Key Takeaways
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A plan that looks good on paper can create major roadblocks when you actually need care, especially if prior authorizations and appeals are frequent hurdles.
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The lowest-rated Medicare Advantage plans in 2025 often receive poor CMS star ratings due to delays, denials, and poor member experience—not because of how much they cost.
Why Some Medicare Advantage Plans Become Burdens
When you first review a Medicare Advantage plan, it may seem like it checks all the right boxes. It may offer additional benefits, an affordable monthly cost, and an appealing provider network. However, once you’re enrolled, you may realize that the plan’s structure creates unnecessary friction when it comes to accessing care.
The worst plans typically look fine on the surface, but they often include hidden obstacles like excessive prior authorization requirements, complicated appeals processes, and inconsistent communication. By the time you notice these problems, you’re already locked in for the year unless you qualify for a Special Enrollment Period.
What Makes a Medicare Advantage Plan “Bad”?
The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage plans using a five-star system. These ratings reflect performance in key areas such as customer service, access to care, and overall quality. In 2025, the lowest-rated plans typically hold 2.5 stars or less.
Plans with low star ratings often share the following issues:
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Delays in authorizing needed care
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High denial rates for procedures and prescriptions
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Limited or shrinking provider networks
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Confusing or burdensome appeal processes
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Poor customer service and response times
CMS reviews these metrics annually. A low rating usually signals consistent trouble across multiple categories, and poor scores in areas like member experience and complaints are especially concerning.
Prior Authorization: A Key Frustration Point
One of the biggest red flags in poorly rated Medicare Advantage plans is overuse of prior authorizations. These are approvals you must get before receiving specific services, treatments, or prescriptions. In a well-functioning plan, prior authorizations are reasonable and timely. But in low-rated plans, this process often becomes an obstacle.
In 2025, CMS requires plans to respond to standard prior authorization requests within 7 calendar days, and within 72 hours for expedited requests. But even with this guidance, some plans drag their feet or issue vague denials that force you into the appeals process.
Services most commonly requiring prior authorization include:
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Diagnostic imaging (e.g., MRIs, CT scans)
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Skilled nursing facility care
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Durable medical equipment
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Some prescription drugs
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Home health services
Plans with poor service often require more authorizations than necessary, increasing the time between diagnosis and treatment.
The Appeals Maze: Why Timelines Matter
If your care gets denied, you have the right to file an appeal. But with the worst Medicare Advantage plans, the appeals process can feel intentionally difficult.
Here’s how the standard Medicare Advantage appeals process works in 2025:
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Reconsideration Request (First-Level Appeal): Must be submitted within 60 days of the denial. The plan typically must respond within 30 days.
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Independent Review Entity (IRE): If the plan upholds its denial, your case moves to an IRE.
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Administrative Law Judge (ALJ): If the IRE also denies coverage, you can request a hearing before an ALJ if the value is over $180 in 2025.
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Medicare Appeals Council: You may request further review by the Medicare Appeals Council.
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Federal District Court: As a final step, you can take your case to court if the disputed amount exceeds $1,840.
For someone simply trying to access care, this process can feel overwhelming and slow. And each stage often requires additional paperwork, justification from your doctor, and waiting periods.
Plans with low ratings often have more denials that end up in this lengthy appeals cycle. Even if you eventually win the appeal, you may delay your treatment by weeks or months.
Network Problems That Are Easy to Miss
The provider network is another area where problems in bad plans surface. Medicare Advantage plans contract with specific doctors, hospitals, and pharmacies. If your plan’s network is limited or unstable, you could face difficulty getting appointments or keeping your preferred providers.
Red flags include:
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Narrow networks: Plans with very few in-network specialists or facilities.
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Provider turnover: Doctors and facilities that frequently leave the network.
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Surprise out-of-network charges: Especially if network information is outdated or hard to verify.
In 2025, CMS requires plans to update online provider directories at least monthly. Yet some of the worst-rated plans fail to keep this information accurate, leaving you to find out the hard way that your doctor is no longer in-network.
Star Ratings: More Than Just a Score
CMS star ratings aren’t arbitrary. They’re based on more than 40 performance measures, including:
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Member complaints and disenrollment rates
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Timeliness of care
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Chronic condition management
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Customer service experiences
Plans with 4 stars or higher in 2025 are generally considered reliable, while those with 3 stars or lower often have repeat issues. A rating of 2.5 stars or less indicates consistent underperformance.
The CMS star ratings are updated every October, just before the Medicare Open Enrollment period. These updates give you time to evaluate whether your current plan has improved or declined before making decisions for the following year.
Common Traps in Low-Rated Plans
Several common issues contribute to why some Medicare Advantage plans earn low ratings in the first place:
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Benefit restrictions: Some plans may limit supplemental benefits like dental or vision to specific vendors or conditions.
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Opaque policies: Policies on coverage, appeals, or even basic benefits may be hard to understand or inconsistently applied.
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Inadequate coordination of care: If you have chronic or complex conditions, coordination between your providers and the plan is crucial. Poorly rated plans often fail in this area.
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Underfunded member services: Delayed responses, dropped calls, and unresolved issues often result in member complaints.
These problems tend to snowball. Once you encounter one issue, like a denied claim, you may find yourself navigating multiple roadblocks to resolve it.
Open Enrollment Is Your Window of Opportunity
If you’re in a poorly performing plan, the Medicare Open Enrollment Period from October 15 through December 7 is your chance to switch. During this time, you can:
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Change to a different Medicare Advantage plan
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Return to Original Medicare
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Join a stand-alone Medicare Part D drug plan if leaving Medicare Advantage
You can also use the Medicare Advantage Open Enrollment Period (January 1 through March 31) to switch to another Medicare Advantage plan or return to Original Medicare.
These windows are crucial. Unless you qualify for a Special Enrollment Period due to a life event, you’re generally locked into your plan for the rest of the year.
How to Protect Yourself from Bad Plans
You can’t always spot a bad Medicare Advantage plan at first glance, but there are ways to reduce your risk:
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Check the CMS Star Rating: Avoid plans with fewer than 3 stars.
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Read the Summary of Benefits: Look for hidden restrictions on services, providers, or drug coverage.
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Verify the Provider Network: Call your doctors and specialists to ensure they still accept the plan.
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Review prior authorization policies: Look for how many services require advance approval.
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Examine the appeals process: Make sure it’s clearly defined and accessible.
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Ask questions: Contact a licensed agent listed on this website who can walk you through the pros and cons.
When You Can’t Wait a Year
In some cases, you may be able to leave a poorly performing plan before the next Open Enrollment. These Special Enrollment Periods (SEPs) can be triggered by events such as:
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Moving out of your plan’s service area
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Losing other credible coverage
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Plan contract termination with Medicare
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Becoming eligible for Medicaid or Extra Help
In 2025, CMS also grants a SEP if your plan consistently receives a star rating of fewer than 3 stars for three years in a row. This lets you switch to a higher-rated plan immediately.
If your situation qualifies, act quickly. These SEPs are time-limited and require documentation.
A Plan That Works Shouldn’t Be a Struggle
You shouldn’t have to fight for care, chase down approvals, or navigate confusing appeals just to use your Medicare Advantage plan. In 2025, the worst plans aren’t necessarily the ones with the highest premiums or the fewest extras. They’re the ones that make getting care harder than it should be.
If you’re already in one of these plans or trying to avoid them altogether, take the time to research your options thoroughly. And don’t make these decisions alone. Reach out to a licensed agent listed on this website who can help you review your plan choices, explain the fine print, and guide you toward better coverage.
