If you’ve ever said, “I picked a plan with a $0 premium, so I’m covered,” you’re not alone — but you’re not exactly right, either.
The truth is, your premium is just one piece of the puzzle. What really matters when something major happens — a hospital stay, surgery, or ongoing treatment — is your out-of-pocket maximum (MOOP).
In 2026, out-of-pocket maximums are going up again for many Medicare Advantage plans. But even if your plan advertises a “low MOOP,” that doesn’t always mean you’re protected from big bills.
Let’s break down what your out-of-pocket maximum actually covers, what it doesn’t, and how to use it to keep your costs under control.
What Your Out-of-Pocket Maximum Actually Covers
Your out-of-pocket maximum is the ceiling on how much you’ll pay for covered medical services in a plan year. Once you hit that number, your plan covers the rest at 100%.
Here’s what counts toward your MOOP:
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Doctor visit copays and coinsurance
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Hospital stays and surgeries
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Outpatient procedures
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Emergency room and urgent care visits
Once you reach the MOOP, you’re protected from additional in-network medical costs for the rest of the year.
Sounds great, right? It is — but only if you understand the fine print.
What the Out-of-Pocket Maximum Doesn’t Cover
Here’s where people get tripped up. The MOOP only applies to medical costs covered by your plan. It doesn’t cover:
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Dental, vision, and hearing care (unless specifically included)
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Out-of-network charges in most cases
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Monthly premiums
So if your doctor visits or hospital bills push you toward your MOOP, great — you’ll cap out at that number. But if your drug costs are also stacking up, those expenses are completely separate.
That means you could hit your MOOP and still be paying hundreds more each month for prescriptions.
How MOOPs Work in 2026
For 2026, Medicare Advantage plans can set their maximum in-network MOOP up to the limit Medicare allows. That number is typically around $8,850 for in-network services — and up to $13,300 if you go out-of-network.
That’s the maximum allowed. Some plans advertise lower MOOPs (like $4,000–$6,000), but they may come with higher copays or limited networks.
So before you get too excited about a “low MOOP,” look at how easily you could hit it. Plans often shift costs into higher copays, coinsurance percentages, or narrower provider lists.
How to Tell If Your MOOP Is “Good” or “Bad”
There’s no one-size-fits-all answer — but here’s how I help people think through it:
A lower MOOP might make sense if:
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You have chronic conditions or expect high medical use
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You see specialists often
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You prefer more predictable costs
A higher MOOP might be fine if:
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You’re generally healthy and only see the doctor a few times a year
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You want a lower premium and can afford higher bills if something unexpected happens
The key is knowing your own comfort level with financial risk.
Don’t Confuse MOOP with Deductible or Drug Costs
This one trips up almost everyone.
Your deductible is what you pay before your plan starts sharing costs — like an entry fee.
Your MOOP is the total you could pay for covered services after all copays, coinsurance, and deductibles are added up.
And again, your Part D drug spending lives in its own world — with its own stages and limits. MOOP does not stop those drug costs.
So if you take expensive prescriptions, you’ll want to check your drug coverage separately from your medical MOOP.
Questions to Ask Before You Choose Your 2026 Plan
Before you pick your plan this year, ask:
- What’s my in-network MOOP for 2026?
- Does my plan have an out-of-network MOOP, and how high is it?
- Which services count toward the MOOP — and which don’t?
- How much could I realistically pay in a “bad” health year?
- How are drug costs handled separately from medical costs?
If you can answer these questions confidently, you’ll avoid the biggest MOOP-related surprises that catch people off guard every year.
FAQs
What exactly is an out-of-pocket maximum (MOOP)?
It’s the most you’ll pay for covered medical services in a year before your Medicare Advantage plan covers the rest at 100%.
Does Medicare's out-of-pocket maximum include my prescription drugs?
No. Drug costs are separate under Part D and do not count toward your medical MOOP.
Do Medicare premiums count toward the out-of-pocket maximum?
They don’t. Your monthly premium is a fixed cost and doesn’t apply to your MOOP total.
Can my out-of-pocket maximum change every year?
Yes. Medicare sets a new limit each year, and individual plans can adjust their MOOP amounts annually — so review it before re-enrolling.
Are out-of-network costs included in my MOOP?
Only if your plan specifies it. Most Medicare Advantage plans have separate MOOPs for in-network and out-of-network care.
Get Ahead of the Fine Print
Here’s the truth: most people don’t hit their MOOP. But the ones who do are usually the people who never saw it coming.
Take time now — before AEP begins — to understand your total exposure. If you’re comparing plans, don’t stop at the premium. Look at what happens if life throws you a curveball.
Your out-of-pocket maximum is your financial safety net. Make sure you know exactly how strong (or thin) it really is before you sign up for 2026.
