Medicare Advantage Says It Covers Everything—But There’s a Catch Hiding in the Details

Key Takeaways

• Medicare Advantage plans often promote all-in-one coverage, but network restrictions, prior authorizations, and plan-specific limitations may affect how and when you receive care.

• Costs may not be as straightforward as they appear—what’s included in the plan may be offset by higher out-of-pocket expenses or limited provider choices.

What Medicare Advantage Promises—and Why It Sounds So Good

When you first hear about Medicare Advantage, it might sound like the perfect package. These plans are advertised as offering everything Original Medicare does—plus extras like dental, vision, and hearing. They consolidate your Medicare Part A and Part B coverage into one plan and usually include prescription drug coverage.

You might also be told that this type of plan includes wellness perks, gym memberships, and more comprehensive care coordination. On paper, it feels like convenience and coverage wrapped together.

But that’s only one side of the story.

What You’re Really Signing Up For

Medicare Advantage, also known as Medicare Part C, operates differently from Original Medicare. While Original Medicare is run by the federal government, Advantage plans are provided by private companies that contract with Medicare. This fundamental difference impacts how care is delivered, what’s covered, and what you might end up paying.

Network-Based Care

Most Medicare Advantage plans use networks of doctors, specialists, hospitals, and pharmacies. If you go outside this network, your care might not be covered—or you may pay significantly more.

• HMO (Health Maintenance Organization) plans often require you to choose a primary care provider and get referrals for specialists.

• PPO (Preferred Provider Organization) plans offer a bit more flexibility but still reward you financially for staying within the network.

If your preferred doctor or hospital isn’t in the network, you may have to either switch providers or reconsider the plan.

Prior Authorization: The Hidden Gatekeeper

A major difference between Medicare Advantage and Original Medicare is the use of prior authorizations. This means your doctor may need to request approval from the plan before certain procedures, treatments, or prescriptions are covered.

This extra layer of bureaucracy can:

• Delay treatment

• Lead to denied claims

• Cause administrative frustration for both you and your provider

In 2025, prior authorization remains one of the most debated aspects of Medicare Advantage plans. Federal agencies continue to evaluate how often these delays impact health outcomes.

Out-of-Pocket Costs Aren’t Always Predictable

One of the main attractions of Medicare Advantage is the promise of capped out-of-pocket spending. For 2025, the maximum in-network out-of-pocket limit is $9,350, and up to $14,000 when you include out-of-network costs.

That might sound like a safety net—and in some ways, it is. But how you reach those numbers matters:

• Each visit to a specialist, lab, or hospital may come with a separate copayment or coinsurance.

• Emergency visits or urgent care might cost more than you expect.

• If you have chronic conditions that require frequent services, costs can accumulate rapidly.

Original Medicare doesn’t have a built-in out-of-pocket cap, but many people choose to pair it with a Medicare Supplement (Medigap) plan to help cover those gaps more predictably.

Prescription Drug Coverage May Be Included—But Check the Formulary

Most Medicare Advantage plans include Medicare Part D coverage. However, not all formularies (the list of covered drugs) are created equal. Some medications might be excluded, require step therapy, or need prior authorization.

In 2025, the Medicare Part D landscape includes a new $2,000 cap on annual out-of-pocket prescription drug costs. That’s a significant improvement for all Medicare drug plans—but it doesn’t guarantee your medication will be on the plan’s list, or that it’ll be placed in a low-cost tier.

Make sure to review:

• Which drugs are covered

• What tier your medication is in

• Whether your pharmacy is in the preferred network

Benefits That Sound Great—Until You Try to Use Them

Many Advantage plans market dental, vision, hearing, and wellness benefits as value-added extras. While this can be helpful, there are limits you need to understand:

• Dental coverage often focuses on cleanings and exams, with limited support for crowns or root canals

• Vision may only cover a basic annual exam and a narrow allowance for eyeglasses

• Hearing benefits could include discounted hearing aids but not full coverage

• Fitness perks may only apply to specific gyms or programs

These extras can be useful, but they are not as generous as they may appear in advertising. You’ll want to ask questions like:

• Is there a waiting period before using these services?

• Are there annual coverage limits or dollar caps?

• Which providers accept the plan for these services?

Travel and Emergency Care: Stay Close or Pay More

If you travel often or spend time in different states during the year, Medicare Advantage plans can be restrictive. Unlike Original Medicare, which is accepted nationwide, many Advantage plans only cover emergencies when you’re outside your service area.

Here’s what you need to ask:

• Does the plan cover urgent care or telehealth visits while traveling?

• What happens if you need hospitalization away from your home state?

• Can you receive routine care out of network?

Some PPO plans offer limited travel coverage, but the rules vary. In 2025, these limitations continue to surprise beneficiaries who assume their plan offers the same freedom as Original Medicare.

Enrollment and Plan Switching Aren’t Year-Round

Another catch hidden in the details is the limited timeframe in which you can change or leave a Medicare Advantage plan:

• Initial Enrollment Period (IEP): Begins three months before your 65th birthday and lasts for seven months total.

• Annual Enrollment Period (AEP): From October 15 to December 7, you can switch plans or return to Original Medicare.

• Medicare Advantage Open Enrollment Period (MA OEP): From January 1 to March 31, you can switch to another Advantage plan or return to Original Medicare—but only once.

Outside these periods, you need to qualify for a Special Enrollment Period (SEP) due to specific life events such as moving, losing employer coverage, or entering a care facility.

Star Ratings May Not Tell the Full Story

Each year, Medicare assigns a Star Rating (1 to 5) to Advantage plans based on factors like member experience, care quality, and customer service. But even high-rated plans can have issues with access, billing, or provider satisfaction.

Keep in mind:

• Ratings are averaged across the plan’s entire service area

• They may not reflect your local provider network’s performance

• They don’t guarantee that prior authorization delays won’t happen

Don’t rely solely on the stars. Ask for the plan’s summary of benefits and provider directory, and verify what’s included before you enroll.

What to Do Before You Sign Up

Before enrolling in any Medicare Advantage plan, take these steps to make an informed decision:

• Compare plan costs and benefits carefully using the official Medicare Plan Finder tool

• Ask for the Summary of Benefits and Evidence of Coverage

• Confirm provider participation in the plan’s network

• Review prescription drug formularies to see if your medications are covered

• Check for prior authorization requirements on the services you use most

Choosing the right coverage isn’t just about what’s promised—it’s about what actually works for your health, lifestyle, and budget.

Look Closer at the Fine Print Before You Commit

Medicare Advantage plans do offer a range of benefits under one roof, but that doesn’t always mean they offer better value. It depends on your specific health needs, where you live, and how often you access care. The trade-offs—restricted networks, prior authorizations, limited flexibility—can become costly surprises if you don’t dig deeper.

If you’re unsure whether Medicare Advantage is the right choice for you, it’s best to get personalized advice. Speak with a licensed agent listed on this website to discuss your options in detail before making a decision.