Key takeaways:
Original Medicare enrollees have access to most doctors and hospitals in the U.S. But people with private Medicare Advantage plans must use in-network care with certain healthcare professionals and facilities to avoid higher out-of-pocket costs.
A Medicare Advantage plan must meet a standard of network adequacy. This means enrollees must have access to at least 29 types of healthcare professionals and 14 kinds of facilities within certain distances and travel times. There are also limits on how long it takes to get appointments.
Original Medicare has no cap on an enrollee’s yearly cost-sharing, but Medicare Advantage has limits. In 2026, the out-of-pocket maximum can’t be more than $9,250 for in-network covered services or $13,900 for in-network and out-of-network covered services combined.
Medicare Advantage plans, which are private alternatives to original Medicare (Part A and Part B), cover certain healthcare professionals and facilities. People enrolled in original Medicare have access to almost every doctor and hospital in the U.S. But Medicare Advantage enrollees trade extra benefits for a narrower network of healthcare professionals and facilities.
We will discuss how those network limits work and your yearly out-of-pocket maximum spending limits for in-network and out-of-network care.
What is a Medicare Advantage network?
A Medicare Advantage network includes the physicians, other healthcare professionals, and medical facilities that are covered by a specific plan for non-emergency care. Generally, these are the healthcare professionals and hospitals that have a contract with the Medicare Advantage plan. A plan geographically includes one or more counties or “county equivalent” service areas — and sometimes an entire region, state, or group of states.
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People with original Medicare have access to 99% of healthcare professionals and facilities in the U.S. (excluding pediatric care). Compared to someone in their area covered by original Medicare, the average Medicare Advantage enrollee has access to about half of the doctors and other medical care.
What are Medicare Advantage network limits?
Medicare Advantage enrollees typically have narrower networks than people covered by original Medicare. These networks must provide “adequate access to covered services” for the enrollees served. Depending on where you live and the Medicare plan you have, your network could restrict your care options to very few doctors in your area.
For instance, many people in the Houston area and far beyond may want care at the The University of Texas MD Anderson Cancer Center. But the oncology hospital has contracts with only a few Medicare Advantage plans (though they may have a “working relationship” with your plan). Many people travel from other parts of Texas and other states for care, and your Medicare Advantage plan may not cover your cancer treatment at MD Anderson. But you may have access through your out-of-network benefits, which typically results in higher out-of-pocket costs and require prior authorization.
Network adequacy
The healthcare professionals and facilities included in a Medicare Advantage plan must meet a standard of network adequacy. This means at least 29 types of healthcare professionals and 14 kinds of facilities are accessible to enrollees within certain distances and travel times — which vary based on the population and density of your plan’s service area. The rules also limit how long enrollees should wait for appointments. The Centers for Medicare & Medicaid Services checks Medicare Advantage plans for network adequacy every 3 years, or more often if there are complaints.
Good to know: Certain specialities and facilities fall outside of the adequacy minimums for Medicare Advantage plans. For example, children’s hospitals and specialized, long-term care facilities don’t count toward the minimum requirement.
Minimum network adequacy for Medicare Advantage plans
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What are the Medicare Advantage out-of-pocket maximums for 2026?
The Medicare Advantage annual out-of-pocket spending cap per enrollee varies, but the out-of-pocket maximum in 2026 can’t be more than $9,250 for in-network covered services or $13,900 for in-network and out-of-network covered services combined.
You can’t combine Medicare Advantage with Medigap. So there’s no supplement insurance to help with Medicare Advantage out-of-pocket costs.
What are the pros and cons of in-network and out-of-network care?
Using the healthcare professionals and facilities in your network can save you money by limiting your out-of-pocket costs. Going outside of your plan’s coverage network typically results in higher out-of-pocket costs — but this may be necessary for the care you want or need. Also, there are different out-of-pocket limits for in-network care only versus services outside of your plan’s network combined with in-network care.
Does Medicare Advantage require prior authorization?
Prior authorizations, or utilization management, are coverage reviews that insurance companies use to control costs. Often, this can delay or deny your care. Prior authorization is common for Medicare Advantage plans. In 2024, Medicare Advantage plans had nearly 53 million prior authorization requests, or about 1.7 requests on average for every enrollee. That’s compared to nearly 50 million in 2023 or about 1.8 for every enrollee.
Prior authorization isn’t usually needed for care provided to original Medicare enrollees. But starting in 2026, a 6-year pilot program in 6 states will test coverage reviews for certain Part-B covered care.
What is the out-of-pocket limit for Medicare Part D plans?
Medicare Part D enrollees have a $2,100 out-of-pocket cap in 2026 for covered medications. After your spending hits that amount, your prescription plan pays for 100% of your covered medications for the rest of the year.
Which Medicare Advantage plan has the largest network?
On average nationwide, non-Anthem Blue Cross and Blue Shield Medicare Advantage plans have the widest networks followed by United Healthcare plans. That means these plans include the highest percentage of physicians that are available to original Medicare enrollees.
People covered by original Medicare have access to 99% of healthcare professionals and facilities in the U.S. (excluding pediatric care). About 1% of non-pediatric physicians opted out of Medicare in 2024. According to KFF, the average Blue Cross plan offers access to 59% of physicians or “participating providers” that original Medicare enrollees can use. Enrollees in United Healthcare plans can access about 58% of “participating providers” available to people with original Medicare.
The bottom line
Original Medicare enrollees have access to most doctors and hospitals nationwide. But, to avoid paying extra out-of-pocket costs, people with private Medicare Advantage plans must access in-network care with certain healthcare professionals and facilities in the plan’s service area. Medicare Advantage plans must meet a standard of network adequacy, but the options are still relatively limited on average in comparison to original Medicare.
While Original Medicare has no cap on an enrollee’s yearly cost-sharing, Medicare Advantage plans do. In 2026, the Medicare Advantage out-of-pocket maximum can’t be more than $9,250 for in-network covered services or $13,900 for in-network and out-of-network covered services combined.
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References
Biniek, J. F., et al. (2026). Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024. KFF.
Cottrill, A., et al. (2025). How many physicians have opted out of the Medicare program?
Jaffe, S. (2025). Complaints about gaps in Medicare Advantage networks are common. Federal enforcement is rare. KFF News.
KFF. (2025). There are a lot of Medicare Advantage plan options in my area. How do I decide which plan is best for me?
Medicare.gov. (2025). Network adequacy. Centers for Medicare & Medicaid Services.
Medicare.gov. (2025). Understanding Medicare Advantage plans. Centers for Medicare & Medicaid Services.
Medicare Payment Advisory Commission. (2026). Report to the Congress: Medicare payment policy.
National Archives. (2026). Network adequacy. Code of Federal Regulations.
Office of Inspector General. (2026). Medicare Advantage: Industry segment-specific compliance program guidance. U.S. Department of Health and Human Services.
Rae, M., et al. (2025). Medicare Advantage enrollees have access to about half of the physicians available to traditional Medicare beneficiaries.
Ramsay, C., et al. (2024). Medicare Advantage: A policy primer. The Commonwealth Fund.
The University of Texas MD Anderson Cancer Center. (2024). Medicare and Medicaid plans accepted.
