Key Takeaways
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Many top-rated Medicare Advantage plans receive high CMS scores, but gaps in coverage can still catch you off guard if you’re not careful.
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Reviewing plan details such as out-of-pocket limits, referral requirements, and network coverage is essential to avoid surprises during care.
What Medicare Advantage Promises—and What It Doesn’t Guarantee
Medicare Advantage plans offer an alternative to Original Medicare by combining Part A and Part B into a single plan. Most also include prescription drug coverage, and many offer additional services like dental, vision, or hearing. These all-in-one packages appeal to many beneficiaries seeking simplicity.
However, despite being labeled as the “best” plans, even highly rated Medicare Advantage options do not eliminate every cost or coverage concern. Plans are rated annually by the Centers for Medicare & Medicaid Services (CMS) on a 5-star scale, taking into account quality, member satisfaction, and service delivery. But a 4.5 or 5-star rating doesn’t mean the plan will fit your specific health or financial needs.
Common Gaps You May Not Notice Immediately
Even top-performing plans come with certain limitations that may not be obvious during enrollment. Here are the most commonly overlooked gaps that deserve your attention:
Provider Networks Can Be Restrictive
Medicare Advantage plans operate within provider networks. These are often limited to certain doctors, hospitals, and clinics. If you go outside the network, your care might not be covered or may cost more.
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HMO plans typically require referrals and offer no coverage outside the network except in emergencies.
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PPO plans offer more flexibility but may still charge higher out-of-pocket costs for non-network services.
If your preferred doctor or specialist isn’t in the network, you may have to change providers or risk additional costs.
Prior Authorization Requirements Delay Care
Most Medicare Advantage plans require prior authorization for services like MRIs, surgeries, or even some prescriptions. While this process controls costs and ensures medical necessity, it can delay necessary treatments.
You may be surprised how often you need pre-approval, especially for:
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Durable medical equipment (like walkers or oxygen machines)
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Skilled nursing facility care
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Advanced imaging tests
Out-of-Pocket Maximums Are Plan-Specific
One of the benefits of Medicare Advantage is the annual out-of-pocket maximum for covered services, which Original Medicare does not offer. However, these caps vary widely by plan and only apply to in-network services.
For 2025, the maximum out-of-pocket limit allowed by Medicare is $9,350 for in-network care. Some plans set lower limits, but you must verify this detail during enrollment.
Out-of-network costs can fall outside this limit entirely, making the real financial exposure much higher than you anticipated.
Limited Coverage Outside the Plan’s Service Area
Medicare Advantage plans are typically regional. If you travel frequently or live part of the year in another state, your plan might not cover care outside your home area, except for emergencies.
Before choosing a plan, consider:
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Does the plan include national travel coverage?
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Are you required to use providers within your local county or state?
Some plans offer travel benefits, but they are not guaranteed across all providers. This is especially important for “snowbirds” or those with family in other regions.
Prescription Drug Formularies Can Be Restrictive
Although many Medicare Advantage plans include prescription drug coverage (Part D), each plan maintains its own formulary—a list of covered drugs.
Formularies change annually and often:
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Exclude certain brand-name medications
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Require step therapy (trying cheaper alternatives first)
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Include quantity limits
If your essential medication isn’t covered or requires layers of approval, you could face delays or high out-of-pocket expenses.
Supplemental Benefits May Sound Better Than They Are
Many Medicare Advantage plans promote extras like dental, vision, fitness memberships, transportation, and over-the-counter allowances. These can be useful, but they often come with limitations, such as:
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Annual caps on dental work
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Limited provider networks for eyewear
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Restrictions on which services transportation covers
It’s common for these benefits to look generous on paper, but deliver less value than expected in real-world scenarios.
What CMS Star Ratings Tell You—And What They Don’t
CMS assigns star ratings to Medicare Advantage plans each year, evaluating:
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Management of chronic conditions
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Preventive care measures
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Customer satisfaction
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Access to services
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Call center responsiveness
Plans with 4 stars or higher are generally considered excellent. But these ratings reflect overall plan performance—not whether the plan meets your specific needs or preferences.
For example, a highly rated plan may still:
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Lack your doctor in its network
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Impose high specialist copays
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Offer minimal dental coverage
Always compare benefits, costs, and provider access directly rather than relying on the star rating alone.
Annual Changes Add Another Layer of Complexity
Every fall, Medicare Advantage plans release an Annual Notice of Change (ANOC), which details any upcoming changes for the new year. This includes:
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Monthly premium adjustments
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Changes to covered services
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Updated drug formularies
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Revised copay or coinsurance amounts
In 2025, many plans are modifying out-of-pocket costs and altering supplemental benefits in response to CMS payment adjustments and market competition.
It’s critical to review your ANOC letter carefully between October 15 and December 7 during the Medicare Open Enrollment period. Failure to do so could leave you stuck in a plan that no longer fits your needs starting January 1.
Tips to Help You Evaluate Plans Beyond the Hype
Choosing a Medicare Advantage plan is not just about finding the highest-rated or lowest-cost option. You need to focus on what will serve you best over time. Here’s how to conduct a more informed evaluation:
1. Compare Out-of-Pocket Costs, Not Just Premiums
Low or zero premiums do not mean low overall costs. Consider:
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Copays for specialist visits
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Coinsurance for hospital stays
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Annual out-of-pocket limits
Even if the monthly premium is manageable, high usage costs can add up.
2. Check the Provider and Pharmacy Networks
Search the provider directory to confirm your doctors and preferred hospital are included. Also, check that your usual pharmacy is in-network.
3. Review the Formulary for Prescription Coverage
Look up each of your current medications to make sure they are covered, and check what tier they fall under. This directly affects your drug costs.
4. Ask About Referral Rules and Prior Authorizations
Determine if the plan requires you to get referrals for specialists and how frequently services need prior approval.
5. Examine the Details of Extra Benefits
Don’t just see that a plan offers dental or vision coverage. Ask:
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What’s the annual cap on dental procedures?
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Are cleanings and x-rays included?
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Which providers accept the plan’s vision benefits?
The fine print matters when it comes to value.
Gaps Can Be Managed—If You Choose With Clarity
The best Medicare Advantage plan is one that aligns with your healthcare usage, travel habits, medication needs, and budget tolerance. Even highly rated plans come with gaps, but you can manage these by knowing what to expect and comparing features side by side.
To make the most informed choice, speak with a licensed agent listed on this website. They can walk you through the real costs and benefits and help you understand how different plans align with your unique situation.
