What is the maximum out-of-pocket limit for Medicare Advantage plans?

Question

John Becker · Accepted Answer

The federal government sets mandatory caps on out-of-pocket expenses for Medicare Advantage (Part C) plans. Once you reach this limit, your plan pays 100% of covered medical costs for the remainder of the year.

Specific limits vary by plan, but federal guidelines enforce the following thresholds:

* IN-NETWORK SERVICES: The maximum limit is $9,250.

* COMBINED IN-NETWORK AND OUT OF NETWORK SERVICES: The maximum limit is $13,900.

 Keep in mind these important details about the maximum out-of-pocket (MOOP) limit:

* LOWER LIMITS ARE COMMON: While $9,250 is the maximum allowed by the government, many individual plans voluntarily set much lower caps.

* AVERAGES: The average out-of-pocket cap is $5,421 for in-network services, and $9,825 for combined in-network and out-of-network services.

* WHAT COUNTS: Deductibles, copayments, and coinsurance for Part A and Part B covered services count towards this limit.

* WHAT DOES NOT COUNT: Your monthly plan premiums, prescription drug (Part D) costs, and extra supplemental benefits (such as dental, vision, or hearing) do not count toward your medical MOOP.

* PRESCRIPTION DRUGS: Part D prescription drug costs have a separate, dedicated annual out-of-pocket cap of $2,100.

To find out the specific MOOP limit for a plan you are considering, you can review its Summary of Benefits or compare options using the Medicare Plan Finder.

Michael Andrews · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/what-is-the-maximum-out-of-pocket-limit-for-medicare-advantage-plans#michael-andrews

Ellen Diehl · Answer

If you could provide me a little bit more information, I’d be happy to answer your question in detail. They can be anywhere from $7000-$9000 depending on what state you’re in and what company you’re dealing with. If you have an interest in a plan G supplement please reach out to me.

Answered by Ellen Diehl on May 18, 2026

Broker Licensed in GA

Answered by Ellen Diehl Medicare Insurance Agent

Robert Reed · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/what-is-the-maximum-out-of-pocket-limit-for-medicare-advantage-plans#robert-reed

Isom Julian · Answer

The federal maximum out-of-pocket limit for Medicare Advantage plans is $9,350 for in-network services. Once you have hit that limit, your plan will cover 100% of any covered service for the rest of the year. The great news is that many Medicare Advantage plans have set their maximum out-of-pocket limit well below the federal maximum.

Answered by Isom Julian on May 18, 2026

Broker Licensed in OH, FL, GA & 9 other states

Answered by Isom Julian Medicare Insurance Agent

Jason Vallejos · Answer

It varies by plan. Make sure to run a plan comparison before making a decision. You can also look in Medicare.gov for local plans near you.

Zachary Whitaker · Answer

This will vary by company, plan, and county availability.  An annual review is essential.  Please ensure medications and doctors are covered on new plans if a change is desired.

Jennifer Kalbach · Answer

All MA plans have different MOOPS.  Refer to your summary of benefit for this or contact your agent or carrier to find this out.

John Hawk · Answer

For 2026:
$9,250 is the federal MOOP cap for Medicare Advantage (in-network, Part A & B services) — down slightly from $9,350 in 2025. 
A few key points worth knowing for your seminars:
	•	Most plans set their limits well below the federal cap, so actual costs vary by plan. 
	•	Part D drug costs are separate — they don’t count toward the medical MOOP.  The Part D cap is $2,100 for 2026.