Key Takeaways
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Even if a Medicare Advantage plan looks complete on paper, hidden out-of-pocket costs and narrow coverage can lead to surprise bills you never expected.
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Plans with poor CMS star ratings, excessive prior authorization requirements, and limited networks tend to offer less reliable protection, especially during serious medical events.
Medicare Advantage: Not All Plans Are Created Equal
Medicare Advantage plans are offered as an alternative to Original Medicare. These plans often combine hospital, medical, and sometimes drug coverage into one bundled package. On the surface, they may seem attractive due to additional perks or advertised low costs. But some of the worst Medicare Advantage plans have features that can leave you exposed to unexpected medical bills.
CMS, the Centers for Medicare & Medicaid Services, evaluates and rates these plans on a 5-star scale. While high ratings typically indicate good performance and customer satisfaction, plans rated 3 stars or lower raise red flags. Unfortunately, many such plans still exist in 2025, and some are rebranded versions of previously low-rated plans.
The Illusion of Full Coverage
A common trap for beneficiaries is assuming that “bundled” coverage means “complete” coverage. However, many Medicare Advantage plans come with built-in cost-sharing mechanisms that may look reasonable until you need extensive care. Here’s where the hidden costs come in:
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High maximum out-of-pocket limits: For 2025, the maximum allowed in-network out-of-pocket limit is $9,350. Some plans come close to this cap, meaning you could be responsible for thousands before your plan covers 100%.
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Copays for every service: These can include $20-$60 for routine visits, $100-$150 for emergency care, and even higher amounts for diagnostic testing or outpatient surgery.
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Tiered drug pricing: Prescription drugs may fall into different tiers with varying copays, deductibles, or coinsurance. This is especially problematic if you’re prescribed a medication that isn’t in a lower tier.
Narrow Networks Can Be Financial Traps
Another common feature of low-performing Medicare Advantage plans is a restricted provider network. If you unknowingly receive care from an out-of-network provider or need specialized services that your network lacks, you might face massive out-of-pocket bills.
Plans with limited networks might not cover the following unless you have prior authorization or pay out-of-pocket:
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Specialty hospitals
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Cancer treatment centers
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Skilled nursing facilities
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Out-of-state providers
You may also face challenges if you travel frequently or split your time between two states. These types of plans generally do not offer nationwide provider access.
Prior Authorization: A Major Barrier to Care
Many of the worst Medicare Advantage plans require prior authorization for a broad list of services. In 2025, CMS is enforcing stricter oversight, but these requirements still delay care and often result in denial.
Prior authorizations are commonly needed for:
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MRIs, CT scans, and PET scans
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Physical therapy sessions
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Durable medical equipment
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Hospital admissions
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Certain prescription drugs
What makes these policies problematic is the time it takes to process a request, the paperwork involved, and the likelihood of being denied or delayed. For people managing chronic or complex conditions, these hurdles can be both financially and medically costly.
Star Ratings Aren’t Just for Show
Every year, CMS releases updated star ratings for Medicare Advantage plans. In 2025, any plan rated below 3 stars is flagged for underperformance. CMS evaluates plans based on several measures:
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Member satisfaction
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Timely access to care
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Management of chronic conditions
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Complaints and disenrollment rates
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Pharmacy services
Plans with low star ratings tend to have more complaints, higher denial rates for prior authorizations, and inconsistent coverage. If your plan has a low rating, it’s a strong indicator that you may encounter coverage gaps or excessive out-of-pocket expenses.
Unexpected Coverage Gaps in Key Areas
Some plans advertise added benefits, but bury the fine print in pages of coverage limitations. These include:
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Dental and vision: Many plans only cover preventive dental cleanings and limit vision coverage to basic eye exams. Crowns, dentures, eyeglasses, and more advanced services may not be fully covered.
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Hearing aids: While often mentioned as a benefit, these may only be partially covered or limited to certain models.
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Emergency care while traveling: Out-of-area emergencies may be reimbursed at lower rates, or not at all, depending on how the plan defines emergency versus urgent care.
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Rehabilitation services: Inpatient rehab, speech therapy, or skilled nursing care may come with strict visit caps or copays that add up quickly.
Why the Worst Plans Keep Reappearing
One concerning pattern in 2025 is how certain poorly performing plans rebrand each year. They may change names, slightly adjust benefits, or switch network providers, but the underlying issues remain:
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High denial rates
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Poor customer service
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Limited access to providers
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Lack of transparent cost-sharing details
These tactics make it harder for consumers to identify a poor plan during the enrollment window. The same plan with a new name can look like a fresh, competitive offering while carrying the same structural flaws.
CMS Oversight Still Has Gaps
While CMS takes steps to penalize and monitor plans that consistently underperform, enforcement doesn’t always keep pace with rebranding strategies. Some plans operate at the edge of compliance, using vague language in benefit descriptions and aggressive marketing that oversells what is actually covered.
CMS may penalize plans with:
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Persistent low ratings
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High complaint volumes
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Fraud investigations
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Misleading marketing materials
But in many cases, beneficiaries only discover problems once they attempt to use a benefit or dispute a denied claim.
When Medical Needs Escalate, So Do the Bills
A Medicare Advantage plan might work well enough for routine care, but its true performance is tested during serious health events. Hospital stays, outpatient procedures, or cancer treatment can quickly trigger high copays, coverage denials, or network issues.
Many beneficiaries in poor plans face:
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Large hospital copays per day after a set number of days
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Daily limits on skilled nursing facility coverage
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Drug formulary changes that affect access to medication
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Repeated prior authorization requirements even for ongoing treatments
These costs build rapidly and can derail your financial stability during an already difficult time.
Enrollment Periods Limit Your Options
Medicare Advantage enrollment is not flexible year-round. Unless you qualify for a Special Enrollment Period, you must wait until the Annual Enrollment Period (October 15 to December 7) to make changes.
This means if you discover your plan is problematic in January, you may be locked into it for the rest of the year. That can translate to a full 12 months of:
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Higher than expected out-of-pocket costs
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Delayed access to care
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Network confusion
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Claim denials
CMS allows some exceptions for Special Enrollment, including:
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Moving out of the plan’s service area
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Losing other coverage
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Plan termination by CMS
However, these are limited and not guaranteed.
Strategies to Protect Yourself
Before enrolling or re-enrolling in a Medicare Advantage plan, take time to:
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Review the CMS star rating: Focus on plans rated 4 stars or higher.
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Check the network: Make sure your primary care physician and specialists are in-network.
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Review the out-of-pocket maximum: Compare it to your expected healthcare needs.
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Evaluate prior authorization rules: Look for a plan that requires fewer approvals.
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Read the Summary of Benefits carefully: Identify what’s excluded or capped.
This level of detail helps protect you from plans that appear robust on the surface but leave you exposed to hidden costs.
Choosing a Better Path Forward
Not all Medicare Advantage plans are flawed. Many offer strong coverage, broad networks, and responsive service. But the worst plans continue to market themselves aggressively and disguise critical limitations in fine print.
If you’re currently enrolled in a plan that has disappointed you, or you’re researching options for the upcoming enrollment window, don’t rely solely on promotional materials. A licensed agent can help you compare options, understand the real implications of your plan’s features, and identify safer alternatives for your needs in 2025.
Stay Ahead of Surprise Costs With Expert Help
In 2025, Medicare Advantage plans vary widely in quality, value, and reliability. The worst plans tend to look promising until it’s time to use them. Then the illusion of savings disappears under layers of red tape, missing benefits, and large bills.
If you’re unsure whether your current plan is protecting you or exposing you to risk, speak with a licensed agent listed on this website. They can walk you through your plan’s true costs, clarify coverage, and help you make informed choices during the next enrollment period.
