Key Takeaways
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The worst Medicare Advantage plans often come with low CMS ratings, hidden coverage limits, and excessive prior authorization requirements that make it difficult to get necessary care.
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If you keep wondering why a medical service or item wasn’t covered, your plan may have restrictive networks, narrow formularies, or vague language in the Evidence of Coverage document.
When Coverage Surprises Keep Happening
If you’ve ever opened a medical bill and asked yourself, “Why wasn’t this covered?”, you’re not alone. Many Medicare Advantage enrollees find themselves in this frustrating situation. While Medicare Advantage plans must cover everything Original Medicare does, the way they deliver that coverage can vary drastically. Some plans put barriers between you and the care you need.
The worst Medicare Advantage plans might look great on paper, but in reality, they often leave critical gaps in care. These issues tend to show up after enrollment, when you’re already locked in for the year. Let’s explore the red flags you need to look for if you want to avoid repeated surprises from denied services, bills you didn’t expect, or confusing fine print.
CMS Ratings Are a Good Starting Point
Every year, the Centers for Medicare & Medicaid Services (CMS) assigns star ratings to Medicare Advantage plans. These ratings range from 1 star (poor) to 5 stars (excellent) and are based on metrics like customer satisfaction, member complaints, preventive care, and chronic condition management.
Plans that receive fewer than 3 stars are considered below average. In 2025, most Medicare Advantage enrollees are in 4-star or higher plans. If your plan consistently ranks low or has dropped in star rating, it’s worth taking a closer look. CMS ratings are public for a reason: they help you make better-informed decisions about your healthcare coverage.
Prior Authorization: A Major Barrier
One of the hallmarks of a problematic Medicare Advantage plan is excessive reliance on prior authorization. This is the process of requiring your doctor or provider to get approval from your plan before you can receive certain services or medications. While the intent is to control costs, it often ends up delaying or denying medically necessary care.
In some low-rated plans, prior authorization is required for:
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Advanced imaging (MRIs, CT scans)
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Inpatient rehabilitation stays
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Home health services
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Part B medications administered at a clinic
If your plan frequently uses prior authorization, it increases the chances that you’ll experience coverage denials or delays, even when your doctor believes a service is necessary.
Network Limitations Can Catch You Off Guard
Medicare Advantage plans use provider networks, which means you often have to see doctors and facilities within the plan’s contracted list. The worst plans have narrow networks with few specialists or limited access in rural areas.
You might find that:
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A local hospital is out of network
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Your specialist retired or left the plan
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Emergency services are covered differently when traveling
Some plans require referrals even for common specialists, adding another hurdle between you and timely care.
Formularies That Leave Out Key Medications
A Medicare Advantage plan’s formulary is its list of covered drugs. Low-performing plans often exclude common or high-cost medications, or place them on high-cost tiers that require substantial out-of-pocket payments.
A few things to watch for:
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Frequent formulary changes within the year
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Step therapy requirements before accessing a preferred drug
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Lack of coverage for specialty medications
In 2025, CMS requires plans to provide a stable formulary, but poorly performing plans often use loopholes to make changes that affect your medication access.
Out-of-Pocket Costs Add Up Fast
While Medicare Advantage plans set a maximum out-of-pocket (MOOP) limit each year, the worst plans hover near the upper threshold. In 2025, the in-network MOOP limit is $9,350. Many plans set their limit close to this cap, meaning you could face significant financial strain if you require hospitalization, surgeries, or extended treatment.
Other cost-related issues include:
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High copayments for specialists, ER visits, and hospital stays
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Separate deductibles for medical and prescription coverage
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Lack of cost sharing transparency for enrollees
If you find yourself constantly paying more than expected, or if your plan design is unclear about your true financial exposure, it’s a major red flag.
Marketing That Promises Too Much
Aggressive marketing tactics can often mask the deficiencies of the worst Medicare Advantage plans. If you were lured by flashy enrollment materials promising “extra benefits,” only to discover that basic services are hard to access, you may be experiencing the downside of misleading advertising.
Common misleading elements include:
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Overstated dental, vision, or hearing benefits
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Unclear transportation or meal service eligibility
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“Free” benefits that are actually limited by strict conditions
In 2025, CMS has tightened marketing rules, but enforcement gaps remain. If your plan relied more on promises than performance, it could explain why services aren’t being covered as you expected.
Hidden in the Evidence of Coverage
The Evidence of Coverage (EOC) document outlines what your Medicare Advantage plan covers and what it doesn’t. In low-rated plans, the EOC often uses vague language or includes footnotes that add hidden limitations. If you only review your plan during enrollment season and don’t study the EOC, you might miss:
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Conditions attached to supplemental benefits
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Exclusions for certain procedures
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Variations in coverage depending on provider type
The EOC for 2025 plans is required to be available online, but it’s not always easy to read. If something wasn’t covered and you’re not sure why, reviewing the fine print may uncover the answer.
You’re Locked In Until the Next Enrollment Period
One of the most frustrating aspects of Medicare Advantage is the timeline. After you enroll during the Annual Enrollment Period (October 15 to December 7), you’re typically locked into your plan for the following year.
The Medicare Advantage Open Enrollment Period (January 1 to March 31) allows you to switch plans once, but many people miss this window. If you’ve already used your one switch or didn’t know about it, you’re likely stuck with your current plan until the next enrollment season.
That means a poor choice now could impact your access to care, your financial stability, and your peace of mind for the rest of the year.
Supplemental Benefits May Sound Good but Deliver Little
Some of the worst plans promote their supplemental benefits loudly, but offer little real value. In 2025, many plans advertise add-ons like:
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Over-the-counter (OTC) allowances
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Fitness memberships
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Limited dental cleanings or hearing aid support
However, these benefits may be limited by:
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Strict provider networks
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Reimbursement restrictions
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Usage caps that reset annually but are hard to track
The result is a benefit that sounds great during enrollment but proves difficult or impossible to use when needed.
Chronic Condition Support May Be Lacking
Medicare Advantage is supposed to help manage chronic conditions, especially for beneficiaries with complex healthcare needs. But plans with low CMS ratings often fall short in this area.
You may notice:
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Gaps in care coordination
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Delays in medication delivery
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Lack of access to specialists for conditions like diabetes or COPD
In 2025, plans are supposed to focus on improved outcomes, but poorly structured networks and underfunded services continue to leave many people underserved.
What You Can Do If You Suspect You’re in a Bad Plan
If you’ve read this far and recognized several issues in your own plan, it may be time to reevaluate your options. Here’s what you can do:
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Review your plan’s CMS star rating
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Examine your EOC for coverage rules and limitations
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Track your actual out-of-pocket costs to see if they align with your expectations
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Use the Medicare Advantage Open Enrollment Period to make a switch (if it’s between January and March)
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Contact a licensed agent listed on this website to help you explore better plans for the next enrollment period
Being informed is your best defense against poor coverage. The worst Medicare Advantage plans often rely on your inaction. Don’t let them.
Making Better Medicare Decisions for the Year Ahead
Choosing the right Medicare Advantage plan takes more than comparing monthly costs or glancing at benefit summaries. If you’ve ever asked why something wasn’t covered, it’s likely because your plan didn’t offer what you thought it did.
The worst plans operate in the gray areas of the system: low CMS ratings, vague documentation, restrictive networks, and empty promises. In 2025, with changes in coverage rules and increased scrutiny, you have more tools than ever to choose wisely.
Take time to review your options, read the fine print, and ask the hard questions. If you’re unsure, reach out to a licensed agent listed on this website who can help walk you through your choices. Don’t wait until another unexpected bill shows up.
