Key Takeaways
-
Many Medicare Advantage plans appear attractive on the surface, but their hidden restrictions, delays in care, and narrow networks may only become apparent when you actually need medical services.
-
CMS assigns star ratings to Medicare Advantage plans. Plans with fewer than 3 stars are consistently associated with poor customer service, limited provider access, and high denial rates for needed care.
The Problem Doesn’t Start Until You Need Care
You might feel confident after enrolling in a Medicare Advantage plan that promises extras like dental, vision, or fitness perks. But what you don’t see upfront can be the biggest problem. The worst Medicare Advantage plans are often structured to look competitive while quietly putting up barriers that only surface when you seek real medical help.
Unlike Original Medicare, Medicare Advantage plans operate through private companies that create their own rules on provider networks, referrals, and prior authorizations. That flexibility often works against you, especially when plans cut costs by restricting access or denying services.
CMS Ratings: A Critical Tool That Many Overlook
Every year, the Centers for Medicare & Medicaid Services (CMS) publishes star ratings to help you evaluate Medicare Advantage plans. These ratings range from 1 to 5 stars and measure everything from chronic condition management to customer service.
Plans rated below 3 stars are considered poor performers. If your plan has a low star rating, CMS is essentially warning you that this plan has not been meeting expectations in areas that matter most:
-
Preventive care access
-
Handling of appeals and complaints
-
Speed and accuracy of service authorizations
-
Customer satisfaction
-
Member retention
If you’re in a plan with 2 stars or lower, it’s likely you’re dealing with delays in care, restricted choices, and higher denial rates.
When Prior Authorization Delays Turn Into Health Risks
A key red flag in many of the lowest-rated Medicare Advantage plans is the overuse of prior authorization. This is when your plan requires you or your provider to get approval before certain services or medications are covered.
On paper, it sounds like a safeguard. In practice, it can become a barrier to timely care. These delays may:
-
Postpone surgeries or imaging scans
-
Prevent immediate access to physical therapy or home health services
-
Force you to wait days or weeks to see a specialist
In emergency or progressive conditions, these wait times could lead to worse outcomes. And unfortunately, the worst plans often deny authorization outright or require repeat requests.
Limited Provider Networks That Leave You Stranded
Not all Medicare Advantage plans give you wide provider access. The worst ones have ultra-narrow networks with few specialists or primary care providers in your area.
This might not matter when you first enroll, but once you need care for something serious, the consequences become clear:
-
Long travel distances to see an in-network doctor
-
Being told your preferred hospital or provider doesn’t accept your plan
-
Inability to receive a referral for specialty care
Some plans advertise having thousands of providers, but only a small fraction may be available near you. CMS has penalized several plans over the years for misrepresenting their network size and access.
Out-of-Pocket Costs Add Up Quickly
Medicare Advantage plans must cap annual out-of-pocket spending. For 2025, the in-network limit is $9,350, and combined in- and out-of-network costs may go as high as $14,000.
But the worst plans often structure their cost-sharing in a way that makes reaching those caps more likely. You may experience:
-
High copayments for specialist visits, often $50 or more
-
Expensive coinsurance for hospital stays or outpatient surgery
-
Tiered drug formularies that push brand-name drugs into high-cost tiers
If you have a chronic illness or require frequent services, those costs add up fast. And once you’re locked in, it’s not easy to switch.
Supplemental Benefits That Sound Better Than They Are
Many people are drawn to Medicare Advantage plans for the additional perks like dental, vision, hearing aids, or transportation.
But here’s the issue: the worst plans offer these benefits with so many limitations, they end up being difficult to use. For example:
-
Dental coverage might be limited to $500 per year, which doesn’t cover a crown or root canal
-
Vision exams may be included, but the allowance for glasses could be minimal
-
Hearing aid coverage could involve large out-of-pocket costs or be limited to certain models
These perks are used as marketing hooks, but they rarely make up for poor medical coverage.
Appeals Process That Works Against You
If your care is denied by a Medicare Advantage plan, you have the right to appeal. But some of the lowest-rated plans make this process unnecessarily complicated.
What you may encounter:
-
Denial letters that lack clear reasoning
-
Long wait times for appeal decisions
-
Requirements for excessive documentation from your doctor
In many cases, beneficiaries abandon the appeal due to frustration or lack of help. This is particularly problematic for older adults managing complex conditions.
CMS regularly reviews how plans handle appeals and complaints. Plans with poor records in this area often receive 2-star or even 1-star ratings.
Marketing Practices That Mislead Instead of Inform
The worst Medicare Advantage plans often rely on aggressive or confusing advertising to gain enrollees. You may have seen:
-
TV ads promising “extra benefits”
-
Mailers implying you can get free services
-
High-pressure phone calls encouraging immediate sign-up
While not outright illegal, many of these tactics stretch the truth. Once enrolled, you might discover the benefits are minimal or that you’ve lost access to providers you previously used.
In 2024, CMS implemented stricter marketing rules for plan sponsors, but misleading promotions still exist. If a plan sounds too good to be true, it usually is.
Switching Plans Is Limited by Strict Enrollment Periods
Once enrolled, you’re not always able to switch plans right away. Medicare Advantage follows specific timelines for changes:
-
Annual Enrollment Period: October 15 to December 7
-
Medicare Advantage Open Enrollment: January 1 to March 31
Outside of these periods, you can only switch if you qualify for a Special Enrollment Period due to certain life events.
This means that if you pick a poor plan, you might be stuck with it for months. During that time, you could face denials, unexpected bills, or trouble accessing care.
What CMS Star Ratings Mean for You in 2025
As of 2025, CMS continues to update its rating methodology to better reflect what matters to enrollees. The rating system includes over 40 performance measures, such as:
-
Timeliness of care
-
Accuracy of drug pricing
-
Management of chronic conditions
-
Member experience
Only a few plans earn 5 stars. If a plan has fewer than 3 stars for three consecutive years, CMS may flag it for termination. Consistently low-rated plans also lose access to marketing incentives like Special Enrollment Periods.
You can review your plan’s star rating each fall during open enrollment. Plans with high ratings typically demonstrate better service quality, access, and patient satisfaction.
Pay Attention Before You Enroll
The worst Medicare Advantage plans often don’t seem problematic until you actually need care. By then, it may be too late to avoid delays, denials, or unexpected costs.
Here’s what you can do now:
-
Review CMS star ratings before enrolling
-
Ask for the Summary of Benefits and Evidence of Coverage
-
Look up the provider directory and call to verify network access
-
Understand the prior authorization rules for major services
-
Consider how often you might need specialist care or hospitalization
Plans that offer everything at a glance may not deliver when it counts. The most reliable options are those that have stood the test of time in quality ratings, service records, and transparency.
The Real Cost of a Bad Medicare Advantage Plan
A low-performing Medicare Advantage plan might cost you more in frustration and lost health outcomes than it saves in premiums. The trade-off is rarely worth it if you experience:
-
Delayed surgeries or treatments
-
Denied prescriptions
-
Financial hardship from high cost-sharing
-
Loss of trust in your care team due to coverage issues
Health care should bring peace of mind, not uncertainty. If you’re unsure about your current plan or are considering enrollment, speak with someone who can break down the details clearly.
Don’t Let a Bad Plan Surprise You When It Matters Most
Choosing the wrong Medicare Advantage plan can have lasting consequences, especially when your health is on the line. Don’t wait until you’re already in trouble to realize your coverage has serious gaps.
Reach out to a licensed agent listed on this website for help understanding your options and comparing plans based on your health needs, provider preferences, and financial goals. An informed decision now could protect you from regret later.
