Key Takeaways

• Some Medicare Advantage plans advertise broad coverage but severely restrict access to care when you need it most, especially during hospitalization or complex treatment.

• Plans with low star ratings (under 3 stars) often indicate poor customer service, delays in prior authorizations, and limited provider networks, which can result in delayed or denied care.

Promises vs. Reality: What Happens When Your Health Takes a Turn

When you first enroll in a Medicare Advantage plan, everything may look appealing. Many plans promote added benefits and lower monthly premiums. But problems often surface when you’re already in the middle of a health emergency. That’s when some of the worst Medicare Advantage plans reveal their hidden flaws: care delays, network limitations, and denied treatments.

In 2025, more Americans than ever are enrolled in Medicare Advantage. Unfortunately, a growing number also discover too late that their plan may not deliver the dependable access to care they expected, particularly when urgent or complex health issues arise.

What Defines a “Worst” Medicare Advantage Plan in 2025?

While no plan markets itself as being subpar, certain characteristics often signal future complications. These traits may not stand out during enrollment, but they can have serious consequences once you begin needing regular medical care:

Low Star Ratings

Medicare Advantage plans receive star ratings from the Centers for Medicare & Medicaid Services (CMS), ranging from 1 to 5 stars. In 2025:

• A 2-star plan indicates below-average performance in quality, service, and member satisfaction.

• Plans under 3 stars for three consecutive years risk losing eligibility for enrollment.

Low star ratings are a warning sign that current enrollees experience issues such as:

• Denied claims

• Poor customer service

• Inaccurate billing

• Delayed access to specialists

Narrow Provider Networks

One of the most common and damaging issues with low-performing Medicare Advantage plans is a limited network of doctors and hospitals. You may enroll thinking your local specialists are covered, only to find out later they are out-of-network or have left the plan altogether.

This means:

• You may need to switch providers during active treatment.

• You could face steep out-of-pocket costs for out-of-network care.

• You may experience long wait times for available in-network appointments.

Excessive Prior Authorizations

In 2025, CMS has attempted to reduce burdens around prior authorizations, but some plans still use them aggressively. If you are hospitalized or require surgery, these approvals can slow down treatment significantly.

The worst plans often:

• Require prior approval for common diagnostic tests, therapies, and prescriptions

• Delay urgent treatments

• Deny coverage unless extensive documentation is submitted

When you are in the middle of a health crisis, waiting for approvals can result in worsening health or unnecessary suffering.

Poor Out-of-Pocket Cost Protections

While some Medicare Advantage plans tout low or even no monthly premiums, what matters more is how much you pay during care.

The worst plans often come with:

• High copayments for specialist visits and procedures

• Steep coinsurance percentages for hospital stays

• Maximum out-of-pocket limits that approach the federal cap (in 2025, this is $9,350 for in-network services)

These costs can quickly overwhelm your budget if you require multiple treatments or hospitalization.

Limited Supplemental Benefits in Practice

Many plans advertise supplemental benefits like transportation, dental, or meal delivery. But under the worst-performing plans, these features may come with significant restrictions:

• Mileage or appointment limits on transportation

• A limited selection of dental providers

• Reduced or seasonal access to benefits

While these perks might influence your choice during enrollment, they often prove difficult to use when you need them.

When the Cracks Show: Mid-Crisis Breakdown

The real test of a Medicare Advantage plan happens not during enrollment, but when you are sick, recovering from surgery, or managing a chronic illness. At that point, every delay, denial, or unexpected bill takes a toll.

In a health emergency, these are the moments when weak plans break down:

• Hospitalization: Some plans may cover only specific hospitals in a region. If your local ER is out-of-network, you may have to be transferred.

• Skilled Nursing Facility (SNF) care: Medicare covers up to 100 days after a hospital stay, but some Advantage plans require stricter approval processes or may not contract with your preferred SNF.

• Rehabilitation or Physical Therapy: Frequent sessions may require multiple prior authorizations, limiting your recovery speed.

• Specialist Care: If a condition worsens and you need a specialist urgently, limited networks can mean waiting weeks.

By the time these issues become apparent, you may be locked into your plan until the next Open Enrollment Period, which occurs from October 15 to December 7 each year. Outside of that, your ability to switch is limited unless you qualify for a Special Enrollment Period.

Common Member Complaints Against Low-Rated Plans

According to recent CMS data and beneficiary reports, some of the most common frustrations reported with poorly rated Medicare Advantage plans include:

• Long hold times with customer service

• Billing errors that require multiple calls to correct

• Providers dropping from the network mid-year

• Authorizations denied despite clinical urgency

• Unclear benefit explanations and inconsistent documentation

These complaints are not isolated incidents. When seen across a broad membership base, they are indicators of systemic issues within the plan’s administration.

How Star Ratings Reflect Real-World Experience

CMS updates its star ratings every fall, and in 2025, a significant number of plans have ratings between 2.5 and 3 stars. These ratings factor in more than 40 performance measures, including:

• Managing chronic conditions

• Preventive care access

• Member experience

• Customer service responsiveness

• Complaints and appeals

Low star ratings often align with:

• Frequent member grievances

• High turnover in provider networks

• Lack of timely screenings or vaccinations

Avoiding these plans means looking at ratings before enrollment and not relying solely on plan advertisements.

How to Avoid Picking a Poor-Performing Plan

You can protect yourself from these mid-year surprises by taking a few specific steps during the Medicare Open Enrollment Period:

1. Always Check the Star Rating

Plans rated 4 stars or higher consistently perform better in customer satisfaction, care access, and cost predictability. Be wary of plans below 3 stars, especially if they’ve been rated that low for multiple years.

2. Review the Network Directory Carefully

Before enrolling, verify that your current doctors, specialists, and hospitals are in the network. Then confirm again directly with the provider office, as directories can be outdated.

3. Scrutinize the Evidence of Coverage (EOC)

The EOC explains what is covered, what costs apply, and how benefits are accessed. Pay close attention to:

• Hospitalization costs

• Prior authorization requirements

• Out-of-pocket maximums

• Coverage rules for out-of-network care

4. Consider Your Current and Anticipated Health Needs

A plan that works for someone who only visits their doctor twice a year may not serve well for someone managing diabetes, heart disease, or recovering from surgery. Choose a plan that reflects your health priorities.

5. Look Beyond Marketing

Don’t be swayed by flashy ads, giveaways, or vague promises of “comprehensive” care. Focus on hard facts: plan documents, ratings, provider participation, and coverage rules.

The Price of Poor Choice: Long-Term Consequences

When you pick a substandard Medicare Advantage plan, the ripple effects can last well beyond a single year:

• Delayed diagnoses can result in disease progression.

• Switching providers during ongoing treatment can disrupt your continuity of care.

• Unexpected bills can deplete your retirement savings.

• Mental stress from paperwork and appeals can impact recovery.

In 2025, your healthcare choices are too important to leave to chance. Each year brings changes in networks, benefits, and plan performance. One mistake could cost you your health, your time, and your peace of mind.

When You’re Ready to Make a More Informed Choice

The true strength of a Medicare Advantage plan isn’t in the brochure—it’s in how well it performs when your health is on the line. Plans with weak ratings, narrow networks, and excessive authorization rules can seem harmless until you’re in the middle of a crisis.

That’s why it’s essential to get personalized guidance before you commit to a plan. If you’re unsure whether your current plan protects you during emergencies, or if you’re looking to switch during the next enrollment period, get in touch with a licensed agent listed on this website for advice. Your future self will thank you.