What Is the Medicare Maximum Out-of-Pocket Limit?

One of the most important Medicare numbers is also one of the most misunderstood: the maximum out-of-pocket limit, often called the MOOP.

At first glance, it sounds simple. You pay medical bills during the year, and once you reach a certain amount, Medicare pays everything else.

But Medicare rarely gives us anything quite that simple.

The first thing you need to understand is that there is not one universal Medicare maximum out-of-pocket limit.

If you have Original Medicare, the rules are very different from Medicare Advantage. Prescription drug expenses have yet another out-of-pocket limit. And even among Medicare Advantage plans, the maximum can vary considerably from one plan to another.

Understanding these differences can help you evaluate the real financial risk behind your Medicare coverage.

What Does Maximum Out-of-Pocket Mean?

A maximum out-of-pocket limit is the most you should have to pay during a calendar year for certain covered healthcare expenses under your health plan.

Throughout the year, you may pay deductibles, copayments and coinsurance.

Once the expenses that qualify toward your plan’s maximum reach the limit, the plan generally pays 100% of covered Medicare medical services for the remainder of that year.

That sounds reassuring — and it can be.

But there is an important catch:

Not everything you spend counts toward that maximum.

Premiums generally don’t count. Prescription drug expenses are handled separately. Services that aren’t covered by the plan may not count. And with some plans, going outside the provider network can dramatically change your costs.

That’s why the MOOP should be viewed as a measure of financial exposure, not simply another number printed in a Medicare brochure.

Original Medicare Has No Annual Medical Out-of-Pocket Maximum

This surprises many people.

Original Medicare — Part A and Part B — has no annual ceiling on what you could spend out of pocket for covered medical care.

Medicare itself makes this clear: unless you have additional coverage, such as Medigap, Medicaid, employer or retiree coverage, there is no yearly limit on your out-of-pocket costs under Original Medicare.

Under Original Medicare, you can face expenses such as:

• Part A deductibles and hospital cost-sharing
• Part B deductibles
• Part B coinsurance
• Certain skilled nursing facility costs
• Other Medicare-approved cost-sharing

For many Part B services, after you satisfy the deductible, you generally pay 20% of the Medicare-approved amount.

Twenty percent may not sound frightening when we’re discussing a $100 doctor visit.

It becomes a very different conversation when you’re discussing chemotherapy, expensive outpatient procedures, repeated medical treatments or other major healthcare expenses.

There is no built-in Original Medicare rule that says, “You’ve spent enough this year. You’re finished.”

That is one of the primary reasons people with Original Medicare frequently purchase Medicare Supplement insurance, commonly known as Medigap.

If you’re deciding how much financial exposure you’re willing to accept, our article on Medicare Advantage vs. Medigap explores this difference in greater detail.

Medicare Advantage Does Have a Maximum Out-of-Pocket Limit

Medicare Advantage works differently.

Every Medicare Advantage plan must place an annual maximum on what an enrollee pays for covered Medicare Part A and Part B medical services.

Once you reach your plan’s applicable maximum, the plan pays 100% of covered Medicare medical services for the remainder of that calendar year. Medicare explains this protection in its comparison of Original Medicare and Medicare Advantage.

But here’s where people often make a mistake:

The maximum allowed by Medicare is not necessarily the maximum your particular plan uses.

Plans can establish lower limits.

For 2026, the maximum allowable Medicare Advantage out-of-pocket limit is $9,250 for in-network covered medical services. For plans that cover both in-network and out-of-network care, such as many PPOs, the combined maximum allowable amount can reach $13,900.

However, many plans have maximums below those federal ceilings.

KFF’s analysis of 2026 Medicare Advantage plans found an enrollment-weighted average in-network out-of-pocket limit of approximately $5,421, considerably below the $9,250 maximum allowed.

That illustrates why you should never assume all Medicare Advantage plans provide the same financial protection.

Here’s an Example

Suppose Plan A has:

$0 monthly plan premium

and a

$9,250 maximum out-of-pocket limit.

Plan B costs:

$80 per month

but has a:

$4,500 maximum out-of-pocket limit.

Many people immediately look at Plan A and say:

“Why would I pay $80 a month when this plan costs nothing?”

That’s understandable.

But premium and financial risk are two different things.

The $0-premium plan could expose you to thousands of dollars more in medical expenses during a serious illness.

That doesn’t automatically make Plan B better.

It simply means you need to evaluate more than the premium.

This is why we frequently say:

Premium is not the same thing as cost.

A Medicare plan should be evaluated based on what happens when you actually need healthcare — not simply what happens when you’re healthy.

What Counts Toward a Medicare Advantage MOOP?

Generally, your cost-sharing for Medicare-covered Part A and Part B services counts toward your Medicare Advantage medical out-of-pocket maximum.

That may include:

• Primary care copayments
• Specialist copayments
• Hospital cost-sharing
• Outpatient surgery cost-sharing
• Diagnostic testing
• Imaging
• Physical therapy
• Medicare-covered medical treatments
• Coinsurance for certain medical services

Your actual plan determines the applicable cost-sharing, which is why reviewing the plan’s Evidence of Coverage and Summary of Benefits matters.

Medicare also notes that Medicare Advantage costs can depend on the services you use, whether providers are in the plan’s network and the plan’s yearly out-of-pocket limit.

What Usually Does NOT Count Toward the Medical MOOP?

This part is just as important.

Your Medicare Advantage medical maximum generally does not mean that every dollar you spend on healthcare stops once you hit that number.

Expenses that may be separate include:

• Your Medicare Part B premium
• Medicare Advantage plan premiums
• Part D prescription drug costs
• Non-covered services
• Certain supplemental benefits
• Costs incurred when you don’t follow plan rules

So imagine that someone reaches a $6,000 Medicare Advantage medical MOOP.

That doesn’t mean their total healthcare spending for the year was limited to $6,000.

They may also have paid their monthly Part B premium, a Medicare Advantage premium, prescription costs and other expenses.

That distinction matters when planning a retirement healthcare budget.

Prescription Drugs Have a Separate Out-of-Pocket Cap

Prescription drugs have their own rules.

For 2026, Medicare Part D has a $2,100 annual out-of-pocket cap for covered Part D drugs.

This is separate from the Medicare Advantage medical maximum out-of-pocket limit.

For example, someone enrolled in a Medicare Advantage plan with prescription drug coverage might have:

A $6,000 medical MOOP

and separately

a $2,100 Part D prescription drug out-of-pocket cap.

Those aren’t combined into one $6,000 limit.

They’re two different cost systems.

You can read more about prescription coverage in our guide to what Medicare Part D drug plans cover.

HMO and PPO Limits Can Work Differently

Provider networks also matter.

With many Medicare Advantage HMOs, you generally must receive non-emergency care from providers within the plan’s network to receive coverage, subject to the plan’s rules.

PPOs usually provide greater ability to receive care outside the network, but that freedom can come at a price.

Your PPO may have one maximum for in-network services and a much higher combined maximum covering in-network and out-of-network services.

For 2026, the maximum allowable combined in-network/out-of-network MOOP can reach $13,900.

That means someone who sees “$5,500 maximum out of pocket” on a plan comparison should ask:

Is that in-network only?

That’s a much better question than simply asking whether the plan “has an out-of-pocket maximum.”

The MOOP Is a Risk Number

Here’s perhaps the most useful way to think about the maximum out-of-pocket amount.

Don’t think of it as a bill you are automatically going to receive.

Think of it as an indication of how much medical financial risk you may be assuming.

If you’re healthy, you may never come close to reaching it.

You might have a few doctor appointments, perhaps see a specialist and spend relatively little during the year.

But Medicare isn’t really tested during the years when everything goes right.

It’s tested when something goes wrong.

Cancer.

Heart disease.

A serious accident.

Repeated hospitalization.

Major surgery.

Rehabilitation.

Chronic medical treatment.

That’s when copayments and coinsurance begin accumulating.

A plan that appeared inexpensive in January can look very different by August.

Don’t Choose Medicare Based Only on the Maximum

There is another trap worth avoiding.

A lower MOOP doesn’t automatically make one plan better than another.

You should also consider:

• Are your doctors in the network?
• Is your preferred hospital in the network?
• Are your prescriptions covered?
• What are the drug tiers?
• What are the specialist copays?
• What does hospitalization cost?
• What does outpatient surgery cost?
• Are prior authorizations required?
• What happens outside the network?
• What is the monthly premium?

Medicare decisions work best when you look at the entire financial picture.

Our guide to the three most important questions to ask about Medicare can help you approach that comparison systematically.

Why You Should Check the MOOP Every Year

Medicare Advantage benefits can change from year to year.

Your premium might change.

Copayments can change.

Prescription formularies can change.

Provider networks can change.

And your maximum out-of-pocket exposure can change.

A plan that was financially attractive last year may not look the same next year.

That’s why Medicare coverage deserves an annual review — even if you’re happy with the plan you currently have.

Don’t assume “same insurance company” means “same coverage.”

The Bottom Line

When someone asks, “What is Medicare’s maximum out-of-pocket limit?”, the correct answer begins with another question:

Which type of Medicare coverage do you have?

With Original Medicare alone, there is no annual maximum on your Part A and Part B out-of-pocket expenses.

With Medicare Advantage, there is an annual medical maximum. In 2026, the federal allowable ceiling is $9,250 for in-network covered medical services, while certain plans covering out-of-network services can have a combined limit as high as $13,900. Individual plans may — and frequently do — set lower limits.

Separately, Medicare Part D has a $2,100 out-of-pocket cap for covered prescription drugs in 2026.

The important lesson isn’t simply memorizing those numbers.

It’s understanding your financial exposure.

A $0 premium may look attractive.

A $20 specialist copay may look attractive.

Free dental benefits may look attractive.

But somewhere in that plan’s documents is a number telling you how much financial responsibility you could potentially face during a difficult medical year.

Find that number before you enroll.

Because Medicare isn’t just a medical decision.

It’s a financial decision too.

For official information and plan comparisons, visit Medicare.gov or review the Medicare Advantage plans available in your area. You can also use Medicare Self Enroll to continue researching your Medicare options before making an enrollment decision.

This article is for educational purposes and is not intended as individualized insurance, medical, legal or financial advice. Medicare plan benefits, networks, premiums and cost-sharing vary by plan and location and can change each year.