Medicare Advantage Out-of-Pocket Maximum: What It Actually Caps

Your Summary of Benefits includes a row labeled maximum out-of-pocket limit (or similar wording). That figure caps what you can owe in in-network cost sharing on Medicare-covered medical care in a calendar year. It can make a big difference if you need a lot of medical care during the year.

CMS sets a federal maximum each year. For 2026, that in-network federal maximum for Medicare-covered Part A and Part B services is $9,350, although individual Medicare Advantage plans can set a lower medical out-of-pocket maximum. The medical cap does not include your Part B premium, any plan premium, or pharmacy copays. Your Part B premium does not count toward the plan's medical out-of-pocket maximum.

When I compare Medicare Advantage plans for a client who sees several specialists or expects surgery, MOOP is one of the numbers I look at. Two people can have the same cap on paper and still have very different costs depending on how often they use medical care.

When you compare plans, look at what counts toward the cap, what does not, and how the costs compare with a Medigap plan on Original Medicare. For a broader comparison of Medicare Advantage and Original Medicare, see our Medicare Advantage vs Original Medicare guide. For a closer look at how $0-premium Medicare Advantage plans still leave Part B and copay bills, see Medicare Part B premium in 2026.

What is a Medicare Advantage maximum out-of-pocket limit?#

The maximum out-of-pocket limit is the most you pay in a calendar year for covered Part A and Part B services under your plan's in-network cost-sharing rules.

CMS requires every Advantage plan to include one. For calendar year 2026, the federal maximum for in-network Medicare-covered Part A and Part B services is $9,350 (Medicare.gov cost basics), although many plans set a lower medical out-of-pocket maximum. Check the Summary of Benefits and Evidence of Coverage for the plan you are considering.

Once you hit the limit on in-network Medicare-covered services, the plan pays 100% of covered in-network Part A and Part B services for the rest of the calendar year. You still owe premiums and most drug copays. MOOP does not limit everything you might spend on Medicare in a year.

PPO plans may publish a separate out-of-network maximum. Out-of-network care may accumulate toward a different limit or at a different rate. Read both rows if you use PPO out-of-network benefits.

How is an Advantage out-of-pocket maximum different from a Medigap premium?#

Medigap and Medicare Advantage handle your costs differently. Medigap generally gives you more predictable cost sharing through a monthly premium, while Medicare Advantage uses plan-specific copays and coinsurance with an annual medical out-of-pocket maximum.

A Medigap premium is a fixed monthly charge for standardized supplement coverage behind Original Medicare. Medigap premiums vary by plan, location, age, pricing method, and other factors, so compare the actual premium available to you rather than relying on a general price range. With Medigap, your costs are generally more predictable because the supplement helps cover some of Original Medicare's cost sharing, while you continue to pay the Medigap premium and other applicable costs.

An Advantage maximum out-of-pocket limit is not a premium. It is an annual limit on copays and coinsurance. You might pay $0 plan premium plus copays until you hit the cap. Or you might pay a plan premium with a lower cap and smaller specialist copays.

The right comparison depends on how you use healthcare and what you are comfortable paying. If you rarely need care beyond primary visits, you may never get close to the medical out-of-pocket maximum. If you see several specialists, have regular imaging, or expect a procedure, those costs can add up quickly.

When comparing plans, look at the MOOP along with the plan's copays, network, drug coverage, and the care you expect to use.

What costs count toward my Advantage out-of-pocket maximum?#

In-network copays and coinsurance for Medicare-covered Part A and Part B services generally count. Premiums and most drug spending do not.

Hospital stays, outpatient surgery, imaging, ambulance rides, skilled nursing coinsurance, and specialist visits usually accumulate toward the medical out-of-pocket maximum when provided in network and covered by the plan. Check your Evidence of Coverage for the exact list.

These lines generally do not count:

• Part B premium to Medicare ($202.90 standard in 2026). Medicare Advantage members generally continue to pay the Part B premium separately from the plan's cost-sharing amounts.
• Plan premium to the Advantage carrier
• Part D drug copays at the pharmacy (see below)
• Dental, vision, or hearing extras billed as supplemental benefits
• Most out-of-network PPO shares (separate maximum may apply)

Medical MOOP and Part D drug costs are separate#

MOOP and the Part D drug-cost limit are separate. A Medicare Advantage plan's medical out-of-pocket maximum applies to covered Part A and Part B services under the plan. Covered Part D prescription drug costs follow Part D rules and do not simply roll into the medical MOOP counter.

For 2026, Medicare sets a separate annual out-of-pocket limit of $2,100 on covered Part D drugs (deductible, copays, and coinsurance that count toward that limit). After you reach it, you pay $0 for covered Part D drugs for the rest of the calendar year (Medicare.gov Part D costs). Part D plan premiums and drugs not on the formulary do not count toward that $2,100 figure.

Treat the medical MOOP and your Part D drug costs as separate calculations when comparing plans. Hitting one does not mean you have hit the other.

When you hit the cap mid-year#

After you reach the in-network maximum out-of-pocket limit, the plan pays 100% of covered in-network Part A and Part B services for the rest of the calendar year. The counter resets every January 1, even if you stay on the same plan after your Annual Notice of Change.

Copays you paid in January count toward the new year cap starting fresh on January 1.

Track your Explanation of Benefits remaining maximum out-of-pocket line through the year if you are receiving regular or expensive medical care. Knowing how much of the maximum you have already reached can help you plan for additional copays or coinsurance later in the year.

Should I verify specialists on the Advantage provider directory before enrolling?#

Yes. A low maximum out-of-pocket limit is most useful when the doctors and facilities you actually use participate in the plan's network.

Network status determines whether copays accumulate toward the cap on the services you actually use. Search the carrier directory for the exact plan tied to your residential ZIP. Confirm the individual doctor and office address. Call billing with the plan name and contract year before you rely on an online directory alone.

How hospital and ambulance copays stack toward the cap#

Advantage plans replace Original Medicare cost sharing with plan copays and coinsurance. A hospital stay can involve significant cost sharing before you reach the medical out-of-pocket maximum.

Skilled nursing transitions add another layer. Some plans charge daily copays after day twenty in a skilled nursing facility. Those amounts usually count toward the medical out-of-pocket maximum when provided in network, but the Evidence of Coverage defines the exact list. Do not assume one hospital copay row covers the entire episode.

It is easy to assume that most of your cost sharing is behind you after a hospital stay, but ambulance trips can add additional costs. Ground ambulance fees add quickly when rehab transfers require multiple rides. Each trip may count toward the maximum out-of-pocket limit separately when the plan lists ambulance cost sharing.

PPO out-of-network maximums are a second cap#

PPO plans may show an in-network maximum out-of-pocket limit and a higher combined or out-of-network figure. Out-of-network spending often counts toward the higher cap at a different rate. Snowbirds who split time between Florida and Georgia sometimes trigger out-of-network shares when they seek care outside the plan service area.

Read both caps if you travel. A low in-network limit does not protect you when you receive care out of network except in emergency situations defined by CMS.

Using the maximum out-of-pocket limit when comparing plans#

When comparing plans on Medicare Plan Finder, start with three numbers:

1. In-network maximum out-of-pocket limit
2. Specialist visit copay or coinsurance percentage
3. Estimated annual Part D cost

Do not look at the MOOP by itself. A plan with a lower medical maximum but higher specialist copays can work differently from a plan with a higher maximum and lower copays. The better comparison depends on the type of care you expect to use.

Read Medicare Advantage vs Original Medicare for how Advantage and Original Medicare differ day to day. Advantage vs Medigap in Florida covers exit context. Search the carrier directory for your plan ID, then call each office's billing department to confirm participation before you enroll. Our Medicare Advantage HMO vs PPO guide explains network rules in more detail.

Read your Annual Notice of Change each fall.

Use Medicare Plan Finder for official plan data, then cross-check providers by phone. See also our Medicare guides hub, Medicare tools hub, and Medicare glossary.

Want help comparing your Medicare Advantage costs? We can look at the plan's MOOP, specialist costs, hospital costs, prescriptions, and provider network together. Schedule a free Medicare review or call SwitchBlue Insurance Agency at (850) 613-0057. Phone or video.

Licensed in Florida, Alabama, Georgia, and North Carolina. Independent, not tied to one carrier.

Plan availability, networks, drug formularies, and benefits vary by county and year. For all options in your area, contact Medicare.gov or 1-800-MEDICARE (TTY: 1-877-486-2048).