Key Takeaways

• Some of the worst Medicare Advantage plans disguise critical coverage restrictions behind polished brochures and vague benefit summaries.

• You can avoid getting locked into one of these plans by looking past the surface and checking CMS ratings, provider access, and prior authorization rules.

When a Good-Looking Plan Turns Out to Be a Bad Deal

Each fall, as Medicare Open Enrollment rolls around, you may receive stacks of promotional materials. These brochures promise extra benefits, low monthly costs, and even rewards for healthy habits. But as attractive as these features may seem, they can also obscure the warning signs of a poorly performing Medicare Advantage plan.

The Centers for Medicare & Medicaid Services (CMS) rates plans annually using a 5-star system. While these ratings are a valuable tool, some plans that appear solid still manage to fall short when it comes to real-world performance. Glossy marketing doesn’t always reflect what you’ll actually experience once enrolled.

What the Brochures Don’t Tell You

Marketing materials are legally required to include certain disclosures, but that doesn’t mean they make critical limitations obvious. Many of the worst plans pass under the radar because they offer benefits that look good on paper but are difficult to use in practice.

Key limitations often hidden in enrollment materials:

• Restrictive Provider Networks: Some plans limit you to a small group of doctors or require referrals for specialists, creating delays and headaches.

• Aggressive Prior Authorization: Services like MRIs, outpatient surgeries, and even post-hospital care may require multiple layers of approval.

• Benefit Triggers and Caps: Additional benefits like dental or vision may be capped at levels that don’t cover comprehensive treatment.

• Limited Travel Coverage: While some plans advertise nationwide networks, many only cover urgent or emergency care outside your region.

Why CMS Ratings Matter but Aren’t Enough

CMS publishes its annual Medicare Advantage Star Ratings each fall, evaluating plans across categories like customer service, member satisfaction, health outcomes, and complaints. Plans rated below 3 stars for three consecutive years may be flagged or removed from the Medicare program.

But just because a plan is rated 3 stars or higher doesn’t mean it will meet your needs. Many 3-star plans remain in the system despite significant member complaints or operational issues.

Here’s what to keep in mind:

• Ratings Are Averages: They don’t reflect regional performance, which can vary widely.

• Scores Don’t Cover Everything: Ratings focus on compliance and outcomes, not how well a plan meets your individual expectations.

• A 3-Star Plan Is Barely Passing: You might find lower member satisfaction and weaker provider networks in such plans.

High Pressure and Vague Promises

Some of the most aggressively marketed plans rely on sales tactics that blur the line between education and persuasion. During Open Enrollment, television ads, mailers, and phone calls might push you to act quickly to “lock in” benefits.

Be cautious of plans that:

• Push vague promises like “enhanced coverage” without specifics

• Focus heavily on add-ons while downplaying core coverage restrictions

• Use sales scripts that downplay CMS ratings or provider limitations

If you’re not comparing coverage side-by-side with Original Medicare or another Medicare Advantage plan, it’s easy to miss how limited these plans truly are.

Common Features of Poorly Performing Plans

Plans that consistently receive member complaints or low satisfaction scores tend to share several characteristics. Recognizing these features can help you steer clear of unnecessary complications.

1. Narrow Provider Networks

If a plan only includes a small number of primary care doctors or requires referrals for specialists, your care may be delayed. Worse, if your doctor leaves the plan midyear, you might be stuck finding a new provider.

2. Excessive Prior Authorization Requirements

Prior authorization isn’t inherently bad, but excessive use can delay treatment and burden both you and your doctor. If your plan requires approval for many common services, it could lead to denials or long wait times.

3. High Out-of-Pocket Maximums

CMS allows Medicare Advantage plans to set an annual in-network out-of-pocket maximum up to $9,350 in 2025. Poor plans often set their limits near this threshold, leaving you vulnerable to high costs if you have a serious illness.

4. Limited Supplemental Benefit Access

Dental, vision, and hearing benefits are often highlighted in marketing but may come with strict usage rules, waiting periods, or low coverage limits. In some cases, the benefits are only discounts rather than insurance coverage.

5. Frequent Coverage Denials and Appeals

CMS tracks complaint rates and appeals. Plans with higher rates of overturned denials or complaints often appear less reliable. If a plan’s denial rate is high, that’s a red flag.

How the Annual Enrollment Period Plays Into the Problem

From October 15 to December 7 each year, you can switch Medicare Advantage plans. Unfortunately, this period is also when the worst plans ramp up their marketing efforts.

You may be targeted with messages highlighting fringe benefits without meaningful discussion of the coverage gaps. If you enroll without reading the Summary of Benefits or Evidence of Coverage documents, you may be surprised by:

• Referral requirements

• Prior authorizations for basic services

• Out-of-network care not being covered

• Lack of continuity with your current providers

Warning Signs in the Plan Documents

Glossy brochures don’t reveal everything. But you can find the real details in the Evidence of Coverage (EOC) and Summary of Benefits documents. If a plan won’t make these available before enrollment, consider that a major red flag.

Look closely for:

• How many services require prior approval

• Limitations on dental, vision, and hearing benefits

• Geographic limits on provider access

• Conditions for travel or out-of-area care

Reviewing these documents takes time but could save you a year of frustration.

You Can’t Always Rely on Past Performance

Plans can change dramatically from year to year. In 2024, some plans lost access to provider networks or reduced supplemental benefits. Even if your plan worked well last year, check the Annual Notice of Change (ANOC) every fall to see what’s changing.

You might discover:

• Increased deductibles or copays

• Dropped providers

• New prior authorization rules

• Adjusted drug formularies

CMS requires these changes be disclosed, but they are often buried deep in documents few people read.

Getting Help Before You Commit

Because it’s hard to compare plans side-by-side, many people rely on mailers, ads, or single sales agents for guidance. That’s risky.

Instead, consider:

• Speaking with a licensed agent listed on this website

• Asking specific questions about prior authorizations and provider access

• Comparing the plan’s CMS rating to the national average (currently around 4.1 stars in 2025)

• Reviewing the drug formulary to ensure your medications are covered

What Happens If You Enroll in a Bad Plan?

If you choose a poorly performing plan, you may not be able to change until the next Open Enrollment. There are a few exceptions:

• Medicare Advantage Open Enrollment Period (January 1 to March 31): Allows you to switch to another MA plan or return to Original Medicare.

• Special Enrollment Periods: Available for events like moving, losing other coverage, or qualifying for Medicaid.

However, in most cases, you’re locked into your choice until the next year. That’s why it’s essential to do your homework up front.

Take the Time to Review Before You Enroll

While flashy enrollment materials might catch your attention, they rarely give the full picture. The worst Medicare Advantage plans rely on surface-level appeal while concealing the fine print that impacts your daily healthcare.

Ask yourself:

• Is your current doctor in the network?

• Are your medications on the plan’s formulary?

• How often will you need to get approval before receiving care?

• What is the true cost if you get seriously ill this year?

The more you question the claims in the marketing, the better chance you have of finding a plan that serves you—not just sells to you.

Avoiding a Year of Regret Starts With a Single Conversation

You don’t have to figure this out alone. A licensed agent listed on this website can help you compare options, understand your rights, and choose a Medicare Advantage plan that matches your health needs and financial priorities.

Glossy marketing won’t answer your questions. But a real person can.