Core Insurance Solutions
    By Core Insurance SolutionsOctober 16, 2026
    Medicare MOOP Limits for Seniors: Why 2026’s $5,421 Isn’t the Cap

    Medicare MOOP Limits for Seniors: Why 2026’s $5,421 Isn’t the Cap

    Original Medicare has no yearly out-of-pocket maximum unless you add supplemental coverage, but Medicare Advantage plans do. KFF reports that the 2026 enrollment-weighted average MOOP is $5,421 for in-network services and $9,825 for combined in-network and out-of-network services. Part D drug costs and premiums do not count toward it.

    TL;DR:

    • KFF’s 2026 enrollment weighted averages are $5,421 in network and $9,825 combined; PPO members should compare both figures before using out of network care.
    • Deductibles, copays, and coinsurance for covered Part A and Part B care count toward the cap, but premiums, Part D drugs, and uncovered services do not.
    • HMOs usually have one lower in network cap, while PPOs often set a higher combined cap; verify both limits in the Summary of Benefits.
    • After reaching the limit, the plan pays 100% for Part A and Part B services for the calendar year’s remainder; premiums and drug costs continue.
    • Compare each plan’s premium plus its MOOP against likely yearly care costs, and check the limit annually because cost sharing can change.
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    Table of Contents

    What the Medicare MOOP limit is and how it works

    MOOP stands for maximum out-of-pocket. Under Original Medicare, Parts A and B carry no annual cap, so someone without supplemental coverage faces open-ended exposure for the 20% coinsurance on Part B services. Medicare Advantage changes that by putting a ceiling on what you pay in a year.

    Here is how the pieces fit together:

    • The cap applies to Part A and Part B covered services only, as Medicare.
    • Each plan’s MOOP varies, so check the plan’s materials for its limit.
    • The plan, not Medicare, decides its premiums, deductibles and copays, and those cost-sharing amounts can change only once a year.
    • Deductibles, copays and coinsurance you pay for covered services build toward the cap.

    The tradeoff matters when you choose coverage. Original Medicare offers open-ended exposure unless you add a supplement, while Medicare Advantage trades that for a capped yearly total. A low premium can still come with a high MOOP, so you need to look at both numbers together.

    2026 federal caps and enrollment-weighted averages

    The federal government sets the highest MOOP a Medicare Advantage plan may carry, and plans can choose lower amounts. The averages below show where real plans land, which is more useful than the ceiling when you are comparing options.

    KFF puts the 2026 enrollment-weighted average at $5,421 in-network and $9,825 combined in-network and out-of-network. That gap tells you how much more exposure comes with going outside a plan’s network.

    2026 in-network and combined MOOP averages

    Plan type shapes these numbers. KFF’s analysis of MOOP variation finds that HMOs generally carry lower in-network MOOPs, while PPOs tend to have higher in-network averages plus a separate, higher combined cap.

    Trends matter too. KFF notes that average in-network MOOPs rose by roughly $700 between 2023 and 2026, and its trend analysis describes a decline in earlier years before the recent climb. The practical lesson is simple: a plan that looked generous last year may not look the same this year. Your MOOP may change from year to year, so check it rather than assuming it stayed the same. CMS publishes the calculation files behind the official limits if you want to see how they are built.

    What counts toward your MOOP and what does not

    Reading a plan’s materials is easier when you know which charges move you closer to the cap. Medicare describes yearly limits on what you pay for covered Part A and Part B services.

    What typically counts:

    • Deductibles for Part A and Part B covered services
    • Copayments for covered visits, tests and procedures
    • Coinsurance on covered services

    What typically does not:

    • Part D prescription drug spending, which has its own cost structure
    • Monthly premiums
    • Services the plan does not cover

    Which payments count can depend on the plan, so confirm the details in its documents. Because details differ from plan to plan, confirm the specifics in the plan’s own documents.

    Pro Tip: Ask the plan to show, in writing, which of your usual costs build toward the MOOP, and keep your Explanation of Benefits statements so you can track your running total.

    How MOOP differs between HMO and PPO plans

    A headline MOOP figure in an ad can mislead if you do not know which number it is. HMOs usually show one in-network MOOP, and it is often lower than a PPO’s. PPOs frequently list two figures, an in-network cap and a higher combined cap that covers in-network and out-of-network care together, which KFF’s variation analysis describes in detail.

    Keep these distinctions in mind:

    • An HMO’s single in-network cap is simple to read, but care outside the network may not be covered the same way.
    • A PPO gives you more freedom to see out-of-network providers, and its higher combined cap shows what that freedom can cost in a heavy-use year.
    • Two plans with the same in-network MOOP can have very different combined caps.

    You will find these amounts on the plan’s Summary of Benefits and its Evidence of Coverage. Look for both the in-network and the combined figure before you compare. If out-of-network care is a possibility for you, our guide on Medicare Advantage out-of-network rules walks through how those costs work.

    How to use MOOP when you compare plans

    Start with your own health picture, then use the cap as a safety net rather than the whole decision. Our guide on choosing a Medicare plan that fits your health and budget covers the wider process. For the MOOP piece, work through these steps:

    1. Write down the in-network MOOP and, for PPOs, the combined MOOP for each plan.
    2. Check which services count and whether Part D is handled separately.
    3. Estimate your likely visits, procedures and prescriptions for the coming year.
    4. Add the premium to your expected costs, then add a worst-case scenario at the MOOP.
    5. Compare plans on both the likely total and the worst-case total.

    Questions worth asking an agent or plan representative: Is the cap in-network only? Do all my doctors and hospitals sit inside the network? How are pharmacy costs handled? Do payments from third parties count? Which services need prior authorization?

    Pro Tip: A low premium can be offset by a high MOOP in a heavy-use year, so compare the premium plus the MOOP, not the premium alone.

    What happens after you reach your MOOP

    Once you pay the plan’s limit for covered Part A and Part B services, the plan pays 100% of those covered services for the rest of the calendar year. The cap resets at the start of the next plan year.

    If something looks off, take these steps:

    • Review your Explanation of Benefits to confirm which charges counted.
    • Call the plan’s customer service or claims line about any bill you think is wrong.
    • Ask for claims advocacy help if a dispute drags on.
    • Look into Extra Help for Part D, Medicaid eligibility and state assistance programs.
    • Reach Medicare directly through the help and contact options.

    Reaching the cap does not change your Part D costs or your premium, so plan for those separately.

    Why we recommend an annual plan audit

    Our view is that a yearly review is worth considering alongside any single number on a plan card. Plans may change their cost-sharing each year, so we look at the MOOP alongside premiums and drug costs, using our Holistic Health Needs Assessment, Unbiased Carrier Comparison, Prescription Cost Optimization, annual policy audits and claims advocacy. Bring the checklist above to any agent conversation, and see our 2026 Part D and Medigap timing guide for drug-cost context.

    — Core Insurance Solutions

    Get a MOOP-focused plan review with us

    If you want help reading your numbers, we can walk through your plan’s MOOP, premiums and prescriptions with you. Our services page describes the Holistic Health Needs Assessment, Unbiased Carrier Comparison, Prescription Cost Optimization, annual policy audits and claims advocacy we offer. You can also watch our Medicare 101 webinar replay or schedule a free consultation to start.

    Core Insurance Solutions

    This article is general information, not a substitute for advice from a qualified financial advisor. Consult a qualified financial professional about your own circumstances before acting on anything here.

    FAQ

    Does Medicare have an out-of-pocket maximum per year?

    Original Medicare, which is Parts A and B, does not have one without supplemental coverage, according to Medicare.gov. Medicare Advantage plans do have a yearly limit on covered Part A and Part B services.

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

    It is the most you pay in a year for covered Part A and Part B services, and each plan sets its own amount within the federal maximum. KFF reports the 2026 enrollment-weighted averages are $5,421 in-network and $9,825 combined.

    Do premiums and drug costs count toward the MOOP?

    No. Medicare.gov explains that the MOOP covers Part A and Part B services only, so monthly premiums and Part D prescription costs stay outside it.

    Why do PPOs show two MOOP numbers?

    PPOs often list an in-network cap and a higher combined cap for in-network and out-of-network care together. KFF’s analysis shows this can leave PPO members more exposed if they use out-of-network providers.

    Sources

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