Key Takeaways
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The worst Medicare Advantage plans often promote simplicity and convenience, but in practice, they add layers of confusion to what should be straightforward medical care.
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You may find yourself trapped in complex referral processes, denied treatments, and uncertain coverage timelines despite thinking you chose a plan that “does it all.”
The Appeal of Simplicity: A False Promise
Medicare Advantage (MA) plans are often marketed as an all-in-one solution, promising to combine Medicare Parts A and B, and sometimes Part D, into one convenient package. On the surface, this sounds efficient and organized. But not all MA plans deliver on this promise. In fact, the worst ones take something that should be simple—your healthcare—and make it frustratingly complex.
Low CMS Star Ratings Signal Caution
Every year, the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage plans on a 5-star scale. Plans with a rating of fewer than 3 stars are generally considered substandard. These ratings are based on multiple factors, including:
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Member complaints
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Customer service responsiveness
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Preventive care delivery
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Management of chronic conditions
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Prescription drug safety and accuracy
If your plan has hovered at 2.5 stars or lower for multiple years, that’s a red flag. It often correlates with poor performance in authorization processing, medical service access, and follow-through on care.
When “All-In-One” Means More Paperwork
One of the main attractions of Medicare Advantage is the promise of bundled services. But in the worst plans, bundling turns into bottlenecking. You may experience:
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Repeated requests for prior authorizations
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Delays in approval for basic services
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A flood of forms to complete for routine referrals
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Confusion over in-network versus out-of-network benefits
Rather than simplifying your experience, these plans force you to take on the administrative burden yourself.
Referrals That Feel Like Obstacle Courses
In traditional Medicare, you usually have direct access to specialists. But many Medicare Advantage plans—particularly the worst-performing ones—require you to go through a primary care physician for a referral. This process becomes problematic when:
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The referral must be renewed for every visit
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The authorization expires after a short time (often 30 to 90 days)
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The referral must go through several internal reviews
In the worst plans, even urgent referrals can be delayed or denied, leading to postponed treatments.
Networks That Constantly Shift
Medicare Advantage plans often use a network of preferred providers. This isn’t inherently bad, but the worst plans are notorious for having:
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Limited networks with few specialists
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High provider turnover mid-year
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Poor communication about provider changes
In these plans, the doctor you saw last month may no longer be in the network today. If you don’t verify every time you make an appointment, you risk unexpected out-of-pocket costs.
Preauthorization: A Constant Hurdle
Many low-rated plans require preauthorization for:
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Diagnostic imaging (MRIs, CT scans)
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Hospital admissions
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Outpatient surgeries
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Physical therapy sessions
In 2025, CMS has tightened rules to standardize preauthorization across MA plans, but implementation varies widely. Poorly rated plans continue to delay or deny authorizations more frequently than others, undermining continuity of care.
Confusing Drug Formularies and Coverage Gaps
Prescription drug coverage is another area where the worst plans make things harder than they need to be. While many include Part D coverage, their formularies often:
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Exclude commonly prescribed medications
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Change tier placement mid-year
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Require step therapy (forcing you to try less expensive drugs first)
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Impose high copayments for brand-name medications
Even though CMS mandates a $2,000 cap on out-of-pocket drug costs starting in 2025, poorly structured formularies can still lead to delays, denied prescriptions, and unclear cost-sharing.
Denied Claims and Appeals Fatigue
If you’ve ever had a claim denied, you know the frustration of appealing. In the worst plans, this becomes a recurring issue. Reasons include:
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Vague denial letters
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Complex or unclear appeal instructions
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Short windows for submission
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Poor customer support
You may have to file multiple appeals or wait weeks to get a resolution. Some plans also auto-deny claims hoping members won’t challenge the decision.
Weak Customer Support Infrastructure
When your plan fails to guide you, support matters. Unfortunately, low-rated Medicare Advantage plans typically have:
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Long call center wait times
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Poorly trained representatives
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Inconsistent answers to the same question
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Limited after-hours or weekend support
In times of urgent need, this lack of reliable help can become more than a nuisance—it can impact your care.
Emergency Care Isn’t Always Covered Like You Think
Many people assume emergency services are always covered. While CMS requires Medicare Advantage plans to cover emergency care regardless of network, the worst plans:
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Reclassify certain visits as non-emergent after the fact
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Deny payment if proper authorizations aren’t filed
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Impose higher cost-sharing for out-of-network facilities
This can lead to bills you didn’t expect, even when you acted responsibly.
Hidden Out-of-Pocket Costs
Medicare Advantage plans are required to cap out-of-pocket costs. For 2025, this limit is $9,350 for in-network services and $14,000 for combined in- and out-of-network services. But in practice, poor plan designs can still leave you with:
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Frequent copayments for each visit
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Additional fees for urgent care
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Separate deductibles for various service categories
When you’re seeing multiple specialists or managing a chronic condition, these costs pile up quickly.
Annual Changes Make Comparison Difficult
Every year during the Medicare Annual Enrollment Period (October 15 to December 7), plans are allowed to change key features. Poor-performing plans often:
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Shift costs from premiums to copayments
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Alter their drug formularies without clearly stating it
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Drop providers from the network
If you don’t thoroughly review your Annual Notice of Change (ANOC), you may unknowingly accept a plan that no longer suits your needs.
CMS Oversight Has Limits
While CMS does monitor Medicare Advantage plans, enforcement takes time. Poorly performing plans can stay on the market for years if they hover just above the lowest threshold. In 2025, CMS can issue penalties or remove plans, but by then, the harm may already be done to thousands of beneficiaries.
Don’t Let Glossy Brochures Fool You
Marketing materials from the worst plans tend to overemphasize extras like gym memberships, dental cleanings, or vision exams. While these perks are nice, they don’t make up for poor medical care access. It’s crucial to evaluate:
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CMS star ratings
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Provider networks
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Prior authorization requirements
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Customer support quality
Many plans with heavy advertising spend less on actual medical services and more on branding.
Protect Yourself With the Right Questions
Before enrolling in any plan, ask:
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What is the CMS Star Rating?
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Are my current doctors and hospitals in-network?
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What services require prior authorization?
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How are emergency and urgent care services handled?
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How does the plan handle denied claims and appeals?
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What changes occurred in the last ANOC?
The worst plans will dodge or downplay these questions. That’s your cue to keep looking.
It Shouldn’t Be This Hard to Get the Care You Need
Medicare Advantage plans should help you manage your healthcare, not add roadblocks. Unfortunately, the worst plans make even basic care more complicated, less transparent, and more expensive over time.
If you’re feeling overwhelmed by options or unsure about whether your current plan serves you well, it’s time to take action. Speak with a licensed agent listed on this website to get advice tailored to your situation and ensure your Medicare Advantage plan truly supports your healthcare needs.
