Key Takeaways
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A 5-star Medicare Advantage plan doesn’t guarantee that it covers everything you expect. Dig into the benefits, limitations, and out-of-pocket expenses before you enroll.
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In 2025, coverage gaps in top-rated plans often involve dental, vision, prescription tiers, and out-of-network care. Always read the Evidence of Coverage document.
What the CMS Star Rating Actually Tells You
Every year, the Centers for Medicare & Medicaid Services (CMS) assign a star rating to Medicare Advantage plans. This rating ranges from 1 to 5 stars, with 5 being the highest. The 2025 CMS rating reflects plan performance in areas such as preventive care, member satisfaction, managing chronic conditions, and customer service.
While a high star rating signals a well-managed plan with good performance, it does not mean the plan automatically fits your personal healthcare needs. The rating does not account for whether your doctors are in-network, how generous the dental coverage is, or whether your specific medications are on the plan’s formulary.
Key Metrics in the Star Rating
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Member experience and satisfaction
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Managing chronic conditions
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Preventive care
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Customer service
But missing from this list are personalized factors like:
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Whether your preferred specialists are covered
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If you travel out of state and need national network access
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Coverage for hearing aids, eyeglasses, or dentures
So before relying on the CMS star rating alone, ask yourself: does this plan match your actual needs?
What You Think You’re Getting vs. What You Actually Get
Many Medicare Advantage plans market themselves as all-in-one solutions, suggesting that they cover everything Medicare beneficiaries might need. But in 2025, not all benefits are created equal.
Some plans advertise dental, vision, hearing, and fitness benefits. However, these are often limited in scope, capped annually, or available only through specific provider networks.
Common Areas Where Coverage Falls Short
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Dental Coverage: May include only cleanings and X-rays but exclude root canals or crowns.
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Vision Benefits: Often cover a basic eye exam but little or no help for eyeglasses or contacts.
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Hearing Coverage: Some plans only cover hearing exams, not hearing aids.
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Prescription Drugs: Medications in higher tiers may come with significant coinsurance.
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Out-of-Network Care: Emergency services may be covered, but routine care outside the network may result in full cost to you.
If you’re counting on robust dental or prescription drug coverage, you need to verify exactly what is included in the plan documents. Do not assume that all Medicare Advantage plans include comprehensive benefits just because they’re labeled as “the best.”
You May Be Responsible for More Out-of-Pocket Costs Than You Expect
One reason many people switch to Medicare Advantage is the perceived predictability of costs. But while these plans cap your out-of-pocket expenses, the maximum allowable in-network limit for 2025 is $9,350. If your plan also allows out-of-network care, your combined in-and-out-of-network limit could rise as high as $14,000.
That means even with a 5-star plan, you could still pay thousands annually if you require:
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Frequent hospitalizations
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Specialist visits
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Tier 3 or Tier 4 medications
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Durable medical equipment
And while Original Medicare doesn’t cap your costs unless you have a Medigap policy, it does provide predictable coverage across all providers who accept Medicare.
Copayments and Coinsurance Can Add Up
Even when services are covered, you may face copayments such as:
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$40–$75 for specialist visits
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$100–$150 for emergency room visits
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20%–30% coinsurance for outpatient surgeries
Review the Summary of Benefits to estimate your costs based on your actual usage patterns.
Coverage Rules Can Restrict Your Access to Care
Another issue is the utilization rules that accompany Medicare Advantage plans. These are policies such as prior authorization and step therapy, which can delay or limit your access to care.
Prior Authorization
This means your doctor must get approval from the plan before delivering certain services or treatments. Common services requiring authorization include:
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MRIs or CT scans
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Inpatient hospital stays
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Home health care
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Skilled nursing facility care
Step Therapy
For prescription drugs, plans may require you to try less expensive medications before they approve the one your doctor prescribed. This can be especially problematic for chronic condition management.
Even if a plan has top CMS ratings, it may apply strict rules that limit your access to the care you prefer. Make sure you’re comfortable with these protocols before enrolling.
Are Your Doctors and Hospitals in the Network?
Network adequacy is a key consideration when evaluating any Medicare Advantage plan. Plans vary greatly in the number and type of providers included, and network changes can occur annually.
Ask the following questions:
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Are your primary care doctor and specialists in the plan’s network?
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Are your preferred hospitals and urgent care centers included?
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If you live part of the year in another state, will you have access to care there?
Also, remember that in-network providers change from year to year. A plan that works for you now might not be ideal next year if your provider leaves the network.
Travel and Out-of-State Coverage Are Often Limited
Do you travel frequently, live in a different state for part of the year, or visit grandchildren in another region? Many Medicare Advantage plans offer limited coverage outside your service area, especially for routine or non-urgent care.
In 2025, some plans offer national networks or reciprocal arrangements, but most are still geographically restricted. Emergency care is generally covered anywhere in the U.S., but if you need a check-up or chronic condition management outside your home region, it may not be covered.
Verify whether your plan includes any travel or visitor coverage options before making a decision.
Supplemental Benefits Sound Great but Often Fall Short
Medicare Advantage plans frequently advertise additional perks that go beyond what Original Medicare covers. These include:
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Fitness memberships
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Over-the-counter allowances
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Meal delivery after a hospital stay
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Transportation to medical appointments
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Home modifications for accessibility
However, these benefits usually come with strict eligibility rules, annual limits, and usage caps. In fact, many enrollees underuse or never use these benefits at all.
In 2025, CMS has implemented Mid-Year Enrollee Notification of Unused Supplemental Benefits, so you’ll be alerted if you haven’t used your perks. Still, these benefits shouldn’t be your primary reason for choosing a plan.
Choosing the Best Medicare Advantage Plan for Your Needs
If you’re comparing Medicare Advantage plans in 2025, it’s important to go beyond the surface-level features and star ratings. Focus on the following:
1. Understand the Total Costs
Evaluate:
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premiums (if any)
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Copayments and coinsurance
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Out-of-pocket maximums
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Deductibles for medical and drug coverage
2. Check the Drug Formulary
Make sure your medications are covered, especially brand-name and specialty drugs. Review:
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Drug tiers
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Preferred pharmacies
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Mail-order options
3. Confirm Provider Access
Review the provider directory:
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Are your doctors and specialists in-network?
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Are there local hospitals and facilities nearby?
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Are telehealth options available?
4. Read the Plan Documents
Two documents are especially important:
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Evidence of Coverage (EOC): Explains your rights, coverage, and limitations
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Summary of Benefits (SB): Gives a side-by-side comparison of key costs and benefits
5. Look at the Plan’s History
Has the plan maintained a high CMS rating over multiple years? Or did it just earn a high score this year? Stability matters.
Even the Best Plan Isn’t the Right Fit for Everyone
In the end, the best Medicare Advantage plan isn’t the one with the highest CMS score or the most TV ads. It’s the plan that matches your specific doctors, prescriptions, travel habits, and budget. It’s the one that doesn’t leave you surprised by high out-of-pocket costs or limited coverage when you need it most.
Don’t rely on branding or rankings alone. Make sure you carefully compare plan documents and talk to a professional about your unique situation.
Get Help Comparing Medicare Options Today
If you’re unsure about what your current or potential Medicare Advantage plan really covers, it’s time to get clarity. Review the fine print, understand the costs, and evaluate the trade-offs.
For one-on-one support, get in touch with a licensed agent listed on this website. They can help you:
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Review and compare plan documents
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Check provider networks and formularies
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Clarify hidden rules like prior authorization
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Ensure your expected needs are actually covered
Don’t wait until the next enrollment period to discover what’s missing. Make an informed decision now.
