Key Takeaways

• Some of the best-rated Medicare Advantage plans in 2025 still come with unexpected limitations, especially when it comes to provider access, prior authorization, and out-of-pocket costs.

• You should always evaluate more than just CMS star ratings. A plan that looks ideal on paper may not suit your actual medical needs or financial expectations.

What You Think You’re Getting with a Top-Rated Medicare Advantage Plan

Medicare Advantage plans often sound like a smart choice. Many come with extra perks beyond Original Medicare, such as dental, vision, hearing, or gym memberships. Some are highly rated by the Centers for Medicare & Medicaid Services (CMS), with 4- or 5-star ratings. It’s easy to assume that a high rating means you’re getting the best coverage available.

CMS star ratings evaluate factors like customer service, member experience, health outcomes, and complaint resolution. These ratings are useful, but they don’t always reflect how well a plan performs for your individual healthcare needs.

What CMS Ratings Actually Measure

CMS uses a 5-star scale to rate Medicare Advantage plans based on:

• Preventive care and chronic condition management

• Member complaints and disenrollment rates

• Customer service

• Timeliness of care and appeals resolution

• Member experience surveys

While these are important metrics, they may not reveal network limitations, strict authorization rules, or regional coverage issues that affect your day-to-day healthcare.

The Network May Be Smaller Than You Expect

One common surprise with highly rated plans is that they often have limited provider networks. Unlike Original Medicare, where you can see any provider that accepts Medicare, Medicare Advantage plans usually require you to use in-network doctors, hospitals, and specialists.

Smaller Networks, Bigger Trade-Offs

• Many plans restrict you to a narrow network in your geographic area.

• Seeing an out-of-network specialist may lead to higher costs or no coverage at all.

• Some plans require a referral to see a specialist, delaying care.

Even if a plan has a 5-star rating, it could lack access to your preferred providers. And networks can change from year to year, even mid-year, without warning.

Prior Authorization Can Delay Care

Another surprise? Prior authorization. This is when your plan must approve a treatment or test before you can get it covered. It’s a common feature in Medicare Advantage plans and can affect a wide range of services, from diagnostic imaging to surgeries.

What Prior Authorization Means for You

• Approval may take days or weeks.

• Delays can impact time-sensitive care.

• If authorization is denied, you could be stuck with the full cost or forced to appeal.

This gatekeeping approach helps the plan manage costs but often frustrates both patients and providers. High CMS star ratings don’t necessarily reflect how restrictive or time-consuming a plan’s prior authorization process may be.

The Real Story Behind Out-of-Pocket Costs

Medicare Advantage plans are required to have an annual maximum out-of-pocket (MOOP) limit. For 2025, the MOOP is $9,350 for in-network care and $14,000 for combined in-network and out-of-network care. Once you hit that amount, the plan must cover 100% of covered services for the rest of the year.

However, many people never reach this cap because of high copayments, coinsurance, and deductibles. These costs add up quickly, especially if you have a chronic illness or need frequent specialist visits.

Hidden Costs to Watch For

• Hospital stays may involve daily copayments that increase after a few days.

• Emergency room visits often have higher copays than primary care.

• Outpatient surgeries and advanced imaging typically come with significant coinsurance.

Even a well-rated plan can leave you with substantial bills if you don’t understand how these cost-sharing elements work.

Coverage for Supplemental Benefits Isn’t Always Reliable

One major selling point of Medicare Advantage is the inclusion of extra benefits not covered by Original Medicare. In 2025, many plans still advertise vision, dental, hearing, and over-the-counter (OTC) benefits. But the fine print often tells a different story.

Benefit Limitations Are Common

• Dental coverage may only cover preventive services, not crowns or root canals.

• Vision benefits may include an eye exam but not the cost of glasses or lenses.

• Hearing coverage might pay for one hearing aid, not two.

• OTC benefits may come with quarterly caps or limited eligible items.

Worse, some of these benefits are only available through specific vendors or require scheduling through the plan’s network, adding more hurdles for you.

Prescription Drug Coverage Has Gaps

Most Medicare Advantage plans include prescription drug coverage (Part D), but that doesn’t mean you’re fully protected from high drug costs.

In 2025, a $2,000 annual cap on out-of-pocket drug costs is in effect under Part D, but this only kicks in after you’ve paid a significant amount through deductibles, copays, and coinsurance.

Challenges in Drug Coverage

• Formularies (approved drug lists) vary between plans.

• Tiered pricing means brand-name drugs can still be costly.

• Step therapy may require trying cheaper drugs before getting coverage for the prescribed one.

A plan with high ratings could still leave you paying hundreds per month for medications that fall outside their preferred drug list.

Your Region May Not Be Represented in the Ratings

CMS star ratings are based on national metrics and may not reflect the performance of your plan in your specific county or state. Some plans operate differently across regions, even if they share the same name and branding.

What This Means for You

• Your plan may perform well nationwide but poorly in your local area.

• Ratings do not reflect access to care in rural or underserved locations.

• State-specific regulations and provider availability can dramatically affect your experience.

Always review the Annual Notice of Change (ANOC) and Summary of Benefits for your specific ZIP code rather than relying solely on CMS ratings.

Changes from One Year to the Next Can Affect Coverage

Even if you’re happy with your current plan, annual changes could surprise you. Each fall, your Medicare Advantage plan may update its premiums, deductibles, copayments, provider networks, and drug coverage.

Common Plan Changes in 2025

• Removal of key providers from networks

• Reduction or elimination of supplemental benefits

• Higher cost-sharing for hospital or outpatient services

• Updated drug formularies that exclude medications you take

If you miss the Annual Enrollment Period (October 15 to December 7), you could be locked into a plan that no longer meets your needs.

High Ratings Don’t Guarantee Customer Satisfaction

Just because a plan earns 4 or 5 stars doesn’t mean members are universally satisfied. Star ratings are weighted heavily toward clinical measures and processes, not individual frustrations with billing, claims, or customer support.

Member Complaints May Still Be High

• Call center wait times may be long.

• Appeals can be time-consuming.

• Denials for services may be more frequent than expected.

A plan might rank highly because it manages chronic diseases well or offers preventive services, but that doesn’t help if you’re constantly battling red tape to get care.

You May Not Be Eligible for Certain Benefits

Some Medicare Advantage plan perks are only available to specific populations, such as those with chronic conditions, low incomes, or those enrolled in Special Needs Plans (SNPs).

Don’t Assume Every Benefit Applies to You

• Transportation services may be limited to dual-eligible beneficiaries.

• Meal delivery benefits may only follow hospital discharges.

• Care coordination programs might require a chronic condition diagnosis.

Unless your plan explicitly confirms your eligibility, don’t count on these extras as guaranteed features.

What You Should Really Do Before Choosing a Plan

Choosing a Medicare Advantage plan in 2025 requires more than just comparing CMS star ratings. Here are the key steps to take:

• Confirm your doctors and hospitals are in-network.

• Review the plan’s prior authorization rules.

• Evaluate annual out-of-pocket costs, not just premiums.

• Understand coverage details for dental, vision, and hearing.

• Check the plan’s Part D formulary for your medications.

• Read the Summary of Benefits and ANOC for your county.

• Ask if benefits apply to you specifically, or only to certain subgroups.

A plan might look great on the surface, but only a detailed review will tell you whether it fits your needs.

Star Ratings Alone Won’t Protect You from Disappointment

By now, you know that a 5-star rating doesn’t mean a 5-star experience. Provider access, approval delays, regional variations, and rising cost-sharing can all take the shine off a plan that initially seems like the perfect fit.

If you want a Medicare Advantage plan that works for your specific needs, don’t rely solely on the CMS scorecard. Talk with someone who understands how these plans work.

For guidance tailored to your situation, reach out to a licensed agent listed on this website. They can help you compare options, understand costs, and avoid unpleasant surprises down the road.