Medicare Advantage Maximum Out-of-Pocket 2026: $9,250 In-Network Ceiling Scenarios — Mooop

What Is the Medicare Advantage MOOP Cap for 2026 and Who Sets It

The Medicare Advantage maximum out-of-pocket (MOOP) for 2026 is the annual ceiling on what a plan can charge for covered Part A and Part B services. The medicare advantage mooop 2026 cap is set by the Centers for Medicare & Medicaid Services (CMS) at $9,250 for in-network care. This cap is a statutory limit that applies to all Medicare Advantage plans, though individual plans may set lower limits.

CMS establishes the MOOP ceiling each year as part of the Medicare Advantage rate announcement and final rulemaking process.¹ This increase reflects broader healthcare cost trends and is the maximum amount a plan can require a member to pay out-of-pocket for covered Part A and Part B services within the plan's network.

The MOOP applies only to Medicare Advantage plans, not Original Medicare. Original Medicare Parts A and B carry no annual out-of-pocket maximum, meaning a beneficiary with a serious illness could face unlimited cost-sharing.² The MOOP cap is a core consumer protection feature of Medicare Advantage, designed to limit financial exposure for enrollees.

Plans can set their own MOOP below the federal ceiling. A plan might offer a $3,400 in-network cap as a competitive feature, while another might set it at the full $9,250. The plan's specific MOOP is disclosed in the Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents.

How Much Can Medicare Advantage Actually Cost in 2026

Total annual costs for a Medicare Advantage enrollee include the plan premium, the MOOP cap, and Part D prescription drug costs. The $9,250 in-network MOOP applies only to Part A and B services. Part D prescription drug costs fall under a separate MOOP structure, which for 2026 is capped at $2,000 under the Inflation Reduction Act.³

Consider a hypothetical enrollee with a $0 premium plan and a $9,250 in-network MOOP. If they require significant medical care, their maximum Part A and B spending is $9,250. If they also need expensive prescription drugs, their Part D costs are capped at $2,000 under the Inflation Reduction Act.³ Combined maximum exposure in this scenario: $11,250, not including the plan premium.

For a plan with a $100 monthly premium and a $4,500 in-network MOOP, total maximum Part A and B costs would be $5,700 ($1,200 premium + $4,500 MOOP). The premium does not count toward the MOOP.⁴ This distinction matters when comparing plans — a low-premium plan with a high MOOP may cost more in a high-utilization year than a higher-premium plan with a low MOOP.

In-Network vs Out-of-Network MOOP: Real Spending Scenarios

Medicare Advantage plans use provider networks, and the MOOP structure differs sharply between in-network and out-of-network care. For 2026, the combined in-network and out-of-network MOOP cap is $14,750.¹ This means an enrollee who receives care outside the plan's network faces a significantly higher spending ceiling.

Suppose a retiree in Florida needs a knee replacement. If they choose an in-network surgeon and hospital, their maximum cost for that surgery is capped at the plan's in-network MOOP — for example, roughly $5,000. If they prefer a specialist outside the network, the same surgery could cost them up to the out-of-network MOOP combined cap before the plan covers remaining costs at 100%¹.

For a typical enrollee who travels frequently, out-of-network coverage becomes critical. A plan with a national PPO network may offer lower out-of-network MOOP than a regional HMO. The difference in network structure can mean thousands of dollars in potential exposure.

Which Services Count Toward the $9,250 Cap and Which Do Not

The $9,250 in-network MOOP applies to cost-sharing for Medicare Part A and Part B covered services received in-network. This includes hospital stays, doctor visits, lab tests, durable medical equipment, and outpatient procedures. Copayments, coinsurance, and deductibles for these services all count toward the cap.

Part D prescription drug costs operate under a separate MOOP. For 2026, the Part D out-of-pocket cap is $2,000, and this amount does not count toward the $9,250 Part A/B MOOP.³ Supplemental benefits like dental cleanings, vision exams, or hearing aids also do not count toward the cap, even if the plan charges a copay for them.

Services not covered by Medicare at all — such as long-term custodial care or cosmetic surgery — are not subject to the MOOP. An enrollee who needs extended nursing home care would pay those costs entirely out-of-pocket, with no cap.

Why MOOP Is Rising and What It Means for 2026 Enrollees

The MOOP ceiling has increased steadily over recent years. Average medical MOOP and deductible levels climbed between 2025 and 2026, continuing a multi-year trend observed by industry analysts.⁵ This rise reflects underlying healthcare cost inflation, increased utilization, and changes in plan benefit design.

Medicare Advantage enrollment reached approximately 33 million beneficiaries in 2025, representing roughly half of all Medicare-eligible adults.⁶ As enrollment grows, plans face pressure to manage costs while maintaining competitive benefits. Raising the MOOP allows plans to keep premiums low while shifting more cost-sharing to high-utilization members.

Approximately 2.8 million Medicare Advantage and MAPD enrollees in non-$0 premium plans continuing into 2026 will face increased costs compared to 2025.⁷ For these enrollees, the combination of higher premiums and a higher MOOP ceiling means greater potential out-of-pocket exposure. Reviewing the ANOC for 2026 is essential to understand how an individual plan's costs have changed.

Comparing Plans by True Out-of-Pocket Exposure, Not Just Premiums

Choosing a Medicare Advantage plan based solely on the monthly premium can be misleading. The true cost comparison requires evaluating the MOOP, deductible, copay structure, and network breadth together.

For a healthy enrollee who uses minimal services, Plan A with a $0 premium may be the cheapest option. For an enrollee with chronic conditions who expects to hit the MOOP, Plan C's $3,400 MOOP plus $1,800 premium totals $5,200 — significantly less than Plan A's $9,250 maximum¹.

The MOOP comparison also affects Medicare Advantage enrollment decisions. An enrollee who expects high medical costs should prioritize a low MOOP plan, even if the premium is higher. An enrollee who rarely visits a doctor may prefer a $0 premium plan with a high MOOP as insurance against catastrophic costs.

When Medicare Advantage MOOP Protections Fall Short

The MOOP cap provides important protection, but it has limitations. The cap applies only to in-network care for most plan types. An enrollee who unknowingly sees an out-of-network provider could face balance billing or higher cost-sharing that counts toward the $14,750 combined cap rather than the $9,250 in-network cap.

The MOOP does not cover Part D drug costs. An enrollee taking a high-cost specialty medication could hit the $2,000 Part D cap separately, adding to total annual healthcare spending¹. For someone managing both a chronic condition and expensive prescriptions, total out-of-pocket costs could reach $11,250 or more².

Plan networks can change mid-year. A provider who was in-network in January may leave the network in July, forcing the enrollee to find a new provider or pay out-of-network rates. The MOOP cap does not protect against network disruptions, only against the cost of services received.

Your Next Step

Review your 2026 Annual Notice of Change (ANOC) to find your plan's specific in-network MOOP. Compare it to the $9,250 federal ceiling and note whether your plan's cap increased from 2025. If you are considering switching plans during the Annual Enrollment Period (October 15 to December 7), compare at least three plans by total maximum cost — premium plus MOOP — not just the monthly premium. Use the Medicare Plan Finder at Medicare.gov to see each plan's MOOP, deductible, and copay structure side by side.