Even Seasoned Retirees Are Getting Trapped by the Worst Medicare Advantage Plans—and Paying the Price

Key Takeaways

• Some Medicare Advantage plans come with hidden risks like prior authorization delays, restricted networks, and poor plan ratings, which may not be evident at first glance.

• In 2025, even experienced retirees are finding themselves burdened by denied claims and unexpected out-of-pocket costs from plans that seem appealing on the surface.

How Lower Star Ratings Can Reveal a Plan’s Shortcomings

The Medicare Star Rating system remains one of the most reliable indicators of plan quality. Ratings range from 1 to 5 stars and are updated annually by the Centers for Medicare & Medicaid Services (CMS). A 1- or 2-star plan consistently performs poorly in key areas such as member experience, customer service, and clinical care.

Low-rated plans often reflect:

• High volumes of complaints or grievances

• Poor outcomes on preventive care metrics

• Inadequate customer service or lack of timely appeals processes

• Frequent issues with medication access or coverage

You might assume these plans wouldn’t even make it onto your comparison list. However, some still appear in search results, mail offers, and even local plan booklets, particularly in rural or underserved areas where plan choices are limited.

Prior Authorization Is a Hidden Barrier

One of the least understood elements of some Medicare Advantage plans is prior authorization. While it’s a standard tool used to control costs and prevent unnecessary treatments, it can delay or deny care even when medically necessary.

In 2025, CMS has introduced new rules to limit the misuse of prior authorization, but many plans still require it for:

• Skilled nursing facility admissions

• Advanced imaging (MRI, CT scans)

• Outpatient surgeries

• Physical therapy beyond a certain number of visits

Even seasoned retirees with a good understanding of the Medicare system can find themselves frustrated when facing these hurdles during an urgent medical need.

Doctor and Hospital Networks That Don’t Go Far Enough

You may expect that your current doctors or specialists will be covered, only to learn later that your preferred providers are out-of-network. Worse, some low-performing plans advertise broad networks but deliver narrow access in practice.

Common issues include:

• Specialist appointments delayed due to limited participating providers

• Nearest in-network hospital located hours away, especially in rural counties

• Long waits for primary care due to provider shortages within network

You should never assume a provider will remain in-network just because they were covered last year. Network participation can change from one plan year to the next, and plans are not required to notify you when a doctor leaves their network.

Prescription Drug Coverage Gaps That Hit When You Least Expect

In 2025, Medicare Advantage plans continue to include prescription drug coverage, but formularies (the list of covered drugs) vary widely. The worst plans have formularies with:

• Fewer generic options

• Limited brand-name coverage for chronic conditions

• High tier placement for common medications

• Step therapy requirements before approving more effective treatments

You may only realize a drug is not covered—or is placed on a high-cost tier—when you go to fill it. By then, switching plans is only possible during the next enrollment period unless you qualify for a Special Enrollment Period.

Cost-Sharing Pitfalls That Add Up Fast

Plans that initially look affordable can turn costly once you start using them regularly. This is especially true in low-rated plans that rely on:

• High copayments for specialists, often $50 to $75 per visit

• Coinsurance rates of 20% or more for outpatient services

• Emergency room copays over $100

• Tiered cost-sharing based on service complexity

While Medicare sets an annual out-of-pocket maximum for Advantage plans, in 2025 this limit can still be as high as $9,350 for in-network services alone. Some plans set higher thresholds for combined in- and out-of-network care, which can quickly overwhelm a fixed retirement budget.

Appeals and Denials: When the Burden Falls on You

Appealing a denied claim under a poor Medicare Advantage plan can be time-consuming and confusing. Lower-rated plans are more likely to:

• Issue denials without sufficient clinical justification

• Delay claim processing and appeals responses

• Lack clear documentation or guidance for enrollees

In 2025, CMS continues to require a formal grievance and appeals process, but the quality of that process varies. Some plans fail to inform beneficiaries of their appeal rights or use complex language that makes it hard to pursue a fair outcome.

Extra Benefits That Sound Better Than They Work

Many Medicare Advantage plans promote non-medical perks like dental, vision, hearing, fitness memberships, and meal delivery. While these can be valuable, low-rated plans often:

• Offer only minimal coverage limits (e.g., $200 annual dental maximum)

• Require use of very specific providers or networks

• Provide inconsistent access to promised services

• Change or drop benefits from one year to the next without adequate notice

These extras should never be the deciding factor. The worst plans use them to distract from core deficiencies in healthcare access, quality, and customer support.

Misleading Marketing Still Exists Despite Tighter Oversight

Despite updated CMS marketing guidelines as of 2025, misleading advertisements still surface, especially during the Annual Enrollment Period from October 15 to December 7. These may include:

• Overstated benefit language not applicable in your area

• Implying provider participation that doesn’t exist

• Using Medicare logos or branding to imply government endorsement

It’s important to review all materials carefully and verify plan details using official sources like the Medicare Plan Finder or by contacting a licensed agent listed on this website.

Enrollment Lock-In Can Make a Bad Choice Hard to Fix

Unless you qualify for a Special Enrollment Period due to a life event (like moving or losing coverage), most people are locked into their plan choice for the year after the Annual Enrollment Period closes.

That means:

• A bad decision in October could result in 12 months of restricted care access

• Limited ability to switch plans until the next Open Enrollment

• No do-over if hidden costs or coverage problems arise mid-year

In 2025, Medicare Advantage Open Enrollment runs from January 1 to March 31, but this only allows you to switch to another Advantage plan or back to Original Medicare once.

What to Look for to Avoid the Worst Plans

It takes more than comparing premiums to make a smart Medicare Advantage decision. Here’s what to evaluate closely:

• Star Rating: Avoid plans rated under 3 stars. Aim for 4 or 5 stars if available.

• Prior Authorization Rules: Read the Summary of Benefits or Evidence of Coverage to understand which services require approval.

• Network Size: Confirm that your doctors, specialists, and hospitals are still in-network for 2025.

• Drug Coverage: Use the plan’s formulary to verify that your medications are covered and check tier placement.

• Out-of-Pocket Maximum: Look beyond the premium. Compare the plan’s total cost structure.

• Extra Benefits: Treat extras as a bonus, not the core of your decision.

Use the Annual Notice of Change (ANOC) letter sent in September to review changes to your current plan. If your plan has dropped in rating or changed coverage terms, that’s a red flag.

Staying Proactive Saves You Trouble Later

Even retirees with years of experience on Medicare can be caught off guard by shifting plan structures, deceptive promotions, and fine print. The Medicare Advantage landscape in 2025 includes over 3,900 plan options nationwide, and the worst ones count on you missing details that matter.

You can protect yourself by:

• Starting plan comparisons early, preferably in September

• Reviewing CMS plan ratings and complaints

• Reading each plan’s Summary of Benefits and Evidence of Coverage

• Contacting a licensed agent listed on this website for unbiased guidance

The Cost of a Bad Plan Isn’t Always Measured in Dollars

A poorly performing Medicare Advantage plan doesn’t just strain your wallet. It can delay essential treatments, limit your provider access, and increase stress during already challenging health situations. Even experienced enrollees can find themselves surprised by how much care is delayed, denied, or narrowed under one of the worst plans.

If you’re unsure whether your current or prospective plan is working in your best interest, don’t wait until something goes wrong. Get clarity before you enroll.

Speak with a licensed agent listed on this website today to review your options and protect your healthcare in 2025.