What costs count toward the annual out-of-pocket maximum on a Medicare Advantage plan?

Question

Angelina Giambri · Accepted Answer

Your annual out-of-pocket maximum includes the copays, coinsurance, and deductibles you pay for covered Medicare Part A and Part B medical services. It does not include your monthly plan premium, Part D prescription drug costs, or services that are not covered by your plan. Once you reach the maximum, you pay $0 for covered in-network Part A and Part B services for the rest of the year.

Answered by Angelina Giambri on July 31, 2026

Agent Licensed in FL & OH

Answered by Angelina Giambri Medicare Insurance Agent

Chris Smith · Answer

The Max Out Of Pocket (MOOP) consists of the member's financial contributions toward copays (fixed dollar amounts for services), coinsurances (percentages of allowable charges) and the plan medical deductible.

It is important to note that prescription drug coverage has a separate MOOP each year, and that amount is set and regulated by CMS each plan year.

Plan premiums, dental and vision costs above the plan's fixed allowances, balance billing, Part B excess charges and services not covered by the plan are excluded from the plan's annual out-of-pocket maximum and may be the responsibility of the member.

Priscilla Ramos · Answer

The annual out-of-pocket maximum (MOOP) on a Medicare Advantage plan includes copays, coinsurance, and deductibles paid for covered Medicare Part A and Part B services.

Does NOT include: Monthly premiums, Part D prescription drug costs, or noncovered services.

Once the MOOP is reached, the plan pays 100% of covered Part A and Part B services for the rest of the calendar year, subject to the plan's network rules.

Jeffrey Brucculeri · Answer

If you are referring to the out-of-pocket maximum on the health portion of the plan, it would apply to your deductible and any of your copays, coinsurance payments or Part B drug coinsurance. It does not include any copays you might pay for dental, vision or hearing services. The Part D, prescription drug, True Out-of-Pocket max, is separate. If you have any further questions, feel free to contact me.

Answered by Jeffrey Brucculeri on July 28, 2026

Agent Licensed in OK, KS, MO & TX

Answered by Jeffrey Brucculeri Medicare Insurance Agent

Kelsey Hentzen · Answer

Doctor visit copays, Specialist visit copays, Hospital copays and coinsurance, Outpatient surgery costs, Diagnostic tests (MRI, CT scans, X-rays, lab work), Physical, occupational, and speech therapy, Chemotherapy and radiation therapy, Durable medical equipment (DME), Dialysis, Emergency room and urgent care copays, Ambulance services, Other Medicare-covered Part A and Part B services. What is typically not included is the prescription costs (Part D).

Answered by Kelsey Hentzen on July 28, 2026

Broker Licensed in KS & MO

Answered by Kelsey Hentzen Medicare Insurance Agent

Andrew Zurbuch, MBA · Answer

A good topic to understand. Out-of-pocket medical costs that are covered claims. Office visit copays for doctors, specialists, a coinsurance percentage for durable medical equipment, & outpatient surgery. Not prescriptions filled at a local pharmacy & not mail order prescriptions. Thank you.

Answered by Andrew Zurbuch, MBA on July 28, 2026

Broker Licensed in IN, FL, KY, MO, OH & TN

Answered by Andrew Zurbuch, MBA Medicare Insurance Agent

Jaye Maxx Alexander II · Answer

What fully counts to MOOP - Maximum Out of Pocket: Deductibles, Co Pays, Co Insurance. The monthly premium payments do not count toward MOOP.

Mike Fields · Answer

The annual out-of-pocket maximum on costs applies to just about anything that your Plan Carrier was responsible for. Hospital stays, Dr Visits, Tests, Procedures, etc. It does not apply to health items, procedures, Prescriptions or other items that you pay for yourself and wasn't paid through the carrier.

Answered by Mike Fields on July 28, 2026

Agent Licensed in SC, CO, GA, IN, NC & TN

Answered by Mike Fields Medicare Insurance Agent

Jim Carlson · Answer

All copays; drugs not included. Rehab care will be some out-of-pocket cost. Premiums not included. Drugs oop expense

What costs count toward the annual out-of-pocket maximum on a Medicare Advantage plan?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents Hub
A non-government resource website

What costs count toward the annual out-of-pocket maximum on a Medicare Advantage plan?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents HubA non-government resource website

Medicare Agents Hub
A non-government resource website