Key Takeaways
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What’s advertised as a top-rated Medicare Advantage plan may still carry restrictions that impact referrals, networks, and travel coverage.
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Always review plan documents in detail, including Summary of Benefits, Evidence of Coverage, and Star Ratings, before enrollment.
Why Star Ratings Are Just a Starting Point
When searching for the best Medicare Advantage plans, you’ll often see CMS Star Ratings used as a benchmark. These ratings, provided by the Centers for Medicare & Medicaid Services (CMS), evaluate plan performance on a 5-star scale. Plans are scored on factors like customer service, managing chronic conditions, member experience, and preventive care.
While a high star rating (4 or 5 stars) signals that a plan performs well overall, it does not mean the plan is ideal for your unique healthcare needs. These ratings are based on national benchmarks and do not account for whether your preferred doctor is in-network, whether you travel frequently, or if you require specialized care that needs referrals.
Before enrolling, consider the star rating as just one part of the decision—not the final word.
Understanding Network Limitations
Medicare Advantage plans usually operate through Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) structures. These networks define where and how you receive care.
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HMOs typically require you to use doctors and hospitals within a defined local network and may require referrals for specialists. You usually need a primary care doctor coordinating your care.
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PPOs offer more flexibility, allowing you to see out-of-network providers at a higher cost, and generally do not require referrals. However, they still often have preferred provider lists, and using out-of-network care can lead to unexpected bills.
This becomes particularly problematic if you live in one state and travel to another frequently or have a part-time residence elsewhere. Even top-rated plans may have narrow networks that limit coverage when you’re outside your local service area.
Specialist Access Isn’t Always Simple
Some Medicare Advantage plans are marketed as covering a wide range of specialists, but in practice, getting an appointment might be far more difficult. Here’s why:
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Referral Requirements: Many plans require a referral from your primary care provider to see a specialist. If your plan is an HMO, this referral process is almost always mandatory.
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Wait Times and Availability: A plan may technically cover a specialist type in your region, but the available providers might be few, and appointment availability may be limited.
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Out-of-Network Restrictions: If the specialists you need are outside the plan’s network, you could face higher out-of-pocket costs or may not be covered at all.
It’s important to review the plan’s provider directory and confirm availability before making a decision.
Drug Coverage: The Fine Print Matters
Nearly all Medicare Advantage plans include prescription drug coverage, but coverage details vary widely. Here are the key elements to examine closely:
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Formulary (Drug List): Every plan has its own list of covered drugs, often organized into tiers. Higher-tier drugs usually have higher copays.
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Prior Authorization: Some medications require your doctor to obtain permission from the plan before the drug will be covered.
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Step Therapy: You may be required to try a lower-cost drug before the plan covers a more expensive one, even if your physician prefers the higher-tier drug.
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Coverage Rules: Limitations on quantity, refill frequency, or pharmacies may apply.
For 2025, Medicare Part D plans (including those embedded in Advantage plans) include a $2,000 annual out-of-pocket maximum for prescription drugs. However, how fast you reach that cap and what you pay along the way still depends on your plan’s structure.
Emergency and Travel Coverage May Be Limited
One of the most overlooked areas when evaluating Medicare Advantage plans is how they handle travel and emergency care. While plans are required to cover emergency services anywhere in the United States, other types of care often come with limitations.
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Routine Care While Traveling: Many plans only cover non-emergency care if it’s received within your service area. If you’re out of town and need to see a doctor, you may have to pay out-of-pocket.
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Snowbirds and Dual Residency: If you live in one state in the summer and another in the winter, you must check whether the plan’s network includes providers in both locations. Some PPOs offer partial coverage outside your area, but HMOs often do not.
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International Travel: Standard Medicare Advantage plans generally do not cover care received outside the U.S. unless it’s for emergency services in very limited circumstances.
If you expect to travel, ensure your plan supports your mobility without risking unexpected bills.
Supplemental Benefits Sound Generous but Come with Rules
Medicare Advantage plans often promote additional services not covered by Original Medicare. These can include:
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Dental and vision benefits
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Hearing aids
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Fitness memberships
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Over-the-counter allowances
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Transportation to medical appointments
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In-home support services
While these extras sound appealing, they often come with usage limits, network restrictions, or approval requirements. For instance:
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A dental benefit may only cover cleanings and x-rays, but not major procedures like crowns or dentures.
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OTC allowances may be restricted to certain vendors and product lists.
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Transportation benefits might be limited to a fixed number of rides per year.
In 2025, fewer plans are offering over-the-counter and transportation benefits compared to 2024. Always read the Evidence of Coverage (EOC) to understand what’s actually provided.
Prior Authorization Can Delay Care
Many of the highest-rated plans still require prior authorization for various services. This means your doctor must get approval from the insurance plan before you receive specific treatments or services.
Services that often require prior authorization include:
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Advanced imaging (like MRI or CT scans)
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Inpatient hospital stays
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Skilled nursing facility care
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Durable medical equipment
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Physical therapy
Although prior authorization is meant to control costs and ensure medical necessity, it can lead to treatment delays. You may also have to resubmit documents or appeal if the authorization is denied.
For 2025, CMS has implemented stricter oversight on the use of prior authorizations, but the requirement still exists in many plans and should not be overlooked.
Out-of-Pocket Costs Vary More Than You Think
Even if a plan offers attractive premiums, it’s essential to look beyond the monthly cost and consider your potential annual spending. The total out-of-pocket costs depend on how often you use care and what services you need.
Here are the general cost categories you should evaluate:
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Copayments: Set dollar amounts for specific services, like $40 for a specialist visit or $100 for urgent care.
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Coinsurance: A percentage of the cost of services, such as 20% of an outpatient surgery.
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Deductibles: The amount you must pay before your plan begins covering certain services.
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Maximum Out-of-Pocket (MOOP) Limit: The total amount you’ll pay in a year before the plan pays 100% of covered services.
For 2025, the maximum allowed MOOP for Medicare Advantage plans is $9,350 for in-network care. Some plans set lower limits, but the number alone doesn’t reflect your likely costs unless you review the copays and coverage for the services you expect to use.
Annual Plan Changes Require Ongoing Review
A plan that worked well for you in 2024 may no longer be the best option in 2025. Medicare Advantage plans can change:
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Premiums and deductibles
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Provider networks
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Drug formularies
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Supplemental benefits
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Out-of-pocket cost structures
You’ll receive an Annual Notice of Change (ANOC) every fall, summarizing how your plan will change in the upcoming year. Review this document carefully during the Medicare Open Enrollment period from October 15 to December 7.
Don’t assume your plan is still a good fit just because you’ve used it before. Compare it against other options each year to avoid surprises.
How to Read the Fine Print Effectively
To understand what you’re really getting with a Medicare Advantage plan, review these documents:
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Summary of Benefits: Provides a high-level comparison of what’s covered and how much it costs.
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Evidence of Coverage (EOC): Offers detailed information on rules, limitations, provider networks, and covered services.
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Provider and Pharmacy Directories: Lists in-network doctors, specialists, and pharmacies.
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Drug Formulary (Part D): Details which medications are covered and under what conditions.
Focus on how the plan handles your specific needs. If you have chronic conditions, take regular medications, travel frequently, or see specialists often, these factors should weigh heavily in your decision.
Your Health Needs Deserve More Than a 5-Star Label
Choosing a Medicare Advantage plan is about more than finding one labeled “best” or “top-rated.” You need to consider the nuances of coverage, networks, medications, and benefits that matter to you. A plan that works perfectly for someone else may be entirely unsuitable for your circumstances.
To make the best decision, consult all available resources, read plan materials carefully, and compare multiple options side by side. Open Enrollment gives you the opportunity to adjust your plan every year, and it’s wise to take full advantage of that window.
For personalized guidance, speak with a licensed agent listed on this website who can help you weigh the fine print and choose the Medicare Advantage plan that truly fits your life.
