Key Takeaways

• Some Medicare Advantage plans reduce costs by narrowing provider networks, resulting in the sudden loss of access to trusted doctors or specialists.

• A low star rating, high denial rates, and unclear out-of-network policies are strong indicators of a poor plan that could compromise your continuity of care.

When Your Doctor Disappears from the Plan

You might join a Medicare Advantage plan expecting convenience and cost savings, only to find out later that your preferred doctors are no longer in-network. This often happens without much warning. Plans are allowed to change their provider networks throughout the year, even after you’ve enrolled. As a result, you’re left scrambling for care or forced to start over with unfamiliar providers.

In 2025, this issue is more common than ever. As Medicare Advantage enrollment continues to grow, many plans are under pressure to cut costs. One of the easiest ways for them to do that is to shrink provider networks. Unfortunately, this directly impacts your access to care.

How Networks Work in Medicare Advantage

Medicare Advantage plans use provider networks to manage costs. These networks include doctors, hospitals, specialists, and other healthcare professionals who agree to contract terms and reimbursement rates set by the plan.

There are three common network types:

• Health Maintenance Organization (HMO): Requires you to use in-network providers for all non-emergency care. Out-of-network care is typically not covered.

• Preferred Provider Organization (PPO): Offers more flexibility but charges higher costs for out-of-network services.

• Private Fee-for-Service (PFFS): Offers variable access and reimbursement, often making provider acceptance unpredictable.

In all these types, a plan can decide at any time to remove providers or renegotiate contracts. These decisions can lead to abrupt changes in your access to care.

Star Ratings: Not Always What They Seem

Medicare assigns star ratings to Medicare Advantage plans, ranging from 1 star (poor) to 5 stars (excellent). However, a 3-star or lower rating in 2025 should raise a red flag.

Lower-rated plans are more likely to:

• Have a limited or unstable provider network

• Receive frequent complaints about denied services

• Offer subpar customer service

• Lack transparency in cost-sharing or coverage terms

A plan’s star rating reflects various aspects of performance, but it often misses nuances like hidden network instability. So even a plan rated 3.5 stars might drop your doctor mid-year if cost pressures mount.

The Real Cost of Losing Your Doctor

When your Medicare Advantage plan removes a provider from its network, the impact can be more than just inconvenient. Here’s what can happen:

• Disrupted treatment plans: If you’re receiving ongoing care for a chronic condition or recently had surgery, losing access to your established doctor can delay recovery or require you to start over.

• Increased out-of-pocket costs: If you continue seeing your old doctor, you may have to pay the full cost out of pocket, which can be hundreds or even thousands of dollars.

• Referrals and authorizations reset: Many plans require referrals to see specialists. Switching to a new primary care provider means starting the referral process all over again.

• Loss of trust and continuity: The relationship with your physician is built on trust. Losing that connection can be emotionally and physically stressful.

Prior Authorization Delays Add Another Layer

Many of the worst-performing Medicare Advantage plans also use aggressive prior authorization requirements. This means even if your new provider recommends a test or procedure, the plan may delay or deny it.

In 2025, prior authorization is still a major hurdle for patients in lower-rated plans. These delays are especially problematic when:

• You’re transitioning to a new doctor who is unfamiliar with your medical history

• You require time-sensitive treatments or surgeries

• The plan lacks a streamlined appeals process

This leads to postponed diagnoses, increased emergency visits, and sometimes irreversible health consequences.

Why the Worst Plans Drop Providers Mid-Year

Plan sponsors typically review their network agreements every year. However, contracts can be altered or terminated at any time. Reasons for dropping providers mid-year include:

• Cost-cutting measures: Plans may remove high-cost specialists or hospitals to control spending.

• Disputes over reimbursement: If providers and plans cannot agree on payment terms, contracts may be canceled.

• Mergers and acquisitions: When healthcare systems or insurers merge, existing agreements may change.

Unfortunately, Medicare does not require plans to notify you individually when a doctor leaves the network unless you are actively under that provider’s care. Even then, the notice may arrive too late.

Limited Recourse Once You’re Locked In

Once you enroll in a Medicare Advantage plan, switching plans mid-year is usually only allowed during specific times or under qualifying circumstances. These include:

• Annual Enrollment Period (AEP): From October 15 to December 7 each year. Changes take effect on January 1.

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

• Special Enrollment Period (SEP): Granted for specific life events, like moving or losing other coverage.

If your plan drops your doctor mid-year and it doesn’t meet the criteria for an SEP, you may be stuck until the next enrollment period.

What to Look for Before You Enroll

Preventing surprises starts with a careful plan review. Don’t just go by premiums and advertised extras. Scrutinize the following areas:

• Provider directory: Make sure your doctors are listed as in-network. Contact their offices to confirm they’re accepting the plan.

• Network stability: Look for plans with a history of stable contracts and broad access.

• Star ratings: Be cautious with plans rated below 4 stars.

• Customer complaints: Check the Medicare website for reviews and complaints, particularly those related to network access.

• Referral policies: Understand how much red tape is involved in seeing specialists.

• Out-of-network coverage: Especially important if you travel or split time between locations.

Coverage Limitations You Might Miss

Plans that seem attractive on the surface often hide limitations in the fine print. In 2025, common limitations in poorly rated plans include:

• Narrow hospital networks: Some plans cover only one or two hospitals in a large metro area.

• Limited specialist availability: Especially for cardiology, oncology, or behavioral health.

• No national network: If you live in one state and travel frequently to another, your plan may not cover doctors across state lines.

• Hidden tiered networks: Some plans have tiers of in-network providers, charging you more for certain doctors even if they appear “in-network.”

Understanding these limits before enrolling helps you avoid surprise costs and care disruptions later.

Are You Eligible to Switch?

If you’re currently enrolled in a Medicare Advantage plan and your doctor is dropped, evaluate your eligibility to change:

• MA Open Enrollment Period: Runs January 1 through March 31. You can make one switch.

• Special Enrollment Period: If your doctor leaving the network causes significant care disruption, you might qualify. Contact Medicare or a licensed agent to confirm.

• Five-Star Special Enrollment: If a 5-star plan is available in your area, you can switch once between December 8 and November 30 of the following year.

In all cases, changes must be submitted through Medicare or with the help of a licensed agent.

Medicare Advantage Isn’t Always the Right Fit

While many people appreciate the extra benefits offered by Medicare Advantage, the worst plans often fall short where it matters most: access to care. If you find yourself facing sudden provider loss, confusing authorizations, or rising costs, consider whether staying enrolled in a Medicare Advantage plan is still in your best interest.

Original Medicare with a Medigap policy and standalone Part D plan may offer more predictable access and fewer network restrictions, though the out-of-pocket structure is different.

A Closer Look Helps You Stay in Control

The worst Medicare Advantage plans often look appealing at first glance, especially during enrollment season when ads are everywhere. But once you need care, those hidden limitations come to the surface.

To protect yourself:

• Compare plan networks carefully

• Be skeptical of low-premium marketing

• Monitor your doctors’ network status regularly

• Use every available enrollment window to make a switch if needed

You deserve consistent, high-quality care. If your current plan isn’t providing that, it’s time to consider your options. Speak with a licensed agent listed on this website to review your choices and make a confident, informed decision.