Key Takeaways

• The worst Medicare Advantage plans often disrupt your long-term relationships with doctors and specialists, breaking the continuity of care you’ve built over years.

• CMS star ratings can help you identify poorly performing plans, but you still need to look beyond ratings to understand a plan’s limitations on access and provider networks.

What Continuity of Care Means to You

Continuity of care refers to the long-term relationship between you and your healthcare providers. It means seeing the same doctors who know your history, coordinating care across specialists, and maintaining consistent treatment plans. For Medicare beneficiaries managing chronic conditions, this continuity can directly affect your quality of life, treatment success, and even safety.

Unfortunately, some of the worst Medicare Advantage plans break that continuity. Whether it’s a narrow network, frequent changes to participating providers, or sudden coverage restrictions, these plans can fragment your care.

CMS Ratings Offer a Starting Point

The Centers for Medicare & Medicaid Services (CMS) provides star ratings to Medicare Advantage plans each year. These ratings range from 1 to 5 stars and reflect various performance areas, including:

• Member experience

• Access to care

• Chronic condition management

• Customer service

• Complaints and disenrollment rates

While these scores can help you avoid some poorly performing plans, they don’t always reveal the full picture. A plan with a 3-star rating might still offer limited provider access or require excessive prior authorizations.

In 2025, over 30% of Medicare Advantage plans have ratings of 3.5 stars or lower. If you’re not careful, you could end up in a plan that compromises not just your benefits, but your ability to continue seeing your preferred doctors.

Warning Signs of the Worst Plans

Several characteristics often appear in Medicare Advantage plans that are rated poorly by beneficiaries or healthcare advocates. These features can disrupt your care in subtle but harmful ways:

Limited or Changing Provider Networks

Some plans restrict you to a small network of providers, making it hard to keep your existing primary care physician or specialists. Worse, providers may drop from the network without much notice, leaving you to scramble for a replacement.

Annual contract renegotiations between plans and doctors mean a provider you see today might not be in-network next year. This leads to interrupted care and forces you to restart treatment plans with new providers.

Aggressive Prior Authorization Policies

The worst plans require frequent prior authorizations, even for routine or ongoing treatments. In 2025, CMS has implemented oversight to limit unnecessary delays, but some plans still create obstacles.

For example:

• Imaging tests like MRIs and CT scans

• Physical therapy

• Prescriptions for name-brand medications

When approvals are delayed or denied, it interrupts the flow of your care and forces doctors to find alternatives that may not work as well.

Frequent Plan Changes Year to Year

Some Medicare Advantage plans undergo major changes each January:

• Provider network reshuffling

• Changes in formularies (covered medications)

• Copayment increases

• Modifications to service area coverage

If you’re enrolled in one of these plans, your care landscape might look very different every 12 months. This instability makes it difficult to maintain treatment plans, especially for those managing multiple conditions.

Poor Care Coordination

Many of the lowest-rated plans fail at coordinating care between specialists, hospitals, and primary care physicians. This lack of integration results in repeated tests, medication conflicts, or inconsistent treatment protocols.

When care isn’t coordinated, you become the point-person for your own healthcare. You’re left tracking referrals, managing prescription renewals, and explaining your medical history repeatedly.

High Complaints and Disenrollment Rates

CMS collects data on how many people voluntarily leave a plan each year, as well as formal complaints filed. Plans with higher-than-average disenrollment often share characteristics like unexpected costs, limited provider access, or denial of services.

By 2025, these metrics have been given more weight in the CMS star ratings. A high disenrollment rate is a clear red flag that a plan might be failing its members.

How Disrupted Continuity Affects Your Health

The worst Medicare Advantage plans don’t just inconvenience you. They can cause measurable harm to your health outcomes, especially if you suffer from chronic or complex medical conditions. Here’s how:

• Delayed Diagnoses: Changing doctors means starting from scratch, which can delay the detection of serious conditions.

• Medication Errors: When care isn’t coordinated, different providers may prescribe conflicting drugs.

• Missed Follow-Ups: Inconsistent care leads to lapses in routine screenings, immunizations, or lab work.

• Mental Stress: Constantly navigating new provider networks can add anxiety and frustration, which can worsen physical conditions.

Continuity of care is more than convenience. It is essential to safe, effective, and compassionate treatment.

The Role of Medicare Advantage Plan Types

In 2025, Medicare Advantage comes in several formats. Some are more prone to undermining continuity than others:

• Health Maintenance Organizations (HMOs): These plans often have narrow networks and require referrals, making it harder to see the same providers year to year.

• Preferred Provider Organizations (PPOs): While more flexible, some PPOs still limit out-of-network care with higher costs.

• Special Needs Plans (SNPs): Tailored for certain chronic conditions or institutional care, these plans usually have stronger care coordination, but enrollment requirements apply.

If continuity of care matters to you, scrutinize the network rules, referral processes, and out-of-network policies before enrolling.

How to Protect Yourself During Enrollment

Avoiding the worst Medicare Advantage plans requires more than comparing premiums and copays. You need to dig deeper:

• Check the Provider Directory: Make sure your current doctors and specialists are in-network.

• Ask About Referrals: Understand whether you’ll need them for specialist visits and how long approvals take.

• Review the Annual Notice of Change (ANOC): This document outlines what’s changing in your plan for the coming year.

• Study the Star Ratings: Pay close attention to metrics related to care access, care coordination, and customer complaints.

• Call Your Doctor’s Office: Verify directly whether they accept the plan in question for the upcoming year.

By dedicating time to research during the October 15 to December 7 Open Enrollment Period, you can avoid enrolling in a plan that compromises your care.

CMS Oversight Efforts in 2025

CMS has increased scrutiny of Medicare Advantage plans in 2025 due to ongoing concerns about prior authorizations and inadequate provider networks. New rules require:

• Faster turnaround for prior authorization decisions

• Public reporting of denial rates

• Stronger protections during transitions when providers leave the network

Still, enforcement varies, and some plans find ways around these rules. That’s why beneficiary awareness remains your best defense.

What to Do If You’re Already in a Poor-Performing Plan

If you discover that your current Medicare Advantage plan is undermining your care, you have options:

• Use the Medicare Advantage Open Enrollment Period (Jan 1 to Mar 31): You can switch to another Medicare Advantage plan or return to Original Medicare.

• Special Enrollment Period (SEP): If you move, lose other coverage, or experience certain life changes, you may qualify to switch outside the standard window.

• File an Appeal or Grievance: If you’ve been denied care or experienced delays, submit a formal complaint with your plan and Medicare.

Switching plans mid-year isn’t always ideal, but it’s better than staying in a plan that harms your health.

Clear Choices Begin With the Right Questions

Before choosing a Medicare Advantage plan, ask:

• Are my providers in the network now, and will they be next year?

• What is the plan’s record with prior authorizations?

• How often do members leave the plan voluntarily?

• Does the plan work well for people with chronic conditions like mine?

• What happens if a key specialist leaves the network mid-year?

Asking these questions now can help you avoid the pitfalls of poor continuity and unexpected disruptions.

Protecting Your Healthcare Journey

Choosing the wrong Medicare Advantage plan doesn’t just impact your wallet. It affects the doctors you see, the medications you can get, and the stability of your long-term treatment. As you compare options during the enrollment window, keep your personal healthcare journey front and center.

If you’re unsure whether your current plan is helping or hurting your continuity of care, speak with a licensed agent listed on this website. They can help you assess your options and guide you toward a plan that keeps your health relationships intact.