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Introduction
Medicare Advantage enrollment continues to grow. According to the Kaiser Family Foundation, more than 33 million Americans — representing over 54% of all Medicare beneficiaries — are now enrolled in Medicare Advantage plans in 2026. That's up from just 19 million a decade ago.
If you're turning 65 or reviewing your current coverage during the Annual Enrollment Period, understanding how these plans differ matters. Not all Medicare Advantage plans are created equal, and the features that work for your neighbor may not work for you.
Here are seven features worth comparing before you make your decision for 2026.
1. Maximum Out-of-Pocket Limits
One of the biggest advantages of Medicare Advantage over Original Medicare is the annual out-of-pocket maximum. Original Medicare has no cap on what you could spend in a year — meaning a serious illness could result in unlimited costs.
Medicare Advantage plans are required by CMS to cap your annual out-of-pocket spending. For 2025, the maximum allowed limit is $8,850 for in-network services. However, many plans set their limits lower, ranging from $3,000 to $7,500 depending on the plan and region.
When comparing plans, look at both the in-network and combined in-network/out-of-network limits. A lower maximum means more predictable costs if you face a major health event.
2. Monthly Premium vs. Total Cost
Many Medicare Advantage plans advertise $0 monthly premiums, and this is true — you may pay nothing beyond your Part B premium (which is $185 per month for most beneficiaries in 2025). However, $0-premium plans often have higher copays, coinsurance, and deductibles.
A plan with a $50 monthly premium might actually cost you less overall if it includes lower copays for services you use regularly. Calculate your expected total annual cost based on your typical healthcare usage, not just the monthly premium.
According to KFF analysis, the average Medicare Advantage enrollee paid approximately $18 per month in plan premiums in 2025, plus their Part B premium.
3. Provider Network Type and Size
Medicare Advantage plans come in different network structures:
- HMO (Health Maintenance Organization): You must use in-network providers except for emergencies. Typically requires referrals for specialists.
- PPO (Preferred Provider Organization): You can see out-of-network providers at higher cost. No referrals required.
- PFFS (Private Fee-for-Service): Any provider who accepts the plan's terms can treat you.
- SNP (Special Needs Plan): Designed for specific populations with chronic conditions, dual eligibility, or institutional care needs.
About 58% of Medicare Advantage enrollees are in HMO plans, according to CMS data. Before enrolling, verify that your current doctors, specialists, and preferred hospitals are in-network. Provider directories change annually.
4. Prescription Drug Coverage (Part D)
Most Medicare Advantage plans include prescription drug coverage (MA-PD plans). However, drug formularies vary significantly between plans. A medication that's covered on one plan's formulary might be Tier 3 or not covered at all on another.
Key drug coverage features to compare:
- Formulary tiers: Lower tiers mean lower copays
- Prior authorization requirements: Some plans require approval for certain medications
- Step therapy: Some plans require you to try cheaper alternatives first
- Coverage gap (donut hole): While the coverage gap is shrinking due to the Inflation Reduction Act, plans still vary in gap coverage
Starting in 2025, the $2,000 annual cap on Part D out-of-pocket costs provides important protection for those with expensive medications.
5. Extra Benefits Beyond Original Medicare
Medicare Advantage plans often include benefits that Original Medicare does not cover:
- Dental coverage: Routine cleanings, X-rays, and sometimes major dental work
- Vision coverage: Eye exams, glasses, and contact lenses
- Hearing coverage: Hearing exams and hearing aids
- Fitness programs: Gym memberships like SilverSneakers or similar programs
- Over-the-counter allowances: Monthly credits for OTC medications and health products
- Transportation: Rides to medical appointments
According to CMS, 97% of Medicare Advantage enrollees have access to some dental benefits, 97% have vision benefits, and 82% have hearing benefits. However, the scope and dollar limits of these benefits vary widely.
6. Star Ratings and Quality Scores
CMS rates Medicare Advantage plans on a 1 to 5 star scale annually, with 5 stars being the highest. Ratings are based on factors including:
- Member satisfaction and complaints
- Preventive care services
- Chronic condition management
- Customer service responsiveness
- Drug pricing and safety
For 2025, approximately 74% of Medicare Advantage enrollees are in plans rated 4 stars or higher. Higher-rated plans often receive bonus payments from CMS, which they can use to enhance benefits.
While star ratings provide useful information, they represent plan-wide averages. Your individual experience may vary based on your specific providers and health needs.
7. Prior Authorization Requirements
Prior authorization is when your plan requires approval before covering certain services, tests, or procedures. This is an area where Medicare Advantage plans often differ significantly from Original Medicare.
CMS has been working to reduce excessive prior authorization requirements, with new rules taking effect that require faster decisions and limit unnecessary denials. When comparing plans, research which services require prior authorization and how quickly the plan processes requests.
Some plans are more restrictive than others. If you have ongoing healthcare needs that require specialist visits or specific treatments, understanding a plan's prior authorization policies is essential.
What to Do Next
- Check your current doctors — Use Medicare.gov's Plan Finder tool to verify your providers are in-network for plans you're considering.
- List your medications — Enter your prescriptions into the Medicare Plan Finder to see how each plan covers your specific drugs.
- Review star ratings — Compare quality scores at Medicare.gov, keeping in mind that ratings are updated each October.
- Calculate total costs — Factor in premiums, deductibles, copays, and your typical healthcare usage to estimate annual spending.
- Talk to a licensed agent — Independent insurance agents can compare multiple carriers and help you understand plan differences at no cost.
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This article is for informational purposes only and does not constitute insurance or financial advice. Coverage, costs, and availability vary by plan and location. Always consult a licensed insurance professional before enrolling in any Medicare plan.