Your Medicare Advantage out-of-pocket maximum (MOOP) counts deductibles, copayments, and coinsurance for Part A and Part B covered services received from in-network providers. Once your spending hits that cap, your plan pays 100% of covered medical services for the rest of the year. In 2026, the maximum MOOP that any Medicare Advantage plan can set is $9,250, though many plans choose a lower limit.
Costs That Count Toward Your MOOP
Three types of cost-sharing push you closer to your out-of-pocket maximum:
- Deductibles: The amount you pay before your plan starts sharing costs for Part A (hospital) and Part B (medical) services.
- Copayments: Flat-dollar amounts you pay at the time of a service, like $40 for a specialist visit or $300 per day for a hospital stay.
- Coinsurance: Your percentage share of a covered service, such as paying 20% of the cost of an outpatient surgery.
All three apply only to services covered under Medicare Part A and Part B. That includes hospital stays, doctor visits, lab work, imaging, outpatient procedures, durable medical equipment, and other standard Medicare-covered care. Every dollar of cost-sharing you pay for these services through in-network providers gets tracked by your plan and applied toward your annual limit.
Costs That Do Not Count
Several categories of spending never move the needle on your MOOP, even though they come out of your wallet:
- Monthly premiums: Neither your Part B premium nor your Medicare Advantage plan premium counts toward the cap.
- Part D prescription drug costs: Copays and coinsurance for medications covered under your plan’s drug benefit are tracked separately. Starting in 2025, Part D has its own annual cap of $2,000 for covered prescriptions, but that spending stays in its own bucket.
- Non-covered services: If Medicare doesn’t cover something (most cosmetic procedures, for example), paying for it out of pocket won’t count.
- Out-of-network charges in HMO plans: HMO-type Medicare Advantage plans generally don’t cover out-of-network care except in emergencies, and any costs you pay out of network won’t apply.
How PPO Plans Handle Out-of-Network Spending
If you have a PPO Medicare Advantage plan, you can see out-of-network providers for a higher cost. These plans typically have two separate limits: a lower in-network MOOP and a higher combined MOOP that includes both in-network and out-of-network spending. Your in-network cost-sharing always counts toward both limits. Out-of-network cost-sharing counts toward the combined limit but not necessarily toward the lower in-network cap.
This distinction matters. If your plan has a $5,000 in-network MOOP and a $8,000 combined MOOP, spending $4,000 at out-of-network providers won’t get you any closer to triggering the $5,000 in-network protection. You’d need to accumulate $5,000 specifically from in-network cost-sharing to hit that threshold, or $8,000 total from any providers to reach the combined cap.
Supplemental Benefits Like Dental, Vision, and Hearing
Many Medicare Advantage plans offer extra benefits that Original Medicare doesn’t cover, including dental care, vision exams, eyeglasses, and hearing aids. Whether cost-sharing for these benefits counts toward your MOOP depends on your specific plan. CMS rules allow plans to include supplemental benefit cost-sharing in the MOOP calculation, but they aren’t required to.
Cost-sharing structures vary widely across these benefits. About 62% of plans charge cost-sharing for hearing aids, and those amounts can be significant. Comprehensive dental services carry coinsurance in roughly 22% of plans, with a typical rate around 50%. Vision cost-sharing is rare, with only about 6% of plans charging anything for eye exams. Check your plan’s Evidence of Coverage document to see whether these expenses apply toward your MOOP or sit outside it entirely.
How the MOOP Limit Is Set
CMS sets the ceiling for MOOP limits each year based on what the most expensive 5% of Original Medicare beneficiaries spend out of pocket. Plans can’t exceed this mandatory ceiling, but they can set their cap lower. CMS publishes three tiers: a mandatory (highest) limit, a lower limit based on the 85th percentile of spending, and an intermediate limit that falls between the two. Plans that choose a lower MOOP limit can advertise that as a selling point during enrollment.
Your plan tracks your spending throughout the year and is required to notify you and your providers when you’ve reached your limit. After that point, covered Part A and Part B services from in-network providers are fully paid by the plan for the remainder of the calendar year. The counter resets to zero on January 1.
How to Check Your Specific Limit
Your plan’s MOOP appears in the Summary of Benefits you received at enrollment and in the full Evidence of Coverage document. You can also find it by searching your plan on Medicare.gov or calling the number on the back of your plan ID card. When comparing plans during open enrollment, pay attention not just to the dollar amount of the MOOP but to which costs your plan includes in the calculation, especially if you use supplemental benefits or see out-of-network providers regularly.