Key Takeaways
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Some of the worst Medicare Advantage plans seem to avoid scrutiny by staying off major problem lists until enrollees experience the issues themselves.
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These plans often earn low CMS star ratings and impose strict prior authorization rules, limited provider networks, and unexpected out-of-pocket costs.
The Illusion of Stability Before Enrollment
When you’re evaluating Medicare Advantage plans, it’s natural to look for reassurance in star ratings, plan descriptions, and marketing materials. Yet some of the worst plans are experts at maintaining a clean public image. They may not be flagged in consumer alerts or widely discussed in complaints. However, once you enroll, the issues often surface quickly.
The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage plans annually using a 5-star system. While this seems helpful, plans with 2 or fewer stars can continue to operate for years. Poor performance on customer service, member complaints, and access to care are often buried under generic promotional language. You may not notice the warning signs until after you’ve committed to the plan.
How CMS Ratings Work—and What They Miss
Each year, CMS evaluates plans based on more than 40 performance measures across key categories:
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Member experience
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Management of chronic conditions
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Preventive care delivery
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Customer service
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Complaints and disenrollments
Plans with consistently low performance (2.5 stars or below) are flagged, but not necessarily removed. In fact, unless a plan earns fewer than 3 stars for three consecutive years, it generally remains on the market. Even when CMS does issue warnings, they are often overlooked by new enrollees because marketing materials and online tools can make these plans appear comparable to more highly rated ones.
Worse, some plans improve just enough in one or two areas to raise their overall score slightly without resolving major problems.
Why These Plans Escape the “Problem List”
Several factors contribute to the survival and appeal of poorly performing plans:
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Rebranding: Some plans change names or shift under new ownership, which makes it harder to track their performance history.
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Minimal Penalties: CMS does impose penalties or sanctions in extreme cases, but many plans with subpar service simply continue with little consequence.
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Narrow Targeting: Poor plans may focus marketing on areas or populations with lower complaint rates or less familiarity with Medicare options.
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Aggressive Advertising: Some of the worst-performing plans spend heavily on TV, digital, and mail ads that highlight limited-time benefits but don’t mention CMS star ratings or utilization barriers.
The Trouble Often Starts with Prior Authorization
After you enroll, you might discover that your plan requires approval before you can access:
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Specialist visits
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Diagnostic imaging (e.g., MRIs or CT scans)
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Durable medical equipment
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Physical therapy
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Home healthcare services
While prior authorization is common across Medicare Advantage, poorly rated plans tend to overuse it. The process becomes time-consuming, paperwork-heavy, and stressful. Worse, delays in care can directly impact your health. You may find yourself in a loop of denials, appeals, and repeated documentation.
CMS has taken steps in 2025 to improve prior authorization timelines and transparency, but enforcement varies. If a plan fails to comply, you may be stuck with delays until you switch during an enrollment period.
Network Limitations Catch You Off Guard
One common issue with low-rated Medicare Advantage plans is their extremely narrow provider networks. They might:
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Include very few in-network primary care doctors
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Lack local specialists
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Offer limited choices for rehabilitation or skilled nursing facilities
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Require travel for routine or specialty care
These network restrictions don’t always become obvious until after enrollment. You may call to schedule an appointment, only to discover your preferred provider isn’t covered or has left the network.
In 2025, CMS requires that plan directories be up-to-date, but inaccuracies and outdated listings still occur. If you can’t find care nearby, you may face long wait times or go out-of-network at higher personal cost.
Hidden Costs in the Fine Print
Even when premiums and deductibles seem reasonable, the worst Medicare Advantage plans introduce high costs in other areas:
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Copayments for urgent care, specialist visits, and hospital stays may be much higher than expected.
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Tiered drug formularies can place common prescriptions into higher-cost categories.
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Out-of-network penalties may apply even during emergencies if the provider doesn’t bill correctly.
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Unexpected maximum out-of-pocket (MOOP) costs can hit you mid-year, especially if your plan has separate limits for in- and out-of-network care.
By the time these costs accumulate, you may already be halfway through the year and stuck with the plan until the next enrollment period.
Disenrollment Is Common—But the Process Isn’t Easy
CMS monitors the percentage of members who leave a Medicare Advantage plan before the year is over. High disenrollment rates are often a red flag that the plan failed to meet expectations. However, some plans manage to stay under the radar by minimizing visibility into these numbers.
Switching plans outside the annual Open Enrollment Period (October 15 to December 7) usually requires a Special Enrollment Period (SEP). Qualifying events include:
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Moving out of your plan’s service area
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Loss of coverage
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Plan termination by CMS
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Other unique circumstances, such as low-performing plan status
Even if your plan qualifies as low-performing, you must actively request an SEP through Medicare. Many enrollees don’t know this option exists until they speak with a licensed agent.
The Worst Plans Target Vulnerable Populations
Plans that consistently underdeliver often focus on:
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Individuals with chronic health conditions
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Low-income Medicare beneficiaries
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Dual-eligible enrollees (Medicare and Medicaid)
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Seniors unfamiliar with Medicare rules
Marketing in these populations may focus on certain add-on benefits, like dental or vision, while minimizing the real challenges like restrictive networks, delayed care, and denial of necessary services. In 2025, CMS is monitoring these marketing tactics more closely, but loopholes still exist.
Quality Improvement Doesn’t Happen Overnight
Plans with a history of low star ratings may eventually improve—but it often takes years. CMS uses a multi-year lookback period when calculating star ratings, which means one year of improvement doesn’t erase a history of poor performance.
If a plan earns fewer than 3 stars for 3 consecutive years, CMS may issue a warning or even terminate the contract. But by that time, thousands of beneficiaries may have been affected.
You shouldn’t have to wait for CMS to take action. Be proactive by checking:
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Current and prior CMS star ratings
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Member satisfaction scores
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Complaint statistics
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Prior authorization volume
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Network size and provider availability
How to Avoid the Trap
Before choosing any Medicare Advantage plan, follow these steps:
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Use Medicare.gov’s Plan Finder to compare CMS star ratings.
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Call providers directly to confirm whether they accept the plan.
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Review the plan’s Summary of Benefits carefully for exclusions, limits, and authorization rules.
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Ask about prescription drug tiers and see where your medications fall.
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Speak to a licensed agent listed on this website who can explain enrollment periods and evaluate your needs.
Avoid choosing a plan based only on marketing or special offers. Plans that seem too good to be true often come with significant trade-offs in care access and cost.
Why the Worst Plans Still Thrive in 2025
Even in 2025, with increased CMS oversight and transparency tools, underperforming plans continue to enroll unsuspecting beneficiaries. Reasons include:
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Complex plan structures that make comparison difficult
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Information overload during Open Enrollment
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Misleading advertising that omits the downsides
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Lack of personalized guidance in decision-making
Until systemic changes take stronger effect, the best defense is a thorough understanding of your options and a willingness to seek expert advice.
Take Control Before the Damage Is Done
Enrolling in a Medicare Advantage plan that doesn’t meet your needs can cost you in both money and peace of mind. Unfortunately, the worst plans often avoid scrutiny until you’re already feeling the consequences. Knowing what to look for now helps you avoid regret later.
For help reviewing your options, reach out to a licensed agent listed on this website. They can guide you through plan comparisons, eligibility for Special Enrollment Periods, and strategies to protect your healthcare access and financial well-being.
