Medicare Advantage Maximum Out-of-Pocket Limits 2026: What You Need to Know

“Out-of-pocket maximum” is not exactly the most exciting phrase in the Medicare vocabulary, but it may be the single most valuable number written into a Medicare Advantage plan. It is the built-in ceiling on what a family pays for covered medical care in a year, the safety net that keeps a hospitalization or a new diagnosis from turning into an open-ended bill. This guide covers the 2026 maximum out-of-pocket (MOOP) limits, how they differ between HMO and PPO plans, what actually counts toward that ceiling, and what generally happens once a person reaches it.

Where HMO and PPO Fit In (and Where They Don’t)

It helps to zoom out one level first, since these terms don’t apply everywhere in Medicare.

• Original Medicare (Parts A and B) has no network structure at all. It’s run directly by the federal government on a fee-for-service basis, so there’s no in-network versus out-of-network distinction, and HMO and PPO simply don’t come into play.
• HMO and PPO only exist within Medicare Advantage (Part C). Medicare Advantage benefits are delivered through private insurance companies rather than directly by the government, and those insurers generally use the same network-based plan types common in commercial insurance.
• Medigap, a separate supplemental policy that pairs only with Original Medicare, isn’t an HMO or a PPO either. It generally can’t be combined with a Medicare Advantage plan, since a person is on one path or the other.

With that bigger picture in mind, here’s what separates the two plan types a person actually encounters while shopping for Medicare Advantage coverage.

HMO and PPO: The Basic Difference

An HMO (Health Maintenance Organization) generally requires care to come from doctors and facilities in the plan’s network, often with a primary care physician coordinating referrals to specialists. A PPO (Preferred Provider Organization) generally allows a person to see providers outside the network too, usually at a higher cost, without needing a referral first. That network flexibility is the main reason PPOs carry a second, higher combined MOOP that HMOs typically don’t need.

What the MOOP Actually Protects Against

• Original Medicare (Parts A and B) has no annual cap on out-of-pocket costs at all, which means a serious illness can generate bills that keep adding up with no ceiling.
• Every Medicare Advantage plan is designed to include an annual out-of-pocket limit for covered Part A and Part B services, a protection Original Medicare does not offer on its own.
• Once a person’s covered cost-sharing reaches that limit, the plan generally covers 100% of Part A and Part B costs for the remainder of the calendar year.

The 2026 MOOP Numbers

• Mandatory in-network limit: $9,250, a decrease of $100 from the $9,350 limit in 2025. This is the highest amount any plan is permitted to set for in-network Part A and B cost-sharing.
• Combined in-network and out-of-network limit: $13,900 for plans that cover out-of-network care, mainly PPOs.
• Plans often set lower limits than the federal ceiling. The average in-network limit across Medicare Advantage enrollees in 2026 is roughly $5,421.
• About 9% of enrollees, an estimated 1.8 million people, are in plans set right at the $9,250 maximum.

How the Limit Differs Between HMO and PPO Plans

• HMO plans generally use a single in-network MOOP only, since HMO coverage typically does not extend to routine out-of-network care beyond emergencies and urgent care. The average HMO in-network limit in 2026 is about $4,636.
• PPO plans generally set two limits: a lower in-network limit and a higher combined limit that applies once out-of-network providers enter the picture. The average PPO in-network limit is about $6,592, and the average combined limit is about $9,825.
• The practical trade-off: the flexibility to see out-of-network providers on a PPO generally comes paired with a higher typical MOOP than most HMO plans carry.

What Counts Toward the Limit, and What Doesn’t

• Counts toward the MOOP: copays, coinsurance, and deductibles paid for Medicare-covered Part A and Part B services.
• Does not count: the plan’s monthly premium, the standard Part B premium, and Part D prescription drug costs, which carry their own separate cap of $2,100 in 2026.
• For HMO enrollees, care from an out-of-network provider generally is not covered at all outside emergencies or urgent care, so those costs are not simply excluded from the MOOP, they are typically the family’s full responsibility.

What Happens Once the Limit Is Reached

• Once total in-network cost-sharing for covered services reaches the plan’s MOOP for the year, the plan generally pays 100% of covered Part A and Part B costs for the rest of that calendar year.
• The limit resets to zero every January 1, along with the rest of a plan’s annual cost-sharing structure.
• Reaching the medical MOOP does not affect Part D prescription drug costs, which run on a separate, independent cap.

A Real-World Example of How the MOOP Works

Consider a senior enrolled in an HMO plan with a $6,000 in-network MOOP. A hip replacement, follow-up rehab, and a handful of specialist visits generate $6,000 in copays and coinsurance by August. From that point forward, the plan generally covers 100% of covered Part A and Part B costs for the rest of the year, including any additional hospital stays, specialist visits, or procedures. Without that cap, and without a Medigap policy, the same sequence of events under Original Medicare could have kept generating bills with no ceiling in sight. That gap is exactly what the MOOP is designed to close.

Why the MOOP Often Matters More Than the Premium

A $0 monthly premium tends to get the most attention when a family compares plans, but in a year with real medical needs, the MOOP is frequently the number that matters more. Original Medicare carries no out-of-pocket cap on its own, which is the main reason many people on Original Medicare also carry a Medigap policy. Senioridy’s Medicare Advantage vs. Original Medicare guide lays out that broader comparison in detail. For the fuller picture of premiums, copays, and how the MOOP fits into a plan’s total cost structure, Senioridy’s Medicare Advantage Costs Explained guide walks through each piece.

Comparing Plans With the MOOP in Mind

When comparing Medicare Advantage plans available in a given ZIP code, families may find it helpful to ask a few pointed questions rather than focusing on the premium alone:

• What is this plan’s in-network MOOP, and how does it compare to other plans available in the area?
• Is this a PPO with a separate, higher combined limit, and does that matter given the doctors and specialists the senior currently sees?
• How much has the senior’s care actually cost in a typical year, and in a year with a hospitalization or new diagnosis?

A SHIP (State Health Insurance Assistance Program) counselor can walk through these questions for free, without any sales incentive tied to the outcome. Reach a local counselor through shiphelp.org, available in every state at no cost, or compare specific plans directly using Medicare’s official Plan Finder.

Frequently Asked Questions

Does the MOOP include my monthly premium?

No. The MOOP applies only to copays, coinsurance, and deductibles for covered Part A and Part B services. Monthly premiums, including the Part B premium, are paid separately and are not counted toward the limit.

Can a plan change its MOOP mid-year?

No. A Medicare Advantage plan’s MOOP is set for the full calendar year when the plan is approved by CMS. It generally cannot be raised mid-year, though a person could switch to a different plan with a different MOOP during an eligible enrollment period.

Does reaching the MOOP lower my prescription drug costs too?

No. The medical MOOP and the Part D prescription drug out-of-pocket cap ($2,100 in 2026) are two separate limits. Reaching one does not affect progress toward the other, so a family tracking a senior’s costs generally needs to watch both.

Find Senior Care Providers Near You

Understanding the MOOP is one part of planning for a parent’s or spouse’s care. When it is time to look at actual providers, Senioridy’s in-home senior care directory and skilled nursing facility directory can help families compare options in their area.

This article is for informational purposes only and does not constitute legal, financial, or medical advice. Medicare Advantage out-of-pocket limits and cost-sharing figures are set annually by CMS and individual insurers and are subject to change. Costs can vary by plan and location, so always confirm current details with your specific plan’s Summary of Benefits. For free, personalized Medicare guidance, contact your SHIP counselor at shiphelp.org, available in every state at no cost.