Key Takeaways
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Some Medicare Advantage plans advertise low costs and broad coverage but leave out critical details about limitations, especially around networks, referrals, and prior authorizations.
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Star ratings are helpful, but even 3-star or 3.5-star plans can come with hidden expenses and coverage restrictions that aren’t obvious until you actually try to use the plan.
What You Don’t See in the Brochure Matters More Than You Think
When you review a Medicare Advantage brochure, it may seem like everything is covered. You might see routine dental, vision, hearing, and even gym memberships included, all under a predictable monthly premium. But the worst Medicare Advantage plans often leave out key facts in their marketing materials. Those missing details could lead to unexpected bills, delays in care, or outright denials when you need healthcare the most.
Let’s take a closer look at the gaps many of these plans hide, how they can cost you, and what red flags to watch for during enrollment season.
Star Ratings Are a Starting Point, Not a Guarantee
Medicare Advantage plans are rated on a scale of 1 to 5 stars, with 5 being the highest. These ratings are based on performance in several areas:
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Member experience
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Customer service
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Management of chronic conditions
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Access to preventive services
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Complaints and plan changes
While it may be tempting to assume that anything with at least 3 stars is acceptable, that’s not always the case. Many of the plans that cause the most issues are rated between 2.5 and 3.5 stars.
Star ratings don’t reflect:
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How narrow a provider network might be
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How burdensome the prior authorization process is
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Whether members face repeated delays in care
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What percentage of out-of-network claims are denied
You need to dig deeper than the star rating to understand what the plan will actually be like in practice.
Limited Networks That Restrict Your Choice
Some of the worst-performing plans in 2025 continue to rely on narrow networks. These plans:
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Exclude major hospitals and health systems
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Have limited specialists, especially in rural areas
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Make it difficult to get second opinions
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May require you to change your primary doctor
If you go outside the plan’s network, you may be responsible for the full cost of care, or face steep out-of-pocket expenses. The average out-of-network coinsurance can be as high as 40% to 50%, depending on the service.
The brochures often advertise access to “many doctors,” but don’t specify that those doctors may be concentrated in only certain counties or cities.
Prior Authorization: A Barrier to Timely Care
A troubling feature of the worst Medicare Advantage plans is the overuse of prior authorization requirements. In 2025, this still remains a major complaint among enrollees.
Here’s how it impacts you:
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You may need approval before getting an MRI, physical therapy, or even certain medications.
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Delays of 7 to 14 days are common, and urgent requests can still take 72 hours or more.
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If denied, you must go through an appeals process, which can take weeks.
According to recent data, more than 80% of denied authorizations are overturned on appeal, but only if the enrollee is persistent. Most give up before that point, leading to care gaps or out-of-pocket expenses.
Hidden Costs That Aren’t Advertised
While brochures highlight low monthly premiums, they often gloss over the out-of-pocket structure. Here are common cost traps:
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High copays for specialist visits (often $50 or more)
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Emergency room copays of $100 to $150
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Daily hospital copays that can add up to over $1,000 for a 5-day stay
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Prescription drug tiers with high coinsurance for brand-name medications
The 2025 maximum out-of-pocket limit for Medicare Advantage plans is $9,350 for in-network care and $14,000 for combined in-network and out-of-network care. Poorly designed plans often set their MOOP at these highest thresholds, leaving you exposed to thousands in costs during a health crisis.
Weak Drug Coverage That Leaves You Paying More
Prescription drug coverage under these plans may sound comprehensive but often includes:
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Tiered formularies that make brand-name drugs prohibitively expensive
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Step therapy, where you must try cheaper drugs first
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Narrow pharmacy networks
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Exclusion of common specialty drugs
Some plans also shift medications to higher tiers year over year, increasing your share of cost even if your treatment hasn’t changed.
Even with the new $2,000 out-of-pocket cap on Part D drug costs in 2025, some Medicare Advantage plans still structure drug coverage in a way that gets you to that cap faster, especially if you need multiple brand-name prescriptions.
Routine Benefits With Strict Limits
Plans often boast about including extras like dental, vision, and hearing coverage. But the fine print typically includes:
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Annual dental benefit caps as low as $500 to $1,000
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Vision exams only every 2 years, or glasses limited to basic frames
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Hearing aids covered only once every 3 years with a cap on brands or providers
These limitations are rarely clear upfront. You might assume you’re getting full coverage when, in reality, you’ll be paying out of pocket for anything beyond a narrow list of approved services.
Referrals Required for Nearly Everything
Another hidden inconvenience is the need for referrals. While Original Medicare and Medigap policies generally don’t require referrals, many Medicare Advantage HMOs do.
This means you may have to:
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Get approval from your primary care provider (PCP) before seeing a specialist
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Wait several days for scheduling
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Repeat the referral process for each new issue
Some of the worst plans even require new referrals for follow-up visits, creating frustration and delays.
Gaps in Emergency and Urgent Care When Traveling
If you travel or live in multiple states throughout the year, you could be caught off guard. The worst Medicare Advantage plans:
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Do not cover non-emergency care outside your service area
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Limit urgent care to affiliated centers, even out of state
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Require you to return home for follow-up visits
In contrast, Original Medicare with a Medigap policy allows you to receive care from any provider that accepts Medicare nationwide.
Lack of Transparency During Enrollment
During the Medicare Open Enrollment period from October 15 to December 7 each year, plan materials can be difficult to compare. Many of the worst plans rely on vague language such as:
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“Some providers require prior authorization”
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“May include network restrictions”
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“Low copays for many services”
Unless you review the full Summary of Benefits and Evidence of Coverage, which are often lengthy documents, you may not realize what’s being left out.
Annual Changes That Aren’t Always Clear
Even if a plan looks okay this year, Medicare Advantage plans can and do change annually. Each fall, you should receive an Annual Notice of Change (ANOC). The worst plans often:
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Make major changes without clearly highlighting them
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Shift providers or drop coverage for key services
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Increase copays or deductibles quietly
If you miss the ANOC or don’t review it in detail, you may find out too late that your plan no longer fits your needs.
Poor Customer Support and Appeals Process
Customer service is often lacking in the worst Medicare Advantage plans. Common complaints include:
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Long hold times (over 30 minutes)
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Agents who lack training or authority to resolve issues
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Poor support during authorization denials or billing disputes
A weak support structure makes it harder to get timely answers or advocate for your care when problems arise.
Watch for These Red Flags During Enrollment
To avoid getting locked into a poorly performing Medicare Advantage plan, pay attention to these warning signs:
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Star ratings below 3.5
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High out-of-pocket maximums
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Frequent prior authorization requirements
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Poor or shrinking provider networks
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Confusing drug formulary tiers
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Vague language in plan brochures
If anything feels unclear, request the complete Summary of Benefits and the Evidence of Coverage. Take the time to review the fine print and compare across multiple plans before enrolling.
Be Prepared Before You Commit
What appears attractive on a Medicare Advantage brochure may not tell the whole story. The worst plans in 2025 rely on attractive buzzwords while quietly limiting access, adding layers of bureaucracy, and exposing you to higher costs.
Take the time to:
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Examine the provider directory
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Review the drug formulary in detail
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Look at the plan’s track record for complaints and denials
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Confirm the availability of extra benefits and how they are structured
Your health and your wallet deserve better than being surprised by gaps that could have been spotted with a closer look.
Make an Informed Medicare Choice This Year
Don’t let marketing language or incomplete brochures steer you into the wrong Medicare Advantage plan. What isn’t said in the sales material is often what matters most to your health and finances. Take control by asking the right questions, comparing the fine print, and understanding what truly impacts your costs and care access.
If you need help evaluating your options or have questions about how to spot these hidden issues, speak with a licensed agent listed on this website. They can walk you through each detail and help you feel confident in your Medicare decision.
