Key Takeaways

• Medicare Advantage plans may look attractive on the surface, but coverage limitations and cost-sharing rules can lead to unexpected out-of-pocket expenses, especially during serious medical events.

• Even highly rated plans under the CMS 5-star system are not immune to gaps in coverage or narrow provider networks that affect your care access when you need it most.

What Medicare Advantage Plans Offer at First Glance

Medicare Advantage plans, also called Part C, are offered by private companies approved by Medicare. They combine Medicare Part A (hospital insurance) and Part B (medical insurance) into one plan. Most also include Part D prescription drug coverage and offer additional benefits like dental, vision, and hearing.

Plans are required to cover everything Original Medicare does, but they often do so with different structures. Instead of standardized costs like coinsurance under Original Medicare, Medicare Advantage plans usually have set copayments and network restrictions. This is where expectations often clash with reality.

CMS Ratings Don’t Tell the Whole Story

The Centers for Medicare & Medicaid Services (CMS) rate Medicare Advantage plans on a 1-to-5-star scale based on performance measures like customer service, managing chronic conditions, and access to care. While a 5-star rating indicates high overall performance, it doesn’t mean the plan is the right fit for every individual.

Here are some limits to keep in mind:

• A plan may score high on customer satisfaction but have a narrow provider network in your area.

• Ratings are based on past performance and don’t guarantee future coverage terms.

• A plan may offer strong preventive services but higher out-of-pocket costs for inpatient or specialist care.

This means you shouldn’t rely solely on CMS star ratings when evaluating a plan.

Where Things Break Down During Major Medical Needs

Medicare Advantage plans work well for many people when managing routine care, annual check-ups, or generic prescriptions. But challenges often emerge during medical emergencies, hospitalizations, or prolonged specialist treatment.

Here are key problem areas where benefits may not align with expectations:

1. Prior Authorization Requirements

Many Medicare Advantage plans require prior authorization for services like MRIs, physical therapy, home health care, and inpatient rehabilitation. This means you need advance approval from the plan before receiving care, or it may not be covered.

The delays caused by this process can result in postponed treatment. For complex cases, this can mean a serious interruption in your care plan, and the burden falls on you or your doctor to navigate the red tape.

2. Limited or Narrow Networks

Unlike Original Medicare, which allows you to see any provider who accepts Medicare nationwide, Medicare Advantage plans often restrict you to a local network of doctors, specialists, and hospitals.

If you travel or split time between two states, a plan with a tight network might not cover care out of your home area unless it is an emergency. Even within your region, a preferred provider might not be in-network.

Out-of-network care may be denied or reimbursed at a lower rate, and the surprise bills can be significant.

3. Unexpected Cost-Sharing During Hospital Stays

Medicare Advantage plans set their own structure for inpatient hospital costs. Some plans charge a flat fee per day for the first few days of a hospital stay, which can quickly accumulate to thousands of dollars.

In contrast, Original Medicare has a single deductible per benefit period. Many people assume their Advantage plan covers hospital stays the same way, but this is not always the case. And once you reach your plan’s maximum out-of-pocket limit (which in 2025 can be as high as $9,350 for in-network services), costs reset the next calendar year.

4. Prescription Drug Coverage Gaps

Most Medicare Advantage plans include drug coverage, but not all cover the same drugs or place them in the same cost tiers. High-cost drugs may fall into higher tiers with steep copays or coinsurance.

And although the new 2025 $2,000 out-of-pocket cap under Part D is a significant relief, not all plans handle this transition equally. Your prescriptions must be on the plan’s formulary and approved under utilization rules. Prior authorization or step therapy might apply.

5. Limited Access to Specialists

Some Medicare Advantage plans require a referral from your primary care doctor before seeing a specialist. While this gatekeeping is meant to coordinate care, it can cause delays in diagnosis or treatment.

If you have a chronic illness or a new diagnosis that requires urgent specialist input, these restrictions can be frustrating or even risky. Moreover, if the specialist you want is out-of-network, your plan may not pay at all unless it’s a medical emergency.

Important Cost Considerations in 2025

Even though Medicare Advantage plans often market themselves as offering more for less, the reality in 2025 includes a number of financial variables:

• Maximum Out-of-Pocket Limit: For in-network services, the limit is $9,350 in 2025. Once you hit that threshold, the plan pays 100% of covered costs. However, this limit resets annually and doesn’t include premiums or non-covered services.

• Out-of-Network Costs: Plans with PPO structures may offer partial coverage outside the network, but those costs can be subject to higher limits of up to $14,000 in combined expenses.

• Copay Accumulation: Even small copays for office visits, labs, and imaging can build up rapidly during periods of illness or injury.

It’s important to understand the difference between paying less upfront and potentially paying more later when it matters most.

What You Should Do Before Enrolling

Choosing the right Medicare Advantage plan isn’t about picking the one with the most features. It’s about knowing how those features perform under pressure. Here are some practical steps:

• Review the Plan’s Summary of Benefits: This outlines what’s covered, what you pay, and any authorization rules.

• Check the Provider Directory: Ensure your preferred doctors, hospitals, and specialists are in-network.

• Compare Drug Formularies: Confirm your medications are covered and what tier they fall under.

• Understand Referral and Authorization Rules: Look for details on what services require extra approval.

• Ask About Travel Coverage: Especially if you plan to visit family or live seasonally in another state.

Make sure to also compare plan documents like the Annual Notice of Change and Evidence of Coverage to detect upcoming changes that may affect your access or costs.

What the CMS Star Ratings Mean in Practice

A CMS star rating is a useful tool, but it is not a personalized endorsement. For example:

• A plan may have 5 stars due to outstanding preventive care metrics, but perform poorly in managing complex care episodes.

• The star system does not rate individual providers or the adequacy of the plan’s network in your specific zip code.

• Ratings are updated annually, so a 5-star plan in 2024 may fall in 2025 if performance metrics slip.

You should treat CMS ratings as one factor in your decision, not the deciding factor.

Balancing Extra Benefits with Coverage Realities

Many Medicare Advantage plans offer extras that Original Medicare does not, including:

• Dental and vision services

• Hearing aids

• Over-the-counter item allowances

• Fitness memberships

These benefits are helpful, but they should not outweigh essential medical coverage when making a choice. The value of a dental cleaning is minor compared to being denied access to a needed cardiologist or an expensive drug.

Remember that extra benefits often come with usage limits, provider restrictions, or exclusions that are easy to overlook in glossy plan brochures.

Think Long-Term About Your Health and Mobility

Your health needs may be simple now, but Medicare Advantage plans are year-long commitments. Outside the annual open enrollment window (October 15 to December 7), it’s difficult to switch unless you qualify for a Special Enrollment Period.

If your needs change mid-year due to a new diagnosis or relocation, your ability to get broader coverage might be limited until the next plan year. That’s why the best plan today might not be the best plan for future you.

When Coverage Doesn’t Match the Crisis

The reality is that many enrollees only discover their Medicare Advantage plan’s true coverage when they face a serious health challenge. Whether it’s being told a rehab facility is out-of-network or learning that a cancer treatment requires prior authorization, these surprises create financial stress and care delays.

Reading the fine print and questioning assumptions is key. The most advertised plan isn’t always the most reliable during a crisis.

Making Medicare Advantage Work for You

Medicare Advantage plans can be beneficial when chosen carefully. They work best when:

• You have stable health needs

• Your providers are in-network

• You understand the plan’s approval and cost-sharing structure

• You actively review the plan annually during open enrollment

But if you require complex care, see multiple specialists, or value unrestricted provider choice, you should compare your Medicare Advantage option to Original Medicare plus a Medigap plan.

Don’t Let the Extras Distract You From the Essentials

The best Medicare Advantage plans may appeal to you with fitness benefits, allowances, and convenience. But when it comes to serious health issues, those extras won’t help if your care is delayed, denied, or comes with large bills.

Before enrolling or staying in a plan, speak with a licensed agent listed on this website. They can help assess your health needs, evaluate plan documents, and ensure you understand your real coverage—not just what looks good on paper.