Medicare Advantage Maximum Out-of-Pocket (MOOP) Explained (2026)

One number matters more than almost any other when you're comparing Medicare Advantage plans: the yearly maximum out-of-pocket, or MOOP. Every Advantage plan has to have one, and it's a real protection. Once your share of the cost for covered care hits that ceiling, the plan pays 100% for the rest of the year. Original Medicare has no yearly out-of-pocket cap of its own, so unless you have supplemental coverage such as Medigap or Medicaid, its costs have no ceiling.

In This Guide

• Key Takeaways
• What Is the Medicare Advantage Maximum Out-of-Pocket?
• Why Original Medicare Has No Cap of Its Own
• What Counts Toward the Cap, and What Doesn't
• In-Network vs. Out-of-Network Limits
• How to Find Your Medicare Advantage Maximum Out-of-Pocket
• Frequently Asked Questions
• Learn More

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

The maximum out-of-pocket, usually shortened to MOOP, is the most you'll pay in cost-sharing for covered medical care in a single year. It's the copays, coinsurance, and deductibles you rack up for Part A and Part B services, added up across the year and stopped at a ceiling. This isn't a feature some plans offer and others skip. Every Medicare Advantage plan is required by federal rule to have a yearly maximum out-of-pocket limit.1

The rule lives in the Medicare Advantage regulations, which say a plan must set an in-network MOOP for basic benefits that's no higher than the annual limit the Centers for Medicare & Medicaid Services (CMS) calculates.1 So the cap isn't marketing. It's a floor of protection that comes standard with every Advantage plan.

What happens when you hit it is the whole point. Once your cost-sharing for the year reaches your plan's MOOP, you're done paying for covered services. The plan picks up 100% of the cost of covered Medicare care for the rest of the calendar year.1 Then the counter resets on January 1 and you start over.

Why Original Medicare Has No Cap of Its Own

This is the contrast that makes the MOOP worth understanding. Original Medicare, the traditional program run directly by the government, has no yearly out-of-pocket limit of its own. Medicare.gov states the exception plainly: there's no yearly limit on what you pay unless you have supplemental coverage, such as Medigap, Medicaid, or employer, retiree, or union coverage.1,2

Think about what that means in practice. Under Part B, after you meet the deductible, you generally pay 20% coinsurance of the Medicare-approved amount for covered services, and there's no ceiling on that 20%.2 A routine year, that's fine. But a year with a major surgery, months of treatment, or a long specialist run, and that 20% keeps adding up with nothing to stop it. That open-ended exposure is the gap supplemental coverage fills. You can buy a Medigap policy alongside Original Medicare, and if you already have Medicaid or employer, retiree, or union coverage, that coverage can put a ceiling on what you pay.1

Medicare Advantage takes a different route to the same worry. Instead of a supplement you buy separately, the out-of-pocket cap is built into the plan. That built-in ceiling is one of the biggest structural differences between the two paths, and it can be the deciding factor.

What Counts Toward the Cap, and What Doesn't

The MOOP is specifically a cap on your Part A and Part B cost-sharing.1 That's the hospital, doctor, and outpatient side of your care: the copays for specialist visits, the coinsurance on outpatient surgery, the cost-sharing on a hospital stay. Those are the dollars that count up toward the limit.

Your prescription drug costs are a separate story. Part D drug spending is capped under its own rule, not folded into the medical MOOP.1 Most Advantage plans bundle in drug coverage,3 but the drug cap and the medical cap are two different ceilings running in parallel. So when you look at a plan's MOOP, read it as your protection on the medical side, and check the separate Part D out-of-pocket cap for the drug side.

In-Network vs. Out-of-Network Limits

You have to read your own plan closely here, because plans don't all set the cap the same way. A plan may set different limits for in-network and out-of-network care.1

A local preferred provider organization (PPO) plan, which also covers care outside its network, must have two numbers: an in-network cap for care from in-network providers and a combined cap that counts what you spend in and out of network together.1,2 The in-network cap applies only to in-network providers, so when you see a doctor outside the network on a PPO, that spending counts toward the combined cap, not the in-network one.1

CMS sets the ceiling on all of this. Each year it calculates the maximum MOOP amount using Medicare's own fee-for-service data, and a plan's in-network MOOP can't be any higher than that limit.1 Plans can always come in lower, and some do to compete. What they can't do is exceed the CMS cap.

How to Find Your Medicare Advantage Maximum Out-of-Pocket

Because CMS resets the ceiling every year and each plan picks its own number underneath it, there's no single dollar figure that's right for everyone.1 The only number that matters is your plan's. Two reliable places to find it:

• Your plan's Summary of Benefits. Every Advantage plan publishes one, and the MOOP is listed there, usually near the top of the cost section. If your plan has separate in-network and out-of-network limits, both appear here.
• The Medicare Plan Finder. Medicare's official comparison tool shows the out-of-pocket maximum for every plan in your area side by side, which makes it easy to compare that ceiling across plans you're weighing.

When you're comparing plans, don't stop at the monthly premium. A plan with a low premium and a high out-of-pocket cap can cost you far more in a bad year than a plan that charges a little more upfront but caps your exposure lower. The MOOP is where the real financial protection lives, so give it as much weight as the premium.

Learn More

Find personalized help comparing a Medicare Advantage plan's out-of-pocket cap at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.