Key Takeaways

• A high Medicare Advantage star rating doesn’t guarantee low out-of-pocket costs or broad access to care. Some of the worst plans can still look good on paper.

• You may end up paying more than expected in 2025 due to narrow networks, rising copayments, and drug tier games, especially if you have chronic conditions or need specialist care.

Medicare Advantage: Not Always the Value You Expect

If you’re evaluating Medicare Advantage plans in 2025, it’s easy to assume a high star rating means a plan offers reliable coverage and low costs. But the truth is, even plans with decent ratings can still come with serious downsides once you start using them. Star ratings are based on many factors, but they don’t always reflect your out-of-pocket experience or access to care.

Medicare Advantage plans may be structured to limit what you pay upfront, but they can also shift costs in other ways that catch you off guard. In this article, you’ll learn how seemingly respectable plans still end up being some of the worst when it comes to financial surprises and access to needed services.

How Star Ratings Work—And What They Leave Out

CMS uses a 5-star scale to evaluate Medicare Advantage plans. These ratings are based on factors such as:

• Member satisfaction

• Preventive care metrics

• Customer service

• Chronic condition management

• Complaints and plan performance over time

While these metrics are valuable, they often overlook important issues such as:

• Real-world out-of-pocket costs

• Prior authorization barriers

• Denials of necessary care

• Limited specialist access

• Sudden formulary changes

So, a plan with a 4-star rating in 2025 might still deny high-cost medications or require multiple referrals before seeing a specialist. That’s why you need to look beyond the rating.

1. Narrow Networks Still Dominate Many Poor-Performing Plans

One of the most common issues with the worst Medicare Advantage plans is a restricted provider network. You may not realize how small your options are until you try to schedule an appointment.

Many plans in 2025 still use:

• Limited access to primary care doctors and specialists

• Strict referral requirements for specialists

• Out-of-network penalties or full-cost charges

If you live in a rural area or rely on a specific doctor, this can make even a highly rated plan unworkable. Worse, switching plans outside of the Annual Enrollment Period (October 15 to December 7) is only allowed in certain situations.

2. Copays and Coinsurance That Add Up Quickly

Copayments may seem reasonable at first, especially if you rarely see a doctor. But plans can bury higher costs in:

• Specialist visit copays of $40 to $60 or more

• Emergency room copays ranging from $100 to $150

• Coinsurance rates of 20% to 30% for diagnostic tests or outpatient procedures

In 2025, these out-of-pocket costs can rise fast, especially for people managing diabetes, heart disease, or cancer. That’s why some plans look affordable on the surface but become expensive when real health needs arise.

3. Prescription Drug Tiers That Shift the Burden to You

Part D drug coverage is built into most Medicare Advantage plans, but this is another area where poor-performing plans can hit your wallet.

You might encounter:

• Non-preferred brand drugs placed in higher tiers

• Insulin not covered under the new $35 cap depending on plan design

• Frequent formulary changes or step therapy requirements

While 2025 brings a $2,000 annual cap on out-of-pocket prescription costs under Part D, that doesn’t eliminate other problems like being required to try cheaper drugs first or struggling with prior authorization.

4. Prior Authorization That Delays or Blocks Care

Many of the worst plans rely heavily on prior authorization to control costs. This means you must get advance approval before receiving certain services or medications.

In practice, this often leads to:

• Delays in treatment for diagnostic tests, surgeries, or rehab

• Paperwork burden for providers

• Outright denials of coverage for care your doctor recommends

As of 2025, CMS has proposed streamlining prior authorization requirements, but it still remains a pain point. You might not know how restrictive a plan is until you’re denied or delayed at a critical moment.

5. Supplemental Benefits With Strings Attached

Some plans advertise extras like dental, vision, hearing, and fitness memberships. But many of these benefits come with fine print:

• Annual caps on dental benefits, sometimes as low as $500

• Limited vision providers or frame allowances

• Hearing aid discounts rather than full coverage

These perks are often used to make plans look more appealing, but they may not actually reduce your out-of-pocket expenses in any meaningful way. Worse, using these benefits sometimes requires using third-party vendors you’re unfamiliar with.

6. Maximum Out-of-Pocket Limits That Look High in Practice

In 2025, the maximum out-of-pocket (MOOP) limit for in-network services is $9,350. Some of the worst plans set their MOOP at or near this maximum.

That means:

• If you need multiple hospital stays or ongoing specialist care, you could hit your MOOP in one year.

• You may face up to $14,000 in combined out-of-pocket spending if your plan also includes out-of-network benefits with a separate MOOP.

While a MOOP is a form of financial protection, many beneficiaries don’t realize how close they may come to reaching it.

7. Limited Appeal and Grievance Processes

If you get denied a medication, procedure, or provider, you technically have the right to appeal. But in practice, poorly rated plans can make this difficult.

Common issues include:

• Slow or unclear responses to appeals

• Short deadlines to provide documentation

• No assistance navigating the process

By the time a decision is overturned (if it ever is), your health might have suffered. The best way to protect yourself is to avoid these plans in the first place.

8. Marketing That Hides the Downsides

Even in 2025, aggressive marketing tactics are still common during Medicare Open Enrollment. You may see ads highlighting benefits without any mention of restrictions.

These promotions often omit:

• Prior authorization requirements

• Network size

• Coverage limitations

This leads some beneficiaries to pick a plan based on perks instead of substance. Once enrolled, it can be very difficult to change until the next open enrollment period.

9. Plans That Look Good Only in Certain Zip Codes

Medicare Advantage plans are regionally designed, meaning one plan could perform well in one area and poorly in another. Just because a plan has a 4-star rating nationally doesn’t mean it performs well locally.

If your local network is thin or essential hospitals are excluded, that plan may not work for you even if its benefits look attractive on paper. This is especially important for Postal Service annuitants who move after retirement.

10. Hidden Changes Year-to-Year

Every year, plans can change their formularies, provider contracts, and benefit structures. While you should receive an Annual Notice of Change (ANOC), many people either don’t read it or find it confusing.

In 2025, look closely for:

• New copay amounts

• Specialist referral policies

• Drug formulary removals or tier changes

Even a plan that worked well in 2024 may be one of the worst in 2025 if the changes affect your specific needs.

Choosing a Medicare Advantage Plan Shouldn’t Leave You Regretting It

The worst Medicare Advantage plans may carry impressive star ratings or flashy benefits, but that doesn’t mean they deliver true value. From restrictive networks to rising out-of-pocket costs, many plans in 2025 still leave enrollees frustrated and underserved.

That’s why it’s important to go beyond surface-level details and ask deeper questions:

• Are your doctors in-network?

• What will your actual costs be for medications and outpatient care?

• Are supplemental benefits useful or just marketing fluff?

Before you enroll, take time to compare your options carefully. Review your Annual Notice of Change, speak with a licensed agent listed on this website, and consider how your health needs may evolve in the next year. A little research now can save you a lot of money and stress later.