Key Takeaways
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The worst Medicare Advantage plans often follow the rules yet leave you facing coverage delays, hidden restrictions, and rising out-of-pocket costs.
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Many low-rated plans (3 stars or below from CMS) still get renewed and heavily marketed, making it essential to dig deeper before enrolling.
What Makes a Medicare Advantage Plan One of the Worst
Some Medicare Advantage plans may appear legal and compliant on paper, but still fail to meet your expectations when you actually need care. These plans don’t have to violate any federal rules to cause frustration. Instead, they rely on limited provider networks, burdensome prior authorizations, and misleading marketing to quietly erode the value you receive.
Here are the most common features that define a substandard plan:
Low CMS Star Ratings
Every year, the Centers for Medicare & Medicaid Services (CMS) publishes a Star Rating system to help you compare plans. The ratings range from 1 to 5 stars, with 5 being excellent. Plans rated 3 stars or below typically:
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Score poorly on customer service
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Have high rates of appeals or complaints
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Delay or deny access to necessary care
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Fall short on chronic condition management
Despite these red flags, many low-rated plans remain on the market and even renew contracts year after year. CMS allows this unless the plan consistently underperforms over a 3-year period, at which point penalties or sanctions may apply.
Restrictive Provider Networks
A common tactic of lower-quality plans is to keep their provider network small. This means:
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Fewer specialists are available in your area
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You may need to travel farther for care
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Your preferred doctors may not be included
Even worse, networks can change yearly. So even if a provider was in-network when you enrolled, that could change in 2025 or any future year, disrupting your care midstream.
Aggressive Use of Prior Authorizations
Worst-performing Medicare Advantage plans are known to overuse prior authorizations. While intended to control costs, this requirement often leads to:
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Delayed access to critical procedures
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Extra paperwork and stress for you and your provider
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Denials for services that are later overturned on appeal
In 2024, CMS reported that nearly 13% of prior authorization requests were denied. Although many were ultimately approved on appeal, the process introduced unnecessary delays in treatment.
Out-of-Pocket Surprises
While Medicare Advantage plans are required to cap annual out-of-pocket spending (in 2025, the maximum is $9,350 for in-network services), this protection doesn’t always mean affordability. Lower-rated plans often:
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Set high copays for specialists and hospital stays
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Charge more for brand-name drugs
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Offer fewer supplemental benefits, increasing your total costs
You may find yourself paying significantly more than expected, especially if your health declines and you need more care.
Misleading Plan Marketing
Low-performing plans often rely on vague or exaggerated marketing messages. These materials might emphasize perks like dental or vision coverage, but gloss over:
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High prior authorization rates
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Gaps in provider networks
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Weak prescription coverage tiers
CMS has tightened rules in recent years to curb misleading advertising, but even compliant marketing can be carefully worded to downplay a plan’s true limitations.
Poor Handling of Appeals and Complaints
Every Medicare Advantage plan must provide a process for appealing denied services. However, the worst plans are slow to respond and frequently deny claims without adequate explanation. This leads to:
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Repeated resubmissions and documentation
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Delays in needed care
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Higher rates of complaints filed with CMS
CMS tracks how each plan handles grievances and includes it in the star ratings. Consistent mishandling is a warning sign you shouldn’t ignore.
Why These Plans Are Still Available in 2025
You might wonder why a Medicare Advantage plan with known issues still exists. The answer lies in how the Medicare system is structured.
CMS Allows Some Underperformance
Unless a plan earns fewer than 3 stars for three consecutive years, CMS usually permits it to continue operating. Even then, termination isn’t automatic. In fact, many plans bounce back after a single good year.
Additionally, some plans cover geographic regions with limited competition. If you live in such an area, your choices may be more limited, making it easier for lower-quality plans to remain in the mix.
Marketing and Sales Influence
Marketing plays a huge role in Medicare plan selection. Flashy ads, national commercials, and sales tactics by call centers can all make a plan seem more attractive than it really is. Unfortunately, some of these marketing campaigns:
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Do not emphasize star ratings
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Avoid discussing provider access limitations
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Focus on superficial perks
By the time you realize your mistake, you may already be enrolled.
How to Spot a Problematic Plan Before Enrolling
Protecting yourself from one of the worst Medicare Advantage plans starts with doing your homework. Here are steps you can take:
Review the CMS Star Rating
Check a plan’s current star rating for 2025. If it has a score below 4 stars, investigate why. CMS publishes detailed data showing exactly where a plan underperforms.
Ask About Provider Networks
Before you enroll, verify that your primary care doctor and specialists are in-network. Call the provider directly if needed. Also ask:
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Are there in-network providers nearby?
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What happens if a doctor leaves the network mid-year?
Request a Summary of Benefits
Every plan must provide a document outlining copays, coverage, and limits. Review this carefully and watch for:
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High copays for outpatient or specialist visits
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Hospitalization coverage details
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Prior authorization requirements
Scrutinize the Drug Formulary
If you take medications, review the plan’s 2025 formulary. Look for:
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Whether your drugs are covered
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Which tier your drugs fall under
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Copayment amounts for each tier
Plans with poor drug coverage can result in hundreds of dollars in extra out-of-pocket expenses each year.
Understand the Appeals Process
Ask the plan how long it takes to process appeals or grievances. If a plan is vague or hard to reach, take it as a warning sign.
Compare with Original Medicare and Medigap
Medicare Advantage isn’t your only choice. Some people may prefer Original Medicare with a Medigap plan for more predictable costs and fewer restrictions. Explore all options before enrolling.
What Happens If You Pick the Wrong Plan
Even if you realize your Medicare Advantage plan isn’t right for you, you may not be able to switch immediately. Here are the timelines that apply in 2025:
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Annual Enrollment Period (AEP): Runs from October 15 to December 7. This is your main chance to change plans.
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Medicare Advantage Open Enrollment Period (MA OEP): From January 1 to March 31. If you’re already in a Medicare Advantage plan, you can make a one-time switch.
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Special Enrollment Periods (SEP): Triggered by certain life events, such as moving or losing other coverage.
If you’re stuck in a poor plan outside these windows, you may face months of limited access and high costs before you can change.
Steps You Can Take to Avoid Regret
To steer clear of the worst plans, commit to a thorough review of your options:
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Use the official Medicare Plan Finder to compare features and star ratings
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Talk to your current doctors about what plans they accept
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Consult the plan’s Evidence of Coverage (EOC) document
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Be skeptical of overly persuasive TV ads or telemarketers
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Work with a licensed agent listed on this website to get personalized advice
Even a few hours of careful research can save you from a year of health coverage frustration.
You Deserve Better Than a Bare-Minimum Plan
The worst Medicare Advantage plans may not technically break rules, but they often fall short in ways that matter to you: access, affordability, and support. In 2025, with more enrollees than ever relying on these plans, it’s critical to choose wisely.
Remember, a shiny brochure or a smooth-talking sales pitch doesn’t guarantee quality care. Pay attention to the details: the star ratings, the provider network, the costs, and the experiences of other enrollees.
If you’re feeling unsure, reach out to a licensed agent listed on this website. They can help you review all your options, compare plan documents, and choose a Medicare Advantage plan that actually supports your needs.
