Key Takeaways
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Even the highest-rated Medicare Advantage plans can have hidden drawbacks unless you ask the right questions upfront.
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Understanding CMS star ratings, coverage rules, and provider access can help you avoid costly mistakes.
Why High Ratings Aren’t the Full Picture
Each year, the Centers for Medicare & Medicaid Services (CMS) evaluates Medicare Advantage plans and assigns a star rating between 1 and 5. These ratings are based on factors like member satisfaction, plan performance, customer service, and preventive care.
While a 4.5 or 5-star rating may suggest a top-tier plan, that doesn’t mean it’s the right fit for your needs. Ratings are useful indicators, but they don’t account for how the plan works in your local area, which doctors are in the network, or how well it coordinates with your medications and providers.
What CMS Ratings Measure
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Preventive services such as screenings and checkups
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Chronic condition management
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Customer service and complaint resolution
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Member experience with the plan
These are important markers of quality, but they don’t reflect whether your specific doctors or prescriptions are covered, or whether you’ll face limitations with referrals or prior authorizations.
What You Should Ask Before Enrolling
The best Medicare Advantage plans promote attractive features like extra benefits, broad networks, and strong ratings. But unless you ask targeted questions, you could miss crucial details.
Ask About Provider Networks
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Are your current doctors and specialists in-network?
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What happens if your provider leaves the network midyear?
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Does the plan cover care outside your local area if you travel or move temporarily?
Provider access is one of the most commonly overlooked issues. Even highly rated plans may have narrow networks that restrict your choices or require referrals for specialists.
Ask About Prior Authorization
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Which services and treatments require prior authorization?
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How often are these requests denied or delayed?
Some plans heavily rely on prior authorization for tests, hospital stays, or even routine procedures. Delays can create barriers to timely care and may be frustrating when dealing with complex health conditions.
Ask About Prescription Coverage
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Are your current prescriptions covered under the plan’s formulary?
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What tier are your medications in, and what are the cost-sharing amounts?
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Are there any step therapy or quantity limits?
Prescription drug coverage varies widely between plans. In 2025, most Medicare Advantage plans integrate Medicare Part D coverage, but formularies can still change annually. It’s important to check this during open enrollment.
The Allure of Extra Benefits
One of the main reasons Medicare Advantage plans appeal to beneficiaries is the additional benefits many offer. These might include services not covered by Original Medicare.
Common Extra Benefits in 2025
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Routine dental and vision care
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Hearing aids
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Wellness and fitness memberships
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Over-the-counter (OTC) benefit cards
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Transportation to medical appointments
While these benefits sound appealing, they are not standardized. You should look closely at what’s actually offered:
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Is there a dental provider network?
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Are vision or hearing benefits capped annually?
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Do OTC allowances roll over?
Don’t assume all these extras work the same way across plans. Details matter, and what looks generous on paper may be difficult to use in practice.
What to Know About Costs
It’s common to see promotional language around low monthly premiums or added value. But focusing only on premiums can be misleading.
Key Costs to Compare
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Deductibles: Some plans have medical or drug deductibles that apply before coverage starts.
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Copayments and coinsurance: Understand what you’ll pay for routine doctor visits, hospital stays, emergency care, and prescriptions.
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Maximum out-of-pocket (MOOP) limits: In 2025, the maximum for in-network care can be up to $9,350. Once you reach this, the plan pays 100% of covered services.
You must review all cost components together to understand your financial exposure, especially if you have ongoing medical needs.
Coverage Area Limitations
Unlike Original Medicare, which is accepted nationwide, Medicare Advantage plans operate within defined service areas. If you move out of your plan’s area, you may have to change plans.
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Many plans limit coverage to a specific region or county.
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Emergency coverage is available anywhere, but routine or specialist care may not be.
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Snowbirds and frequent travelers should be especially cautious about network access.
It’s vital to verify whether your care will be covered if you split your time between states or move during the year.
Plan Changes Can Happen Annually
Medicare Advantage plans can change from year to year. Even if you love your plan in 2025, its coverage, network, or costs may look different in 2026.
Key Changes to Watch For Each Fall
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Premium adjustments
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Benefit reductions or eliminations
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Provider network changes
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Drug formulary changes
CMS requires plans to notify you of these changes through the Annual Notice of Change (ANOC), usually sent each September. Be sure to read it carefully to avoid surprises in the next calendar year.
Enrollment Periods and Timing
You can only join or change a Medicare Advantage plan during specific periods:
Medicare Open Enrollment: October 15 to December 7
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During this time, you can switch from Original Medicare to a Medicare Advantage plan, or switch between Advantage plans.
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Coverage changes take effect on January 1.
Medicare Advantage Open Enrollment: January 1 to March 31
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Allows beneficiaries already enrolled in a Medicare Advantage plan to switch to a different Advantage plan or return to Original Medicare.
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Only one change is allowed during this window.
Outside of these periods, you generally must qualify for a Special Enrollment Period due to events like moving, losing other coverage, or becoming eligible for Medicaid.
Ratings Don’t Measure Plan Fit
Star ratings do not measure how well a plan fits you. A top-rated plan may work great for many, but not for someone with your doctors, prescriptions, or travel habits.
When choosing a plan, ask yourself:
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Does this plan fit my lifestyle?
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Will I be able to continue seeing my preferred providers?
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Can I afford the out-of-pocket costs if my health needs change?
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Are my medications easy to access under this plan?
Personal alignment matters more than popularity or perks.
How to Compare Plans Wisely
Take your time to review all available Medicare Advantage plans in your area. CMS provides a comparison tool at Medicare.gov, which can help narrow options. Use filters for:
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Plan ratings
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Covered medications
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Provider network availability
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Extra benefits
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Estimated out-of-pocket costs
Speak with a licensed agent if you’re unsure how to interpret the details. A well-informed decision now can prevent complications later.
When You Need Help, Ask the Experts
The world of Medicare Advantage can be filled with terminology, variations, and trade-offs. Even well-meaning plans can end up frustrating if you don’t ask the right questions upfront.
Don’t rely solely on ratings or advertisements. Use your enrollment periods to reassess your needs each year, ask deeper questions, and look beyond surface-level benefits.
If you’re unsure which Medicare Advantage plan aligns best with your needs, now is the time to talk to a licensed agent listed on this website. Their guidance can help you make a smart, informed decision tailored to your unique circumstances.
