55%Eligible beneficiaries in Medicare Advantage, 2026
$9,250Maximum in-network out-of-pocket limit
$13,900Maximum combined in- and out-of-network limit
$5,421Average in-network limit across plans
The 2026 numbers
| Measure | 2026 |
|---|---|
| Share of eligible Medicare beneficiaries in Medicare Advantage | 55% (about 35 million people), per KFF |
| Share of Advantage enrollees in Special Needs Plans | 23% |
| Legal maximum out-of-pocket, in-network | $9,250 (down $100 from $9,350 in 2025) |
| Legal maximum out-of-pocket, in- and out-of-network combined | $13,900 |
| Average in-network limit across plans | $5,421 (HMOs about $4,636, PPOs about $6,592) |
Plans may set limits below the legal maximum, and many do. Your plan's own limit is in its Evidence of Coverage and Annual Notice of Change.
What the out-of-pocket limit covers
The limit applies to Part A and Part B covered services. Once you reach it, the plan pays 100% of covered services for the rest of the year. It does not include your monthly premium or Part D drug costs, which have their own limit.
What to check before you choose or keep a plan
- Network: are your doctors, hospital, and pharmacy in it? HMOs generally do not cover out-of-network care except emergencies.
- Your plan's out-of-pocket limit, not just the premium.
- Prior authorization: which services need approval first, such as imaging, surgery, or skilled nursing.
- Drug coverage: check every medication and its tier.
- Extra benefits: dental, vision, and hearing often have small annual dollar limits. See what Original Medicare covers.
- Part B premium: you still pay it ($202.90 in 2026) on top of any plan premium.
Advantage vs Original Medicare with Medigap
| Medicare Advantage | Original Medicare + Medigap | |
|---|---|---|
| Doctor choice | Plan network | Any provider accepting Medicare |
| Annual out-of-pocket limit | Yes, up to $9,250 in-network | Medigap Plan G leaves only the Part B deductible ($283) |
| Premiums | Often $0 plan premium (plus Part B) | Part B plus a Medigap premium |
| Prior authorization | Common | Rare |
| Switching later | Possible, but Medigap may require medical underwriting | Medigap guaranteed during the first 6 months after 65 |
Switching back is not always easy. If you leave Advantage for Original Medicare after your first year, many states let insurers use medical underwriting for a Medigap policy. Think about this before you drop Original Medicare.
You can change plans during open enrollment (through December 7), or between January 1 and March 31 if you are already in an Advantage plan.