Key Takeaways
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Many top-rated Medicare Advantage plans receive high CMS ratings, but those scores don’t always reflect out-of-pocket costs or network restrictions that could affect your access to care.
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Supplemental perks might look appealing in advertisements, but they can distract from more important plan features like annual out-of-pocket maximums and prior authorization requirements.
Medicare Advantage Plans: The Promises vs. the Reality
Each year, the Centers for Medicare & Medicaid Services (CMS) assigns star ratings to Medicare Advantage plans on a scale from 1 to 5. These ratings evaluate performance across multiple quality measures like customer service, member experience, chronic condition management, and preventive services. Plans that receive 4 stars or higher are considered high-performing. However, even a 5-star plan might not be the right fit for your specific needs.
While CMS ratings are useful, they don’t tell the full story. Ads often emphasize the most favorable parts of a plan—like dental, vision, gym memberships, or drug benefits—without mentioning the trade-offs. What you don’t see in the ads could have a serious impact on your out-of-pocket expenses, provider choices, or treatment timelines.
CMS Ratings Are Helpful, But Not Definitive
Medicare Advantage star ratings consider:
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Preventive care and screenings
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Member complaints and satisfaction
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Chronic condition management
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Access to timely appointments
What they do not consider:
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The size or quality of provider networks
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The ease of getting referrals or authorizations
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Real costs for routine vs. specialized care
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Your ability to see out-of-network providers
So while a 4.5-star plan might reflect strong overall performance, it could still be restrictive or expensive in ways that affect your care.
The Illusion of Extra Benefits
Many Medicare Advantage plans advertise a long list of additional benefits. These might include:
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Vision and dental coverage
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Hearing aids
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Over-the-counter allowances
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Transportation services
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Meal delivery
While these can be valuable, they vary significantly between plans and regions. Some are only available under limited conditions or through specific providers. Others may be capped at low annual limits. Ads rarely explain that these perks may not apply uniformly or may require prior authorization.
Prior Authorization: A Hidden Hurdle
Prior authorization is one of the most overlooked aspects of Medicare Advantage plans. It requires you to get approval from the plan before receiving certain services, treatments, or prescriptions. This step can:
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Delay necessary care
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Result in denials if not properly filed
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Add administrative burden to you and your doctors
By contrast, Original Medicare typically does not require prior authorization for most services. If your treatment plan includes specialists, surgeries, or therapies, checking the prior authorization rules in your Medicare Advantage plan is crucial.
Network Limitations Can Affect Access
Medicare Advantage plans are managed by private companies, which usually create local or regional provider networks. That means:
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You must see in-network doctors for the lowest cost
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Out-of-network care may not be covered at all (except in emergencies)
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Changing providers may require starting over with a new network or obtaining referrals
Some plans offer broader networks, but those options may come with higher costs or be less available in rural areas.
Cost Sharing: The Real Price of Care
While premiums for Medicare Advantage plans can appear low, the true cost lies in:
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Annual deductibles
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Copayments for primary and specialty care
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Coinsurance percentages for hospital stays or outpatient procedures
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Prescription drug tiers and coverage rules
In 2025, Medicare Advantage plans have a maximum in-network out-of-pocket limit of $9,350, and up to $14,000 when including out-of-network care. While this cap helps protect you from catastrophic expenses, you could still be responsible for thousands of dollars depending on your health needs.
Drug Coverage Under Part D
Most Medicare Advantage plans include prescription drug coverage, but formularies vary widely. In 2025, beneficiaries benefit from a $2,000 annual out-of-pocket cap under Part D. Even with this protection, plans still have tiers that affect:
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Which drugs are covered
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How much you pay for generic vs. brand-name prescriptions
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Whether you must try less expensive drugs first (step therapy)
If you rely on ongoing medication, it’s essential to verify that your drugs are covered and affordable under the plan you choose.
Star Ratings and Their Limits
While CMS star ratings are intended to provide a snapshot of a plan’s quality, they are based on aggregated data that may not reflect:
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Current provider availability in your region
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Real-time issues with customer service or claims
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Your specific healthcare needs and preferences
For instance, a plan might have a high rating due to preventive care outreach but still struggle with timely specialty appointments. You should always compare star ratings alongside plan documents like the Summary of Benefits, Evidence of Coverage, and drug formulary.
Annual Enrollment and Switching Plans
Medicare Advantage enrollment happens during specific times of the year:
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Annual Enrollment Period (AEP): October 15 to December 7. You can join, switch, or drop a plan.
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Medicare Advantage Open Enrollment Period (MA OEP): January 1 to March 31. You can switch to another Medicare Advantage plan or go back to Original Medicare.
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Special Enrollment Periods (SEP): Triggered by specific events like moving, losing coverage, or qualifying for Medicaid.
Even after enrolling in a plan with great advertising or a high star rating, you can make a change if it doesn’t suit your needs. But waiting too long can lead to unexpected bills or service disruptions.
Supplemental Coverage Isn’t the Same
Original Medicare beneficiaries often pair their coverage with a Medigap plan and standalone Part D coverage. This combination provides:
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Freedom to see any provider who accepts Medicare
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No need for referrals
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Predictable cost sharing
Medicare Advantage plans consolidate services but often limit flexibility. Be sure you understand the difference in how these options manage care and costs.
Misleading Marketing Tactics
In 2025, CMS continues to regulate how Medicare Advantage plans are advertised. However, misleading impressions can still occur, such as:
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Overstating availability of benefits
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Using fine print to obscure important limitations
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Implying that a plan is endorsed by Medicare
Always read the full plan documentation and consult with a licensed agent listed on this website to confirm the details.
Choosing a Plan Should Start With You
Rather than starting with a commercial, your plan search should begin with your:
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Preferred doctors and hospitals
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Ongoing prescriptions
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Frequency of specialist visits
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Anticipated health needs in the coming year
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Willingness to deal with authorizations and referrals
Once you define your needs, then compare Medicare Advantage plans using CMS ratings as a guide—not a final verdict.
Short-Term vs. Long-Term View
Many plans appear attractive in the short term due to the added perks or lower upfront costs. But over a full year, limitations in coverage or provider access may:
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Result in higher cumulative costs
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Delay necessary care
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Limit your treatment options if your health changes suddenly
Be cautious about switching plans for minor benefits unless you understand the long-term trade-offs.
Why a Second Opinion Matters
Before making any changes, review:
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The plan’s full Summary of Benefits
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The list of in-network providers and pharmacies
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The Evidence of Coverage (EOC) document
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Prior authorization requirements
You can get help from a licensed agent listed on this website to walk through these documents and explain what they mean in practical terms.
Make Informed Decisions That Fit Your Health Priorities
The best Medicare Advantage plan for you in 2025 isn’t the one with the flashiest advertisement or the highest rating. It’s the one that fits your budget, supports your providers, covers your prescriptions, and allows you to get the care you need with minimal barriers.
Before enrolling, speak with a licensed agent listed on this website who can walk you through the fine print and help you weigh the benefits against the potential drawbacks.
