Ernesto Espinosa, Medicare Insurance Agent

Can you help me understand Maximum Out-of-Pocket (MOOP) limits in Medicare plans, from your experience as an agent?

Answer: When I meet with clients in Florida to discuss 2026 Medicare options, I always start with the "Unlimited Risk" of Original Medicare. Many don't realize that without a plan, you face a financial cliff.

1. The Unlimited Risk: Why You Need a Plan

Original Medicare alone is a major liability for two reasons:

The Part B "20% Trap": Medicare covers 80% of outpatient care, but you are responsible for the remaining 20% coinsurance. There is no limit to this. A $100,000 surgery results in a $20,000 bill, and it keeps growing.

The Part A Hospital Trap: You pay a $1,736 deductible for every benefit period. If hospitalized long-term, you face daily copays: $434/day (days 61–90) and $868/day (days 91–150). After that, you pay 100%.

Whether you choose Medicare Advantage or a Supplement, you are buying a "ceiling" to stop these unlimited costs.

2. The 2026 MOOP: Florida’s Reality

In Florida's competitive market, plans offer much lower Maximum Out-of-Pocket (MOOP) limits than the federal maximum of $9,250.

Local Reality: In counties like Miami-Dade or Broward, I often see MOOPs between $500 and $2,500.

The "Invisible" Costs: Your medical MOOP does not include the Part D drug cap, which is $2,100 in 2026. These are separate buckets.

3. Florida Dental: Insurance vs. Discounts

Florida plans almost always include dental, but the type of coverage matters:

Dental Insurance: Often features $0 copays for preventive and even comprehensive care. However, they have an Annual Maximum (usually $1,500–$3,000). Once hit, you pay 100%.

Discount Plans: These offer lower negotiated rates, but you pay the full discounted price yourself.

4. 2026 Comparison Table

Feature FL Medicare Advantage Medigap Plan G

Medical MOOP $500 – $3,400 $283 (Part B Deductible)

Drug Cap $2,100 (Separate) $2,100 (Separate)

Dental Copays Often $0 (Insurance model) 100% (Out-of-pocket)

Hospital Cost Small daily copays. $0 (Covers all gaps).

Risk Protection Caps the 20% at your MOOP. Eliminates the 20% entirely.