Medicare · Supporting
Medicare Advantage programs: what they cover, what they cost, and when you can enroll
Last reviewed September 17, 20263 min readBy the Goodsurance editorial team Reviewed by the Goodsurance editorial team
Original Medicare covers roughly 80% of approved Part B costs and pays a fixed share of inpatient care, but it has no annual limit on your total spending. The Part B coinsurance is 20% with no ceiling, so a serious illness or a series of outpatient procedures can leave large bills even after Medicare pays its share.
What Medicare Advantage is and how it differs from Original Medicare
Medicare Advantage adds a maximum out-of-pocket (MOOP) limit. In 2026, the federal cap on in-network spending is $9,250; once you reach your plan's MOOP, covered in-network services cost you nothing for the rest of the year. The combined cap covering both in-network and out-of-network costs is $13,900 in 2026. According to KFF, the enrollment-weighted average in-network MOOP across 2026 Advantage plans is $5,421, meaning most plans set their limit well below the federal ceiling.
The structural tradeoff is the network. Advantage plans contract with specific doctors and hospitals, and whether a provider is in-network affects both your costs and, in some plan types, your access. Original Medicare reaches almost any provider nationwide who accepts Medicare assignment.
2026 out-of-pocket limits for Medicare Advantage
Once you hit your plan's limit, covered in-network services cost you nothing for the rest of the year.
Types of Medicare Advantage plans
| Plan type | How the network works | Referral for specialists |
|---|---|---|
| HMO | Closed network; out-of-network care generally not covered except emergencies | Required |
| PPO | Open network; out-of-network covered at a higher cost share | Not required |
| PFFS | Any provider who accepts the plan's payment terms may treat you | Not required |
| SNP | Network varies; enrollment limited to people who meet program-defined criteria | Varies |
Special Needs Plans (SNPs) serve three groups: people who are dual-eligible for Medicare and Medicaid (D-SNP), people in institutional long-term care (I-SNP), and people with specific chronic conditions (C-SNP). Qualifying criteria are program-defined and vary by plan.
HMOs and PPOs account for the large majority of Advantage enrollment. To find out which plan types operate in your area and what their networks include, please contact us to discuss plan options.
Costs and coverage in 2026
Every Medicare Advantage plan must cover the full scope of Original Medicare: inpatient hospital stays, outpatient services, lab work, durable medical equipment, home health care, and hospice. Hospice stays are billed directly through Original Medicare even when you are in an Advantage plan.
Most plans bundle Part D drug coverage. In 2026, the out-of-pocket cap on covered Part D drugs is $2,100 for the year. Once you reach that cap, covered formulary drugs cost you $0 for the rest of the calendar year.
Many plans also offer supplemental benefits such as routine dental, vision exams, hearing aids, and fitness programs. What each plan provides varies; you will need to check your plan's Evidence of Coverage to see what applies to your specific situation.
Premiums. Premiums differ by plan and market. Some plans carry a $0 premium, though you still pay the Part B premium regardless of which plan you choose. In 2026, the standard Part B premium is $202.90 per month. Plans with richer benefits or broader networks generally carry higher monthly premiums.
Prior authorization. Advantage plans may require approval before covering certain services. Under CMS rule CMS-0057-F, which took full effect January 1, 2026, plans must issue a standard prior-authorization decision within 7 calendar days. Expedited decisions, for cases where a delay could seriously harm your health, must come within 72 hours, and any denial must include a specific reason.
Prior authorization: how long your plan has to decide
Any denial must include a specific reason. These rules took full effect January 1, 2026.
When you can join or change a Medicare Advantage plan
Annual Enrollment Period (AEP): October 15 to December 7. This is the primary window each year for joining, switching, or dropping a Medicare Advantage or Part D plan. Changes made during AEP take effect January 1.
Medicare Advantage Open Enrollment Period (OEP): January 1 to March 31. If you are already enrolled in a Medicare Advantage plan, this window lets you switch to a different Advantage plan or return to Original Medicare, and separately add a standalone Part D drug plan. You may make one change during this period.
Special Enrollment Periods (SEPs). Certain qualifying events allow changes outside the standard windows. Common triggers include moving out of your plan's service area, losing other creditable coverage, and qualifying for Extra Help with drug costs. The SEP type and duration depend on the qualifying event.
To find out more about coverage in your area and which plans fit your situation, please contact us to discuss plan options.
Common questions about IRMAA appeals
Quick answers, fast .
Tap any question to expand. Each links to a fuller standalone answer.
Does Medicare pay for hearing aids
Original Medicare does not cover hearing aids or fittings.
Some Medicare Advantage plans may include a hearing benefit, but what they cover varies by plan.
Does Medicare cover ambulance services?
Yes, in limited situations.
Medicare Part B covers emergency ambulance transportation when traveling any other way could endanger your health, taking you to the nearest appropriate hospital or facility. You pay 20% of the Medicare-approved amount after the $283 Part B deductible in 2026. Air ambulance is covered only when ground transport cannot reach you or would take too long. Non-emergency ambulance trips, for example to dialysis, are covered only when a doctor provides a written order stating they are medically necessary. Medicare does not cover ambulance rides taken purely for convenience.
Does Medicare cover skilled nursing facility care?
Yes, on a short-term basis.
Medicare Part A covers skilled nursing facility (SNF) care after a qualifying inpatient hospital stay of at least 3 days, when you need daily skilled care like nursing or therapy. In 2026 you pay $0 for days 1 through 20 of each benefit period, $217 per day for days 21 through 100, and all costs after day 100. Coverage is for skilled care while you recover, not for long-term or custodial care (help with daily activities like bathing or dressing), which Medicare does not cover. Long-term nursing home care is generally paid through Medicaid or private funds.
Does Medicare cover physical therapy?
Yes.
Medicare Part B covers outpatient physical therapy that is medically necessary to treat your condition. You pay 20% of the Medicare-approved amount after the yearly Part B deductible ($283 in 2026). There is no longer a hard dollar cap on therapy, but once your physical and speech therapy together pass $2,480 in 2026, your therapist must add a note (called a KX modifier) confirming you still need care. Claims above $3,000 may be reviewed for medical necessity. Part A covers physical therapy you receive as a hospital inpatient or in a skilled nursing facility. A doctor or therapist must set up and regularly review your plan of care.
Does Medicare cover mental health services?
Yes.
Medicare covers mental health care across its parts in 2026. Part B covers outpatient services like therapy, counseling, and visits with psychiatrists, psychologists, and clinical social workers, and since 2024 it also covers marriage and family therapists and mental health counselors. You pay 20% of the Medicare-approved amount after the $283 deductible, and one depression screening each year is free. Part A covers inpatient mental health care, with a lifetime limit of 190 days in a freestanding psychiatric hospital. Part D covers most mental health medications. Many of these services are also available by telehealth, and Medicare Advantage plans cover at least the same benefits.
Does Medicare cover chiropractic care?
Partly.
Medicare Part B covers one specific chiropractic service: manual manipulation of the spine to correct a subluxation (when one or more bones of the spine are out of position) that a doctor confirms is medically necessary. You pay 20% of the Medicare-approved amount after the $283 Part B deductible in 2026. Medicare does not cover other services a chiropractor might offer, such as X-rays, massage therapy, acupuncture, or routine wellness visits, so you would pay the full cost for those. Some Medicare Advantage plans include extra chiropractic or wellness benefits beyond this.
Does Medicare cover home health care?
Yes, when you qualify.
Medicare Parts A and B cover home health care if a doctor certifies that you are homebound (leaving home takes a major effort) and need part-time skilled care, such as skilled nursing, physical therapy, occupational therapy, or speech therapy. A Medicare-certified home health agency must provide the care under a plan your doctor reviews. You pay $0 for covered home health visits in 2026, and 20% for any durable medical equipment. Medicare does not cover 24-hour home care, meal delivery, or homemaker services like cleaning when that is the only care you need.
Does Medicare cover vision care?
Mostly no for routine care.
In 2026, Original Medicare does not cover routine eye exams for glasses or contact lenses, and it does not pay for the glasses or contacts themselves. It does cover some medical eye care: yearly glaucoma screenings for people at high risk, diabetic retinopathy exams, treatment for eye diseases, and cataract surgery (including one pair of standard glasses or contacts afterward). For those covered services you pay 20% after the $283 Part B deductible. Many Medicare Advantage plans add a routine vision benefit covering eye exams and an allowance for glasses.
Does Medicare cover hearing aids?
Original Medicare does not cover hearing aids or the exams used to fit them.
Some Medicare Advantage plans include a hearing benefit, but coverage varies by plan.
Does Medicare cover diabetes supplies and testing?
Yes.
In 2026 Medicare covers most diabetes care across two parts. Part B (outpatient care and equipment) covers blood sugar monitors, test strips, lancets, and continuous glucose monitors (CGMs) as durable medical equipment, plus diabetes screenings and a self-management training program. You pay 20% of the Medicare-approved amount after the $283 Part B deductible. Part D (drug coverage) covers insulin and related supplies like syringes, and in 2026 your insulin is capped at $35 for a month's supply. If you have a Medicare Advantage plan, it covers at least the same diabetes benefits, sometimes with added extras.
Does Medicare cover durable medical equipment?
Yes.
Medicare Part B covers durable medical equipment (DME): reusable medical gear your doctor prescribes for use at home, such as wheelchairs, walkers, hospital beds, oxygen equipment, CPAP machines, and blood sugar monitors. You pay 20% of the Medicare-approved amount after the $283 Part B deductible in 2026, and Medicare pays the other 80%. To be covered, the item must be ordered by a Medicare-enrolled doctor and supplied by a Medicare-enrolled supplier, and some items are rented rather than bought. Equipment meant mainly for use outside the home, or only for comfort or convenience, is not covered.
Which is better, Medigap or Medicare Advantage?
Neither is better for everyone; they suit different needs.
Medigap (also called Medicare Supplement, a private policy that pairs with Original Medicare) lets you see any doctor nationwide who accepts Medicare with no network and very predictable out-of-pocket costs, but you pay a monthly Medigap premium and add a separate Part D drug plan. Medicare Advantage (Part C, your Medicare benefits through a private plan) often has a lower or $0 plan premium, bundles drug coverage and extras like dental and vision, and caps your yearly out-of-pocket costs, but uses provider networks and may require prior approval. People who travel, want maximum doctor freedom, and prefer steady costs often lean Medigap; people who want low premiums, extras, and a network they are comfortable with often lean Medicare Advantage. With both, you still pay the Part B premium ($202.90 per month in 2026). To find out which fits your situation, reach out to a licensed Goodsurance advisor at 1-888-301-8091 (TTY 711), Mon to Fri 8 am to 5 pm PT.