Key Takeaways

• The worst Medicare Advantage plans in 2025 tend to have low star ratings and are associated with high rates of denied claims and limited access to healthcare providers.

• Understanding the scope of prior authorization, network restrictions, and appeals processes is essential before enrolling in any plan.

What Makes a Medicare Advantage Plan the “Worst” in 2025?

In 2025, not all Medicare Advantage plans are created equal. While many plans offer valuable benefits, others compromise your care by limiting provider choices and denying necessary treatments. You may not see the flaws on the surface, but deeper scrutiny often reveals patterns of red flags, especially among plans rated poorly by the Centers for Medicare & Medicaid Services (CMS).

A low star rating, particularly 2.5 stars or fewer, often signals persistent problems like poor customer service, claim denials, and complaints. Plans are rated on a scale of 1 to 5 stars, with 5 being the highest in quality and satisfaction. Plans on the lower end often fail to deliver consistent or comprehensive care.

Denial of Medically Necessary Care Is a Growing Concern

One of the most alarming patterns in the worst Medicare Advantage plans is the frequency with which they deny medically necessary care. Even when services are covered by Medicare rules, some Advantage plans introduce additional hurdles that lead to:

• High rates of claim denials

• Delays in treatment approval

• Increased patient frustration

In fact, CMS oversight has shown that plans with lower star ratings tend to deny services more frequently, forcing you to go through a lengthy appeals process just to access standard care. These plans often require prior authorization for basic procedures, hospital stays, or even recurring prescriptions, leaving you vulnerable during urgent or ongoing health issues.

Restricted Provider Networks Limit Your Choices

Another defining trait of poor-quality Medicare Advantage plans is the presence of narrow provider networks. These networks often exclude:

• Top-tier specialists

• Major hospitals or academic medical centers

• Physicians you may already have a relationship with

If you enroll in one of these plans, you may find that your preferred doctor or specialist is not included. Worse, you could be forced to travel farther for care or switch providers entirely. While all Medicare Advantage plans have some form of network structure, the worst-performing ones severely restrict your access and offer little flexibility if your health needs change.

High Out-of-Pocket Costs Despite Low Premiums

While it might seem financially appealing to choose a plan with a low monthly premium, these plans often shift costs to you in the form of high out-of-pocket expenses. This includes:

• Higher copayments for specialist visits

• Increased coinsurance for hospitalizations

• More out-of-pocket costs for outpatient services

In 2025, the maximum out-of-pocket limit for Medicare Advantage plans is set by CMS, but many of the worst plans place you near the top of that threshold without offering proportionate care. The illusion of affordability disappears once you actually need ongoing or complex treatment.

Overuse of Prior Authorization Requirements

The worst plans rely heavily on prior authorization as a gatekeeping tool. Instead of streamlining care, this administrative barrier causes:

• Delays in receiving medically necessary procedures

• Denials that require multiple rounds of appeals

• Increased stress and administrative burden on patients

CMS has flagged this as a critical area in need of reform, especially as it relates to hospital admissions, rehabilitation care, and advanced imaging. You should review a plan’s use of prior authorizations before enrolling, as excessive reliance is a strong indicator of future obstacles.

Inadequate Supplemental Benefits

While many plans advertise extra perks like dental, vision, or fitness benefits, the lowest-rated plans in 2025 often fall short in delivering real value. These plans may:

• Impose tight limits on usage

• Cover only basic or preventive services

• Exclude necessary follow-up care or specialist evaluations

These shortcomings become apparent when you attempt to use the advertised benefits and discover they’re insufficient, unavailable in your area, or restricted to a narrow group of providers. The worst plans tend to treat supplemental benefits more like marketing tools than practical healthcare services.

Poor Customer Service and Member Experience

CMS uses member experience surveys to assess how enrollees feel about their plan. Plans with frequent complaints, unresolved disputes, or long wait times for support are routinely downgraded in their star ratings. Poor customer service often includes:

• Confusing explanations of benefits and billing

• Unhelpful or inaccurate information from support representatives

• Difficulty resolving appeals or coverage issues

If you can’t get timely, accurate help when something goes wrong, it adds frustration to an already stressful medical situation. That’s why CMS places significant weight on service and responsiveness in their annual evaluations.

Unstable Provider Contracts and Network Changes

In 2025, some plans continue the trend of altering their provider networks mid-year. This means that a doctor you relied on in January may no longer be covered by July. These midyear changes often:

• Disrupt treatment plans

• Force enrollees to change providers unexpectedly

• Undermine long-term doctor-patient relationships

Plans that frequently update their networks without transparent communication create instability in your care. Reviewing a plan’s history of provider turnover is important to ensure continuity.

Lack of Transparency in Coverage and Appeals

Transparency is another problem in the worst Medicare Advantage plans. These plans often:

• Provide vague or hard-to-find policy documents

• Fail to explain why services were denied

• Make it difficult to understand appeals timelines

You may find yourself confused about what’s covered, how much you’ll owe, or how to challenge an unfair denial. In contrast, better-rated plans tend to provide clear and detailed member handbooks, searchable online tools, and robust support.

Misleading Marketing Practices Continue

Despite increased scrutiny from CMS, misleading marketing remains a concern, particularly among low-rated plans. You may be exposed to advertisements that:

• Overpromise benefits without disclosing limitations

• Use generic language that hides exclusions

• Avoid discussing network limitations or prior authorization

While regulatory agencies are cracking down on misleading ads in 2025, many plans still push the boundaries. Reviewing the fine print and speaking with a licensed agent can help you avoid plans that overpromise and underdeliver.

Warning Signs to Watch For During Enrollment

When evaluating plans during Medicare Open Enrollment (October 15 to December 7), look out for the following red flags:

• Star ratings below 3

• Frequent mention of prior authorization in the summary of benefits

• Network directories with limited specialists

• Low caps on supplemental benefits

• High historical complaint rates with CMS

Take your time to compare the fine details, not just the headlines. Always check how a plan has performed in recent years and whether its provider list includes the healthcare professionals you trust.

Timeline of Key Decisions in 2025

Medicare beneficiaries have specific windows in which they can evaluate or change their plan:

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

• October 15 to December 7: Annual Enrollment Period to make changes for the next year.

• Special Enrollment Periods: Triggered by qualifying events such as moving, loss of other coverage, or plan changes.

During these periods, reassess whether your current plan has denied claims, limited your providers, or caused confusion. If so, it’s time to consider other options.

Why Star Ratings Matter More Than Ever in 2025

Star ratings remain the most accessible way to compare plans quickly. In 2025, CMS has enhanced the rating system to place more weight on customer complaints and denied claims, making it a stronger indicator of quality. Plans with fewer than 3 stars for multiple years are at risk of being terminated or removed from Medicare offerings.

Use the star rating as a filter to eliminate plans with chronic problems. Plans with 4 stars or higher tend to perform better across customer service, health outcomes, and transparency.

Choose Carefully: Your Health Depends on It

The worst Medicare Advantage plans in 2025 often hide behind attractive features, only to reveal their limitations when you need coverage the most. Denied claims, limited networks, high out-of-pocket costs, and weak customer support are all strong reasons to steer clear.

Before making a decision, speak with a licensed agent listed on this website. They can help you evaluate options based on your specific health needs and financial situation, ensuring you select a plan that prioritizes your well-being.