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The real out-of-pocket maximum on every Sioux Falls Medicare Advantage plan for 2026

A $0 premium and an $80 premium in the same county can carry a real difference in your worst-case bill — and only one of those numbers is on the brochure.

Big Sioux Benefits Data Desk

Published September 28, 2026 · 15 min read · Sourced from carrier plan filings & CMS.gov

The out-of-pocket maximum, not the premium, is the number that decides what a bad year actually costs you on a Sioux Falls Medicare Advantage plan — and for 2026, the plan with the lowest premium in Minnehaha County is not the plan with the lowest out-of-pocket maximum. Sanford's $0-premium Align ChoicePlus carries a combined maximum out-of-pocket of $4,900, while Sanford's own $66-a-month Align ChoiceElite carries a lower $3,500 cap, per each plan's 2026 Summary of Benefits filed directly with CMS. Meanwhile Wellmark's Blue Medicare Advantage Enhanced PPO, at $80 a month the priciest of the three, also carries the highest out-of-pocket ceiling of the three at $5,000, per Wellmark's own 2026 Annual Notice of Change.

None of that shows up on a rate card that only lists the monthly premium. We pulled the actual 2026 plan documents — Summary of Benefits and Annual Notice of Change filings, the legal documents each carrier is required to send enrollees, not a marketing page — for three of the five standard Medicare Advantage PPOs sold to anyone with Medicare in Minnehaha County, plus the CMS landscape data already tracked in this site's own plan database. Every figure below is sourced. Two plans, both from Aetna, are marked as unverified because we could not independently pull their maximum out-of-pocket from a primary document this session — more on that below, and it is exactly the kind of gap a phone call or a licensed agent closes in minutes.

What "out-of-pocket maximum" actually means

The maximum out-of-pocket amount (MOOP) is the ceiling Medicare requires every Medicare Advantage plan to set on what you pay, in a single calendar year, for covered Part A and Part B services — hospital stays, surgery, skilled nursing, doctor visits, imaging, and the like. Once your own spending on those services hits the MOOP, the plan pays 100% of your covered care for the rest of that year. Two things trip people up:

• In-network vs. combined. The in-network MOOP only counts money you spend with providers in the plan's network. The combined MOOP is what you'd hit if some of your care was out-of-network, and on a PPO it's almost always a higher number than the in-network figure.
• It excludes your premium and, on every plan checked for this guide, your drug costs. Sanford Health Plan's own 2026 Summary of Benefits for Align ChoicePlus states plainly that the maximum out-of-pocket amount "does not include costs related to prescription drugs." Your monthly premium and your Part D spending are separate lines you have to add back in to see your real total exposure — which is exactly what the worked example further down does.

A PPO (preferred provider organization) is the network type behind every one of Minnehaha County's five standard Medicare Advantage plans — it means you can see providers outside the network, usually at a higher cost, without needing a referral. A Part D deductible is the amount you pay for covered prescriptions before your drug coverage starts sharing the cost; on the plans below it ranges from $300 to $615 depending on the drug's tier, the cost-sharing category — generic, preferred brand, specialty, and so on — a plan assigns to each covered drug.

Why two plans from the same carrier can carry such different MOOPs

It isn't random that Align ChoiceElite and Align ChoicePlus, two PPOs from the same company, land at different combined maximums. Every year, each Medicare Advantage plan submits a "bid" to CMS estimating its cost of covering Medicare-eligible care. When a plan's bid comes in under a CMS benchmark, the plan earns a rebate it's required to spend on extra value for members — a lower premium, a richer supplemental benefit like dental or a fitness program, or a lower MOOP. A carrier can choose to spend that rebate differently across its own plan lineup: put more of it into the premium (Align ChoicePlus, at $0/mo) or more of it into the out-of-pocket protection (Align ChoiceElite, at the lower $3,500 MOOP). Neither choice is wrong — they're simply different bets on what a member is more likely to value, which is exactly why comparing plans on premium alone misses the actual design decision each one made.

Minnehaha County's own chronic-condition rates make that design choice a real local question, not an abstract one. Among adults in the county, 31.7% have high blood pressure and 10% have a diagnosed diabetes diagnosis, per CDC PLACES county-level data already tracked in this site's plan database. Someone actively managing either condition is statistically more likely to see the inside of a specialist's office or a hospital in a given year than someone who isn't — which tilts the honest math in this article's worked example further toward the lower-MOOP plan, not the lower-premium one.

The real 2026 numbers: Minnehaha County's five standard PPOs

Sioux Falls (Minnehaha County) is the largest Medicare market in South Dakota, with 39,532 Medicare beneficiaries, per CMS's own county enrollment data. For 2026 it offers five standard Medicare Advantage PPOs open to anyone with Medicare, across 5 carriers — plus Dual-Eligible and Institutional Special Needs Plans and Medica Cost plans, covered further down. Here is the full five-plan roster with premium, Part D deductible, CMS star rating, and — where we could independently verify it against a primary source this session — the real 2026 maximum out-of-pocket amount.

Premiums, deductibles, and star ratings: CMS Medicare Advantage / Part D Landscape (PY2026), plan year 2026. Out-of-pocket maximums for Align ChoicePlus and Align ChoiceElite: Sanford Health Plan 2026 Summary of Benefits. Out-of-pocket maximum for Blue Medicare Advantage Enhanced PPO: Wellmark 2026 Annual Notice of Change.

Why the $0 plan isn't automatically the safer one

Line the three verified plans up side by side and a pattern breaks that most people assume holds: that the cheapest premium is also the lowest-risk choice.

Source: Sanford Health Plan and Wellmark 2026 plan documents (see citations above), plan year 2026.

Align ChoiceElite, the plan with the highest premium of the two Sanford options, has the lowest maximum out-of-pocket of all three plans checked. Align ChoicePlus, the $0-premium option, sits in the middle. And Wellmark's Enhanced PPO manages to be the highest premium and the highest MOOP — the one combination that offers no upside on either number. None of that is visible from a premium comparison alone, which is the entire reason a "cheapest plan" search on premium is an incomplete comparison, not a wrong one.

A worked example: what a bad year actually costs

Say you need a hip replacement and a short hospital stay in 2026 — enough care to hit your plan's full out-of-pocket maximum, a realistic scenario for a major surgery year. Add twelve months of premium to the MOOP for each plan to see your real worst-case annual cost, separate from your Part B premium and any drug spending:

This math leaves out two things that matter just as much: your Part D drug costs, which run on the separate $2,100 cap described below, and whether your specific doctors and hospital sit inside each plan's network — an out-of-network claim resets the math entirely. A premium-only comparison catches neither.

Three scenarios, three different "best" plans

The honest answer to "which plan is best" depends entirely on how much care you actually use in a given year. Run the same three plans through three realistic scenarios and the ranking changes each time:

In a healthy year, the $0-premium ChoicePlus wins outright — there's no MOOP to worry about if you never approach it. In a moderate year, ChoicePlus is still cheapest, because its $0 premium keeps compounding its advantage as long as your cost-sharing stays well under the gap between plans. Only in a major-care year does ChoiceElite's lower MOOP catch up and pass ChoicePlus. Blue Medicare Advantage Enhanced doesn't win any of the three scenarios among these plans — it's the costlier choice in every row, which is a genuinely useful thing to know before assuming a higher premium buys better protection.

How Sioux Falls compares to the rest of the country

All three Sioux Falls plans checked here run well under what Medicare Advantage members typically pay out-of-pocket nationally. CMS sets a mandatory ceiling every plan in the country must stay under — for 2026, no plan can set its in-network MOOP above $9,250 or its combined MOOP above $13,900, per KFF's analysis of CMS's own 2026 plan data, published May 28, 2026. Most plans set their own limit well below that ceiling, and the enrollment-weighted national average for 2026 is $5,421 in-network and $9,825 combined.

Source: KFF — Medicare Advantage Out-of-Pocket Limits: Variation and Trends, May 28, 2026.

The three Sioux Falls plans checked for this guide run roughly half the national combined average — a genuinely good local fact, not a sales line, because it's the same figure any competitor could pull from the same public CMS data. It doesn't mean every plan in the county is this strong; it means these three specific plans are, and the two Aetna plans need their own confirmation before you assume the same pattern holds.

Why Medicare Cost plans are a different animal entirely

Minnehaha County also carries four Medica Cost plans for 2026 — Prime Solution Thrift, Standard, Core, and Premier, ranging from a $58.7 to a $334.7 monthly premium, per CMS's PY2026 landscape data. A Medicare Cost plan, authorized under a different section of federal law (Section 1876) than a Medicare Advantage plan (Part C), works differently in a way that matters directly to this article's subject: per CMS's own description of how Cost plans function, members can use providers outside the plan's network and have that care paid under Original Medicare's rules instead of the plan's own cost-sharing structure.

That sounds like flexibility, and it is — but it also means care you get outside the plan runs on Original Medicare's ordinary 20% coinsurance with no MOOP protecting you, the same uncapped exposure Original Medicare alone carries. A Medicare Advantage MOOP is a promise: spend this much, and you're done for the year. A Cost plan doesn't make that same promise the moment you step outside its network. If a Cost plan is on your list, ask specifically how out-of-network cost-sharing is capped, if at all, before assuming it behaves like the PPOs compared above.

Source: CMS — Medicare Cost Plans; premium figures: CMS Medicare Advantage / Part D Landscape (PY2026), plan year 2026.

Special Needs Plans: a different cost-sharing picture

Minnehaha County's four Dual-Eligible Special Needs Plans (D-SNP) — for people on both Medicare and Medicaid — and two Institutional Special Needs Plans (I-SNP), for nursing-home residents, don't fit the same premium-vs-MOOP comparison, because most carry $0 cost-sharing by design, per each plan's own CMS-filed notes in this site's plan data. A D-SNP's real cost-sharing depends on your specific Medicaid category rather than a simple MOOP dollar figure, and one structural risk is worth knowing about regardless of cost: a coordination-only D-SNP, the type all four Minnehaha County D-SNPs are, has a narrower integration with your Medicaid benefits than a fully integrated plan — ask specifically how your Medicaid and Medicare benefits are coordinated before enrolling.

How to check any plan's real MOOP yourself, and how enrollment timing fits in

You don't need to wait for a data desk to pull this number. Three ways to get it directly:

1. Medicare.gov Plan Finder. Enter your ZIP code, open a plan's full details, and look under its medical cost-sharing section for "out-of-pocket maximum" — most listings show both the in-network and combined figures.
2. Ask the carrier for the Summary of Benefits or Evidence of Coverage by name. Both are legal documents every Medicare Advantage plan must publish annually, and both state the MOOP explicitly — the same documents we pulled for this article.
3. Add the premium back in. A MOOP alone isn't the full picture. Multiply the monthly premium by 12 and add it to the MOOP, the way the worked example above does, to see your real worst-case annual number for medical care.

Whichever method you use, check the plan's Part D drug deductible and out-of-pocket cap separately — the medical MOOP and the drug cap never combine into one number, on any plan checked for this guide.

Timing matters too. The Annual Enrollment Period (AEP), October 15 through December 7 every year, is the main window to switch Medicare Advantage or Part D plans for the coming year — any change made now takes effect January 1, 2027. If you're already on a Medicare Advantage plan, the Medicare Advantage Open Enrollment Period (MA OEP), January 1 through March 31, gives you one more chance to switch to a different Medicare Advantage plan or drop back to Original Medicare, though not to switch from one stand-alone Part D plan to another. Someone newly eligible for Medicare instead uses their Initial Enrollment Period (IEP), the seven-month window built around their 65th birthday. Whichever window applies to you, running the MOOP math above before you enroll — not after — is what makes it useful.

How we help

This is one of the checks we run for every Sioux Falls household we talk to: not just the premium, but the maximum out-of-pocket, the Part D deductible, and whether your specific doctors and hospital sit inside a plan's network — the plans we offer in the Sioux Falls area, compared side by side on the numbers that actually differ. It costs nothing to ask, because carriers, not you, pay the agent.

Sioux Falls' hospital picture, for context

A network's real value shows up when the MOOP math above gets tested — and Sioux Falls runs on two competing systems. Both carry strong CMS quality ratings, which matters independently of which plan you choose:

Source: CMS Hospital Compare — Overall Star Ratings.

Sanford runs its own Medicare plans — the Align lineup checked above — so those plans naturally favor the Sanford network. If your doctors are at Avera, confirm network status before enrolling regardless of how favorable a plan's MOOP looks on paper; an out-of-network MOOP is a much less comfortable number to actually hit.

What to watch before this year's Annual Enrollment Period

1. Pull the MOOP for every plan you're seriously considering — not just the premium — before October 15.
2. Confirm the Aetna figures directly if either of Minnehaha County's two Aetna plans is on your list; we could not verify them this session.
3. Add 12 months of premium to the MOOP for a real worst-case total, the way the worked example above does.
4. Check your Part D deductible and the $2,100 cap separately — the medical MOOP never covers drug spending on these plans.
5. If a Medica Cost plan is on your list, ask specifically how out-of-network costs are capped before assuming it behaves like a Medicare Advantage PPO.

How we know all this: Big Sioux Benefits runs every article through a data desk that cross-references the CMS Medicare plan landscape and county enrollment data already in this site's own plan database against primary carrier filings pulled fresh for this piece — Sanford Health Plan's and Wellmark's own 2026 Summary of Benefits and Annual Notice of Change documents, and KFF's May 2026 national out-of-pocket-limit analysis — built by Strategic AI Architects. Two figures (the Aetna out-of-pocket maximums) could not be independently confirmed this session and are marked as such rather than estimated. This is education, not advice; confirm your plan's exact costs with a licensed agent or Medicare.gov. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. Big Sioux Benefits is a licensed independent insurance agency (NPN DEMO-NPN-00000000). Not connected with or endorsed by the United States government or the federal Medicare program. We take no payment from any carrier to feature a plan.