Medicare Advantage MOOP: Check What the $9,250 Cap Leaves Out
MOOP is the yearly limit on what you pay for Medicare Part A and Part B covered services in a Medicare Advantage plan. For 2026, the federal in-network maximum is $9,250 and the combined in-network plus out-of-network maximum is $13,900, according to KFF’s 2026 analysis. Most plans set lower limits, and Part D drug spending is tracked separately.
TL;DR:
- Only cost sharing for covered Part A and Part B care counts toward the cap; premiums, Part D drugs, and uncovered services do not.
- For 2026, KFF reports weighted average limits of $5,421 in network and $9,825 combined; PPOs average $6,592 versus $4,636 for HMOs.
- Out of network nonemergency care without authorization may cost you the full bill and may not count toward the cap; emergencies receive coverage.
- Full Medicaid may cover Medicare deductibles, copays, and coinsurance, but assistance varies by state; Extra Help lowers Part D costs without changing the MOOP.
- Check the Evidence of Coverage and Annual Notice of Change each fall, confirming provider network status and whether supplemental benefits count toward your limit.
Table of Contents
- What counts toward your Medicare Advantage MOOP and what doesn’t
- Federal caps and the 2026 numbers: maximum versus what plans really set
- How HMO, PPO and network rules change your MOOP
- Medicaid, LIS and why MOOP may matter less for some enrollees
- How to check and compare a plan’s MOOP
- Almond Insurance: help comparing MOOP and enrolling
- FAQ
- Sources
What counts toward your Medicare Advantage MOOP and what doesn’t
Medicare’s own booklet says every Medicare Advantage plan must set a yearly limit on out-of-pocket costs for Part A and Part B services. Once you reach it, the plan pays the cost of covered Part A and Part B services for the rest of the year. The word “covered” matters. Only bills for services your plan covers can move you toward the cap.
Here is what typically counts:
- Deductibles for Part A and Part B covered services
- Copayments, such as a flat amount for a specialist visit
- Coinsurance, such as a share of the cost of an outpatient procedure
- Inpatient hospital cost-sharing for a covered stay
- Outpatient facility charges for covered surgery or imaging
Here is what does not count:
- Your monthly plan premium
- Part D prescription drug costs
- Services the plan does not cover
- Non-emergency care outside the network when your plan gives no out-of-network coverage
Think of a hospital stay with a deductible and daily copays, followed by physical therapy with a copay per visit. Each of those payments adds to your total. A monthly premium paid all year adds nothing.
Supplemental benefits like vision, dental and hearing are common in 2026, but KFF notes they may or may not count toward a plan’s MOOP depending on how the plan is designed. The only way to know is to read your plan’s Evidence of Coverage.
The MOOP is a cap on covered cost-sharing, not on everything you spend on health care. That gap is where surprise bills come from, which is why we walk clients through it line by line.
Original Medicare has no cap at all, so the MOOP is one of the main protections Medicare Advantage offers. MedPAC’s 2026 status report describes that trade-off: lower premiums and out-of-pocket limits, in exchange for network rules.
Federal caps and the 2026 numbers: maximum versus what plans really set
The federal maximum is a ceiling, not a typical bill. KFF reports that the maximum allowable out-of-pocket cap fell by $100 between 2025 and 2026, to $9,250 for in-network services. Plans that cover both in-network and out-of-network care can reach a combined limit of $13,900.
What most people face is lower. KFF’s enrollment-weighted averages for 2026:
- $5,421 for in-network services
- $9,825 for in-network plus out-of-network services combined
- About 13% of enrollees are in plans with in-network limits of $3,000 or less
- About 68% are in plans with limits above $3,000 up to $7,000
- About 19% are in plans with limits above $7,000, including those at the $9,250 maximum
Roughly one in ten enrollees sits in a plan at the full $9,250 in-network cap. So the maximum is real, but it is not where most people land.
Why would a plan pick a lower cap? Plan design is shaped by bids, rebates and quality bonuses, which KFF discusses in its brief. MedPAC’s March 2026 report adds context on payment policy and plan behavior behind those benefit choices. A plan may lower its cap to attract members, then offset the cost elsewhere, such as in copays, networks or extra benefits.
Plan type also moves the averages. KFF finds that PPOs average $6,592 for in-network limits, while HMOs average $4,636. Because PPOs are more common in rural areas, rural averages run higher. KFF also notes the average in-network limit fell from 2017 to 2023, then rose by about $700 from 2023 to 2026. A plan with a low cap last year may not have one this year, so check every fall.
How HMO, PPO and network rules change your MOOP
HMO plans generally ask you to use their network, and in return they tend to carry lower in-network limits. PPOs let you see out-of-network providers, and they usually come with higher limits. Medicare.gov’s plan-type comparison says PPOs often have higher average in-network limits than HMOs, and that HMOs typically do not cover out-of-network care except in specified situations.
Many plans publish two numbers:
- In-network limit: counts only what you pay to providers in the plan’s network
- Combined limit: counts in-network and out-of-network spending together, and it is higher
For example, a PPO may list separate in-network and combined limits. If you stay in network, the in-network limit applies. If you also see out-of-network providers, check whether those bills count toward the combined limit. You could pay more before reaching it.
Some guidance to keep in mind:
- If you rely on specific out-of-network doctors, plan around the combined limit, not the in-network one.
- Medicare.gov warns that non-emergency care outside the network without authorization may mean paying the full cost, and those costs may not count toward your MOOP.
- Emergencies work differently. Providers must treat you, and those services are covered regardless of network status.
- KFF notes that prior authorization rules and networks affect how fast you reach the cap and what you pay before then.
Pro Tip: Confirm whether a plan is an HMO, PPO or HMO-POS before you rely on any MOOP figure, because the same dollar amount protects you very differently in each.
Medicaid, LIS and why MOOP may matter less for some enrollees
If you have full Medicaid along with Medicare, the MOOP may rarely come into play. Medicaid can pay some or all of your Medicare cost-sharing, such as deductibles, copays and coinsurance. The result is that dually eligible enrollees often owe little or nothing for covered services, even when the plan’s cap sits in the thousands.
A few things to keep straight:
- Medicaid wrap-around help varies by state. MACPAC’s compendium of state Medicaid payment policies is a useful place to look up how a state handles Medicare cost-sharing.
- The Low-Income Subsidy, also called Extra Help, lowers Part D costs. Part D remains separate from the Medicare Advantage MOOP, so LIS does not change your MOOP.
- Your state Medicaid office or a Medicare counselor can tell you which protections apply to you.
- Even with Medicaid, read your plan materials. Confirm how cost-sharing is handled and whether providers can bill you.
A caregiver helping a parent with both coverages should not assume the MOOP is irrelevant. It may be, but it depends on the state, the exact Medicaid category and the plan. Our team at Almond Insurance helps families sort that out. You can start with our Medicare 101 page if the terms are new.
How to check and compare a plan’s MOOP
Finding the number is easier once you know where to look.
- Open the Medicare.gov Plan Finder and look up the plan. Note the MOOP, and whether it is in-network only or combined.
- Read the plan’s Evidence of Coverage and Annual Notice of Change (ANOC). They explain what counts toward the cap, with examples.
- Compare MOOP next to premiums, provider networks, Part D drug costs and prior authorization rules.
- Estimate your expected care for the year, then see how close it gets to the cap.
A worked example can help compare plans. Consider the cost-sharing you expect for planned care and specialist visits, then compare that total with each plan’s MOOP. Also check whether your providers are in network. A lower cap and a suitable network may point in the same direction, while lower copays or a better network in another plan could change the comparison.
KFF recommends checking plan documents and Medicare.gov each Open Enrollment, because limits change from year to year.
Pro Tip: If ANOC language or a network directory looks confusing, call the plan or ask us. We read these documents every fall.
Almond Insurance: help comparing MOOP and enrolling
Reading a plan’s cap is one thing. Knowing whether it protects you is another. We are a family-focused Medicare agency in Rockford, Illinois, serving Northern Illinois and Southern Wisconsin, and we explain plans in plain language. Our advisory help is paid by the insurance carriers when you enroll, so you do not pay us directly for it.
Here is how we help:
- New-to-Medicare guidance for people turning 65 or retiring
- Medicare Advantage and Supplement comparison, including side-by-side MOOP review
- Part D prescription review, since drug costs sit outside the MOOP
- Annual coverage review
- Enrollment support from first question to final form
Read about our Medicare Advantage guidance, then explore our services page and bring your current plan’s ANOC.
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
Do Medicare Advantage plans have a MOOP?
Yes. Every Medicare Advantage plan must set a yearly limit on what you pay for Part A and Part B covered services. After you reach it, the plan pays for covered services for the rest of the year, as Medicare’s plan booklet explains.
What is the Medicare MOOP for 2026?
The federal maximum for in-network services is $9,250, and the combined in-network plus out-of-network maximum is $13,900, per KFF’s 2026 analysis. Many plans set lower limits, so check your own plan’s documents.
What is the maximum out-of-pocket for Medicare Advantage?
The ceiling is the federal cap, but the typical plan sits below it. KFF’s enrollment-weighted average is $5,421 for in-network services, and about 19% of enrollees are in plans with limits above $7,000. Premiums and Part D drug costs do not count toward the cap.
Does the MOOP reset every year?
Plan limits apply for the year, and you should check your plan materials to confirm how the limit works. Because plans can change their limits, read your Annual Notice of Change before you renew.