Medicare Advantage Plans by State: Coverage Gaps and Costs

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Medicare Advantage plans vary dramatically by state, and the difference can cost you thousands per year. Some states offer near-zero-premium plans with broad networks. Others leave seniors with narrow networks, high out-of-pocket maximums, and surprise billing gaps.

Medicare Advantage enrollment topped 34 million Americans as of late 2025, yet the plan you get in Florida looks almost nothing like the plan you get in Wyoming. The gap between the best and worst states for Medicare Advantage coverage can exceed $4,000 per year in out-of-pocket costs.

What Medicare Advantage Actually Covers (and What It Doesn't)

Medicare Advantage, also called Medicare Part C, replaces Original Medicare Parts A and B through a private insurer. Plans must cover everything Original Medicare covers, but the network restrictions, cost-sharing rules, and extra benefits differ sharply by plan and by state.

Original Medicare pays approximately 80% of a hip replacement after the Part B deductible, which sits at $257 in 2026. Medicare Advantage plans often lower your upfront cost but restrict you to in-network surgeons and facilities. Step out of network for that hip replacement, and some plans cover nothing at all.

Medicare does not cover most dental, vision, or hearing under Original Medicare. Many Advantage plans advertise these extras, but the actual dollar limits are often low. A $1,500 dental allowance sounds useful until your crown costs $2,200.

State-by-State Cost Differences Are Significant

County-level benchmarks set by the Centers for Medicare and Medicaid Services determine how much insurers receive per enrollee, and those benchmarks vary enormously. High-benchmark counties attract more plans and more competition, which drives premiums down and benefits up.

Florida, particularly South Florida and the Tampa Bay area, consistently ranks among the highest-benchmark markets in the country. Seniors in Miami-Dade County can find multiple $0-premium plans with dental, vision, and gym benefits included. Compare that to rural Wyoming or parts of Alaska, where one or two plans may exist and monthly premiums can run $80 to $150 with far fewer extras.

Out-of-pocket maximums tell the real story. Federal rules cap in-network out-of-pocket costs for Medicare Advantage at $9,350 in 2026. But plan-set maximums vary. Florida plans frequently set their cap below $5,000. Plans in low-benchmark rural states often sit at or near the federal ceiling. For a senior with a major illness, that gap is roughly $4,000 to $5,000 in real exposure.

State insurance regulations add another layer. Some states require Advantage plans to offer stronger continuity-of-care protections or mandate coverage of specific services. New York has historically required broader network adequacy standards than most Southern states.

Drug Coverage Gaps Catch People Off Guard

Medicare Part D covers prescription drugs, and most Advantage plans bundle Part D coverage. But formularies, which are the lists of covered drugs, differ by plan.

Duloxetine, the generic version of Cymbalta, is widely covered under Part D formularies because it is a high-volume generic. Most Medicare Advantage plans with Part D include it at a low tier, meaning a $0 to $10 copay for most enrollees. Prolia, the brand-name osteoporosis drug administered by injection in a clinical setting, is a different situation. Because it is administered in a physician's office, Prolia typically falls under Medicare Part B rather than Part D. Medicare Part B covers 80% of the approved amount after the deductible, and your Advantage plan then covers the remaining cost-sharing. Whether that gap costs you $0 or several hundred dollars depends on your specific plan's cost-sharing structure for Part B drugs.

Always confirm drug coverage before enrolling. The Medicare Plan Finder tool at Medicare.gov lets you enter your specific medications and compare plans by total estimated drug cost.

Who Qualifies and When It Matters for State Selection

Medicare eligibility starts at 65 for most Americans. It also applies to people under 65 with permanent kidney failure qualifying for ESRD coverage or those who have received Social Security Disability Insurance for 24 months.

If you are approaching 65 and choosing where to retire, your Medicare Advantage options should factor into that decision alongside taxes and cost of living. Florida's combination of $0-premium Advantage plans and no state income tax makes it a particularly strong option financially. If you are weighing a move, our Best States for Retirees to Avoid Taxes analysis breaks down the full tax picture, and our States That Don't Tax Social Security post covers another major retirement income concern.

Your Medicare costs are one piece of a much larger financial picture in retirement. Use our retirement cost calculator to model how state-level differences in taxes, healthcare costs, and cost of living combine into a real annual number.

Key Takeaways

The 2026 federal out-of-pocket maximum for Medicare Advantage in-network costs is $9,350, but competitive markets like South Florida frequently offer plans capped below $5,000.
The 2026 Medicare Part B deductible is $257, and Original Medicare covers 80% of approved costs including hip replacements after that deductible is met.
Rural and low-benchmark states often have one to two Advantage plan options with monthly premiums of $80 to $150, while high-benchmark counties in states like Florida offer multiple $0-premium plans.

Compare your state's healthcare costs, tax burden, and overall cost of living against every other state at Live or Die Here.

Sources

Where to confirm these figures

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