Key Takeaways
-
The worst Medicare Advantage plans often require extensive prior authorizations, restrict access to care, and delay reimbursements, putting your health at risk and creating administrative burdens.
-
A CMS star rating below 3.5 is a red flag. These lower-rated plans frequently fail to meet expectations for service, access, and satisfaction.
What You Thought Was Covered Might Require a Fight
At first glance, many Medicare Advantage plans appear to offer comprehensive coverage. However, some of the worst plans make you work for every benefit. You may find yourself entangled in a maze of prior authorizations, denied claims, and delayed services. These hurdles are not accidental. They’re part of how some plans keep their costs low at the expense of your time, peace of mind, and sometimes even your health.
Understanding the Red Flags of Poor-Performing Plans
The Centers for Medicare & Medicaid Services (CMS) assigns star ratings to Medicare Advantage plans. Ratings range from 1 to 5, with 5 stars being excellent. Plans rated below 3.5 stars consistently underperform across various quality and service categories. These ratings are updated annually and are publicly available.
A low CMS rating usually indicates that the plan has problems such as:
-
Delays in care
-
Poor customer service
-
Complicated or denied reimbursements
-
Limited access to providers
If you’re enrolled in a plan with a low rating, it could be a signal that you’ll face unnecessary obstacles when seeking basic healthcare.
Prior Authorization: The Most Common Barrier
One of the most frustrating features of the worst Medicare Advantage plans is their overuse of prior authorization. This is a process that requires you to get approval before receiving certain treatments, medications, or services.
In 2025, CMS continues to monitor and issue new rules to reduce excessive prior authorization use. But poorly rated plans often still require:
-
Prior authorization for common diagnostic tests such as MRIs or CT scans
-
Approval before starting physical therapy or other rehabilitation services
-
Requests for permission to see out-of-network specialists
These delays can interfere with timely treatment and force you to wait while your health potentially worsens.
Appeals and Denials: Another Administrative Burden
When a Medicare Advantage plan denies a claim or service, you have the right to appeal. But some plans make the process so burdensome that many beneficiaries either give up or miss the appeal window.
Here’s what this can look like:
-
Denied claims without adequate explanation
-
Confusing instructions on how to appeal
-
Long response times that exceed CMS recommendations
CMS requires plans to process expedited appeals within 72 hours and standard appeals within 14 days. However, low-rated plans often miss these timelines, leaving you with unresolved health needs.
In-Network Limitations Reduce Your Options
Many Medicare Advantage plans restrict you to a network of approved doctors, specialists, and facilities. This might seem reasonable, but the worst plans have:
-
Narrow networks that exclude major hospitals
-
Sudden changes to network providers without timely notice
-
Limited availability of specialists in rural or underserved areas
This limitation can be especially harmful if you travel frequently or need specialized care not available in-network. While some plans offer coverage for out-of-network services, they often come with higher out-of-pocket costs or require separate pre-approval.
Hidden Out-of-Pocket Costs Catch You Off Guard
Although all Medicare Advantage plans are required to set a maximum out-of-pocket (MOOP) limit, the worst plans stretch this to the highest allowable thresholds. In 2025, the in-network MOOP can be as high as $9,350.
You might think you’re saving money with lower premiums or added extras, but these plans often have:
-
High coinsurance rates for hospital stays or specialists
-
Separate deductibles for medical and prescription drug coverage
-
Limited coverage for durable medical equipment or skilled nursing care
These costs add up quickly, especially when you’re managing chronic conditions or recovering from surgery.
Prescription Drug Coverage Can Be Unreliable
Part D prescription drug coverage is often bundled with Medicare Advantage plans. However, the worst-performing plans have inconsistent drug formularies and poor pharmacy networks. In 2025, Medicare has capped out-of-pocket drug costs at $2,000 annually, but some plans still manage to create barriers by:
-
Requiring step therapy before approving brand-name medications
-
Removing commonly used drugs from their formularies mid-year
-
Using limited pharmacy networks that exclude convenient options
These practices may leave you with higher drug costs or without access to your preferred medications altogether.
Poor Coordination With Medicare Rules
The worst Medicare Advantage plans often struggle with compliance and updates. In 2025, CMS has introduced new rules to improve transparency and simplify prior authorizations, yet low-rated plans may lag behind in implementation. These delays can impact your access to timely and accurate information.
Some ongoing issues include:
-
Poor integration of Medicare’s electronic prior authorization systems
-
Incomplete information during plan marketing and enrollment
-
Delayed updates to provider directories or drug formularies
If your plan is not keeping up with federal standards, you could be left confused about your rights and benefits.
Customer Service That Feels More Like a Wall Than a Window
Customer service is one of the key metrics CMS uses to rate plans. Poor customer service makes it even harder to get care when you need it. Common complaints in low-rated plans include:
-
Long hold times
-
Inaccurate or conflicting information
-
Lack of follow-through on prior requests or appeals
In 2025, CMS continues to promote digital access tools and transparency. However, plans that don’t invest in improving their support systems leave you to navigate a complex healthcare system on your own.
Marketing That Doesn’t Match Reality
Medicare Advantage marketing is heavily regulated, but some low-rated plans still skirt the edge. Glossy brochures and friendly representatives may highlight extras like dental, vision, or hearing benefits. But these perks often distract from core weaknesses such as:
-
Poor network access
-
Frequent denials of necessary care
-
Difficult prescription access
By the time you discover these issues, you may be locked into a plan until the next Open Enrollment period, unless you qualify for a Special Enrollment Period due to specific life events.
What You Can Do Right Now
If you suspect your plan is underperforming or you’re experiencing many of the issues mentioned, you do have options. Medicare allows plan changes during:
-
Annual Open Enrollment: From October 15 to December 7 each year
-
Medicare Advantage Open Enrollment: January 1 to March 31, for those already enrolled in a Medicare Advantage plan
-
Special Enrollment Periods: Triggered by specific life events like moving, losing coverage, or plan termination
When evaluating other plans, look closely at:
-
CMS star ratings for 2025
-
Provider network access
-
Drug coverage and pharmacy availability
-
Customer service reviews
You can also speak with a licensed agent listed on this website to explore your options in detail.
Don’t Let a Low-Rated Plan Undermine Your Healthcare
The wrong Medicare Advantage plan can force you into a cycle of delays, denials, and disputes. It may promise comprehensive coverage but make you fight for every treatment, test, and reimbursement. By knowing what to look for and understanding how the worst plans operate, you can make more informed choices and protect your health and finances.
If you’re unsure whether your current plan is serving you well, or if you’re looking ahead to the next enrollment period, get in touch with a licensed agent listed on this website. Their guidance can help you avoid the traps of poor-performing plans and ensure your Medicare benefits work as intended.
