Medicare Out-of-Pocket Maximum (MOOP) — MOOP
Medicare MOOP is the yearly out-of-pocket spending cap on Medicare Advantage plans. In 2026 the in-network cap is $9,250.
Official source: cms.gov
The Medicare Out-of-Pocket Maximum, or MOOP, is a yearly limit on what you pay for covered Part A and Part B services inside a Medicare Advantage plan. Once you hit that limit, your plan pays 100% of covered care for the rest of the calendar year.
Original Medicare does not have a MOOP. If you stay in Original Medicare without a Medigap policy, your share of hospital and doctor costs can keep adding up with no ceiling. That open-ended risk is the main reason many people add Medigap or choose Medicare Advantage.
For 2026, the federal cap a Medicare Advantage plan can set is $9,250 for in-network services. Many plans set their actual MOOP lower, often between $3,000 and $5,500, to attract enrollees. Plans with a separate out-of-network MOOP can charge a higher combined limit.
Premiums, Part D drug costs, and services your plan does not cover do not count toward the MOOP. The 2026 Part D true out-of-pocket cap is a separate $2,100 limit.
If you are healthy and rarely use care, a higher MOOP may be fine. If you have chronic conditions, a hospital stay on the horizon, or expensive specialty drugs, a lower MOOP, or Original Medicare with Medigap, often gives stronger protection.
In real life
- A Medicare Advantage member with a $4,500 MOOP has a knee replacement in March. Once their copays and coinsurance reach $4,500 for the year, the plan pays 100% of covered Part A and Part B services through December.
Also known as
Frequently asked questions about Medicare Out-of-Pocket Maximum (MOOP)
Does Original Medicare have an out-of-pocket maximum?+
No. Original Medicare has no annual out-of-pocket limit. Most people pair it with a Medigap policy or choose Medicare Advantage to add a cap.
What is the Medicare Advantage MOOP for 2026?+
The CMS in-network MOOP for 2026 is $9,250. Plans may set their actual MOOP lower, and many do.
What counts toward the Medicare MOOP?+
Copays and coinsurance for covered Part A and Part B services count. Premiums, Part D drug costs, and non-covered services do not.
What happens after I reach my Medicare Advantage MOOP?+
Your plan pays 100% of covered in-network Part A and Part B services for the rest of the calendar year. The MOOP resets on January 1.
Do Medicare Advantage plans have separate in-network and out-of-network MOOPs?+
PPO-style plans usually do. The in-network MOOP is lower, and the combined in- and out-of-network MOOP is higher.
Source: cms.gov