Medicare Advantage Out-of-Pocket Maximum: 2026 Limits Explained

Every Medicare Advantage plan must cap annual out-of-pocket spending for in-network services. In 2026, CMS sets the maximum allowable cap at $9,250 for in-network costs. Individual plans can set their caps lower — many popular plans use limits between $4,000 and $6,500 — but no plan can exceed $9,250.

This cap is one of Medicare Advantage's strongest selling points. Original Medicare has no out-of-pocket maximum at all — without a Medigap supplement, costs are theoretically unlimited. But the details of how the cap works, what counts toward it, and what doesn't are worth understanding before relying on it as protection.

What Counts Toward the Maximum

The out-of-pocket maximum includes copays, coinsurance, and deductibles your parent pays for covered in-network services. Hospital stays, doctor visits, outpatient surgery, diagnostic tests, skilled nursing facility coinsurance, and durable medical equipment all count.

What Doesn't Count

Several significant expenses do not reduce the remaining distance to the cap:

• Monthly premiums — the Part B premium ($202.90/month in 2026) and any plan premium don't count
• Prescription drug costs — Part D has its own separate out-of-pocket cap ($2,100 in 2026 under the Inflation Reduction Act redesign), and drug spending doesn't cross over to the medical cap
• Out-of-network costs — HMO plans generally cover out-of-network care only for emergencies or urgently needed care; PPO plans cover some out-of-network care at higher cost-sharing and use the plan's combined in-network/out-of-network cap
• Services the plan doesn't cover — anything not in the plan's benefits package doesn't count

How Costs Accumulate in a Bad Year

The out-of-pocket maximum protects against catastrophic medical bills, but getting to the cap means spending thousands of dollars first. Here's a realistic scenario for a parent with serious health events in a single year:

• January: emergency room visit with imaging → $350 copay
• February: cardiac specialist follow-ups (3 visits) → $120 in copays
• March: hospital admission for heart procedure (5 days) → $1,500 copay
• April–June: outpatient cardiac rehab (12 sessions) → $480 in copays
• July: hip replacement surgery with hospital stay → $1,500 copay
• August–October: physical therapy (24 visits) → $960 in copays
• Running total: $4,910

If the plan's out-of-pocket maximum is $5,500, the parent is approaching the cap but hasn't hit it. Every additional service still requires a copay until the total reaches $5,500. In a plan with a $9,250 cap, the parent has $4,340 of exposure remaining.

The Medigap Comparison

Under Original Medicare with Medigap Plan G, the same parent's annual Part A and Part B cost-sharing for all of those services would be $283 — the Part B deductible, before premiums and Part D costs. Plan G covers everything else: hospital deductibles, coinsurance, and the 20% Part B cost-sharing for outpatient services.

The trade-off is the monthly premium. Plan G costs $150–250/month ($1,800–3,000/year), and your parent also needs a separate Part D plan ($10–50/month). So total annual cost with Medigap is roughly $2,200–3,900, excluding the common Part B premium, regardless of how much care is used.

Under Medicare Advantage, the healthy parent pays much less — perhaps $400–800 in copays for a quiet year. But the sick parent can pay $4,000–9,250 in a year with major health events.

What the Cap Doesn't Protect Against

The out-of-pocket maximum creates a ceiling on covered in-network costs. It does not protect against:

Prior authorization denials. If the plan denies a hospitalization, rehab stay, or procedure, the cost doesn't count toward the cap because the plan didn't cover it. The family either pays out of pocket or appeals.

Out-of-network care under an HMO. Emergency care is covered, but follow-up care from out-of-network providers may require plan authorization; care the plan doesn't cover doesn't count toward the cap.

Services that aren't covered. Long-term custodial care, most dental and vision services (beyond what the plan includes), and care outside the plan's service area are outside the cap.

The out-of-pocket maximum is real protection, but it's protection within the boundaries of managed care — not blanket cost certainty. For families weighing that trade-off against Medigap's predictability, the coverage decision guide includes a cost-comparison worksheet that models both paths using your parent's actual health profile.

See more United States guides →