Primary Care Cost Sharing in Medicare Advantage

Changchuan Jiang; Chuan Angel Lu; Lesi He; Arthur S Hong; Xin Hu; Megan Mullins; Boshen Jiao; Joshua M Liao

doi:10.1001/jamahealthforum.2026.2232

. 2026 Jul 10;7(7):e262232. doi: 10.1001/jamahealthforum.2026.2232

Primary Care Cost Sharing in Medicare Advantage

Changchuan Jiang ^1,^2,^3,^✉, Chuan Angel Lu ¹, Lesi He ², Arthur S Hong ^2,^3,⁴, Xin Hu ⁵, Megan Mullins ^2,³, Boshen Jiao ⁶, Joshua M Liao ^2,^3,⁴

¹Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas

²Department of Health Data Science and Biostatistics, Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas

³Division of General Internal Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas

⁴Program on Policy Evaluation and Learning, Dallas, Texas

⁵Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia

⁶Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles

Accepted for Publication: May 15, 2026.

Published: July 10, 2026. doi:10.1001/jamahealthforum.2026.2232

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License, which does not permit alteration or commercial use, including those for text and data mining, AI training, and similar technologies. © 2026 Jiang C et al. JAMA Health Forum.

^✉

Corresponding Author: Changchuan Jiang, MD, MPH, Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 6000 Harry Hines Blvd, Dallas, TX 75390 (changchuan.jiang@utsouthwestern.edu).

Author Contributions: Dr Jiang and Ms He had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jiang, Lu, Hong, Hu, Liao.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Jiang, Lu, He, Liao.

Critical review of the manuscript for important intellectual content: Jiang, Lu, Hong, Hu, Mullins, Jiao, Liao.

Statistical analysis: Jiang, Lu, He.

Obtained funding: Jiang.

Administrative, technical, or material support: Jiang, Lu, Hu.

Supervision: Jiang, Hong, Liao.

Conflict of Interest Disclosures: Dr Hu reported grants from the National Institutes of Health, the Donaghue Foundation, the American Cancer Society, Pfizer, the PhRMA Foundation, Johnson & Johnson, and St Jude Children’s Research Hospital outside the submitted work. Dr Liao reported personal fees from the Medicare Payment Advisory Commission, as well as grants from the Agency for Healthcare Research and Quality and the National Institute on Minority Health and Health Disparities outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Jiang is supported by the University of Texas Southwestern Medical Center Dean’s Clinical Scholar Grant.

Role of the Funder/Sponsor: The University of Texas Southwestern Medical Center had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

^✉

Corresponding author.

PMCID: PMC13355145 PMID: 42430157

This cross-sectional study examines longitudinal trends and plan- and county-level characteristics of $0 cost sharing for in-network primary care physician visits among Medicare Advantage plans from 2019 to 2025.

Key Points

Question

What are the trends in and associated factors of $0 cost sharing for in-network primary care physician (PCP) visits among Medicare Advantage (MA) plans?

Findings

In this cross-sectional study of MA plans from 2019 to 2025, the proportion of MA enrollees in plans offering $0 cost sharing for in-network PCP visits increased from 46.4% to 78.1%. This benefit was more common in less restrictive primary care networks, higher quality plans, and urbanized and high MA-penetration areas, but less in zero-premium plans and high-poverty counties.

Meaning

The rapid expansion of $0 cost sharing for in-network PCPs signifies improved beneficiary access, but its uneven distribution raises equity concerns and implies strategic trade-offs in plan design.

Abstract

Importance

Medicare Advantage (MA) plans increasingly leverage cost-sharing structure to incentivize high-value care utilization, yet national adoption and distribution of $0 cost sharing for in-network primary care physician (PCP) visits remain poorly characterized.

Objective

To examine longitudinal trends and plan- and county-level characteristics of $0 cost sharing for in-network PCP visits among MA plans.

Design, Setting, and Participants

This cross-sectional study involved a retrospective ecological analysis of MA plan-county observations, including general enrollment MA plans (health maintenance organization, preferred provider organization, and health maintenance organization point-of-service plans) offered across US counties from 2019 to 2025. Data were analyzed from December 2025 to March 2026.

Exposures

Plan-level characteristics (plan type, premium status, geographic region, and Centers for Medicare & Medicaid Services star rating) and county-level characteristics (MA penetration, urbanicity, federal poverty level, racial and ethnic composition, and PCP accessibility).

Main Outcomes and Measures

The primary outcome was the enrollment trend in MA plans offering $0 cost sharing for in-network PCP visits from 2019 to 2025. Secondary outcomes included plan- and county-level factors associated with offering this benefit in 2025, estimated using multivariable mixed-effects logistic regression with county-level random intercepts.

Results

The proportion of MA beneficiaries enrolled in plans requiring no cost sharing for in-network PCP visits increased from 46.4% in 2019 to 78.1% in 2025 (P for trend < .001), equating to approximately 15 million additional beneficiaries. In 2025, plans offering this benefit were more likely preferred provider organization plans than health maintenance organization plans (adjusted odds ratio [AOR], 2.14; 95% CI, 2.05-2.23) and featured better performances (5-star rating: AOR, 6.71; 95% CI, 4.83-9.32). Geographically, plans offering this benefit were more prevalent in urbanized counties (AOR, 1.17; 95% CI, 1.11-1.24), had higher MA penetration (AOR, 1.31; 95% CI, 1.22-1.40, and had larger proportions of racial and ethnic minority populations (AOR, 1.18; 95% CI, 1.09-1.28). In contrast, zero-premium plans (AOR, 0.70; 95% CI, 0.68-0.73) and plans offered in high-poverty counties (AOR, 0.82; 95% CI, 0.74-0.90) showed considerably lower availability of $0 cost sharing.

Conclusions and Relevance

This cross-sectional study demonstrates that $0 cost sharing for PCP visits has expanded rapidly under MA but remains unevenly distributed. Lower availability in zero-premium plans and high-poverty areas suggest strategic trade-offs between premiums and point-of-service costs, raising equity concerns that underscore the need to assess whether market-driven benefit design optimizes and sustains high-value primary care access to counties at greater populational health risk.

Introduction

The rapid expansion of Medicare Advantage (MA) plans, particularly those with zero premiums, marks one of the most consequential shifts in the US health insurance landscape for older adults.^1,2,3 Such expansion accelerates the transition from a nationally standardized fee-for-service model to private MA plans with broad flexibility in benefit design and cost-sharing requirements.^4,5 Specifically, unlike uniform cost-sharing requirements in traditional Medicare, MA plans possess the flexibility to modify benefit designs to steer utilization and attract enrollees.^3,6 Consequently, the strategic decisions made by private insurers now effectively determine the financial and physical accessibility of care for the majority of older adults.⁶

Primary care physicians (PCPs) serve as the critical gateway to the health care system in the US, coordinating chronic disease management and preventive services such as cancer screening.^7,8,9 Extensive evidence indicates that even nominal cost sharing can deter use of health service and medication initiation/adherence, even for necessary and recommended care, potentially leading to adverse downstream outcomes.^10,11 Although annual wellness visits are already offered with no cost sharing, eliminating out-of-pocket costs for all PCP outpatient encounters would remove additional financial barriers at the point of entry to the health care system^12,13; however, the extent to which this benefit design has diffused across the national market remains unclear.

In this study, we specifically examined the financial accessibility of direct in-network PCP outpatient encounters as reflected by plan cost-sharing requirements. While the feature of $0 cost sharing for primary care visits is frequently highlighted in plan marketing,^14,15 its longitudinal growth, current prevalence, and distribution across different plan types and geographies have not been characterized.¹⁶ To address this gap, we analyzed the national Centers for Medicare & Medicaid Services (CMS) data to quantify the enrollment-weighted availability of MA plans with $0 cost sharing for in-network PCP visits from 2019 to 2025 and to identify plan- and county-level factors associated with its provision in the general MA market. In addition, we aimed to examine the relationship between cost-sharing status for in-network PCP visits and MA plan performance to better understand the association of plan benefit design and care quality.

Methods

Study Design and MA Plan Data Source

We conducted a retrospective analysis using plan benefit and enrollment data from CMS.^17,18,19,20 Longitudinal data on plan enrollment, plan characteristics (plan type, premium, geographic region, and star-rating performance), and plan-specific cost-sharing information were obtained for each plan-county observation for 2019 through 2025.

The University of Texas Southwestern Medical Center Human Research Protection Program determined that this study was not human participant research, obviating the need for institutional review board review. This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

Study Population

The observation units obtained from CMS files were unique MA plans offered within each US county for individual year between 2019 and 2025 (ie, plan-county–year observations). Because the study targeted the general MA market most available to individual enrollment (ie, health maintenance organization [HMO], preferred provider organization [PPO], HMO point-of-service [HMO-POS] plans), we excluded special needs plans (SNPs), employer group waiver plans, and programs of all-inclusive care for the elderly. Plans with 10 or fewer enrollees were also excluded to support analytic stability.

Cost Sharing for In-Network PCP Visits

The primary outcome was plan-specific cost sharing for in-network PCP visits, derived from the annual CMS plan benefit package data.¹⁷ This measure specifically captures visit-level cost sharing for outpatient physician encounters under the general primary care category. This information was dichotomized for each plan-county–year observation into 2 categories: (1) $0 cost sharing, defined as MA plans requiring a $0 co-payment, $0 coinsurance, and no application of the plan deductible for in-network PCP visits; or (2) more than $0 cost sharing, defined as MA plans requiring a co-payment higher than $0, coinsurance higher than $0, and/or the application of the plan deductible to in-network PCP visits. Notably, because federal law already mandates $0 cost sharing for specific preventive services (eg, annual wellness visits), the $0 cost-sharing category identifies plans that have expanded this benefit to include all routine office visits, acute care visits, or other consultations with an in-network PCP that would typically incur a cost.

County-Level Characteristics

We compiled county-level information from several external data sources, including the latest 2019-2023 American Community Survey 5-year estimates,²¹ the Centers for Disease Control and Prevention’s 2022 Social Vulnerability Index dataset,²² the 2025 County Health Ranking datasets,²³ and the US Department of Agriculture’s 2023 Rural-Urban Continuum Codes.²⁴ For each county, we derived a set of covariates, encompassing basic demographic composition (proportion of the population aged ≥65 years, female individuals aged ≥65 years, and population identifying as a racial or ethnic minority), market availability (MA penetration rate, obtained from CMS public use files²⁵), socioeconomic and health vulnerability (poverty level, measured as the proportion of the population living below the federal poverty line; self-reported fair and poor health status, measured as the proportion of adults reporting fair or poor health), and accessibility of health care services (ratio of population to PCPs; urbanicity, categorizing counties into urban or rural area). MA plans from CMS files were mapped to counties based on the county Federal Information Processing Standard codes linking plans to their respective service areas.

MA Plan Performance

As the most well-recognized assessor of MA plan quality,²⁶ the CMS 5-star rating system summarizes plan-performance metrics across domains of clinical care (eg, preventive screenings, chronic disease management), member experience (eg, ease of obtaining appointments, care coordination), and customer service (eg, administrative operations timeliness, availability).^5,27,28 The resulting composite score ranges from 1 to 5 (in 0.5-star increments). Scores of 4 or more stars (4, 4.5, or 5) not only indicate superior overall performance and patient satisfaction, but also serve as the eligibility threshold of CMS’s quality bonus program.^29,30,31 Conversely, plans with overall ratings of less than 4 stars (1-3.5) denote performance levels ineligible for federal quality bonuses and are subject to increased CMS monitoring and corrective oversight. Herein, we defined low-performance plans as those with an overall CMS rating of less than 4 stars (1-3.5) vs 4 or 4.5 stars indicating high performance and 5 stars indicating top performance.^32,33,34

Statistical Analysis

We evaluated longitudinal trends in MA plans adopting $0 cost sharing for in-network PCP visits by quantifying the proportion of total MA enrollment within each county-year enrolled in such plans. Changes in this proportion were assessed using a Cochran-Armitage trend test.

We then used 2025 data to capture market dynamics and conduct descriptive analyses comparing plan-specific characteristics between the 2 PCP cost-sharing types and the county-level characteristics of the markets where these plans were offered. Standardized mean differences (SMDs) were calculated to assess distributional differences, with values less than 0.1 considered indicative of negligible imbalance between the 2 cost-sharing types. To ensure that these descriptive comparisons reflected national representation of beneficiary experience and plan features, all plan counts and descriptive statistics were weighted by the plan-county enrollment.

Furthermore, we used multivariable mixed-effects logistic regression to identify potential factors associated with offering $0 cost sharing for in-network PCP visits. All plan-specific and county-level characteristics (detailed previously) were included as fixed effects, and a random county-level intercept was incorporated to account for the clustering of plans within counties.

Finally, multivariable mixed-effects logistic regression models were used to assess the association between PCP cost-sharing status and MA plan performance, measured using the overall 2025 CMS star-rating summary score. Secondary analyses further examined associations between PCP cost-sharing status and performance across individual Part C star-rating domains to explore potential mechanisms underlying the association (eTable 1 in Supplement 1).

Statistical analyses were performed using Python, version 3.9.19 (Python Software Foundation), and R, version 4.5.2 (R Foundation for Statistical Computing). All statistical tests were 2-sided and considered statistically significant at P < .05. Data were analyzed from December 2025 to March 2026.

Results

From 2019 to 2025, enrollment in plans offering $0 cost sharing for in-network PCP visits increased from 46.4% to 78.1% of MA beneficiaries (P for trend < .001), equating to approximately 15 million additional Medicare-eligible adults (Figure). In 2025, a total of 61 184 county-plan observations were included, which consisted of 44 498 (72.7%) plans with $0 cost sharing for in-network PCP visits, representing 78.1% of MA enrollment, and 16 686 (27.3%) plans with cosharing for in-network PCP visits, representing 21.9% of MA enrollment. Plans with and without PCP cost sharing were both predominantly zero-premium plans (77.7% vs 79.5%; SMD = 0.04) and located in the South (40.8% vs 37.6%; SMD = 0.07). MA plans with $0 cost sharing were most frequently PPO plans (37.4%) and were associated with higher quality ratings, with 63.5% achieving high or top performance combined (vs 49.0% among cost-sharing plans). In contrast, plans requiring more than $0 cost sharing for in-network PCP visits were comparatively more concentrated among HMOs (46.6%), in the Northeast (25.2%), and more likely to have low-performance ratings (45.1% with 1-3.5 stars) (Table 1).

Dual-axis bar and line chart of Year versus M A enrollees percent and enrollment. Single-panel dual-axis chart with a horizontal axis labeled Year and tick labels 2019, 2020, 2021, 2022, 2023, 2024, and 2025. The left vertical axis is labeled M A enrollees, percent, with a scale from 0 to 100 in increments of 20. The right vertical axis is labeled Enrollment in millions, colored blue, with a scale from 0 to 30 in increments of 5. A boxed legend near the upper left contains two entries: a blue filled circle labeled M A enrollees, and a dark gray bar labeled Enrollment total. Dark gray vertical bars align to each year and reference the right axis; bar heights are approximately 7 million in 2019, 9 million in 2020, 12 million in 2021, 15 million in 2022, 18 million in 2023, 19 million in 2024, and 21 million in 2025. A blue line with circular markers spans 2019 to 2025 and references the left axis; marker values are approximately 47 percent in 2019, 55 percent in 2020, 60 percent in 2021, 69 percent in 2022, 78 percent in 2023, 76 percent in 2024, and 78 percent in 2025. No gridlines, error bars, or point labels are present. — The line plot represents the proportions of all national MA enrollees who were covered by plans offering $0 cost sharing for in-network PCP visits in each corresponding year. Bars represent the count of enrollment in MA plans with such PCP benefit design in each corresponding year. Over-time growth in enrollment was assessed with Cochran-Armitage trend test for statistical significance (P < .001). To concentrate on the plans most widely available to the public, employer-sponsored plans, supplemental need plans (including those for dual-eligible individuals), and plans with fewer than 10 beneficiaries were excluded.

Table 1. Characteristics of General Medicare Advantage (MA) Plans and Counties by Cost-Sharing Type for In-Network Primary Care Physician (PCP) Visit, 2025.

Characteristic	Cost-sharing type in general MA plans, No. (%)^a		SMD
Characteristic	$0 Cost sharing	>$0 Cost sharing	SMD
Total observation (enrollment-weighted share %)^b	44 498 (78.1)	16 686 (21.9)	NA
Plan characteristics^c
Premium type
Zero	35 300 (79.3)	12 957 (77.7)	0.04
Nonzero	9197 (20.7)	3729 (22.4)	0.04
Plan type
HMO	14 371 (32.3)	7772 (46.6)	0.30
HMO-POS	13 503 (30.3)	4944 (29.6)	0.02
PPO	16 624 (37.4)	3970 (23.8)	0.30
Region
Midwest	9652 (21.7)	2744 (16.5)	0.13
Northeast	6269 (14.1)	4198 (25.2)	0.28
South	18 164 (40.8)	6272 (37.6)	0.07
West	10 413 (23.4)	3471 (20.8)	0.06
Plan performance by CMS star rating
Low (1-3.5 stars)	15 479 (34.8)	7532 (45.1)	0.21
High (4-4.5 stars)	27 452 (61.7)	8165 (48.9)	0.26
Top (5 stars)	797 (1.8)	13 (0.1)	0.18
NA	770 (1.7)	976 (5.9)	0.22
County characteristics ^c ^, ^d
Urbanicity^e
Urban	38 351 (86.2)	13 860 (83.1)	0.09
Rural	6147 (13.8)	2827 (16.9)	0.09
Age ≥65 y^f
Q4 (0.254 [0.226-0.741])	5456 (12.3)	1428 (8.6)	0.12
Q3 (0.209 [0.197-0.225])	5903 (13.3)	2202 (13.2)	0.002
Q2 (0.184 [0.170-0.196])	9964 (22.4)	4713 (28.2)	0.14
Q1 (0.149 [0.033-0.169])	23 174 (52.1)	8344 (50.0)	0.04
Female individuals ≥65 y^g
Q4 (0.561 [0.552-0.727])	19 088 (42.9)	9135 (54.8)	0.24
Q3 (0.545 [0.538-0.552])	14 539 (32.7)	4291 (25.7)	0.15
Q2 (0.531 [0.522-0.538])	7702 (17.3)	2155 (12.9)	0.12
Q1 (0.509 [0.279-0.522])	3169 (7.1)	1105 (6.6)	0.002
MA penetration^h
Q4 (0.583 [0.507-1.000])	18 669 (42.0)	6691 (40.1)	0.04
Q3 (0.447 [0.392-0.506])	14 781 (33.2)	5283 (31.7)	0.03
Q2 (0.333 [0.263-0.391])	7907 (17.8)	3072 (18.4)	0.02
Q1 (0.162 [0.220-0.262])	3141 (7.1)	1640 (9.8)	0.10
Percentage of population that is a racial or ethnic minorityⁱ
Q4 (0.874 [0.750-1.00])	21 201 (47.6)	9080 (54.4)	0.14
Q3 (0.625 [0.500-0.749])	13 635 (30.6)	4394 (26.3)	0.10
Q2 (0.375 [0.250-0.499])	6369 (14.3)	2034 (12.2)	0.06
Q1 (0.123 [0.000-0.249])	3293 (7.4)	1178 (7.1)	0.01
Poverty rate^j
Q4 (0.874 [0.750-1.00])	4078 (9.2)	2794 (16.7)	0.23
Q3 (0.622 [0.500-0.748])	10 919 (24.5)	4250 (25.5)	0.02
Q2 (0.375 [0.250-0.497])	14 692 (33.0)	5298 (31.8)	0.03
Q1 (0.123 [0.000-0.249])	14 808 (33.3)	4344 (26.0)	0.16
Self-reported health status^k
Q4 (0.242 [0.215-0.465])	7622 (17.1)	3764 (22.6)	0.14
Q3 (0.194 [0.178-0.214])	13 362 (30.0)	4374 (26.2)	0.09
Q2 (0.163 [0.147-0.177])	15 900 (35.7)	5767 (34.6)	0.03
Q1 (0.134 [0.088-0.146])	7614 (17.1)	2781 (16.7)	0.01
Ratio of population to PCP^l
Q4 (4468 [3117-29 081])	3508 (7.9)	1448 (8.7)	0.03
Q3 (2478 [2047-3116])	7000 (15.7)	2409 (14.4)	0.03
Q2 (1705 [1368-2044])	12 899 (29.0)	5230 (31.3)	0.05
Q1 (1095 [172-1366])	21 091 (47.4)	7600 (45.5)	0.04

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Abbreviations: CMS, Centers for Medicare & Medicaid Services; HMO, health maintenance organization; HMO-POS, health maintenance organization point of service; NA, not available; PPO, preferred provider organization; Q, quartile; SMD, standardized mean difference.

^{^a}

To concentrate on the plans most widely available to the public, employer-sponsored plans, supplemental need plans (including those for dual-eligible individuals), and plans with fewer than 10 beneficiaries were excluded.

^{^b}

The observation represents the total county-plan count for each cost-sharing type in 2025. The percentage represents the share of enrollment covered by the included MA plans in 2025.

^{^c}

Percentages shown in the table are enrollment-weighted column percentages. For each characteristic, these percentages represent the proportion of total 2025 enrollees within each cost-sharing category and sum to 100% across categories within each characteristic group.

^{^d}

Counties were ranked into quartiles (Q1-Q4) based on the values of the corresponding contextual factors. Q4 represents counties ranking in the highest quartile (top 25%) for a given characteristic, often indicating a more disadvantageous profile, while Q1 represents those in the lowest quartile (bottom 25%) or with the least disadvantageous socioeconomic profile. For each characteristic, the median and range of values that define the quartile categories are presented.

^{^e}

Percentage of plans in counties classified as urban or rural, according to the 2023 Rural-Urban Continuum Codes.

^{^f}

County-level mean proportions of the population 65 years or older, according to the 2019-2023 American Community Survey 5-year estimates.

^{^g}

County-level mean proportions of female individuals 65 years or older, according to the 2019-2023 American Community Survey 5-year estimates. Female sex was deemed one of the mapping covariates to estimate the associations with outcome in the study models; therefore, male sex was not a necessary variable and not included.

^{^h}

County-level MA penetration, defined as the proportion of Medicare beneficiaries enrolled in MA plans, obtained from the CMS public files.

^ⁱ

County-level proportions of racial and ethnic minority populations, including individuals who were Hispanic or Latino of any race and non-Hispanic or non-Latino American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian and Other Pacific Islander, 2 or more races, and other race. Data were retrieved from the Centers for Disease Control and Prevention’s 2022 Social Vulnerability Index dataset.

^{^j}

County-level proportions of the population below the 150% federal poverty line, according to the Centers for Disease Control and Prevention’s 2022 Social Vulnerability Index dataset.

^{^k}

County-level proportions of the population reporting fair or poor health (age adjusted). The higher the value, the more adults in the suboptimal health status. Data were retrieved from the 2025 County Health Ranking dataset.

^{^l}

Ratios of the population over the number of PCPs in a given county. The higher the value, the more difficult for patients to access their assigned PCP. Data were retrieved from the 2025 County Health Ranking dataset.

The distribution of plan availability across county-level characteristics was largely comparable between $0 and more than $0 cost-sharing MA plans for in-network PCP visits. Both plan types were highly prevalent in urbanized counties (86.2% vs 83.1%), counties with higher MA penetration (highest quartile [Q4], 42.0% vs 40.1%), greater access to PCP services (lower population to PCP ratio; lowest quartile [Q1], 47.4% vs 45.5%), higher proportions of women 65 years and older (Q4: 42.9% vs 54.8%), and higher composition of racial or ethnic minority groups (Q4: 47.6% vs 54.4%). However, $0 cost-sharing plans, compared with plans requiring PCP cost sharing, were more common in counties with lower poverty rates (Q1: 33.3% vs 26.0%; SMD = 0.16) and less common in counties with higher poverty rates (Q4: 9.2% vs 16.7%; SMD = 0.22) (Table 1).

In multivariable analyses (Table 2), plans offering $0 cost sharing for in-network PCP visits were less likely to be zero-premium plans relative to premium-charging plans (adjusted odds ratio [AOR], 0.70; 95% CI, 0.68-0.73). Conversely, no PCP cost sharing was associated with less restrictive network types relative to HMO (PPO: AOR, 2.14; 95% CI, 2.05-2.23; HMO-POS: AOR, 1.98; 95% CI, 1.89-2.07) but was less prevalent in the Northeast region relative to the Midwest (AOR, 0.78; 95% CI, 0.72-0.85). Plans offering this benefit were also more common in urbanized counties (AOR, 1.17; 95% CI, 1.11-1.24) and associated with higher MA penetration (Q4: AOR, 1.31; 95% CI, 1.22-1.40), higher populations of older adults (Q4: AOR, 1.23; 95% CI, 1.14-1.32), and higher populations of racial or ethnic minority groups (Q4: AOR, 1.18; 95% CI, 1.09-1.28), all relative to the lowest quartile (Q1). In contrast, $0 cost-sharing PCP visits were less likely to be offered by MA plans in counties with the highest poverty rates (Q4: AOR, 0.82; 95% CI, 0.74-0.90). No statistically significant associations were found with county-level PCP accessibility or self-reported health status (Table 2).

Table 2. Associations of Factors and Plan Performance With $0 Cost Sharing for In-Network Primary Care Physician (PCP) Visits, 2025^a.

Variable	Unadjusted		Adjusted
Variable	OR (95% CI)	P value	OR (95% CI)	P value
Model A: independent variables linked to $0 cost sharing for in-network PCP visits
Plan characteristics
Premium type [reference: nonzero]
Zero	0.66 (0.63-0.68)	<.001	0.70 (0.68-0.73)	<.001
Plan type [reference: HMO]
HMO-POS	1.99 (1.91-2.09)	<.001	1.98 (1.89-2.07)	<.001
PPO	2.17 (2.09-2.26)	<.001	2.14 (2.05-2.23)	<.001
Region [reference: Midwest]
Northeast	0.83 (0.77-0.89)	<.001	0.78 (0.72-0.85)	<.001
South	0.85 (0.81-0.89)	<.001	0.90 (0.85-0.95)	<.001
West	0.86 (0.80-0.93)	<.001	0.94 (0.86-1.02)	.16
County characteristics
Urbanicity [reference: rural]	1.17 (1.12-1.21)	<.001	1.17 (1.11-1.24)	<.001
MA penetration [reference: Q1]				<.001
Q4	1.21 (1.13-1.28)	<.001	1.31 (1.22-1.40)	<.001
Q3	1.14 (1.07-1.21)	<.001	1.23 (1.14-1.32)	<.001
Q2	1.10 (1.03-1.18)	.004	1.14 (1.06-1.22)	<.001
Female individuals ≥65 y [reference: Q1]
Q4	1.06 (0.99-1.13)	.07	1.13 (1.05-1.23)	.002
Q3	1.15 (1.08-1.22)	<.001	1.21 (1.12-1.30)	.02
Q2	1.12 (1.05-1.20)	<.001	1.18 (1.10-1.26)	<.001
Age ≥65 y [reference: Q1]
Q4	1.03 (0.97-1.09)	.38	1.23 (1.14-1.32)	<.001
Q3	1.00 (0.94-1.05)	.91	1.10 (1.03-1.17)	.005
Q2	0.93 (0.88-0.98)	.007	0.97 (0.92-1.03)	.32
Percentage of population that is a racial or ethnic minority [reference: Q1]
Q4	0.98 (0.92-1.03)	.41	1.18 (1.09-1.28)	<.001
Q3	1.07 (1.01-1.13)	.03	1.14 (1.06-1.22)	<.001
Q2	1.08 (1.02-1.15)	.008	1.08 (1.01-1.15)	.02
Poverty rate [reference: Q1]
Q4	0.78 (0.74-0.83)	<.001	0.82 (0.74-0.90)	<.001
Q3	0.93 (0.88-0.98)	.01	0.93 (0.86-1.01)	.07
Q2	0.98 (0.92-1.03)	.43	0.96 (0.90-1.03)	.25
Self-reported health status [reference: Q1]
Q4	0.82 (0.76-0.87)	<.001	0.92 (0.83-1.03)	.14
Q3	0.98 (0.91-1.04)	.50	1.01 (0.93-1.10)	.80
Q2	1.02 (0.96-1.10)	.51	1.02 (0.95-1.10)	.55
Ratio of population to PCP [reference: Q1]
Q4	0.82 (0.76-0.87)	<.001	0.97 (0.91-1.04)	.44
Q3	0.98 (0.91-1.04)	.35	1.03 (0.97-1.10)	.34
Q2	1.02 (0.96-1.10)	.85	1.03 (0.96-1.09)	.42
Model B: plan performance associated with $0 cost sharing vs >$0 cost sharing for in-network PCP visits
Top (5-star rating)	7.37 (5.34-10.18)	<.001	6.71 (4.83-9.32)	<.001
High (4- to 4.5-star rating)	1.57 (1.51-1.62)	<.001	1.50 (1.45-1.55)	<.001
Low (1- to 3.5-star rating)	0.71 (0.69-0.74)	<.001	0.74 (0.71-0.76)	<.001

Open in a new tab

Abbreviations: OR, odds ratio; HMO, health maintenance organization; HMO-POS, health maintenance organization point of service; MA, Medicare Advantage; PPO, preferred provider organization; Q, quartile.

^{^a}

Model A aimed to identify potential predictors among plan-specific or county-specific characteristics associated with a plan’s cost-sharing status for in-network PCP visit (dependent variable), before and after adjusting all other covariates listed in Table 1 except for plan star ratings. Model B evaluated plan performance (dependent variable: low, high, or top star rating) in relation to cost-sharing status for in-network PCP visit (independent variable; MA plans with PCP cost sharing as reference group). These analyses were performed both before and after adjusting for all other covariates listed in Table 1. All models incorporated a random intercept variable to account for within-county clustering effect (identified via county Federal Information Processing Standard) across county-plan observations.

Plans without PCP cost sharing had higher plan quality, compared with plans with PCP cost sharing. Specifically, plans without PCP cost sharing had nearly 7-fold higher odds of having top performance (AOR, 6.71; 95% CI, 4.83-9.32), and conversely, 26.0% lower odds of having low performance (1-3.5 stars: AOR, 0.74; 95% CI, 0.71-0.76) compared to plans with PCP cost sharing (Table 2). Domain-specific analyses suggested that the association between $0 PCP cost sharing and higher overall CMS star rating performance was primarily driven by stronger performance in the staying healthy and managing chronic conditions domains (eTables 2 and 3 in Supplement 1).

Discussion

Cost sharing can deter utilization of high-value services such as primary care.^9,10,11,35 Under such context, the growth of MA plans with no cost sharing for in-network PCP visits is important and welcome—but also largely uncharacterized in existing literature.

By quantifying the prevalence of and trends in PCP cost sharing, this study documents widening structural divergence between MA and traditional Medicare, where Part B cost-sharing requirements remain rigid and typically higher unless supplemental plans are in place.³⁶ This widespread elimination of PCP out-of-pocket costs in MA may represent a unique and unprecedented natural experiment for understanding whether cost-sharing reduction is associated with real-world changes in primary care use and affordability for millions of beneficiaries nationwide.^37,38,39

The expansion of $0 cost sharing for in-network PCPs has implications for patient care. Greater primary care access is associated with improved chronic disease management, higher cancer screening rates, and lower emergency department utilization.^37,38,40 At the same time, cost sharing and other out-of-pocket payments reduce health care utilization, including use of high-value services.^41,42 In this context, the widespread adoption of the $0 cost-sharing benefit in MA may reduce a key financial barrier to high-value care for millions of beneficiaries, yet its suggested greater access gains in more resourced markets could inadvertently exacerbate health disparities for socioeconomically disadvantaged populations.

Several findings from this analysis warrant further discussion. First, the higher prevalence of PPO and HMO-POS plans offering $0 cost sharing for in-network PCPs suggests that plans offering broader network flexibility may have extended this generosity to benefit design.^43,44 This pattern may reflect competitive positioning. As MA penetration increases in a given market, plans may use the $0 cost-sharing benefit as a differentiator to attract enrollment.

Second, we found that $0 premium plans were less likely to offer $0 cost sharing for in-network PCP visits, suggesting a potential benefit design trade-off.^44,45 Plans forgoing premium revenue may retain cost sharing at the point of care to balance financial viability.^27,45,46 Viewed in isolation, this pattern might be termed illusory affordability, as beneficiaries selecting zero-premium plans may unknowingly accept higher barriers to essential services.^33,47,48 However, premium reductions may not be an isolated strategy, but rather one of many financial levers (eg, adjustments to specialist or inpatient cost sharing, maximum out-of-pocket limits, or Part D premium buy downs) that are weighed against PCP cost sharing. Inference regarding how such trade-offs translate into clinical outcomes warrants more comprehensive investigation into additional internal actuarial patterns and insurer strategies, which remains beyond the primary scope and focus of the current study.

Third, the observation that $0 cost-sharing plans were more prevalent in counties with higher populations of racial and ethnic minority groups, yet less prevalent in areas with high poverty rates, presents a nuanced picture of benefit design and equity. The increased availability in areas with higher populations of racial and ethnic minority groups may reflect insurers’ strategic decisions, as these populations often experience greater health disparities and may be particularly sensitive to out-of-pocket costs,^33,49 potentially making $0 PCP cost sharing a competitive means to improve health equity metrics within CMS star ratings.⁵⁰ Moreover, these populations are often concentrated in urbanized markets with high MA penetration, where intense competition may further drive the adoption of salient benefits to attract enrollment.⁵¹

Conversely, the lower availability of $0 PCP cost sharing in high-poverty counties likely implies pervasive financial limitations, stemming from tighter payment benchmarks or risk pools with higher anticipated health care costs, that hinder comprehensive first-dollar coverage.^52,53,54 Additionally, this finding may reflect a market dynamic where the most vulnerable enrollees are served by SNPs, which were outside this study’s scope. These plans often feature specialized benefit structures tailored to the dually eligible beneficiaries concentrated in high-poverty areas.⁵⁵ Nevertheless, the exclusion of SNPs does not preclude the potential equity concern: individuals most likely to benefit from $0 cost sharing for PCP visits may face systematic barriers in accessing general enrollment plans that offer such benefits, which could potentially exacerbate health disparities.^29,33

Furthermore, plans offering $0 cost sharing for in-network PCP visits were associated with top-tier CMS star ratings, largely driven by stronger performance in preventive care delivery and chronic disease management domains, where primary care physicians play a central role.⁵⁶ This pattern may reflect high-value benefit design and improved access to primary care but warrant cautious interpretation, since higher-rated plans also receive larger-quality bonus payments and may have greater financial capacity to offer $0 cost sharing for in-network PCPs. The CMS Quality Bonus Program was designed to incentivize top-performing plans to provide better benefits and services, creating competitive pressure that can disadvantage less well-managed plans; from this perspective, the present findings suggest that this mechanism may be working as intended during the study period.

These findings have implications for both beneficiary decision-making and regulatory oversight. Currently, Medicare’s Plan Finder emphasizes premium costs, potentially steering beneficiaries toward zero-premium options without adequate transparency about cost sharing for high-value services.^44,47 Enhanced disclosure requirements could facilitate more informed plan selection.

From a regulatory standpoint, CMS’s star rating system could incorporate measures of primary care accessibility, including cost-sharing generosity.^26,57,58,59 If the $0 cost-sharing benefit is indeed associated with higher plan quality, as this study’s descriptive findings suggest, formalizing this relationship in quality metrics could further incentivize broader adoption. If the benefit is both highly valued by beneficiaries and shown to improve access or outcomes, it could also inform future reforms in traditional Medicare. Nonetheless, benefit design alone is insufficient to ensure equitable access to care.⁶⁰ As prior research on Medicaid nonemergency transportation has demonstrated, simply offering a benefit does not guarantee its utilization.³ Future studies linking $0 cost sharing to actual primary care utilization, preventive service uptake, and downstream health outcomes are warranted to determine whether this market-driven innovation translates into tangible population health improvement.⁶¹

Limitations

This study has limitations. First, the analysis relied on plan-level data and cannot capture individual-level utilization patterns or direct health outcomes. It remains unknown whether beneficiaries enrolling in plans with $0 PCP cost sharing actually use more or less primary care services, such as increased visit rates, disease screenings, or immunizations, compared to individuals in other plan types. Thus, while this study highlights important structural trends in benefit design, it was not configured to empirically evaluate the ultimate clinical relevance or health impact of this benefit, warranting future investigation using beneficiary-level data. Additionally, the ecological design precludes determining whether plans without PCP cost sharing are associated with greater PCP accessibility or clinical capacity. Second, the definition of $0 cost sharing for in-network PCP visits was limited to visit-level cost sharing and did not account for downstream costs (eg, laboratory testing, imaging, medications) that may still pose financial barriers to care. Third, the cross-sectional design precludes causal inference; plans offering $0 cost sharing for in-network PCPs may differ from those that do not in ways not fully captured by the covariates. Additionally, county-level covariates used in this analysis were aggregated to describe the entire area population and may not perfectly mirror the specific profile of the Medicare-eligible population. Therefore, cautious interpretation and future study with more granular, individual-level data are needed. Fourth, while the models explored several county-level factors associated with $0 PCP cost sharing, such as poverty levels, urbanicity, population health risks, and MA penetration as potential proxies for plan flexibility in benefit design, we did not empirically examine direct MA payment policy factors such as benchmarks or rebate percentages given data limitations. As these financial factors are crucial determinants of the rebate dollars available for insurers to enhance benefits, their omission may limit a complete understanding of a plan’s ability to eliminate PCP cost sharing. Moreover, while the study reveals important trends in $0 PCP cost sharing and its association with plan premiums, selected due to their universal relevance and high salience as upfront financial attractors for beneficiaries, we acknowledge that benefit generosity in MA plans is multidimensional and may come at the expense of other benefit margins. Therefore, future research should explore trade-offs across all potential benefit types, such as deductibles, out-of-pocket maximums, detailed supplemental benefits, or various Part D cost-sharing structures, to further explore these dimensions of plan generosity. Lastly, the exclusion of special needs plans may limit generalizability to beneficiaries with high medical and social complexity who are enrolled in plans with specialized benefit designs beyond standard $0 cost sharing for in-network PCP visits.

Conclusions

This cross-sectional study demonstrates that the growth in plans with PCP cost sharing marks an important, fundamental trend in MA benefit structure. While this type of plan benefit can eliminate first-dollar barriers to primary care for individuals, its uneven distribution across the US raises concerns about implications for individuals in less resourced counties. Future research must determine whether this market-driven innovation translates into higher-value care and better health outcomes, and whether policy action is needed to extend any observed benefits for no PCP cost sharing to populations who need it most.

Supplement 1.

eTable 1. Classification of 2025 CMS Part C Star Rating Measures by Relevance to PCP Services

eTable 2. 2025 CMS Part C Star Rating Domain Performance of MA Plans by Cost-Sharing Type for In-Network PCP Visits

eTable 3. Adjusted Associations Between $0 Cost-Sharing for In-Network PCP Visits and 2025 CMS Part C Star Rating Domain Performance

eReferences

jamahealthforum-e262232-s001.pdf^{(257.6KB, pdf)}

Supplement 2.

Data Sharing Statement

jamahealthforum-e262232-s002.pdf^{(16.3KB, pdf)}

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61.Gupta A, Jacobson G, Leonard F. Could notifications help Medicare Advantage beneficiaries utilize their ununsed benefits? The Commonwealth Fund . October 30, 2025, Accessed January 27, 2026. https://www.commonwealthfund.org/blog/2025/could-notifications-help-medicare-advantage-beneficiaries-utilize-their-unused-benefits

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eTable 1. Classification of 2025 CMS Part C Star Rating Measures by Relevance to PCP Services

eTable 2. 2025 CMS Part C Star Rating Domain Performance of MA Plans by Cost-Sharing Type for In-Network PCP Visits

eTable 3. Adjusted Associations Between $0 Cost-Sharing for In-Network PCP Visits and 2025 CMS Part C Star Rating Domain Performance

eReferences

jamahealthforum-e262232-s001.pdf^{(257.6KB, pdf)}

Supplement 2.

Data Sharing Statement

jamahealthforum-e262232-s002.pdf^{(16.3KB, pdf)}

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PERMALINK

Primary Care Cost Sharing in Medicare Advantage

Changchuan Jiang, MD, MPH

Chuan Angel Lu, MD, MPH

Lesi He, MSc

Arthur S Hong, MD, MPH

Xin Hu, PhD, MSPH

Megan Mullins, PhD

Boshen Jiao, PhD

Joshua M Liao, MD, MSc

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Exposures

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Study Design and MA Plan Data Source

Study Population

Cost Sharing for In-Network PCP Visits

County-Level Characteristics

MA Plan Performance

Statistical Analysis

Results

Figure. Bar and Line Graphs Showing National Enrollment Trends in Medicare Advantage (MA) Plans Offering $0 Cost Sharing for In-Network Primary Care Physician (PCP) Visits.

Table 1. Characteristics of General Medicare Advantage (MA) Plans and Counties by Cost-Sharing Type for In-Network Primary Care Physician (PCP) Visit, 2025.

Table 2. Associations of Factors and Plan Performance With $0 Cost Sharing for In-Network Primary Care Physician (PCP) Visits, 2025a.

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases

Table 2. Associations of Factors and Plan Performance With $0 Cost Sharing for In-Network Primary Care Physician (PCP) Visits, 2025^a.