Key Takeaways

• Medicare Advantage plans with low star ratings and limited provider networks may appear cost-effective but often fail when it comes to covering complex medical needs like specialized treatments or chronic disease management.

• Understanding how prior authorizations, narrow networks, and restrictive referral systems work is essential before choosing a plan that could leave you with delays or denials when you need timely care the most.

First Impressions Can Be Misleading

At first glance, some Medicare Advantage plans seem like a logical, even strategic, decision. They often present themselves with manageable monthly premiums, basic coverage, and convenient extras. However, when you need complex procedures, long-term specialist care, or advanced diagnostic services, these same plans can reveal severe limitations.

The worst-performing Medicare Advantage plans in 2025 typically have a CMS star rating of 2.5 or below. These ratings, which range from 1 to 5 stars, are a direct reflection of a plan’s overall quality, including how well it handles chronic conditions, member satisfaction, and access to care. Plans that consistently fall at or near the bottom may fail to deliver essential services efficiently or reliably.

How Star Ratings Help You Spot Trouble

Medicare evaluates plans annually and assigns a star rating based on:

• Member experience

• Preventive care delivery

• Management of chronic conditions

• Customer service responsiveness

A 2-star plan may seem tolerable if your needs are simple and infrequent. But when your situation becomes medically complex, that low rating can translate into frustrating denials, delays, or billing errors. It’s a sign that the plan may have unresolved compliance issues, fewer care management programs, and weaker coordination between providers.

Prior Authorizations: Where Promises Break Down

One of the clearest red flags of the worst Medicare Advantage plans is excessive use of prior authorization requirements. If you need advanced imaging, specialist referrals, or outpatient surgeries, some plans require approval from the insurer before you can proceed.

This may not seem burdensome if you’re healthy. But when you’re:

• Recovering from a heart attack

• Managing cancer treatments

• Seeking pain management or orthopedic procedures

…these administrative hurdles can delay or block access to essential care.

According to CMS data, nearly 98 percent of Medicare Advantage enrollees are in plans that require some form of prior authorization. But it’s the volume, complexity, and speed of those approvals that matter. Lower-rated plans often:

• Take longer to respond

• Require multiple appeals

• Have limited automation to streamline decisions

The Hidden Cost of Narrow Networks

Another common feature of the worst Medicare Advantage plans is a narrow provider network. While some plans boast access to respected hospitals and doctors, others cut costs by restricting your choices.

This can become a serious issue when:

• Your regular doctor or specialist is no longer in-network

• You travel and have difficulty finding a participating provider

• You’re referred to a specialist who isn’t covered under your plan

In complex cases, like managing multiple chronic conditions or coordinating post-surgical rehabilitation, continuity of care becomes vital. A narrow network often forces you to switch providers mid-treatment or pay high out-of-network rates.

Referral Hurdles That Delay Urgent Care

Several low-rated Medicare Advantage plans operate with strict referral gatekeeping systems. This means:

• You must first see a primary care physician (PCP)

• The PCP must issue a referral to a specialist

• Only select specialists within the plan’s network are eligible

When you have an urgent or complex condition, these referral layers can delay diagnosis or treatment. For example, a delay in referring you to a neurologist, cardiologist, or oncologist can mean the difference between early intervention and long-term complications.

Plans that score poorly on care coordination metrics often impose the most rigid referral protocols. In 2025, CMS continues to focus on reducing these access barriers, but the lowest-performing plans remain inconsistent in this area.

Out-of-Pocket Limits Are Not Always Protective

Every Medicare Advantage plan must set an annual maximum out-of-pocket (MOOP) limit, which caps how much you pay for covered services. For 2025, the in-network MOOP limit is $9,350, and the combined in- and out-of-network limit is $14,000.

However, plans with low star ratings often:

• Push costs toward higher copayments and coinsurance

• Apply MOOP limits unevenly between services

• Leave you exposed to significant out-of-network bills

If you require:

• Extended hospital stays

• Skilled nursing care

• Specialized outpatient therapy

…these costs can add up quickly. Even if the plan meets MOOP requirements, how those limits apply in practice may surprise you. Some services may fall outside your cost protections if the plan applies complex tiers or inconsistent billing rules.

Complex Pharmacy Needs Get Complicated Fast

Many Medicare Advantage plans include Part D prescription drug coverage. However, the worst plans in this area show major weaknesses in how they manage:

• Formulary updates

• Step therapy requirements

• Specialty drug access

When you need expensive or specialty medications for conditions like rheumatoid arthritis, multiple sclerosis, or cancer, these plans may:

• Require step therapy (failing on cheaper drugs first)

• Demand repeat authorizations

• Limit quantity or frequency of refills

Even with the 2025 $2,000 cap on out-of-pocket prescription drug costs, your access to medications may be slower or more restricted under poorly managed plans.

Chronic Care Management Is Often Neglected

One of the biggest differentiators between high- and low-quality plans is their investment in chronic care coordination. Plans that score poorly on CMS star ratings often lack:

• Dedicated care managers

• Home health support coordination

• Diabetes or heart failure monitoring programs

Without proactive management, individuals with multiple chronic illnesses experience more:

• Hospital readmissions

• Emergency room visits

• Missed follow-up appointments

If you’re managing multiple diagnoses or rely on a support team to keep your conditions stable, a poorly rated plan can severely disrupt that continuity.

Appeals and Denials: Another Warning Sign

CMS reviews the rate of benefit denials and appeals outcomes in its rating system. The worst plans in 2025 tend to show:

• Higher rates of denied claims

• Fewer successful appeals by members

• Poor transparency in coverage decisions

If your plan regularly denies coverage for:

• Lab tests

• Durable medical equipment

• Post-hospital rehab

…you may find yourself caught in a frustrating cycle of paperwork, delays, or unplanned expenses. While all plans are legally required to offer an appeals process, the ease of navigating it differs greatly.

Member Experience Tells the Real Story

Even if benefits appear standard on paper, the member experience scores give you insight into how a plan treats its enrollees. These measures reflect:

• Timeliness of getting needed care

• Responsiveness of customer service

• Ease of getting prescription drugs

Low ratings here often mean difficulty reaching plan representatives, getting questions answered, or receiving accurate billing information. When your health situation becomes complex, poor customer support can compound the stress.

Why Low Ratings Persist

Despite their weaknesses, poorly rated Medicare Advantage plans still enroll thousands of people every year. This is often due to:

• Misleading marketing

• Eye-catching perks that mask core weaknesses

• Lack of transparency about provider networks

In 2025, CMS enforces stricter rules on advertising and marketing conduct, but many plans continue to find workarounds. Flashy brochures or TV ads cannot show what happens behind the scenes when you’re seriously ill.

What to Look For Instead

To protect yourself, prioritize Medicare Advantage plans that:

• Have a star rating of 4.0 or higher

• Provide clear, upfront details on prior authorizations and referrals

• Offer robust chronic condition management programs

• Publish transparent provider directories

• Include responsive customer support with live help

Also, review the Annual Notice of Change (ANOC) carefully each fall. If you’re already enrolled, this document tells you exactly what will change in your plan starting January 1.

When Smart Choices Matter Most

Medicare Advantage plans aren’t inherently bad. Many deliver excellent care coordination and supplemental benefits. But the worst plans fail at the very moments you need stability and support.

If your health needs are increasing or you anticipate needing specialized care, do not overlook the warning signs:

• A star rating below 3.0

• Prior authorization for basic services

• Limited access to specialists

• Complicated cost-sharing rules

Making a smart choice during open enrollment can protect your health, finances, and peace of mind throughout the year.

Choose Carefully Before You Commit

Now that you’re aware of how the worst Medicare Advantage plans fall short when it matters most, take the next step to protect yourself. Use the CMS Plan Finder tool to check star ratings and benefit comparisons. Don’t rush to enroll in a plan just because it promises add-ons that sound attractive.

If you’re uncertain, speak with a licensed agent listed on this website who can help you evaluate your options in the context of your current health status and future needs. They can help you identify a plan that prioritizes access, support, and stability, especially for complex health situations.