Health care affordability has been a longstanding concern in the U.S., including among older adults, many of whom have relatively low incomes and modest assets to help cover the cost of premiums and medical bills. Medicare offers important financial protection by providing health insurance coverage to 69 million people in the U.S., including adults age 65 or older and younger adults with long-term disabilities. However, Medicare-covered benefits are subject to cost-sharing requirements and exclude some commonly needed services, like dental and vision care.  Additionally, traditional Medicare does not include a cap on out-of-pocket costs.

To help with cost sharing for Medicare-covered services and fill the gaps in Medicare benefits, most Medicare beneficiaries supplement traditional Medicare with additional coverage, such as Medigap, for which policyholders pay an average of $2,600 annually in premiums. More than half of people with Medicare are currently enrolled in Medicare Advantage, which offers extra benefits not available in traditional Medicare and caps annual out-of-pocket costs. Medicare beneficiaries may also have employer- or union-sponsored coverage or Medicaid coverage in addition to Medicare. But some people on Medicare lack additional coverage and face the risk of incurring high out-of-pocket costs if they need expensive medical care.

This analysis documents the different sources of coverage among people with Medicare and examines variation in beneficiary characteristics by source of coverage. The analysis draws on data from the Centers for Medicare & Medicaid Services (CMS) March 2025 Medicare Advantage enrollment files and the 2023 Medicare Current Beneficiary Survey (see Methods for details).

Key Facts

• More than half of all people with Medicare Part A and Part B (54% or 34.1 million in 2025) are enrolled in a Medicare Advantage plan, while 46% (28.7 million) are in traditional Medicare.
• Among traditional Medicare beneficiaries, most (87%) had additional coverage that supplements Medicare benefits in 2023, but 3.5 million beneficiaries (13%) lacked additional coverage, leaving them at risk of facing high out-of-pocket costs for medical care.
• Overall, 14.1 million beneficiaries (23% of all Medicare beneficiaries) had employer or union sponsored coverage in 2023, either as a supplement to traditional Medicare or through group Medicare Advantage plans, another 12.2 million (20%) had Medicaid in addition to traditional Medicare or Medicare Advantage, and the same number, 12.2 million (20%) had a Medicare supplemental insurance (Medigap) policy to supplement traditional Medicare.

• The number and share of Medicare beneficiaries with Medicaid (dual eligible individuals) were substantially higher in Medicare Advantage (68%) than traditional Medicare (32% in 2023).
• Compared to traditional Medicare beneficiaries, Medicare Advantage enrollees were more likely to be Black or Hispanic, have incomes below $20,000 per person, and self-report fair or poor health.

More than Half of All People with Medicare Are Enrolled in Medicare Advantage

In 2025, Medicare Advantage covered more than half (54%) of Medicare beneficiaries with both Medicare Parts A and B, or 34.1 million out of about 62.8 million people. Of the total number of Medicare Advantage enrollees in 2025, most (62%) are enrolled in individual plans available to all Medicare beneficiaries. One in five (21%) are in Special Needs Plans (SNPs) and 17% are enrolled in employer- or union-sponsored group plans, where employers or unions contract with an insurer and Medicare pays the insurer a fixed amount per enrollee to provide benefits covered by Medicare. (These estimates are based on March 2025 Medicare Advantage plan enrollment data and therefore differ from those discussed below and shown in Figure 1, which are based on the 2023 Medicare Current Beneficiary Survey (MCBS)).

Compared to traditional Medicare beneficiaries, Medicare Advantage enrollees were more likely to be Black or Hispanic, have incomes below $20,000 per person, and self-report fair or poor health, based on KFF analysis of the 2023 MCBS (Figure 2, Appendix Table 1).

Most Medicare Beneficiaries in Traditional Medicare Have Additional Coverage that Supplements Medicare Benefits

In 2023, most (87%) people in traditional Medicare had some form of additional coverage, either through Medigap (43%), employer coverage (29%), Medicaid (14%), or another source (1%),based on estimates from the MCBS.But 3.5 million Medicare beneficiaries in traditional Medicare (13%) had no additional coverage. A more detailed discussion of these types of coverage and the characteristics of people with each coverage type is below.

Nearly a Quarter of Medicare Beneficiaries Have Employer Coverage, Either through Group Medicare Advantage Plans or in Addition to Traditional Medicare

In total, 14.1 million Medicare beneficiaries – nearly a quarter (23%) of Medicare beneficiaries overall – had some form of employer or union-sponsored health insurance coverage in 2023 in addition to Medicare Part A and Part B. Of this total, 8.2 million beneficiaries had employer coverage in addition to traditional Medicare (29% of beneficiaries in traditional Medicare), while 5.9 million beneficiaries were enrolled in Medicare Advantage employer group plans. Most people with both Medicare Part A and Part B and employer- or union-sponsored coverage are retirees with Medicare as their primary source of health insurance coverage.

Compared to traditional Medicare beneficiaries overall in 2023, beneficiaries with employer or union-sponsored coverage in addition to traditional Medicare were more likely to have higher incomes ($40,000 or greater per person), a bachelor’s degree or higher, self-report excellent or good health, and were less likely to be under age 65 (Figure 3, Appendix Table 1).

Separately, in 2023, an estimated 5.8 million Medicare beneficiaries had Part A only, a group that primarily includes people who were active workers (either themselves or their spouses) and had primary coverage from an employer plan and Medicare as a secondary payer. People with Part A only cannot enroll in a Medicare Advantage plan, so people with coverage through Medicare Advantage employer group plans are likely to be retired.

Four in 10 People in Traditional Medicare Have a Medigap Supplemental Policy

Medicare supplement insurance, also known as Medigap, covered 2 in 10 (20%) Medicare beneficiaries overall, or 43% of those in traditional Medicare (12.2 million beneficiaries) in 2023. Medigap policies, sold by private insurance companies, fully or partially cover Medicare Part A and Part B cost-sharing requirements, including deductibles, copayments, and coinsurance. Medigap limits the financial exposure of Medicare beneficiaries and provides protection against catastrophic medical expenses. However, Medigap premiums can be costly and can rise with age, among other factors, depending on the state in which they are regulated.

Compared to all traditional Medicare beneficiaries in 2023, beneficiaries with Medigap were more likely to be White, have higher annual incomes (above $20,000 per person), self-report excellent, very good, or good health, and have a bachelor’s degree or higher (Figure 3, Appendix Table 1).

In contrast, a smaller share of traditional Medicare beneficiaries under age 65 have a Medigap policy than traditional Medicare beneficiaries ages 65 and older (1% versus 9%). Federal law provides a 6-month guarantee issue protection for adults ages 65 and older when they first enroll in Medicare Part B if they want to purchase a supplemental Medigap policy, but these protections do not extend to adults under the age of 65 with disabilities, and most states do not require insurers to issue Medigap policies to beneficiaries under age 65.

One in Five People with Medicare Also Have Coverage from Medicaid, with More Covered Under Medicare Advantage than Traditional Medicare

Medicaid, the federal-state program that provides health and long-term services and supports coverage to low-income people, was a source of supplemental coverage for 12.2 million Medicare beneficiaries with low incomes and modest assets in 2023, or 20% of all Medicare beneficiaries. A larger number and share of Medicare beneficiaries with Medicaid (known as dual-eligible individuals) were enrolled in a Medicare Advantage plan (8.3 million, or 68% of all dual-eligible individuals) than in traditional Medicare (4.0 million, or 32%) (Appendix Table 1). For these beneficiaries, Medicaid typically pays the Medicare Part B premium and may also pay a portion of Medicare deductibles and other cost-sharing requirements. Most dual-eligible individuals are also eligible for full Medicaid benefits, including long-term services and supports.

Compared to traditional Medicare beneficiaries overall in 2023, dual-eligible individuals were more likely to have low incomes and relatively low education levels, self-report fair or poor health, identify as Black or Hispanic, and be under the age of 65 (Figure 3, Appendix Table 1).

3.5 Million Traditional Medicare Beneficiaries Lack Supplemental Coverage

In 2023, 3.5 million Medicare beneficiaries – 6% overall –and 13% of beneficiaries in traditional Medicare – had no supplemental health insurance coverage. Traditional Medicare beneficiaries with no additional coverage are fully exposed to Medicare’s cost-sharing requirements, which would mean paying a $1,736 deductible for a hospital stay in 2026, daily copayments for extended hospital and skilled nursing facility stays, and a $283 deductible plus 20% coinsurance for physician visits and other outpatient services. (These costs are in addition to the standard Part B premium amount of $203 per month in 2026). Beneficiaries in traditional Medicare without additional coverage also face the risk of high annual out-of-pocket costs because there is no cap on out-of-pocket spending for Part A and B services in traditional Medicare, unlike in Medicare Advantage plans.

Beneficiaries in traditional Medicare without any form of additional coverage were more likely to have modest incomes (between $20,000 and $40,000 per person) compared to all traditional Medicare beneficiaries in 2023 (Figure 3, Appendix Table 1). Medicare beneficiaries with modest incomes have limited ability to afford Medigap premiums and are unlikely to qualify for Medicaid because their income and assets are not low enough to meet eligibility guidelines.

The number and share of traditional Medicare beneficiaries without any form of supplemental coverage has steadily declined in recent years. Between 2018 and 2023, the number of traditional Medicare beneficiaries without supplemental coverage declined from 5.6 million beneficiaries (10% of the total Medicare population, or 17% of those in traditional Medicare) to 3.5 million (6% of the total Medicare population, or 13% of those in traditional Medicare). This decline likely reflects the increase in Medicare Advantage enrollment over time, which has increased from 20 million in 2018 to 34 million in 2025.

Appendix

The 2025 reconciliation law could have major implications for nearly 15,000 federally certified nursing facilities and the more than 1.2 million people living in them. Nursing facilities provide medical and personal care services for older adults and people with disabilities. In 2023, Medicaid paid for 44% of long-term institutional care costs; 37% of long-term institutional care costs were paid for out-of-pocket; and the remaining 18% was covered by other public and private payers. Although provisions in the reconciliation law do not directly limit or reduce nursing facility services, changes to the Medicaid program could result in reduced payments from Medicaid for nursing facility care and may result in fewer people having Medicaid coverage of nursing facility care (see Box 1 for more on the 2025 reconciliation law.)

This data note discusses the impact of the 2025 reconciliation law on nursing facilities and examines the characteristics of nursing facilities and the people living in them with data from Nursing Home Compare, a publicly available dataset that provides a snapshot of information on quality of care in each nursing facility, and CASPER (Certification and Survey Provider Enhanced Reports), a dataset that includes detailed metrics collected by surveyors during nursing facility inspections. State-level data are also available on State Health Facts, KFF’s data repository with downloadable health indicators. Key takeaways from July 2025 data include:

• There are 14,742 nursing facilities certified by CMS and about 1.24 million residents living in these certified nursing facilities (Figure 1).
• Nursing facility residents receive, on average, about 3.85 hours of nursing care per day from licensed practical nurses (LPN/LVN), registered nurses (RNs), and nurse aides (Figure 2).
• On average, nursing facilities receive 9.5 deficiencies over the course of a survey cycle (Figure 3).
• While nearly all facilities receive at least one deficiency over the course of a survey cycle, 27% of facilities receive serious deficiencies for actual harm or jeopardy posed to a resident (Figure 3).

As of July 2025, there are 14,742 nursing facilities certified by CMS (Figure 1). The number of nursing facilities certified by CMS decreased by 6% between July 2015 and July 2025. There has generally been a steady decline during that time period. In order to receive payment under the Medicare and/or Medicaid programs, nursing facilities are required to follow certain regulations and be certified by CMS. The decreased number of nursing facilities reflects the net change in the number of certified facilities after accounting for newly-certified facilities and facilities that are no longer certified, including facilities that closed.

There are about 1.24 million residents living in certified nursing facilities (Figure 1). Since 2021, the number of nursing facility residents has gradually increased from 1.10 million to 1.24 million. However, between 2015 and 2025, the number of residents living in nursing facilities decreased by 9%, with most of that coming from a steep decline between 2020 and 2021, reflecting the effects of the COVID-19 pandemic. Prior to the pandemic, the number of residents was relatively steady, although it declined from 1.37 million in 2015 to 1.32 million in 2020. COVID-19 exacerbated the decrease in nursing facility residents—in part because nursing facility residents and staff incurred so many deaths during the pandemic.

Residents receive an average of 3.85 hours of nursing care per day, including 0.87 hours of LPN care, 0.68 hours of RN care, and 2.3 hours of nurse aide care (Figure 2). While staffing levels have gradually slightly increased overtime since 2022, the average hours of nursing care that nursing facility residents received declined by 7%, from 4.13 hours to 3.85 hours per resident each day, between July 2015 and July 2025. The decrease was driven by a 19% decline in registered nurse (RN) hours and a 7% decline in nurse aide hours. Licensed practical nurse (LPN) hours increased by 5% in this same time period. The 2024 rule would have required nursing facilities to meet minimum standards in staff hours for RNs and nurse aides but did not include any requirements for LPNs. A Texas judge overturned key elements of the rule in April 2025, the 2025 reconciliation law delayed all provisions of the rule until October 2034 (Box 1), and the Trump Administration rescinded the rule in December 2025. Previous KFF analysis show that just 19% of nursing facilities met the standards at the time of the rule’s passing.

The total hours of nursing care per resident decreased between 2015 and 2025, but rose briefly in 2021. The relatively higher staffing hours per resident in 2021 reflected the fact that the number of residents declined more quickly than the number of total nursing staff hours did between 2020 and 2021. In 2021, the number of staffing hours was 12% lower than in 2020 (data not shown). These lower staffing levels in the last several years align with data as of March 2024 showing that the number of workers employed at long-term care facilities continues to remain below pre-pandemic levels.

Nursing facilities receive an average of 9.5 deficiencies over the course of a survey cycle and 27% of facilities receive deficiencies for actual harm or jeopardy (Figure 3, Box 3). While nearly all facilities receive at least one deficiency during a survey cycle, this analysis focuses on the share with serious deficiencies since there is wide variation in the types of deficiencies a facility may receive. Both the average number of deficiencies and the share of facilities with serious deficiencies have increased over time, which could reflect increased oversight and low staffing levels that lead to staffing-related deficiencies. Between 2015 and 2025, the average count of deficiencies per nursing facility increased from 6.8 to 9.5, an increase of 40%. The increase was generally steady overtime, except for two stable periods: 1) between 2020 and 2022 and 2) between 2024 and 2025 (though 2024 and 2025 reported the highest number deficiencies during the 10-year period). The share of facilities reporting serious deficiencies between 2015 and 2025 increased from 17% to 27%, with a slight decrease between 2024 and 2025. A 2023 report on nursing home staffing by Abt Associates found that better-staffed nursing homes are typically cited for fewer deficiencies or violations of federal regulations, suggesting there may be a relationship between the increase in deficiencies and the general decrease in staffing levels over the 10-year time period.

Medicaid is the primary payer for 63% of nursing facility residents; Medicare for 14% of residents; and the remaining 23% of residents have another primary payer (ex. out-of-pocket) (Figure 4). The share of residents by primary payer has stayed relatively stable over time. Medicare does not generally cover long-term care but does cover up to 100 days of skilled nursing facility care following a qualifying hospital stay. KFF polling shows that four in ten adults overall incorrectly believe that Medicare is the primary source of insurance coverage for low-income people who need nursing facility care. 

Nearly three-quarters (73%) of nursing facilities are for-profit, one-fifth (20%) are non-profit, and the remaining seven percent are government-owned (Figure 5). The share of facilities by ownership type has also stayed relatively stable over time but there was increasing scrutiny over the 73% of facilities that are for-profit during the prior Administration. Despite little change in the type of ownership, there have been reports of private equity firms purchasing nursing facilities and changing operations to increase profits, resulting in lower-quality care. The GAO estimates that about 5% of nursing facilities had private equity ownership in 2022.

The Biden Administration issued a final rule in November 2023 on nursing facilities (separate from the April 2024 staffing rule that was delayed by the 2025 reconciliation law and then rescinded by the Trump Administration in December 2025). The 2023 nursing facility rule requires nursing homes enrolled in Medicare or Medicaid to disclose detailed information regarding their owners, operators, and management, including:

• Anyone who exercises any financial control over the facility;
• Anyone who leases or subleases property to the facility, including anyone who owns 5% or more of the total value of the property; and
• Anyone who provides administrative services, clinical consulting services, accounting or financial services, policies or procedures on operations, or cash management services for the facilities.

Facilities must also disclose whether any of the owning or managing entities are a private equity company or real estate investment trust (REIT). Facilities began self-reporting this data to CMS in early 2024 and the data is now available to the public. However, these data may be incomplete for now as fewer than 100 facilities report private equity ownership and just over 300 facilities report REIT ownership. Other research estimates those counts to be higher. 

The Trump administration has made several recent changes to federal routine vaccination recommendations. Specifically, under the auspices of Secretary Kennedy, who has long questioned the safety and efficacy of vaccines and stated his intention to review vaccine schedules, the CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended changes (including to age group, type of vaccine, and/or clinical decision-making process) to seven vaccine usage recommendations in the United States: Meningococcal; RSV for adults; RSV for children; influenza; COVID-19; Measles, Mumps, Rubella and Varicella (MMRV); and Hepatitis B. These recommendations, which have been adopted by the HHS Secretary or Acting CDC Director, have raised questions about the implications for insurance coverage, since most insurers are required to cover ACIP/CDC recommended vaccines at no-cost, either due to requirements of the Affordable Care Act or other federal statutes.

Below, we provide an overview of each of these changes and what they mean for coverage requirements. As the table indicates, of the seven recent changes, two have no implications for coverage, two removed the coverage requirement, and three expanded the requirement. When a coverage requirement is removed, an insurer could still choose to cover a vaccine at no cost. In fact, AHIP, the trade association for the health insurance industry whose members cover more than 200 million Americans, announced that health plans will continue to cover all ACIP-recommended immunizations that were recommended as of September 1, 2025 with no cost-sharing for patients through the end of 2026. When a coverage requirement is expanded, insurers (with limited exception) must cover the vaccine at no-cost. The insurance requirement extends to vaccines with “individual decision-making” (also known as “shared clinical decision-making”) recommendations as well, which are those “individually based and informed by a decision process between the health care provider and the patient or parent/guardian”.

In addition to federal requirements for coverage, states have the authority to require state-regulated health insurers (employer plans that are fully insured and individual and small-group marketplace plans) to cover vaccines beyond minimum federal requirements (and not necessarily linked to current ACIP/CDC recommendations). As of December 2025, eight states have moved to do so (and one state authorizes the state Commissioner of Insurance to do so). Still, states cannot impose coverage requirements on self-insured employer plans, which cover most (67%) people with employer coverage.

Additional changes to ACIP-recommended vaccine schedules are likely, as President Trump has issued a Presidential Memorandum calling on HHS and CDC to begin a “process to align U.S. core childhood vaccine recommendations with best practices from ‘peer, developed countries’”. Beyond their implications for insurance coverage, changes to vaccine recommendations, particularly those that narrow or limit access, are likely to have other implications, such as driving down already falling vaccine coverage rates in the United States.

Changes to Vaccine Recommendations and Insurance Coverage

Notes:
See KFF, ACIP, CDC, and Insurance Coverage of Vaccines in the United States, for coverage criteria by payer.
*While Medicare Part B is required to cover influenza vaccine by statute, not linked to ACIP/CDC, this change will result in the removal of the multi-dose vaccine from the market.
**CDC has not changed its recommendations for adult hepatitis B vaccinations, which are that adults aged 19–59 years, and adults aged 60 years and older with risk factors for hepatitis B or without identified risk factors but seeking protection, receive the vaccine if they had not been previously vaccinated. See CDC Hepatitis B Vaccine Administration.

Sources:

• https://www.cdc.gov/acip/vaccine-recommendations/index.html
• https://www.cdc.gov/acip/vaccine-recommendations/index.html#:~:text=RSV%20Vaccines%20%2D%20Adults
• https://www.hhs.gov/press-room/acip-recommends-covid19-vaccination-individual-decision-making.html 
• https://www.hhs.gov/press-room/thimerosal-mercury-removed-from-us-flu-vaccines-acip.html
• https://www.hhs.gov/press-room/cdc-immunization-schedule-individual-decision-covid19-standalone-chickenpox-toddlers.html
• https://www.hhs.gov/press-room/acip-recommends-chickenpox-vaccine-for-toddlers.html
• https://www.hhs.gov/press-room/acip-recommends-individual-based-decision-making-hepatitis-b-vaccine-birth-dose-infants-born-women-test-negative-virus.html
• https://www.hhs.gov/press-room/cdc-adopts-individual-based-decision-making-for-hepatitis-b-immunization-for-infants-born-to-women-who-test-negative-for-the-hepatitis-b-virus.html

On January 20, 2025, the first day of his second term, President Trump issued an executive order on “gender ideology” outlining how his administration would view sex and gender and incorporate these concepts into government. This executive order has had widespread implications across government and for federal grantees. One area that has been impacted is the federal government’s data collection efforts. This includes changes to questions about sexual orientation and gender identity (SOGI) in multiple federal surveys, and retreating from plans to incorporate SOGI questions in surveys of the U.S. population by the Census Bureau. While data collection on both sexual orientation and gender has been scaled back or modified, measures relating to gender identity have been more specifically targeted for deletion.

Although several national surveys and data sets have been affected by changes to SOGI data collection and availability, this brief focuses specifically on changes in three national surveys that are representative of these efforts: the National Health Interview Survey (NHIS), the Medicare Current Beneficiary Survey (MCBS), and the National Crime Victimization Survey (NCVS). These surveys are central to the federal government’s efforts to understand the health and well-being of the U.S. population overall (NHIS) and people with Medicare (MCBS) and to understand people’s experiences with criminal victimization (NCVS), and had the potential to meaningfully expand the knowledge base in these areas as they relate to the nearly 14 million U.S. adults who identify as LGBT, and particularly the over 2 million adults who identify as transgender. Limiting SOGI data collection in these and other federal surveys moving forward will present challenges for understanding and assessing the needs and experiences of the LGBTQ population in the U.S.

Overview of Surveys Examined and Adoption of SOGI Metrics

The NHIS, MCBS, and NCVS offer unique opportunities to better understand the experiences of people’s health and well-being. While not the only federal sources that have historically collected SOGI data, these three surveys represent distinct and policy-relevant opportunities for the collection and use of LGBTQ data. The NHIS has included SOGI measures that enable analyses of broad population health measures, including insurance coverage patterns and overall health status. The MCBS could offer rare insight into LGBTQ older adults—a population that is typically difficult to sample due to its relatively small size (just 1.8% of adults over 65 identify as LGBT, but this share is likely to grow larger over time). SOGI data were only recently added to MCBS. Finally, the NCVS has provided SOGI data that is particularly valuable for examining experiences of violence and discrimination, areas where disparities between LGBTQ and non-LGBTQ people have been well documented.

The National Health Interview Survey (NHIS), administered by the National Center for Health Statistics within the U.S. Centers for Disease Control and Prevention, is the largest and oldest national health survey in the U.S. and collects information on a broad range of topics including demographics, socioeconomic factors, health status, health care access, and health coverage. NHIS data provides in depth information across the population, and its size allows for comparisons across groups, including LGBT people.

Questions about sexual orientation were added to NHIS in 2013 and questions related to gender identity were added to the survey in 2022 on an experimental basis to develop a methodology. On adding a sexual orientation variable to the survey (at the time referred to as sexual identity) HHS wrote, “The objective of asking a question on sexual identity in the NHIS is to fill the tremendous gap that exists regarding knowledge of general health behaviors, health status, and health care utilization of LGBT persons.”

The Medicare Current Beneficiary Survey (MCBS), administered by the Centers for Medicare & Medicaid Services (CMS), is the government’s long-running, comprehensive, nationally representative survey of people with Medicare. The MCBS includes questions about beneficiaries’ health care use, health status, cost and payment issues, demographic and housing characteristics, experiences with care, and other domains.

Questions about sexual orientation and gender identity were added to the survey in 2023 to provide the opportunity to gain new knowledge about LGBTQ older adults and people with disabilities covered by Medicare. According to CMS at the time, “Including sexual orientation and gender identity questions on the MCBS will provide nationally representative data on topics such as the accessibility and utilization of health care services by the Lesbian, Gay, Bisexual, and Transgender (LGBT) populations and the resulting health disparities that impact this community. … In no instance have we identified another source of data that would be an effective substitute for the MCBS.” CMS also added an item asking Medicare beneficiaries about their experiences with discrimination from health care providers based on eight demographic factors, including race, language or accent, gender or gender identity, sexual orientation, age, culture or religion, disability, and medical history. This measure, according to CMS, would allow the agency “to capture the most actionable and impactful information about health care experiences that directly influence health outcomes and will provide CMS with additional measures for assessing health equity and fair treatment for underserved populations.”

The National Crime Victimization Survey (NCVS), administered by the Bureau of Justice Statistics within the U.S. Department of Justice, provides nationally representative data on criminal victimization, including frequency, characteristics, and consequences. Data are collected on both crimes reported to the police and crimes not reported. Demographic data is also collected from respondents along with experiences with the criminal justice system.

Questions about sexual orientation and gender identity were added to the survey in 2016. The NCVS included questions asking respondents about their sexual orientation, sex assigned at birth, gender identity, and a clarifying question used when there was a conflict between a respondent’s reported sex assigned at birth and gender identity.¹ Two additional questions were asked among those who had been victimized about whether they believed it was due to “prejudice or bigotry” relating to gender identity or sexual orientation. In support of including these measures, DOJ wrote that they were “identified in other research as subgroups of interest to key stakeholders and, correlates to victimization. For example, sexual orientation and gender identity are recognized in the 2013 reauthorized Violence Against Women Act (VAWA). Additionally, the inclusion of these items will allow researchers to better understand the relationships between these variables and experiences with criminal victimization.”

Why Were SOGI Questions Added to Federal Surveys?

The inclusion of SOGI questions to federal surveys aligned with a range of efforts by the federal government to improve data collection related to sexual orientation and gender identity. Top of Form

The move to collect SOGI data within the federal government was recommended in a National Academies of Sciences Report: Understanding the Well-Being of LGBTQI+ Populations and received support from a number of researchers and advocates. Other activities that led to wider collection of this data include:

• Support in Healthy People 2010, 2020 and 2030 to increase collection of sexual orientation and gender identity data in population surveys.
• In 2016, the Office of Management and Budget (OMB) convened a Federal Interagency Working Group on Improving Measurement of Sexual Orientation and Gender Identity in Federal Surveys “to begin addressing the dearth of data for these populations and the issues surrounding methodological issues in collecting such data.”
• In 2022, pursuant to a Biden administration executive order, the OMB released a report on the best practices for sexual orientation and gender identity data collection in federal surveys.
• In 2023, the Biden administration developed a Federal Evidence Agenda on Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex (LGBTQI+) Equity, a “roadmap for opportunities for the Federal Government to continue to build evidence and leverage data to advance equity for LGBTQI+ people.”
• Efforts within NIH to “Encourage data collection related to SGM [sexual and gender minority] populations in research and the health research workforce.” (Note the webpage for the NIH Sexual & Gender Minority Research Office hasbeen removed under the Trump Administration, likely also a part of broad efforts to align with the Executive Order discussed here).

How SOGI Data Collected in NHIS, MCBS, and NCVS Has Been Used

NHIS

The NHIS data on gender identity and sexual orientation has been used to track insurance coverage among LGBTQ people, including by KFF. Additionally, NHIS SOGI measures have allowed researchers to explore population level disparities among sexual minorities including: examining substance use and sleep problems by sexual orientation and assessing food insecurity, mental health, and health care access, as well as experiences with intersectional disparities.

MCBS

SOGI questions were added to the MCBS in 2023 and were initially released to researchers with approved data use agreements who purchased an “early release” version of the 2023 MCBS Survey File in the fall of 2024 from CMS – about 9 months before the full year of 2023 MCBS Survey File data were made available in July 2025. As such, SOGI data collected in the MCBS have not yet been widely utilized by researchers. Additionally, KFF found that the number of Medicare beneficiaries who identified as transgender in the early release file (the only file to include this data) was too small to generate a reliable estimate. Without data on gender identity in future years, researchers will be unable to pool multiple years of data to produce a more robust sample, as is sometimes done in research with LGBTQ groups in other contexts when necessitated by limited sample sizes.

NCVS

NCVS data has been used to understand the victimization experiences of teens and adults, including LGBTQ people. NCVS has been used to provide representative estimates on transgender people’s experiences specifically. Research has examined the forms of violence experienced by gender identity and sexual orientation. Experiences of victimization among LGBT people have also been examined to assess intersecting factors such as age, race/ethnicity, and relationship to the assailant, alongside comparison to non-LGBT people.

Recent Changes to SOGI Data in Federal Surveys

The Trump administration’s January 2025 Executive Order (EO) 14168 on “gender ideology” required federal agencies to “remove all statements, policies, regulations, forms, communications, or other internal and external messages that promote or otherwise inculcate gender ideology.” With these actions, the Trump administration sought to promote a view of sex as a binary biological concept and to disavow the notion of gender identity – the internal sense and experience of being male, female, transgender, non-binary or something else. Operating under this directive, the federal government undertook an effort to remove gender-identity related content from federal surveys and modify certain content related to sexual orientation and sex in early 2025.

The federal agencies responsible for administering NHIS, MCBS, and NCVS specifically cited EO 14168 in their rationale when requesting changes from the Office of Management and Budget. The changes made to these variables in NHIS, MCBS, and NCVS are as follows (see Table 1 for full question wording, changes, and sources):  

NHIS

Modifications were made to the gender identity question but not the sexual orientation question. The specific changes include:

• removing a question asking about the respondent’s gender identity
• removing the follow-up question where a respondent who selected “something else” could provide a verbatim response to describe their gender identity in their own words

MCBS

Changes were made to the series of SOGI questions, including:

• removing a question asking about the respondent’s gender identity,
• removing a question asking respondents to report their sex assigned at birth on their original birth certificate and replacing it with a question asking the respondent to report their sex (without providing additional information on how to consider the question),
• removing “something else” as a response option to a question about the respondent’s sexual orientation,
• removing the follow-up question where a respondent who selected “something else” could provide a verbatim response to describe their sexual orientation in their own words, and
• removing a question related to the respondent’s experiences with unfair or insensitive treatment from health care providers based on several demographic factors, including their sexual orientation and their gender or gender identity.

NCVS

Modifications were made to most of the gender identity questions but not the sexual orientation questions, including:

• removing a question asking about the respondent’s gender identity,
• removing a question asking respondents to report the sex assigned at birth on their original birth certificate,
• removing a question seeking clarification related to gender identity (asked when sex assigned at birth and gender identity do not align),
• temporarily pausing and then reinstating a question related to whether respondents who had been victimized believed it was due to prejudice or bigotry relating to gender identity, and
• removing training material information on the above questions.

Implications of the Survey Changes

Deleting and modifying questions related to sexual orientation and gender identity from federal surveys will leave gaps in researchers’ ability to understand and analyze the experiences of LGBTQ people, including the challenges they face and their health problems; diminish the ability of policymakers to identify and address health discrimination and equity issues for the population; and limit the information available to health care provider trying to improve care for LGBTQ people and eliminate barriers to care. Limiting data collection related to LGBTQ people and experiences with violence and victimization may also lead to challenges with addressing unmet need in that area. As LGBTQ people face persistent disparate experiences with stigma, discrimination, and victimization, as well as health (including mental health) disparities, across the lifespan, losing access to this federal data is particularly notable.

Because transgender people make up a very small share of the U.S. population overall, it may be difficult for the private and nonprofit sectors to make up for the loss of data from large federal surveys in non-governmental nationally representative surveys, which rarely have a large enough sample size to be able to pull out the experiences of this group. National surveys, with large sample sizes, had started to fill some of that gap. The challenge is especially acute when trying to understand the experiences of a segment of the transgender community. For example, given that only a small share of older adults identifies as LGBTQ and an even smaller share identify as transgender, maintaining the gender identity variable in the MCBS would have provided an opportunity to understand the experiences of a population that would otherwise be very difficult and/or very costly to sample through traditional surveys.  

The Trump administration’s rolling back of data collection related to gender identity, and to some extent sexual orientation, marks a decline in the capacity of the federal government to measure the experiences of LGBTQ people. The full implications for data users, providers, policymakers, and communities will continue to unfold, and ongoing assessment could help clarify the effects of deleted or modified SOGI measures in federal surveys.

1. Asking about both biological sex assigned at birth and gender identity provides a method for identifying people who might identify as male or female rather than as transgender, but who were assigned a different sex on their original birth certificate. This two-step approach to measuring gender identity is a recommended best practice. ↩︎

Commercial health insurance markets remain highly concentrated across coverage types. However, the individual market, which consists mostly of the ACA Marketplaces, has attracted more insurers and witnessed greater insurer competition across a variety of measures since the implementation of the enhanced premium tax credits in 2021, according to a new Healthy System Tracker analysis.

For example, from 2020 to 2023, the average market share of the largest insurer in each state’s individual market declined from 60% to 53%, corresponding with enrollment growth in the ACA Marketplaces driven by the enhanced premium tax credits. By contrast, fully insured employer-sponsored health insurance markets have become less competitive in the past decade. The analysis presents 2013-2023 enrollment and market competition data for fully insured and individual plans both nationally and on a statewide basis.

The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Medicare Advantage plans, which enrolled more than 34 million Medicare beneficiaries or 54% of the eligible Medicare population in 2025, typically offer extra benefits, such as dental, vision, and hearing, often for no additional premium, as well as lower cost sharing compared to traditional Medicare without supplemental insurance. These additional benefits usually come with the trade-off of more restrictive provider networks and greater use of cost management tools, such as prior authorization.

This brief provides an overview of premiums and benefits in Medicare Advantage plans that are available for 2026 and key trends over time. This brief uses data from the CMS Landscape and Benefit files. See methods for more details. In general, this brief refers to individual Medicare plans available for general enrollment, which excludes Special Needs Plans (SNPs), except where noted, and excludes employer plans. A companion analysis describes trends in plan offerings.

Medicare Advantage Highlights for 2026

• Two-thirds of all Medicare Advantage plans with Part D prescription drug coverage (MA-PDs) (67%) will charge no premium (other than the Medicare Part B premium) in 2026, the same as 2025.
• While nearly all individual Medicare Advantage plans (98% or more) are offering vision, dental and hearing benefits, as they have in previous years, the share offering certain other supplemental benefits has declined, such as an allowance for over-the-counter items (66% in 2026 vs. 73% in 2025), a meal benefit (57% in 2026 vs. 65% in 2025), remote access technologies (48% in 2026 vs. 53% in 2025), and transportation (24% in 2026 vs. 30% in 2025).
• The share of Special Needs Plans (SNPs) offering certain supplemental benefits has also declined, such as transportation (67% in 2026 vs 81% in 2025), a meal benefit (66% in 2026 vs 73% in 2025), bathroom safety devices (47% in 2026 vs 54% in 2025), and remote access technologies (44% in 2026 vs 50% in 2025), while the share offering in-home support services (25% in 2026 vs 17% in 2025) and support for caregivers (16% in 2026 vs 5% in 2025) has increased.
• In 2026, a larger share of SNPs than Medicare Advantage plans for individual enrollment offer transportation benefits for medical needs (67% for SNPs vs 24% for individual plans), an allowance for over-the-counter items (94% vs 66%), bathroom safety devices (47% vs 21%), in-home support services (25% vs 7%), and caregiver support (16% vs 5%). A smaller share of SNPs than individual plans offer acupuncture (28% vs 34%) and fitness benefits (86% vs 93%).
• Nearly one-third (32%) of individual Medicare Advantage plans will offer some reduction in the Medicare Part B premium in 2026 as a supplemental benefit, the same as in 2025. Among plans offering a reduction in the Part B premium, more than a third (36%) are offering a reduction of more than $100 a month, while 28% of plans are offering a reduction of $10 or less per month.
• A larger share of SNPs than other Medicare Advantage plans are offering Special Supplemental Benefits for the Chronically Ill, which are extra benefits available to a subset of a plan’s enrollees, particularly food and produce (85% in SNPs vs 11% in individual plans) and general supports for living, such as housing and utilities (72% in SNPs vs 8% in individual plans).

Premiums

The vast majority of Medicare Advantage plans for individual enrollment (89%) will include prescription drug coverage (MA-PDs), similar to 2025 (88%), and the share of MA-PDs where enrollees are responsible for the Medicare Part B premium ($202.90 per month) but no additional premium is 67% in 2026, the same as in 2025 (Figure 1). Nearly all Medicare beneficiaries (98%) have access to a MA-PD with no additional monthly premium in 2026, similar to 2025 (99%).

In 2025, more than three-quarters (76%) of enrollees in MA-PD plans pay no premium other than the Medicare Part B premium. Based on enrollment in March 2025, 9% of enrollees pay at least $50 a month, including 3% who pay $100 or more. CMS estimates that the average monthly plan premium among all Medicare Advantage enrollees in 2026, including those who pay no premium for their Medicare Advantage plan, will be $14.00 a month.

While many employers and unions also offer Medicare Advantage plans to their retirees, complete information about these 2026 plan benefits is not made available. Employer and union plans are administered separately and may have enrollment periods that do not align with the Medicare open enrollment period.

Extra Benefits

Medicare Advantage plans may offer extra benefits that are not available in traditional Medicare and are considered “primarily health related.” Plans are required by law to use rebate dollars (which may be higher for plans that qualify for the quality bonus program) to help cover the cost of extra benefits, reduce cost sharing, or reduce the Part B and/or Part D premium. Beginning in 2019, CMS expanded the definition of “primarily health related” to allow Medicare Advantage plans to offer additional supplemental benefits. Medicare Advantage plans may also restrict the availability of these extra benefits to certain subgroups of beneficiaries, such as those with diabetes or congestive heart failure, making different benefits available to different enrollees.

Availability of Extra Benefits in Individual Plans for General Enrollment

In 2026, 98% or more individual plans offer some vision (99%), dental (98%) or hearing benefits (98%), similar to 2025 (97% or more) (Figure 2). Though these benefits are widely available, the scope of coverage for these services varies. For example, a dental benefit may include cleanings and preventive care or more comprehensive coverage, and often is subject to an annual dollar cap on the amount covered by the plan. From year to year, plans may change the parameters of this coverage, such as increasing or decreasing annual maximums the plan will pay toward the benefit or adjusting cost sharing for services. There is not yet data available about utilization of these benefits or associated costs, so it is not clear the extent to which supplemental benefits are used by enrollees.

Some benefits are being offered by a smaller share of plans in 2026 than in 2025. For example, 66% of plans are offering an allowance for over-the-counter items (vs. 73% in 2025), while 57% are offering a meal benefit (vs. 65% in 2025), and 24% are offering transportation benefits for medical needs (vs. 30% in 2025). A similar share of plans is offering fitness benefits, acupuncture, bathroom safety devices, in-home support services, and support for caregivers of enrollees in 2026 compared with 2025 (Figure 2). This is not an exhaustive list of extra benefits that plans offer, and plans may offer other services such as home-based palliative care, therapeutic massage, and adult day health services, among others.

As of 2020, Medicare Advantage plans have been allowed to include telehealth benefits as part of the basic benefit package – beyond what was allowed under traditional Medicare prior to the COVID-19 public health emergency – which was extended to January 2026. Therefore, these benefits are not included in the figure above because their cost is not covered by either rebates or supplemental premiums. Medicare Advantage plans may also offer supplemental telehealth benefits via remote access technologies and/or telemonitoring services, which can be used for those services that do not meet the requirements for coverage under traditional Medicare or the requirements for the telehealth benefits as part of the basic benefit package (such as the requirement of being covered by Medicare Part B when provided in-person). In 2026, 48% of plans are offering remote access technologies, a decline from 53% in 2025. The same share of plans is offering telemonitoring services (2% in 2026 and 2025).

Availability of Extra Benefits in Special Needs Plans

SNPs are designed to serve a higher-need population and an increasing number of beneficiaries are enrolling in SNPs. A similar share of SNPs in 2026 compared with 2025 are offering dental, vision, hearing, fitness, an allowance for over-the-counter items, and telemonitoring services (Figure 3). However, a smaller share of SNPs is offering transportation benefits for medical needs (67% in 2026 vs 81% in 2025), a meal benefit (66% in 2026 vs 73% in 2025), bathroom safety devices (47% in 2026 vs 54% in 2025), and remote access technologies (44% in 2026 vs 50% in 2025). A larger share of SNPs is offering their enrollees in-home support services (25% in 2026 vs 17% in 2025) and support for caregivers (16% in 2026 vs 5% in 2025) (Figure 3).

In 2026, a larger share of SNPs than plans for other Medicare beneficiaries offer their enrollees transportation benefits for medical needs (67% for SNPs vs 24% for individual plans), an allowance for over-the-counter items (94% for SNPs vs 66% for individual plans), bathroom safety devices (47% for SNPs vs 21% for individual plans), in-home support services (25% for SNPs vs 7% for individual plans), and caregiver support (16% for SNPs vs 5% for individual plans). A smaller share of SNPs than individual plans offer their enrollees acupuncture (28% vs 34%) and fitness benefits (86% vs 93%).

Availability of a Part B Rebate

Both Medicare Advantage enrollees and traditional Medicare beneficiaries pay a monthly Part B premium, which will be $202.90 per month in 2026. Medicare Advantage plans may use the rebate portion of their payments from CMS to reduce the Part B and/or Part D premium. In 2026, nearly one-third (32%) of individual Medicare Advantage plans available for general enrollment will offer some reduction in the Part B premium (or a “Part B Rebate”), the same as the share in 2025, while more than two-thirds (68%) will not offer this benefit (Figure 4).

Among plans that are offering a monthly reduction in the Part B premium, more than a third (36%) are offering a monthly reduction of $100 or more (vs 28% in 2025), 23% are offering a reduction of $50.01 to $100 (vs 25% in 2025), 13% are offering a reduction of $10.01 to $50 (vs 17% in 2025), and 28% are offering a monthly reduction of $10 or less (vs 30% in 2025).

A smaller share of SNPs than individual plans offer a Part B rebate (19% vs 32%). The share of SNPs offering the Part B rebate has declined in 2026 compared with 2025 (19% vs 28%) (Figure 3). In 2026, about half (51%) of SNPs offering the Part B rebate are plans for people who are dually eligible for Medicare and Medicaid (D-SNPs), 39% are plans for people with certain chronic conditions (C-SNPs), and 10% are institutional-SNPs. Although SNPs may offer a Part B rebate, for dual-eligible individuals enrolled in the Medicare Savings Programs, which comprise most enrollment in SNPs, the rebate is paid to the state rather than to the individual because the state Medicaid program pays the Part B premium for these beneficiaries. (Note that the Medicare Savings Programs are not available in Puerto Rico.)

Availability of Special Supplemental Benefits for the Chronically Ill (SSBCI)

Beginning in 2020, Medicare Advantage plans have also been able to offer extra benefits to a subset of a plan's enrollees, that are not primarily health related and are specifically for chronically ill beneficiaries, known as Special Supplemental Benefits for the Chronically Ill (SSBCI). In prior years, Medicare Advantage plans could also participate in the Value-Based Insurance Design Model, which allowed plans to offer these non-primarily health related supplemental benefits to their enrollees using different eligibility criteria than required for SSBCI, including offering them based on an enrollee’s socioeconomic status. However, this model was terminated at the end of the 2025 plan year.

Most individual and SNP Medicare Advantage plans still do not offer these benefits, though more SNP plans generally offer these benefits, particularly food and produce. SSBCI benefits offered in 2026 include food and produce (11% for individual plans and 85% for SNPs), general supports for living (e.g., housing, utilities) (8% for individual plans and 72% for SNPs), transportation for non-medical needs (5% for individual plans and 37% for SNPs), and pest control (3% for individual plans and 23% for SNPs) (Figure 5).

Like for other types of supplemental benefits, the scope of services for SSBCI benefits varies. For example, many plans offer a specified dollar amount that enrollees can use toward a variety of benefits, such as food and produce, utility bills, rent assistance, and transportation for non-medical needs, among others. This dollar amount is often loaded onto a flex card or spending card that can be used at participating stores and retailers, which can vary depending on the vendor administering the benefit. Depending on the plan, this may be a monthly allowance that expires at the end of each month or rolls over month to month until the end of the year, when any unused amount expires.