Medicare Advantage plans: how they work and what to compare in 2026

Joining an MA plan does not mean leaving Medicare. You remain enrolled in Medicare; the private plan simply administers your benefits. You still pay the Part B premium. In 2026, the standard Part B premium is $202.90 per month, and that charge applies regardless of whether you are in Original Medicare or an MA plan.

What changes is how you access care: MA plans use networks of doctors and hospitals, apply their own cost-sharing schedules, and may require prior authorization (advance approval) for certain services.

In short: MA is Original Medicare delivered through a private insurer, with its own network, cost-sharing, and often extra benefits layered on top.

Original Medicare does not have a ceiling on your annual out-of-pocket costs. Part B coinsurance alone is 20% of the Medicare-approved amount with no annual cap. A serious illness can expose you to substantial costs unless you also hold a Medigap (Medicare Supplement) policy.

MA plans are required to set an annual out-of-pocket maximum (MOOP), which is the most you would pay in a calendar year for covered in-network services before the plan covers 100%. In 2026, the federal in-network MOOP cap is $9,250; plans may set lower limits. According to KFF, the 2026 enrollment-weighted average in-network MOOP across plans is $5,421, which means many people are enrolled in plans with limits well below the federal ceiling.

Plans that also cover out-of-network care (typically PPOs) carry a combined in-network plus out-of-network MOOP cap of $13,900 in 2026. Once you reach either threshold within the calendar year, the plan pays 100% of covered services for the remainder of that year.

The MOOP is a ceiling, not a guarantee. Whether you hit it depends on your utilization, the plan's cost-sharing structure, and whether your providers are in network.

In short: The MOOP cap is MA's primary structural advantage over Original Medicare alone; the 2026 federal ceiling is $9,250 in-network, with many plans setting lower limits.

Not all MA plans work the same way. The four most common structures differ mainly in how rigid the network is.

SNPs (Special Needs Plans) have qualifying criteria defined by the specific program they serve. A Dual Eligible SNP (D-SNP) is for people enrolled in both Medicare and Medicaid. A Chronic Condition SNP (C-SNP) is for people with specific serious or disabling conditions. SNP qualifying criteria are program-defined; if you think you may qualify, contact us to discuss plan options.

In short: The plan type you choose determines how flexible your provider access is, and flexibility typically comes with higher cost-sharing.

Prior authorization (PA) means a plan must approve a service before you receive it. Under CMS-0057-F, which took full effect January 1, 2026, MA plans must meet stricter timelines and transparency standards.

For a standard PA request, the plan must issue a decision within 7 calendar days. For an expedited request (when waiting could seriously jeopardize your health), the plan must decide within 72 hours, and any denial must include a specific reason.

These timelines matter because delays in PA can delay care. Knowing the deadline gives you a concrete basis for following up with the plan or filing an appeal if the window passes.

In short: As of 2026, your MA plan has 7 calendar days for a standard PA decision and 72 hours for an expedited one; denials must state a specific reason.

Most MA plans include Part D drug coverage (called MA-PD plans). If your plan includes Part D, a separate standalone Part D plan would be redundant and generally not allowed.

The 2026 Part D rules carry significant changes from prior years. Out-of-pocket spending on covered Part D drugs is capped at $2,100 for the year; once you reach that cap, covered drugs cost $0 for the rest of the year. The coverage gap (often called the donut hole) is eliminated. No Part D plan may set a deductible above $615 in 2026, though many plans set lower deductibles or none at all.

If you delay Part D enrollment beyond your Initial Enrollment Period (IEP), which is the 7 months around your 65th birthday (3 months before, your birthday month, and 3 months after), and you go 63 or more consecutive days without creditable drug coverage, a late-enrollment penalty applies. That penalty adds 1% of the national base beneficiary premium ($38.99 in 2026) for each full month of the gap, and it is permanent.

In short: Most MA plans include drug coverage, and the 2026 out-of-pocket cap for Part D drugs is $2,100; after that, covered drugs cost nothing for the rest of the year.

Understanding the enrollment windows prevents costly mistakes.

The Initial Enrollment Period (IEP) is your first chance to join Medicare. It spans 7 months: the 3 months before your birthday month, your birthday month, and the 3 months after. Enrolling during or before your birthday month gets you the cleanest coverage start.

The Annual Enrollment Period (AEP) runs October 15 to December 7 each year. During AEP you can join an MA plan, switch from one MA plan to another, switch from MA back to Original Medicare, or join or change a Part D plan. Changes take effect January 1.

The Medicare Advantage Open Enrollment Period (MA OEP) runs January 1 to March 31. If you are already enrolled in an MA plan, you can switch to a different MA plan or return to Original Medicare (and join a standalone Part D plan) during this window. You cannot use MA OEP to join an MA plan for the first time.

Special Enrollment Periods (SEPs) exist for specific circumstances, such as moving out of a plan's service area, losing employer coverage, or qualifying for Extra Help (the Low Income Subsidy, or LIS, which reduces Part D costs for people with limited income and resources).

One timing detail that catches people by surprise: COBRA continuation coverage and retiree coverage do not count as active employer coverage for enrollment or late-penalty purposes. The 8-month SEP to enroll in Part B without penalty begins when employment or employer coverage ends, whichever comes first, not when COBRA ends.

In short: AEP (October 15 to December 7) is the main annual window; MA OEP (January 1 to March 31) is for plan members who want to switch.

The premium is only one dimension. A $0-premium MA plan (common in many markets, though availability varies) still costs you the Part B premium each month, and its cost-sharing and network restrictions can easily exceed the savings on the plan premium itself.

When comparing plans, these are the most consequential variables:

• MOOP: The lower the cap, the less you pay in a bad year. The 2026 federal ceiling is $9,250 in-network.
• Network: Confirm your specific doctors and preferred hospitals are in network before enrolling.
• Drug formulary: Check that your current medications appear on the plan's formulary, and at which tier.
• Cost-sharing: Copays and coinsurance for primary care, specialists, and hospital stays vary widely.
• Prior authorization requirements: Some plans require PA for more services than others.
• Extra benefits: Dental, vision, and hearing benefits are plan-specific; benefit amounts and structures render from the plan's filed data and vary per plan.
• Star ratings: CMS rates MA plans on a 1-to-5-star scale annually; higher-rated plans have a track record of better performance on quality and member experience measures.

If comparing plans feels overwhelming or your situation involves multiple chronic conditions, a Medigap alternative, IRMAA (Income-Related Monthly Adjustment Amount, a surcharge for higher earners that applies to both Part B and Part D), or coordination with employer coverage, contact us to discuss plan options with a licensed agent.

In short: Premium is the least important number; network, MOOP, formulary, and prior-authorization practices do more to determine your actual costs.