Key Takeaways

• Medicare Advantage plans that seem convenient on paper can often make accessing care frustratingly complicated, especially when referrals, prior authorizations, and network limitations turn simple visits into logistical nightmares.

• Plans with low CMS star ratings (under 3 stars) often reflect poor performance in critical areas like customer service, provider access, and timely care, making them risky choices for your health and peace of mind.

When a Routine Checkup Feels Like a Maze

A Medicare Advantage plan should simplify your healthcare, not make every doctor visit feel like a puzzle. But the worst plans do exactly that. They introduce barriers, delays, and guesswork into what should be straightforward decisions. And unfortunately, these plans are more common than you might think.

At first glance, many Medicare Advantage plans offer attractive features. But when you need actual care, especially from specialists or hospitals, the fine print becomes an obstacle course. Instead of focusing on your health, you may find yourself chasing referrals, deciphering prior authorization requirements, or learning that your trusted doctor is suddenly out-of-network.

The Red Flags Are Hiding in the Structure

To understand how some Medicare Advantage plans complicate your care, it helps to look at how they’re structured. Plans that consistently rank among the lowest in CMS star ratings often share the following characteristics:

Narrow Provider Networks

One of the biggest challenges is limited access to healthcare providers. The worst Medicare Advantage plans often restrict you to a narrow network that may not include:

• Your preferred primary care provider

• Nearby hospitals

• High-quality specialists for conditions like cancer, heart disease, or diabetes

If you do see an out-of-network provider, you could be responsible for the full cost. Even emergency care can come with reimbursement challenges.

Excessive Prior Authorizations

Prior authorization is when your plan requires approval before you can receive a service or procedure. In well-rated plans, this is limited and streamlined. In low-performing plans, it becomes a bottleneck.

You might face prior authorizations for:

• Diagnostic tests like MRIs or CT scans

• Physical therapy

• Prescription medications

• Specialist visits

This extra layer can delay care for days or even weeks. If you fail to get approval in advance, the plan may deny payment.

Complicated Referral Requirements

Some Medicare Advantage plans require a referral from your primary care physician before you can see any specialist. If your plan has strict referral policies, you’ll need to:

• Schedule an appointment with your PCP first

• Wait for the referral paperwork to process

• Hope the specialist has availability by the time it’s approved

Even if you’re managing a chronic condition, these hoops can become a constant obstacle to timely treatment.

What CMS Star Ratings Can Tell You

The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage plans each year from 1 to 5 stars, with 5 being excellent. A plan with fewer than 3 stars is a warning sign.

What a Low Star Rating Typically Indicates

• Poor customer service: Difficulty getting help or clarity from the plan.

• Delayed care: Members often experience delays in receiving needed care or services.

• Trouble accessing providers: Members report issues with finding in-network doctors or specialists.

• Weak care coordination: Problems in communication between your doctors and your plan.

In 2025, CMS continues to publish these ratings to guide beneficiaries toward higher-quality choices. If a plan has received fewer than 3 stars for three consecutive years, CMS flags it with a low performance icon. That alone should give you pause.

The Hidden Costs Behind the Low Premiums

You might be tempted to choose a plan based on its low monthly premium or the promise of extra perks. But those features can hide serious trade-offs:

• Higher out-of-pocket costs when you go out of network or need prior-authorized services

• Unpredictable bills due to denied claims or uncovered treatments

• Time lost to navigating paperwork, appeals, and denied referrals

In the long run, these costs can outweigh what you save on the premium.

Appeals and Denials: A Frequent Burden

In many of the worst Medicare Advantage plans, the appeals process becomes part of your routine. When your plan denies a claim or a request for care, you have the right to appeal. But the appeals process:

• Is time-consuming

• Requires documentation and follow-up

• Delays access to care

In the meantime, your condition may worsen, or you may have to pay out of pocket just to proceed with treatment.

The worst plans have high rates of initial denials. While some get reversed after appeal, the delay still causes disruption, anxiety, and financial strain.

Poor Communication Makes It Worse

Plans that score poorly often suffer from another critical issue: poor communication. That includes:

• Long wait times when calling customer service

• Inaccurate or conflicting information from representatives

• Limited online access to your coverage details or provider directories

When you’re dealing with a health concern, the last thing you need is confusion about coverage, doctor access, or how to get your prescriptions filled.

Annual Changes That Catch You Off Guard

Another hidden risk is how frequently some Medicare Advantage plans change their coverage rules, provider networks, and drug formularies. These changes typically take effect each January, but the Annual Notice of Change (ANOC) isn’t always clear or easy to understand.

If you’re not closely reviewing these changes each fall during the Annual Enrollment Period (October 15 to December 7), you might find:

• Your doctor is no longer in-network

• A previously covered medication now has new restrictions

• Copayments and coinsurance amounts have increased

CMS requires plans to send the ANOC, but interpreting it can be challenging. Poorly rated plans often make the least effort to communicate these changes clearly.

Enrollment Traps to Watch For

The worst Medicare Advantage plans are often marketed aggressively. While they technically meet CMS rules for marketing, the messaging can be misleading:

• Emphasizing low costs while glossing over utilization restrictions

• Highlighting extra benefits like gym memberships without disclosing provider access limits

• Using vague language about coverage regions

You could end up enrolling in a plan that looks great in ads but limits you in the real world.

That’s why enrollment decisions should always be based on the full picture: provider access, prior authorization policies, customer service quality, star rating, and plan stability over time.

How to Avoid Ending Up in the Worst Plans

Fortunately, there are clear steps you can take to avoid Medicare Advantage plans that overcomplicate care:

1. Check the CMS Star Rating for 2025

Use the Medicare Plan Finder tool on Medicare.gov to view current ratings. Avoid any plan with fewer than 3 stars unless it meets a specific and justifiable need.

2. Review the Provider Directory Carefully

Don’t rely on assumptions. Search for your primary care doctor, specialists, and nearby hospitals. Call their offices to confirm they still accept the plan.

3. Ask About Prior Authorization Requirements

Find out how many services require prior authorization and what the process entails. A high volume of authorizations can signal delays and red tape.

4. Read the Annual Notice of Change (ANOC) Thoroughly

If you’re already enrolled in a plan, the ANOC will tell you what’s changing for the upcoming year. Review it carefully each fall and compare it with other available plans.

5. Speak to a Licensed Agent

Medicare can be complex, and choosing the wrong plan can have serious consequences. A licensed agent listed on this website can help you:

• Compare plan features beyond premiums

• Understand provider access and costs

• Clarify referral and authorization policies

• Navigate enrollment periods and deadlines

Complex Doesn’t Mean Better: Choose a Plan That Works for You

You deserve healthcare that’s accessible, responsive, and respectful of your time. The worst Medicare Advantage plans fail on all three counts, turning each doctor visit into a challenge rather than a solution.

Before you commit to any plan, take the time to look beyond marketing headlines and review the structure, policies, and performance ratings. An experienced, licensed agent listed on this website can guide you through the process so you’re not left untangling coverage surprises after it’s too late.