Key Takeaways

• Medicare Advantage plans often promote their extra perks, but those benefits may come with rules, restrictions, or trade-offs that affect your coverage.

• Choosing a top-rated plan involves more than comparing bonuses. It’s critical to evaluate CMS star ratings, network size, cost-sharing, and coverage limits to avoid surprises later.

What You Really Get with a Medicare Advantage Plan

Medicare Advantage plans, also known as Medicare Part C, bundle Original Medicare (Part A and Part B) into a single plan. They often include additional benefits like dental, vision, hearing, and fitness programs. These extra features make them appealing, especially to those seeking all-in-one coverage. However, every added benefit usually comes with conditions.

In 2025, over 50% of Medicare beneficiaries are enrolled in a Medicare Advantage plan. With such popularity comes great variation. Not all plans are created equal, and the ones with the flashiest extras may not necessarily provide the best core health coverage.

Key Features You Can Expect

• Comprehensive Coverage: Includes Part A (hospital) and Part B (medical) benefits.

• Prescription Drug Coverage: Most plans include integrated Part D drug benefits.

• Extra Benefits: May offer services not included in Original Medicare, such as routine dental exams, vision screenings, over-the-counter allowances, and gym memberships.

• Annual Out-of-Pocket Maximum: Unlike Original Medicare, these plans include a limit on your annual healthcare spending.

• CMS Star Ratings: Medicare uses a 5-star system to rate plan quality. Ratings are updated yearly and reflect performance on care quality, customer service, and member satisfaction.

What CMS Star Ratings Really Tell You

Every fall, the Centers for Medicare & Medicaid Services (CMS) releases updated star ratings for all Medicare Advantage plans. Ratings range from 1 to 5 stars, with 5 stars being the highest quality.

In 2025, CMS ratings still cover key performance categories:

• Preventive services and managing chronic conditions

• Member complaints and plan changes

• Customer service and access to care

Plans with 4 stars or higher are considered high-quality and typically perform well in both service and clinical care. However, a high rating doesn’t mean the plan will suit your personal medical or financial needs. It’s important to look beyond the stars.

Hidden Limits Behind the Extras

The allure of extras like dental care, eyewear, and hearing aids is powerful. These are often the first things people notice when comparing Medicare Advantage plans. Yet these perks often come with their own limitations.

Network-Based Access

Unlike Original Medicare, most Medicare Advantage plans use provider networks. That means your benefits only apply fully when you visit in-network doctors and facilities. You may need referrals for specialists or prior authorization for certain procedures.

If your plan offers dental coverage, for instance, it might only cover routine cleanings from specific providers. More complex procedures like crowns or root canals might require prior approval or come with high copays.

Annual Limits and Frequency Rules

Many supplemental benefits are subject to annual limits, frequency restrictions, or specific schedules. Examples include:

• Dental: Cleanings may be covered only twice a year; other procedures may require coinsurance.

• Vision: Eyeglass allowances may be offered only once every two years.

• Hearing: Plans might cover one hearing aid per ear every three years, with prior authorization.

These limitations aren’t always obvious when enrolling. Reading the fine print in your Summary of Benefits is critical.

Costs Beyond the Premium

Even if a Medicare Advantage plan offers a low monthly premium, it doesn’t mean your total costs will be low. The real expenses come from copayments, deductibles, and coinsurance.

Common Out-of-Pocket Costs in 2025

• Primary Care Visits: Copays typically range from $20 to $40.

• Specialist Visits: May require $30 to $60 copays.

• Urgent Care: Often comes with $50 to $75 copays.

• Emergency Room: You may pay between $100 and $150 per visit.

• Coinsurance: For many services, you may pay 10% to 30% of the cost.

Every plan also includes an in-network maximum out-of-pocket (MOOP) limit, which caps your costs for covered services. In 2025, this limit is $9,350 on average. That’s a financial safety net, but reaching that cap can still be a heavy burden if you face chronic illness or hospitalization.

Prescription Drug Coverage Conditions

Most Medicare Advantage plans include Medicare Part D drug coverage. While this is a convenient feature, it also comes with layers of complexity.

2025 Drug Cost Structure

In 2025, a new out-of-pocket cap of $2,000 for prescription drugs has taken effect. While this offers welcome relief, the cost-sharing model still includes:

• Annual Deductible: Up to $590 in 2025

• Tiered Copayments: Drugs are placed in tiers with varying copays; generics are cheaper, while brand-name and specialty drugs are more expensive.

• Formularies: Each plan has its own list of covered drugs. Your medication might not be included, or it could require prior authorization.

If you rely on prescriptions for chronic conditions, check each plan’s drug list carefully before enrolling.

The Role of Prior Authorization and Referrals

Medicare Advantage plans often require prior authorization before covering certain services like MRIs, surgeries, or extended physical therapy. This is a cost-control measure that can lead to delays in care if not properly managed.

Similarly, referrals from your primary care physician may be necessary before seeing a specialist. If you’re used to the freedom of Original Medicare, these conditions can be frustrating and time-consuming.

Geographic and Plan Variation

Not all Medicare Advantage plans are available everywhere. Plans vary by ZIP code, and benefits can differ significantly across regions. A plan that offers excellent coverage in one area may be far more limited in another.

In rural or underserved areas, provider networks may be thinner, making it harder to find in-network specialists or hospitals. The presence of high-rated plans in your area also influences your choices. Some counties have no 5-star plans at all.

What Happens if You Choose Wrong?

Choosing a plan based only on its extras can lead to unexpected costs and access barriers. Fortunately, you can switch plans during certain times of the year:

• Medicare Annual Enrollment Period (AEP): October 15 to December 7. You can switch, drop, or join a new Medicare Advantage plan.

• Medicare Advantage Open Enrollment Period (MA OEP): January 1 to March 31. If you’re already enrolled in a Medicare Advantage plan, you can switch to a different one or go back to Original Medicare.

• Special Enrollment Periods (SEPs): Triggered by life events such as moving or losing other coverage.

Even with these options, plan changes are limited to specific windows. That’s why it’s critical to get it right the first time.

How to Evaluate the Best Plan for Your Needs

When reviewing Medicare Advantage plans, start by focusing on your personal healthcare needs and budget. Here’s what to consider:

1. Star Ratings and Plan History

Look for plans with at least 4 stars and a consistent history of strong ratings over the past few years. Don’t rely solely on the current year’s rating.

2. Provider and Pharmacy Networks

Make sure your preferred doctors and hospitals are in the plan’s network. Also check that your pharmacy is included, especially if you rely on prescription drugs.

3. Drug Coverage

Review the plan’s formulary. Ensure all your medications are covered and check any restrictions like step therapy or prior authorization.

4. Cost Structure

Estimate your total expected costs based on how often you use care. Look at:

• Copays and coinsurance

• MOOP limit

• Prescription costs

5. Supplemental Benefits

Don’t let extra perks distract from the basics. Make sure any included benefits truly add value to your specific situation.

Picking a Plan with Confidence Starts with Knowing the Rules

The best Medicare Advantage plans in 2025 often advertise convenience and added value. But convenience comes with rules, conditions, and sometimes trade-offs that only become clear when you need care.

Before making your selection, examine each plan from multiple angles. A licensed agent listed on this website can help you compare plans side by side, clarify complex language, and guide you toward a choice that fits your long-term needs.