Key Takeaways

• The worst Medicare Advantage plans in 2025 use restrictive networks, prior authorizations, and vague language in coverage rules to limit your access to care without openly denying it.

• A low CMS star rating (under 3 stars) is a red flag, often reflecting poor customer satisfaction, excessive delays, and frequent complaints about denied services.

Hidden Barriers Behind a Medicare Advantage Plan

Not every Medicare Advantage plan is built the same. While many offer real value and stability, others use the fine print to quietly undercut your care. You may not realize the shortcomings until you need a specialist, a diagnostic test, or even an urgent treatment. In 2025, understanding how these plans operate is more important than ever.

Low-performing Medicare Advantage plans are often rated 2.5 stars or below by the Centers for Medicare & Medicaid Services (CMS). This star rating reflects actual user experiences, quality of care, and responsiveness. Yet many of these plans remain on the market year after year due to loopholes in how they are monitored and renewed.

What the CMS Star Rating Tells You

The CMS star rating system ranges from 1 to 5 stars, with 5 being excellent. Ratings are based on:

• Member experience and satisfaction

• Management of chronic conditions

• Customer service and complaints

• Preventive care and screenings

In 2025, CMS continues to penalize poor-performing plans by flagging them and restricting their ability to market during Open Enrollment. Still, low-rated plans persist, often rebranded or sold under different names. A rating below 3 stars for three consecutive years typically triggers regulatory oversight, but that doesn’t guarantee your experience will be smooth.

1. Prior Authorization Delays Care

One of the most common limitations in poor-quality Medicare Advantage plans is prior authorization. This means your doctor must request approval from the plan before you receive certain services. While prior authorization can prevent unnecessary care in theory, bad plans weaponize it to create delays or denials.

You might need prior approval for:

• MRIs and CT scans

• Specialist visits

• Physical therapy

• Hospital stays

In many cases, approvals take days or weeks. Some denials are overturned on appeal, but only after you’ve waited or paid out-of-pocket. In 2025, CMS has issued guidance urging plans to streamline their prior authorization systems, but enforcement remains inconsistent.

2. Limited Provider Networks Trap You

Some Medicare Advantage plans severely limit your choice of doctors and hospitals. They may advertise a wide network, but once enrolled, you find out:

• Your preferred doctor is out-of-network

• The nearest in-network specialist is hours away

• Some hospitals in your area don’t accept the plan at all

If you see an out-of-network provider, you might have to pay the full cost. Worse, emergency services are sometimes misclassified to avoid coverage. A strong plan allows flexibility. The worst ones make it difficult to access even basic care without going through multiple steps.

3. Sneaky Language in Plan Documents

A major problem with subpar Medicare Advantage plans is the vague or misleading language in their coverage documents. Terms like “medically necessary,” “covered when appropriate,” or “upon plan approval” can be used to deny care while still technically following the plan rules.

Even though CMS requires standardized benefits, plans can interpret and apply these terms differently. You may think something is covered, only to be told it isn’t because it doesn’t meet “plan criteria,” which they don’t disclose until it’s too late.

4. Poor Appeals Processes That Work Against You

If your care is denied, you can appeal. But the worst Medicare Advantage plans have opaque, multi-step appeal processes. In 2025, CMS mandates that plans resolve standard appeals within 7 days and expedited appeals within 72 hours. However, some plans:

• Delay responses with repeated requests for documents

• Deny without clear justification

• Provide phone support that lacks information or expertise

These tactics discourage people from pursuing legitimate appeals. Many simply give up or pay out-of-pocket. This disproportionately affects individuals with chronic conditions who require ongoing treatment.

5. Overuse of Step Therapy for Medications

Step therapy requires you to try cheaper medications first before the plan covers the one your doctor prescribed. While cost-saving in theory, some plans apply it rigidly:

• Forcing you to retry drugs you’ve failed in the past

• Requiring multiple documentation steps

• Delaying access to the correct medication

CMS rules allow step therapy under Medicare Advantage Part B drug coverage, but only if exceptions are granted promptly. Bad plans often make the exception process long and confusing.

6. High Out-of-Pocket Costs Despite Low Premiums

Medicare Advantage plans often attract attention with low monthly premiums. But those costs are just the beginning. The worst plans offset this with:

• High deductibles and copayments

• Tiered pricing for specialists and procedures

• Limited out-of-pocket maximums that still approach the legal limit ($9,350 in 2025)

If you’re hospitalized, require multiple visits, or need durable medical equipment, your costs can quickly escalate. A low premium doesn’t mean the plan is affordable once you actually use it.

7. Poor Coordination With Medicare Part D

Most Medicare Advantage plans include drug coverage, but poor-quality plans tend to have limited formularies and high tier costs. Some issues include:

• Non-coverage of common medications

• Frequent changes in covered drugs mid-year

• Limited pharmacy networks

In 2025, the Part D annual out-of-pocket cap is $2,000. While this helps, some plans make you go through unnecessary steps before applying that protection. Plans are also required to offer the Medicare Prescription Payment Plan, which lets you spread those costs over the year. But bad plans may not clearly explain or implement it.

8. Lack of Supplemental Benefits Where They Matter Most

Many plans promote dental, vision, and hearing benefits. But underperforming Medicare Advantage plans often:

• Offer only minimal coverage (e.g., a cleaning, not full dental treatment)

• Limit networks to a few providers

• Require separate approvals for simple services

You might also encounter supplemental benefits that sound good on paper but are practically unusable. Transportation benefits, meal delivery, or over-the-counter allowances are often difficult to schedule or poorly administered.

9. Poor Customer Service and High Complaint Volume

CMS monitors the number of complaints a plan receives. High complaint volume is usually tied to:

• Delayed responses to inquiries

• Billing disputes

• Denied services without notice

• Inaccurate provider directories

Customer service is your first line of defense when something goes wrong. Poor-performing plans often outsource it or use automated systems that don’t resolve issues.

10. Automatic Enrollment Pitfalls and Renewal Traps

Some Medicare Advantage plans renew automatically each year. If you’re not careful, you could stay enrolled in a poor-quality plan simply because you didn’t review your Annual Notice of Change (ANOC).

Plans may:

• Quietly change coverage rules or drug formularies

• Increase out-of-pocket costs

• Drop key providers from their network

In 2025, Open Enrollment runs from October 15 to December 7. This is your chance to switch plans, drop Medicare Advantage entirely, or return to Original Medicare.

Protect Yourself With a Clearer View

The worst Medicare Advantage plans hide their weaknesses behind shiny brochures and generic promises. By the time you experience the true cost, it can be hard to reverse the damage. In 2025, with stricter CMS regulations and better transparency tools available, you have more power to avoid these pitfalls.

Carefully review the plan’s:

• Star rating (avoid anything under 3 stars)

• Summary of Benefits and Evidence of Coverage (EOC)

• Drug formulary and provider directory

• Prior authorization requirements and appeals processes

If it feels too complex, that’s a sign you need help. Comparing plans isn’t just about cost. It’s about your ability to get the care you need when you need it.

Make the Right Choice With Trusted Help

If you’re questioning whether a Medicare Advantage plan meets your needs, you’re not alone. Every year, millions of people struggle with limitations that weren’t obvious at sign-up. In 2025, you don’t have to settle. Speak with a licensed agent listed on this website who understands the fine print and can help you find a plan that protects your access to care.