Key Takeaways

• A highly rated Medicare Advantage plan might still include hidden limitations such as narrow provider networks, prior authorization barriers, or rising annual out-of-pocket costs.

• Understanding what is not included in the plan materials is as important as knowing what is. The fine print can influence your long-term costs and access to care.

What Makes a Medicare Advantage Plan Seem Like the Best

Medicare Advantage (MA) plans often advertise extra benefits and convenience. Many of the highest-rated plans receive 4 or 5 stars from the Centers for Medicare & Medicaid Services (CMS), which evaluates plans based on quality, customer service, and health outcomes. In 2025, over half of Medicare Advantage enrollees are in plans rated 4 stars or higher.

These plans usually offer:

• Combined Part A and Part B coverage

• Prescription drug coverage (Part D)

• Vision, dental, and hearing services

• Fitness programs and wellness incentives

• 24/7 telehealth services

While these features are attractive, they don’t tell the full story. Some limitations and costs are not clearly outlined, and if you don’t pay attention to them now, they could become major issues later.

Understanding the CMS Star Rating System

CMS assigns star ratings to Medicare Advantage plans annually. Ratings range from 1 star (poor) to 5 stars (excellent). These ratings consider factors such as:

• Member satisfaction surveys

• Clinical quality measures

• Customer service responsiveness

• Chronic condition management

A 5-star plan is rare and often limited to certain regions. However, even a plan with a 4.5-star or 5-star rating may not be the best fit for your personal health needs if it restricts access or includes high cost-sharing in specific areas.

What High Ratings Don’t Show You

Star ratings reflect plan performance across a range of standardized metrics, but they don’t account for your individual circumstances. Here’s what they might not reveal:

1. Provider Network Limitations

Many top-rated plans operate within Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), which limit which doctors and hospitals you can use.

• HMOs require you to use in-network providers and get referrals for specialists.

• PPOs allow out-of-network care but often at much higher costs.

If your preferred doctor or facility isn’t in the network, you could face substantial out-of-pocket expenses or be forced to switch providers.

2. Prior Authorization Requirements

Even high-rated plans can require prior authorizations for services like MRIs, surgeries, or durable medical equipment. This process can delay care and create confusion.

In 2025, CMS has introduced some reforms to prior authorization practices, but many plans still retain these policies for cost control. It is essential to read the plan’s Evidence of Coverage (EOC) to know which services require approvals.

3. Annual Out-of-Pocket Costs

Medicare Advantage plans have a maximum out-of-pocket (MOOP) limit for in-network services. In 2025, this limit is $9,350 for in-network care. However, many plans set their limits below that.

But a lower MOOP does not guarantee lower costs. Consider:

• Copayments for specialist visits, which can range from $30 to $60

• Emergency room visits, often $100 or more

• Tiered prescription drug costs, especially for name-brand medications

Without closely examining your potential utilization and calculating expected costs, you might underestimate your annual spending.

4. Hidden Trade-Offs in Supplemental Benefits

Benefits like dental and vision may come with:

• Annual caps (e.g., $1,000 for dental services)

• Limited provider networks

• Restrictions on frequency (e.g., one eye exam every two years)

So, while these benefits appear attractive, their practical value might be far less than expected.

5. Geographic Coverage Limitations

Plans are tailored to specific counties or regions. A plan that works well in your zip code may offer limited or no coverage if you travel frequently or move states.

This can be particularly problematic if you split time between two residences or require care while away from home. Medicare Advantage’s local focus may not suit those with mobile lifestyles.

Cost Increases Over Time

While a plan may appear affordable now, premiums, deductibles, and cost-sharing requirements can increase from year to year. Even if you’re in a high-rated plan today, it’s important to:

• Review the Annual Notice of Change (ANOC) every September

• Compare your current plan’s 2025 terms against previous years

• Factor in changes to your own health needs and prescriptions

Failing to reassess annually may result in unexpected costs or coverage disruptions.

Prescription Drug Coverage: Not Always as Robust as It Looks

Most Medicare Advantage plans include Part D coverage, but:

• Formularies vary widely

• Coverage phases (deductible, initial coverage, and catastrophic) can affect your costs

• Step therapy may be required before higher-tier drugs are approved

In 2025, Medicare Part D introduces a $2,000 annual out-of-pocket cap. However, some plans may still enforce restrictions such as limited pharmacy networks or require mail-order services for full benefits.

You must compare plan drug lists to your personal prescriptions to avoid gaps or higher costs.

Service Access Delays

Top-rated plans still participate in cost-control strategies that can slow down your access to timely care:

• Delays from prior authorizations

• Waiting times for in-network specialists

• Complicated appeals processes if services are denied

This is especially concerning if you have complex or chronic conditions that require coordinated and prompt care.

Enrollment Periods and What You Can Do

It’s critical to act during the right timeframes:

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

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

• Medicare Advantage Open Enrollment Period (MA OEP): January 1 to March 31 (for switching MA plans or returning to Original Medicare)

If you miss these windows, you may be locked into a plan with rising costs or limited coverage.

Evaluating a Plan Beyond the Advertising

Before choosing a plan:

• Review the Summary of Benefits and Evidence of Coverage documents

• Check CMS star ratings but don’t rely on them alone

• Use Medicare’s Plan Finder tool to compare drug formularies and cost estimators

• Talk to a licensed agent who can walk you through the nuances

Understanding the less-advertised aspects of Medicare Advantage plans will help you select coverage that fits your long-term needs.

Why You Should Be Cautious About Too-Good-to-Be-True Plans

A plan that looks perfect on the surface may mask serious issues:

• Mid-year formulary changes

• Lack of access to specialists

• Rising copays for critical services

• Denial of care due to documentation errors or coverage limitations

In 2025, the variety of plans available makes shopping complex. Do not assume the highest-rated plan is also the most suitable one. Your health status, travel patterns, and preferences should guide your decision.

Smart Medicare Planning Starts With Transparency

When you enroll in a Medicare Advantage plan, you’re replacing Original Medicare with a private alternative. This trade-off comes with pros and cons that are not always fully disclosed in advertisements or marketing materials.

Plans with excellent CMS ratings deserve attention but not blind trust. Only a thorough review of the plan’s actual structure, cost-sharing design, and network access can provide clarity.

If you’re uncertain about the specifics or overwhelmed by the options, it’s important to talk to someone who specializes in this area.

Make Sure the Plan You Choose Works for You Long-Term

Selecting a Medicare Advantage plan in 2025 means balancing immediate benefits with long-term flexibility and access. Before committing, make sure you:

• Understand how the plan handles referrals, authorizations, and appeals

• Verify your providers are in-network and accepting new patients

• Evaluate total yearly costs, not just monthly premiums

• Consider whether your prescription needs align with the plan’s formulary

To avoid costly surprises, get in touch with a licensed agent listed on this website. They can help you compare your choices and match you with a plan that aligns with your health needs, budget, and expectations.