Key Takeaways

• While Medicare Advantage plans often offer low monthly costs and added benefits, they may not fully cover the specific services you expect to use most often.

• Some plans with high CMS star ratings still impose limitations on out-of-network care, prior authorization, and specialized treatment, which can affect your access and out-of-pocket costs.

What You Think You’re Getting vs. What You Actually Get

Medicare Advantage plans, also known as Medicare Part C, are popular alternatives to Original Medicare. They bundle together hospital (Part A), medical (Part B), and often prescription drug coverage (Part D), along with additional services like dental, vision, or hearing care. These plans are offered through private companies that follow rules set by Medicare.

But the promise of all-in-one coverage at a low monthly cost can mask some key gaps. While you may be drawn in by wellness benefits or an attractive out-of-pocket limit, the real test of value comes when you actually need care. And if that care happens to fall into a service category not well-covered by the plan, you may end up with more financial burden than you anticipated.

CMS Ratings Aren’t the Whole Picture

Each year, the Centers for Medicare & Medicaid Services (CMS) assigns a star rating to Medicare Advantage plans, from 1 to 5 stars. Plans with 4 or more stars are considered high-performing, based on quality of care, customer service, and member experience. While helpful, this rating system doesn’t always reflect how well a plan meets your personal health needs.

A plan may receive 5 stars but still:

• Require prior authorization for basic procedures

• Limit access to out-of-network specialists

• Impose high cost-sharing for specific treatments like chemotherapy or skilled nursing care

This means a highly rated plan might not be the best fit if it doesn’t align with your expected care needs. Ratings reflect general performance, not suitability for individual circumstances.

Restrictions That Can Cost You Later

You should be especially cautious if your health needs involve any of the following service areas. These are often the most restricted or poorly reimbursed under some Medicare Advantage plans.

1. Out-of-Network Coverage

Most Medicare Advantage plans operate as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). With HMOs, you typically have to stay in-network for all but emergency services. PPOs allow more flexibility but still charge significantly more for out-of-network care.

In rural areas or during travel, limited networks can mean:

• No access to familiar providers

• Emergency-only coverage in certain situations

• Higher deductibles and coinsurance

Original Medicare, by contrast, allows you to see any provider who accepts Medicare nationwide.

2. Skilled Nursing Facility (SNF) Care

If you need recovery time in a skilled nursing facility after hospitalization, coverage may vary significantly. Some Medicare Advantage plans require:

• Prior authorization before admission

• Shorter covered durations (such as 7–14 days)

• Higher daily copayments after the first few days

By contrast, Original Medicare covers up to 100 days in a SNF after a qualifying hospital stay, with full coverage for the first 20 days and a daily coinsurance afterward.

3. Durable Medical Equipment (DME)

Items like walkers, oxygen tanks, hospital beds, and CPAP machines fall under DME. Some Medicare Advantage plans impose restrictions such as:

• Specific vendor networks

• Lengthy authorization processes

• Limited replacement cycles

This could delay treatment or lead you to pay out-of-pocket if a needed supplier is not in-network.

4. Mental Health and Substance Use Treatment

Mental health parity remains a challenge. While Medicare Advantage plans must provide comparable mental health coverage to medical care, barriers still exist:

• Limited provider networks

• Fewer covered therapy sessions

• Referral requirements

• Restrictions on out-of-network psychologists or psychiatrists

If you rely on ongoing counseling or specialty treatment, it’s important to confirm plan coverage before enrolling.

5. Home Health Services

Plans may advertise robust home health offerings, but access can be more limited in practice:

• Authorization delays

• Caps on the number of visits

• Geographic coverage limitations

Home health is critical for individuals recovering from surgery or managing chronic illnesses, and gaps in this area can lead to unnecessary hospital readmissions.

Prior Authorization Can Delay Care

Nearly all Medicare Advantage plans require prior authorization for some services. This process means your provider must request approval from the plan before delivering a service or medication.

Prior authorization is commonly required for:

• Diagnostic imaging (like MRIs and CT scans)

• High-cost prescription drugs

• Inpatient rehabilitation stays

• Specialty surgeries

This process can result in delays, denials, or forced alternative treatments. In contrast, Original Medicare rarely requires prior authorization, making it more streamlined for timely care.

Prescription Drug Formularies May Limit Your Options

While many Medicare Advantage plans include Part D prescription coverage, they use tiered formularies. These determine:

• Which drugs are covered

• What copay or coinsurance applies

• Whether prior authorization or step therapy is required

If you take brand-name medications or have complex needs, you may find certain drugs aren’t covered or require switching to generics first. Changes to formularies can also occur annually, so what’s covered one year may not be the next.

Supplemental Benefits Might Be Limited or Underused

Extra perks like dental cleanings, gym memberships, transportation, or over-the-counter allowances are often advertised heavily. While attractive, these benefits may have limitations such as:

• Capped dollar amounts

• Limited provider networks

• Reimbursement-only policies

More importantly, CMS reports show that many beneficiaries do not fully use these benefits, either due to lack of awareness or restrictions in availability. That means they don’t always offset the coverage limits in core healthcare services.

Know the Annual Limits and Maximums

Medicare Advantage plans must include an annual maximum out-of-pocket (MOOP) limit for in-network services. In 2025, this limit is $9,350 for in-network care and $14,000 for combined in-network and out-of-network care.

While this protection is important, the real question is how quickly you might reach those limits if:

• You receive care outside the network

• You require expensive treatments not fully covered

• You face high cost-sharing before meeting your deductible

Original Medicare does not have a built-in MOOP, but beneficiaries often pair it with a Medigap plan that helps manage these expenses more predictably.

Star Ratings Can Change Annually

CMS updates star ratings every year based on the previous year’s performance. A plan rated 5 stars in 2024 might drop to 3.5 stars in 2025 due to:

• Customer complaints

• Dropped benefits

• Increased denials

• Poor provider satisfaction

Choosing a plan based only on the most recent rating may not reflect its current value or stability. It’s important to track performance trends and review the plan’s Annual Notice of Change (ANOC) each fall.

Enrollment Windows and Switching Opportunities

You can enroll in a Medicare Advantage plan during:

• Initial Enrollment Period (IEP): The 7-month window around your 65th birthday

• Annual Enrollment Period (AEP): October 15 to December 7

• Medicare Advantage Open Enrollment: January 1 to March 31 (if already in a plan)

If you join a plan and later find it doesn’t meet your needs, you may have limited opportunities to switch. Unless you qualify for a Special Enrollment Period (SEP), you’ll need to wait for one of the above windows.

Matching a Plan to Your Needs Is What Really Saves Money

The best Medicare Advantage plan isn’t the one with the highest star rating, lowest premium, or most extras. It’s the one that works best with your actual healthcare use, expected treatments, and provider preferences.

Ask yourself:

• Are my doctors and hospitals in-network?

• Does the plan cover my regular medications at an affordable rate?

• What’s the total estimated yearly cost, including deductibles and copays?

• Are prior authorizations required for the care I use most?

Evaluating these questions can reveal whether a plan will save you money in the long run or leave you exposed when it matters most.

Choose Your Coverage with Confidence

Medicare Advantage plans offer value, but only when chosen carefully. Pay attention to what’s included, what’s restricted, and how the plan handles care you know you’ll need. If you have chronic conditions or expect frequent provider visits, understanding the fine print can make a significant difference in both cost and access.

To make the right choice, speak with a licensed agent listed on this website. They can walk you through your options based on your personal health profile, ensuring the plan you select truly fits your needs.