Key Takeaways

• Even high-rated Medicare Advantage plans can have critical coverage gaps that are easy to overlook unless you examine the fine print closely.

• CMS ratings provide a helpful starting point, but they do not guarantee comprehensive access, affordability, or consistent care.

They Look Great on Paper, But Reality Is Different

At first glance, many Medicare Advantage plans seem like a great deal. They list an impressive number of benefits: dental, vision, hearing aids, gym memberships, over-the-counter allowances, and more. If you only reviewed the summary, you might feel confident you’ve found the perfect coverage. But that surface-level impression can be misleading.

The worst Medicare Advantage plans tend to overpromise while subtly limiting access, dictating where and how you receive care, and introducing hurdles that only become obvious when you actually need services.

The CMS Star Ratings Aren’t the Whole Story

Each year, the Centers for Medicare & Medicaid Services (CMS) publishes a star rating for Medicare Advantage plans, from 1 to 5 stars. A 4- or 5-star rating might seem like a green light, but it only reflects certain metrics:

• Member experience

• Complaints and disenrollment rates

• Chronic condition management

• Preventive services

What it doesn’t always capture is whether a plan is right for you. A highly rated plan can still have:

• A narrow provider network

• High out-of-pocket costs

• Stringent prior authorization rules

• Poor coverage in rural or remote areas

If you rely solely on the star rating, you could choose a plan that performs well statistically, but fails to meet your real-world needs.

What Gaps Often Go Unnoticed

The worst Medicare Advantage plans excel at looking complete, but here’s where they usually fall short:

Limited Networks

You may be told that a plan covers a large number of doctors and hospitals, but the network may not include your preferred providers. Even worse, some plans drop providers mid-year. That means you might find yourself without access to your specialist or hospital unexpectedly.

Out-of-Pocket Surprises

Although these plans have a maximum out-of-pocket limit (which is federally capped at $9,350 in 2025 for in-network services), getting to that limit can be financially exhausting. Costs add up quickly with:

• Copays for every visit

• Coinsurance percentages for procedures

• Higher charges for out-of-network care (if any is covered at all)

Prior Authorization Hurdles

The worst plans require prior authorization for many services, including:

• Diagnostic imaging

• Physical therapy

• Inpatient stays

• Certain medications

This can delay care, frustrate your doctor, and even result in denial of treatment. These restrictions may not be clear when you first enroll.

Skimpy Supplemental Benefits

Although these plans advertise dental, vision, and hearing coverage, the benefits are often very limited. For example:

• Dental may cover only cleanings and exams

• Vision benefits may not include frames or lenses

• Hearing coverage may come with high copays or limited provider options

What’s listed as a benefit may be more symbolic than functional.

Poor Emergency Coverage While Traveling

If you travel outside your service area, even within the U.S., you might be restricted to emergency or urgent care. Routine care or follow-ups could be denied, leaving you to pay out of pocket or delay care until you return home.

Timing Makes the Problem Worse

When you first enroll in Medicare, you’re presented with a 7-month Initial Enrollment Period (IEP):

• 3 months before the month you turn 65

• The month you turn 65

• 3 months after that month

If you choose a Medicare Advantage plan during this time and later discover it doesn’t meet your needs, you can only switch plans during the Medicare Open Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect January 1 of the following year.

In between, your options are limited. You may qualify for a Special Enrollment Period (SEP) under certain conditions, like moving to a new service area or losing other coverage. Otherwise, you’re often stuck until the next fall.

Red Flags to Watch For

Even before you enroll, you can often spot the worst plans if you know where to look:

• Aggressive marketing that emphasizes extra benefits instead of core coverage

• Low CMS star rating (2.5 or below)

• Unclear provider directories or out-of-date listings

• High prior authorization volume noted in plan documentation

• Member complaints in independent reviews or forums (without naming any platforms)

These signs can alert you that a plan may have hidden issues that become visible only after you start using it.

What You Can Do During Enrollment Periods

Medicare Open Enrollment (October 15 to December 7)

This is your annual chance to:

• Switch from one Medicare Advantage plan to another

• Return to Original Medicare

• Add or drop Part D prescription drug coverage

Review your Annual Notice of Change (ANOC) carefully. It will outline any changes in coverage, network, or costs for the next year.

Medicare Advantage Open Enrollment Period (January 1 to March 31)

If you’re already enrolled in a Medicare Advantage plan, this period allows you to:

• Switch to a different Medicare Advantage plan

• Return to Original Medicare and join a Part D plan

You can only make one change during this window, so evaluate options carefully.

Why Good Marketing Doesn’t Equal Good Coverage

Some of the worst Medicare Advantage plans have robust marketing teams. The messaging is polished. The brochures are glossy. The TV ads are reassuring. But this slick presentation may hide deeper issues.

Good plans invest more in provider networks, customer service, and care coordination. Poor plans may focus heavily on marketing to bring in new enrollees while cutting costs on actual care.

If a plan spends more energy getting your attention than supporting your healthcare, that’s a red flag.

How to Evaluate Plans Beyond the Surface

Before enrolling, ask these critical questions:

• Is my current doctor in-network?

• What are the copays and coinsurance for my most used services?

• What does the plan cover for hospital stays and skilled nursing facilities?

• How does the plan handle prescription drugs? Is there a deductible?

• How restrictive is prior authorization?

• Is emergency care covered while I’m traveling?

• What is the annual out-of-pocket maximum? Is it realistic for my budget?

Don’t rely on marketing material alone. Review the Summary of Benefits, Evidence of Coverage, and star ratings in full.

You Deserve a Plan That Works in Practice

A Medicare Advantage plan that looks great in theory can still leave you exposed to surprise costs, denied services, and missing providers. The worst plans often check all the boxes during enrollment season but fail to deliver meaningful care when it counts.

You have options. The best way to avoid falling into a plan that leaves you unprotected is to seek personalized help. A licensed agent listed on this website can walk you through the key differences, clarify the fine print, and ensure the plan you pick matches your health needs and budget in 2025.