Key Takeaways

• The worst Medicare Advantage plans often go unnoticed until you face unexpected costs, denied services, or delays in care. Asking the right questions ahead of time helps you avoid plans with restrictive features and poor support.

• CMS star ratings, network size, prior authorization policies, and out-of-pocket costs are all red flags to watch. Not all low-cost plans provide real value—some may leave you undercovered when it matters most.

What Happens When You Don’t Ask the Right Questions?

Medicare Advantage plans can look attractive on paper, especially when marketed as all-in-one solutions. But behind the brochures and sales pitches, not all plans deliver the coverage and access to care you may expect. Failing to ask critical questions during enrollment can lead you into one of the worst Medicare Advantage plans—ones that prioritize profit over patient outcomes, and red tape over real service.

In 2025, the Centers for Medicare & Medicaid Services (CMS) continues to update how these plans are evaluated. CMS star ratings offer a quick look at plan performance, but you need to dig deeper to protect your health, your wallet, and your peace of mind.

CMS Star Ratings: Are You Looking Closely Enough?

Every year, CMS assigns a star rating to Medicare Advantage plans, ranging from 1 to 5 stars. Plans with 4 stars or more are generally considered strong performers. But here’s where it gets tricky: a plan with a 3-star rating can still be marketed and sold, even if it has known issues with coverage, customer service, or health outcomes.

If you don’t check the star rating or fail to understand what’s behind it, you may enroll in a plan with:

• High rates of denied claims

• Frequent delays in appeals

• Poor chronic condition management

• Low customer satisfaction

In 2025, CMS places greater weight on patient experience and care outcomes. A low-rated plan often signals that members are struggling to access or afford care. Don’t ignore this metric. If the plan you’re considering is below 3.5 stars, ask why.

Does the Plan Require Prior Authorization for Too Many Services?

Prior authorization is a cost-control tool used by many Medicare Advantage plans. While it’s a legitimate way to prevent unnecessary procedures, excessive use of prior authorization can become a barrier to care.

Some of the worst plans in 2025 still require prior authorization for:

• Specialist visits

• Advanced imaging (MRIs, CT scans)

• Inpatient rehabilitation

• Even routine outpatient procedures

If your plan forces you to wait for approval at every step, your care may be delayed or denied altogether. Ask how many services require prior authorization and what the average turnaround time is for approvals. This question alone can reveal whether a plan values efficient care—or administrative obstruction.

How Limited Is the Provider Network?

Medicare Advantage plans operate within defined networks of doctors, hospitals, and facilities. The worst plans often limit you to a narrow network, especially in rural or underserved areas. In 2025, CMS continues to monitor network adequacy, but enforcement varies by region.

Before enrolling, ask:

• Is my current doctor in-network?

• How far is the nearest network hospital or specialist?

• What happens if I need care while traveling?

If you’re forced to switch providers, or if you can’t find specialists nearby, you may end up paying out-of-pocket for out-of-network services—or skipping care altogether. A narrow network is a common feature of underperforming plans, and it’s often hidden in the fine print.

What Are the True Out-of-Pocket Costs?

Low monthly premiums may sound appealing, but they don’t tell the full story. The worst plans often disguise costs in the form of:

• High copayments for routine visits

• Expensive coinsurance for specialist care or hospital stays

• Annual out-of-pocket maximums that exceed $7,000 for in-network services (as allowed in 2025)

Even if your plan has no deductible, your total spending may climb quickly if each service or prescription comes with a steep cost-share. Ask for a summary of coverage, and calculate your likely expenses based on your known health conditions.

In 2025, the CMS-mandated out-of-pocket limit for Medicare Advantage plans remains high. Don’t assume a lower monthly premium means better value. It may cost you more over the course of the year.

Does the Plan Offer Meaningful Supplemental Benefits?

Medicare Advantage plans often advertise added benefits like dental, vision, hearing aids, transportation, and gym memberships. But in lower-rated plans, these benefits may be so limited that they offer little real value.

Questions to ask include:

• What dental procedures are actually covered?

• Is vision coverage limited to one exam per year?

• Does the transportation benefit have mileage or trip limits?

In 2025, CMS encourages plans to offer supplemental benefits tied to chronic condition management. However, that doesn’t guarantee every plan delivers on this front. If a benefit sounds too good to be true, verify the details.

How Efficient Is the Appeals Process?

Unfortunately, claims denials are still a problem in some Medicare Advantage plans. If your care is denied, you have the right to appeal—but in many of the worst plans, the appeals process is slow, confusing, and often unsuccessful.

Ask:

• What percentage of claims are denied each year?

• How long do appeals usually take?

• Who helps me with the appeals process?

CMS tracks these metrics, and in 2025, appeals efficiency plays a larger role in star ratings. Still, plans with a history of poor outcomes in this area remain available. If a plan can’t clearly explain how appeals are handled, that’s a warning sign.

How Responsive Is Customer Service?

When issues arise, whether with billing, coverage questions, or claims, you want a plan that provides quick and competent support. CMS star ratings include customer service performance, but it helps to ask direct questions:

• What are average hold times when calling member services?

• Are support agents trained to help with complex medical needs?

• Is multilingual support available if needed?

Inconsistent service often reflects a plan that cuts administrative costs at the expense of member experience. In 2025, CMS is paying closer attention to patient complaints and satisfaction—but you should still be proactive and ask these questions before enrolling.

What Is the Plan’s History of Member Complaints?

Every plan generates complaints, but patterns matter. Repeated issues with denied services, billing disputes, and poor communication are red flags.

Look into:

• The plan’s complaint rate compared to the national average

• Whether CMS has sanctioned or fined the plan in recent years

• Any dropped star ratings over time due to performance concerns

You can access this information through CMS plan comparison tools, but you should also ask a licensed agent about complaint patterns in your area. High complaint volumes often track with poor patient experience and untrustworthy administration.

Does the Plan Encourage Preventive Care?

Plans that fail to prioritize preventive services may cost you more in the long run. Preventive screenings, vaccines, and wellness visits are required to be covered under Medicare Advantage—but how actively a plan promotes them varies widely.

Plans that neglect preventive care often:

• Lack outreach for annual wellness visits

• Do not follow up on missed screenings

• Provide no health coaching or chronic disease support

In 2025, CMS rewards plans that excel at preventive care with higher star ratings. If the plan you’re considering is silent on this front, or doesn’t help manage your ongoing conditions, you may be looking at a lower-quality option.

Has the Plan Changed Significantly from the Previous Year?

Plans can change their benefits, costs, and provider networks each year. Some of the worst-performing plans in 2024 made abrupt changes for 2025—such as cutting services, increasing prior authorizations, or narrowing their network—without clearly notifying members.

Before committing, ask:

• What changed between 2024 and 2025?

• Were those changes improvements or reductions?

• How were members informed of those changes?

Failing to ask about recent changes may land you in a plan that looked fine last year but now operates with reduced benefits or higher barriers to care. CMS requires plans to send Annual Notice of Change (ANOC) letters each fall, but many beneficiaries overlook them.

Why Working With a Licensed Agent Matters

Medicare Advantage plans are complex. Plan quality, coverage, and cost can vary even within the same ZIP code. Working with a licensed agent listed on this website can help you avoid plans with a history of poor performance.

An agent can:

• Compare star ratings and plan benefits

• Verify provider participation

• Identify plans with fewer prior authorization hassles

• Estimate your total out-of-pocket costs based on your health needs

Choosing a plan isn’t just about what it covers today—it’s about how it performs when you need it most. If you’re not asking these questions, you could unknowingly enroll in a plan that limits your care, increases your stress, and costs you more over time.

Don’t Overlook These Warning Signs Before You Enroll

The worst Medicare Advantage plans don’t look harmful at first glance. They often advertise broad benefits and low costs, but the details reveal a different story. Ask the right questions, compare multiple factors—not just premiums—and don’t settle for a plan that cuts corners on your health.

If you need help evaluating your options or want a second opinion before enrolling, contact a licensed agent listed on this website. Your health coverage in 2025 deserves more than a guess—it deserves a plan that works for you when it matters most.