Choosing the right Medicare coverage for your needs is a big decision, and it’s understandable if you’re feeling apprehensive. This is especially true when trying to steer clear of the worst Medicare Advantage plans for seniors.

Since 2012, I’ve been helping those new to Medicare find Medicare Advantage plans that meet their needs and budget. I’ve seen firsthand how complex Medicare can be and how important it is to understand the fine print. Over the years, I’ve learned that there’s no single “worst” Medicare Advantage plan because individual needs vary so much.

What works for one person might be a nightmare for another. That’s why I’m here to break down what makes certain Medicare Advantage plans a lousy choice for some and how you can find the best fit for you.

Understanding Medicare Advantage Plans

Medicare Advantage (Medicare Part C) plans are an alternative to Original Medicare (Parts A and B). Private insurance companies approved by Medicare offer these plans. But before we discuss what can make an Advantage plan a poor choice, it’s good to know how they work.

How Medicare Advantage Plans Work

Medicare Advantage plans bundle your Part A and Part B benefits, usually including Medicare Part D (prescription drug coverage). Some even offer extra benefits like vision, dental, or hearing coverage.

Unlike Original Medicare, most Advantage plans have networks of providers you’ll need to use. In return for these bundled services and extras, they come with their own set of rules and restrictions, such as pre-approvals and out-of-pocket expenses, which can sometimes make them less than ideal compared to Original Medicare.

Key Factors to Consider When Avoiding the Worst Medicare Advantage Plans for Seniors

Finding the right Medicare Advantage plan means looking beyond marketing materials and understanding the details. It’s a balance between cost and coverage, and you don’t want to be caught off guard by hidden surprises, aka, out-of-pocket costs. These are some common pitfalls:

1. High Out-of-Pocket Costs: Focusing on the Premium Trap

Many people see zero-dollar premiums and think they’ve found a bargain, but don’t be fooled. Remember, you still have to pay your Medicare Part B premium.

Out-of-pocket expenses can really add up if you aren’t careful. Copayments, coinsurance, and high deductibles can mean thousands of unexpected costs.

2. Restricted Networks and Access to Specialists

Unlike Original Medicare, where you have more freedom to see any doctor who accepts Medicare, most Advantage plans have networks. This can be restrictive if you prefer certain providers or need Medicare Advantage provider care.

A 2017 analysis revealed that Medicare Advantage networks, on average, included less than half (46%) of all Medicare physicians within a county. This means your choices are more limited, and you might need referrals to see specialists. Make sure your Medicare Advantage provider is in-network before enrolling.

3. Prior Authorization Requirements: Delays in Getting Care

Medicare Advantage plans often require prior authorization. You need your plan’s approval before receiving specific tests, procedures, or treatments.

This can be time-consuming, and even though you can always appeal a denial, the process is far from smooth. Data from the Kaiser Family Foundation shows that in 2022, more than 46 million prior authorization requests were made, a 31% increase from the year before.

However, prior authorization denials can sometimes prevent necessary care. The same Kaiser Family Foundation study reported that more than 3.4 million requests (7.4%) were denied, at least partially.

While it’s true that 83.2% of those who appealed were eventually approved, think about the time and energy wasted in that process while waiting for needed care.

4. Lower Star Ratings: The Numbers Can Tell a Story

The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage plans based on various factors, such as customer service, member satisfaction, and the quality of care. While the average rating in 2024 was 4.04 stars (on a 5-star scale), this marked a slight decrease from 4.14 in the previous year.

What does this mean for you?

Lower-rated plans might result in longer wait times, more claim denials, and lower overall quality of care. I encourage you to investigate these ratings beyond the summary, as this can help you find higher-rated plans in your area.

Check out our Medicare Advantage Plans by State and County plan finder for a personalized view of ratings for specific plans in your region.

Additional Concerns

Some other aspects can make some Medicare Advantage plans undesirable.

Changes in Coverage: The Surprise Factor

Keep in mind that Medicare Advantage plan benefits can change each year. What was covered in the past may not be in the future. Formularies can change, doctor networks can shrink, and benefits might get scaled back. It may make you scramble to switch plans during the Medicare Advantage open enrollment period.

Supplemental Coverage Needs: Not a One-Size-Fits-All Solution

In some instances, an Advantage plan won’t be enough. A Medicare Supplement policy might be worth considering if you anticipate many medical costs or have pre-existing conditions.

While Medicare Supplements (Medigap) often come with higher monthly premiums and no extra benefits, they help cover more of your healthcare costs. Remember, the best plan for your neighbor may not work for your circumstances. Carefully assess what you’ll need before jumping in.

Affordable Coverage with a Dual-Eligible SNP Plan

Some folks simply can’t afford Original Medicare or traditional Medicare Advantage plans. Maybe they have low income or a disability. This is where Dual-Eligible Special Needs Plans (D-SNPs) step in. D-SNPs are Medicare Advantage plans for people also on Medicaid.

But what makes these plans special? D-SNPs offer extra benefits that regular Medicare Advantage plans don’t, helping enrollees get better health care. This might include help with:

• Prescription drug costs
• Getting to doctor’s appointments
• Paying for over-the-counter medications
• Regular dental, vision, and hearing care
• Medical equipment

D-SNPs often have very low premiums and copays. This can make a big difference for seniors on a fixed income. Although D-SNPs are only for people on both Medicare and Medicaid, they can make healthcare much more affordable. D-SNP plans may be available depending on where you live, including HMO plans, PPO plans, or PFFS plan coverage. Ask your insurance agent if one of these plans is right for you, or check out the D-SNP plans in your area using our Medicare Special Needs Plan Finder tool.

FAQs about Worst Medicare Advantage Plans for Seniors

Which Medicare Advantage Plans Deny the Most Claims?

There isn’t a specific list of plans with the highest denial rates. Claims are often denied for several reasons: lack of pre-authorization, using an out-of-network provider, and if a service isn’t deemed medically necessary. To better understand the claims approval process with Medicare Advantage, read Your Guide to Medicare Advantage Approvals.

What Medicare Advantage Plan Has the Highest Rating?

Again, there is no “one size fits all” answer.  However, a 5-star rating generally signifies plans providing above-average care and service.   You can search Medicare Advantage plans at your location on Medicare.gov or use our convenient Medicare Advantage Plan Finder Tool.  While checking out plans, review their rating in individual categories like complaints, member experience, and customer service to understand their strengths and weaknesses better.

What are the Best Medicare Advantage Plans?

Picking a Medicare plan can feel like a tough job. You have a lot of choices from companies like Blue Cross Blue Shield, Humana, Aetna, AARP/UnitedHealthcare, Kaiser, and more. It’s super important to find one that fits you just right. But here’s the thing: there’s no single “best” plan for everyone. It all depends on what you need.

Some folks jump at plans with low monthly premiums. Sounds great, right? But sometimes, those plans can mean higher costs when you need care.

Maybe you pay more when you see the doctor or pick up your prescriptions. That’s why it’s important to look at the big picture. Pay attention to the out-of-pocket maximum, drug coverage, additional benefits (that you need), and star rating. These are all important factors.

Conclusion

Remember, when navigating the complex world of Medicare options, a one-size-fits-all solution doesn’t exist. The worst Medicare Advantage plans for seniors don’t meet your specific needs. Consider your health, budget, and priorities to find the best coverage for your circumstances.

Before choosing, research different Medicare Advantage plans, pay close attention to their provider network, and consider talking with a trusted Medicare advisor.