity does not always mean suitability. Before you enroll, you need clarity. That begins with asking the right questions.

Are You Comfortable With a Network-Based Plan?

Most Medicare Advantage plans operate within defined provider networks. That means your access to care is largely determined by whether your doctors and hospitals are in-network.

Ask yourself and the plan representative:

• Are my current doctors in the network?

• What happens if I need to see a specialist who is out-of-network?

• Will I need referrals for specialist care?

• Are there geographic limitations if I travel or live in different states during the year?

Plans like HMOs (Health Maintenance Organizations) typically require referrals and have stricter networks, while PPOs (Preferred Provider Organizations) offer more flexibility but often at a higher cost.

What Are the Out-of-Pocket Costs?

Even though many Medicare Advantage plans tout lower premiums than Original Medicare plus Medigap, they come with cost-sharing that can add up.

Ask:

• What is the annual in-network out-of-pocket maximum?

• What are the copayments or coinsurance for primary care, specialists, hospital stays, urgent care, and emergency room visits?

• Are there separate out-of-pocket limits for out-of-network care?

• Does the plan include deductibles, and if so, how much?

In 2025, the maximum out-of-pocket limit for in-network services under Medicare Advantage is $9,350. Many plans offer lower caps, but it’s essential to confirm the actual number.

Are Prescription Drugs Covered Adequately?

Many Medicare Advantage plans include prescription drug coverage (Part D), but formularies (lists of covered drugs) and cost tiers vary widely.

Be sure to ask:

• Is my current medication on the formulary?

• Are there prior authorization or step therapy requirements?

• What are the copayments for preferred vs. non-preferred drugs?

• Are local or preferred pharmacies nearby and convenient?

• Is mail-order an option, and are there any cost savings?

Also confirm whether the plan uses a standard deductible for prescription drugs. In 2025, the maximum Part D deductible is $590.

What Happens if You Need Care While Traveling?

Original Medicare provides consistent national coverage. Medicare Advantage plans do not.

You should clarify:

• Does the plan offer coverage while traveling outside your home state?

• Will emergency and urgent care be covered nationwide?

• Are there telehealth options to bridge care gaps?

Some plans may provide additional travel benefits or global emergency coverage, but these are not guaranteed.

What Extra Benefits Are Offered – and What Are the Limitations?

In 2025, most Medicare Advantage plans offer benefits that Original Medicare doesn’t, such as:

• Vision, dental, and hearing coverage

• Fitness programs

• Over-the-counter allowances

• Transportation assistance

• Meal services after hospitalization

However, these benefits are often limited in scope.

Ask:

• What exactly is covered under dental or vision? Is it routine care only, or does it include dentures, crowns, or eyeglasses?

• How often can I access these services each year?

• Are there monetary limits for each benefit category?

You should not assume that “extra” benefits are comprehensive. Review plan documents carefully.

Will You Be Required to Get Prior Authorization?

Prior authorization is when the plan must approve a medical service before it’s provided. In 2025, prior authorization remains a point of concern for many beneficiaries.

You need to ask:

• Which services require prior authorization?

• How long does approval typically take?

• What happens if a request is denied?

• Can I appeal, and how difficult is the process?

Services like hospital admissions, certain scans, or outpatient procedures are commonly subject to prior authorization.

Are the Plan’s Ratings and Complaints Publicly Available?

Each year, CMS (Centers for Medicare & Medicaid Services) publishes star ratings for Medicare Advantage plans based on quality, customer satisfaction, and other factors.

Before you enroll, consider:

• What is the plan’s current star rating?

• Have there been complaints about customer service or denied claims?

• Are there red flags about the plan’s financial stability?

Plans are rated on a scale from 1 to 5 stars, with 5 being excellent. You should be cautious about joining any plan rated below 3 stars.

Can You Switch Back If You Change Your Mind?

One of the biggest misconceptions is that switching back to Original Medicare is easy. It’s not always guaranteed that you can get a Medigap policy if you switch after your initial enrollment period.

Ask:

• What is the plan’s disenrollment process?

• If I leave the plan, can I return to Original Medicare with a Medigap plan?

• Will I be subject to medical underwriting if I apply for Medigap later?

In most cases, you may only switch plans during certain times of year, such as the Annual Enrollment Period (October 15 to December 7) or the Medicare Advantage Open Enrollment Period (January 1 to March 31).

What Support and Customer Service Options Are Available?

Your experience with a Medicare Advantage plan heavily depends on its customer service. Some plans offer 24/7 nurse lines, online portals, and care coordination programs, while others may lack basic support.

Ask:

• Is there a dedicated customer support number?

• How can I reach a care manager or nurse?

• Are there online resources and mobile apps?

• What kind of help is available with claims and appeals?

Reliable, accessible support can make a significant difference when you actually need care.

Are You Eligible for Any Special Plans or Cost-Saving Options?

In 2025, some Medicare Advantage plans are tailored for people with specific needs. These include:

• Special Needs Plans (SNPs): For those with chronic illnesses, dual eligibility for Medicaid, or institutional care needs.

• Medicare Savings Programs (MSPs): State-run programs that help with Medicare costs for low-income beneficiaries.

• Extra Help (LIS): Assists with Part D costs for prescription drugs.

If you qualify, these options can significantly reduce your overall healthcare expenses. Ask the plan or a licensed agent to help you determine eligibility.

How Often Does the Plan Change?

Medicare Advantage plans can change their costs, benefits, and provider networks every year. What works for you in 2025 may not be the same in 2026.

Before you commit, find out:

• Has the plan changed significantly over the past few years?

• Will I receive an Annual Notice of Change (ANOC)?

• What should I review each year during Open Enrollment?

Staying informed helps you avoid surprises and make timely adjustments.

Asking the Right Questions Leads to Smarter Choices

Medicare Advantage plans in 2025 offer a wide range of features and potential benefits, but the fine print matters more than the headlines. By asking the right questions upfront, you can avoid limitations that could impact your care or lead to unexpected costs.

If you’re still unsure about which Medicare plan is right for your needs, speak to a licensed agent listed on this website. They can help clarify your options and guide you based on your personal situation and budget.