Key Takeaways

• The worst Medicare Advantage plans often prioritize flashy extras over core healthcare needs, sacrificing provider flexibility and straightforward access to services.

• A low CMS star rating (below 3 stars) is a key indicator that a plan may underperform in important areas like member experience, customer service, and access to care.

When Plans Overpromise and Underdeliver

Some Medicare Advantage (MA) plans look good on paper but reveal their shortcomings when you try to use them. These plans may advertise extensive benefits, yet what they offer in theory can be frustratingly difficult to access in reality. For instance, a plan might boast dental, vision, or fitness perks but bury important limitations in the fine print. Meanwhile, fundamental services like seeing a specialist or getting approval for a procedure often come with excessive barriers.

If you’ve ever wondered why some MA plans seem too good to be true, it’s often because they are. The worst of these plans trade your healthcare flexibility for extras that are rarely worth the cost in time, stress, or delayed care.

What CMS Star Ratings Really Tell You

The Centers for Medicare & Medicaid Services (CMS) uses a 5-star rating system to evaluate Medicare Advantage plans. These ratings cover over 40 quality measures across multiple categories:

• Member experience

• Customer service

• Preventive care

• Chronic condition management

• Complaints and access to services

Plans that earn less than 3 stars are considered poor performers. In fact, CMS may flag these plans for consistently low quality. For 2025, CMS continues to publish annual star ratings during the fall, just before Medicare Open Enrollment begins on October 15 and ends on December 7.

While a high rating doesn’t guarantee a perfect experience, a low rating almost always signals trouble. If you’re reviewing a plan with a 2.5-star or 2-star rating, it’s wise to consider that a red flag.

Loss of Provider Flexibility

Many of the worst Medicare Advantage plans severely restrict your choice of healthcare providers. This often appears in the form of narrow networks or required referrals:

• Limited Networks: You may be restricted to a small list of doctors, specialists, and hospitals. Even within your ZIP code, your preferred provider might not be covered.

• Referrals Required: In some plans, you can’t see a specialist without first getting a referral from your primary care physician. This adds delays, especially for time-sensitive conditions.

• Out-of-Network Penalties: If you go outside the network, you could face significantly higher costs or have no coverage at all unless it’s an emergency.

In contrast, Original Medicare typically offers more flexibility without the requirement to use a specific network of providers.

Prior Authorization and Delayed Care

One of the most common complaints about poor-performing MA plans is the frequent use of prior authorization requirements. This means you or your doctor must get approval from the plan before accessing certain services, such as:

• Diagnostic tests like MRIs or CT scans

• Rehabilitation services

• Hospital stays

• Prescription drugs

While prior authorization is meant to control unnecessary spending, it often delays necessary care. In 2024, reports from healthcare organizations showed that beneficiaries sometimes waited days or even weeks for approvals. In urgent cases, these delays can seriously impact your health.

In 2025, CMS has announced increased scrutiny of prior authorization practices, but many low-rated plans continue to use them extensively, affecting access to timely care.

Extra Benefits That Sound Better Than They Are

The worst Medicare Advantage plans often rely on “extra benefits” as their primary marketing hook. These may include:

• Dental, vision, and hearing benefits

• Transportation services

• Over-the-counter (OTC) allowances

• Fitness programs

While these benefits sound attractive, they often come with strings attached:

• Dental benefits may cover only routine cleanings and exclude dentures or more complex procedures.

• Transportation services may require scheduling days in advance and only allow a limited number of rides per year.

• OTC allowances can be restrictive, with narrow vendor options and monthly caps.

These benefits shouldn’t distract from the core purpose of health insurance: providing access to quality medical care when you need it.

High Out-of-Pocket Costs

Medicare Advantage plans are required to set a maximum out-of-pocket (MOOP) limit each year. In 2025, the MOOP for in-network services is capped at $9,350, and for combined in- and out-of-network services, it’s $14,000.

The worst plans often structure their benefits to keep monthly premiums low but shift substantial costs to you in other ways:

• High specialist copays (often $50 or more per visit)

• Emergency room copays exceeding $100

• Expensive inpatient hospital stays due to daily coinsurance

If you have multiple health conditions, these costs can add up quickly, making what seemed like a cost-effective plan very expensive over time.

Poor Member Support and Service

Low CMS-rated plans often receive poor marks in customer service. If you’ve ever been stuck on hold for an hour or transferred repeatedly without answers, you’ve likely encountered one of these plans. Key warning signs include:

• Difficulty getting coverage questions answered

• Delays in processing appeals or grievances

• Misinformation about plan rules or provider availability

In 2025, CMS continues to evaluate call center wait times and customer satisfaction as key performance metrics. Plans that fall short in these areas are often those that also struggle in access to care and service delivery.

Limited Coverage for Chronic Conditions

Managing chronic conditions requires consistent care, medication, and follow-ups. Some low-performing Medicare Advantage plans do not invest adequately in chronic condition management programs. This can lead to:

• Gaps in medication coverage

• Lack of care coordination between providers

• Missed preventive screenings

This is especially risky if you have conditions like diabetes, heart disease, or COPD. Look closely at a plan’s CMS ratings in chronic care management before enrolling.

Denials and Appeals: A Growing Concern

CMS tracks how often Medicare Advantage plans deny services and how often those denials are overturned on appeal. Poor-performing plans tend to:

• Deny medically necessary services at a higher rate

• Require more documentation for basic care

• Make it harder for enrollees to understand or complete the appeals process

Although beneficiaries have the right to appeal, the process can be time-consuming and overwhelming—especially when your health is at stake.

Enrollment and Switching Timeframes

If you discover you’re enrolled in one of the worst Medicare Advantage plans, know your options for making a change:

• Medicare Open Enrollment (Oct 15 to Dec 7): You can switch plans or return to Original Medicare for coverage starting January 1.

• Medicare Advantage Open Enrollment Period (Jan 1 to Mar 31): Allows you to switch to another MA plan or go back to Original Medicare if you’re already enrolled in a Medicare Advantage plan.

• Special Enrollment Periods (SEPs): Triggered by specific events like moving, losing coverage, or a plan being rated below 3 stars for three consecutive years.

In 2025, CMS continues its policy of allowing an SEP for those enrolled in consistently low-performing plans.

How to Identify Better Alternatives

Avoiding poor-quality plans requires a mix of research and expert input. Here are a few ways to protect yourself:

• Review the CMS Star Rating and avoid plans below 3 stars.

• Compare costs beyond just the monthly premium. Evaluate copays, deductibles, and MOOP.

• Check the provider directory to ensure your doctors and hospitals are included.

• Look at what’s covered—and what’s not—under extra benefits.

• Seek help from a licensed agent listed on this website who can walk you through plan differences in detail.

Protect Your Coverage Before You Commit

Choosing the wrong Medicare Advantage plan can feel like locking yourself into a maze of restrictions, delays, and hidden costs. Even in 2025, when more regulations are in place to protect you, low-rated plans still make it to market and are aggressively marketed with attractive promises that don’t always hold up.

Don’t make your decision based on advertising alone. Read the fine print, compare CMS ratings, and consult with a licensed agent listed on this website before you enroll. Your future healthcare access depends on the choices you make today.