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.

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.

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

Lloyd Griffin · Answer

Currently in 2026 the limit provided by CMS is 9,350 which is the cap for plans yet plans may offer lower limits. Also remember the limit for plans that have in&out of network cost ,cap is higher. Part D has a separate out of pocket max.

Answered by Lloyd Griffin on June 29, 2026

Agent Licensed in MA, CT, FL & 6 other states

Answered by Lloyd Griffin Medicare Insurance Agent

Michael Andrews · Answer

The question is what is the maximum out-of-pocket limit for Medicare Advantage plans? Well, it depends on the plan.

Basically, max out-of-pocket would be your worst case scenario of your Medicare accrued expenses. For instance, if you had a cancer diagnosis and were getting treatments, more than likely you would reach your max out-of-pocket within a few months. Once you hit your max, you will continue to get care. However, you will not have to pay any more towards that care for anything that's approved by Medicare or your Medicare Advantage plan.

Now, one thing to keep in mind is that some plans have a maximum out-of-pocket for in or out of network. You will notice that a lot of plans, if there are out of network services, the max out-of-pocket can sometimes be close to double what it was if it was in network.

Robert Reed · Answer

Another good question. Let's see, it says "What is the maximum out-of-pocket limit for Medicare Advantage plans?"

Well, let me give you a generic answer. For out of network, it's somewhere in the neighborhood of $13,000, a little more than that. And for in-network services, it'll be a little over $9,000.

But keep in mind that it's a generic answer. In fact, if you go to specific plans, those out-of-pocket maximums are typically a lot lower. I would definitely recommend that you get with a broker who can answer those questions on very specific plans, but that gives you a ballpark of out-of-pocket expenses for in-network versus out of network.

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

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.

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

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents Hub
A non-government resource website

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

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