What MOOP caps and doesn't cap
MOOP applies to your medical cost-sharing — deductibles, coinsurance, and copays for Part A and Part B services received in-network. Specifically:
MOOP DOES cap:
- Hospital deductibles and copays.
- Doctor visit copays and coinsurance.
- Outpatient procedure cost-sharing.
- Skilled nursing facility (SNF) copays.
- Most lab tests, imaging, and DME cost-sharing.
MOOP DOES NOT cap:
- Monthly plan premiums — your MA premium is paid every month regardless of whether you've hit MOOP.
- Part D prescription drug costs — Part D has its own separate $2,100 annual OOP cap in 2026.
- Services not covered by your plan — non-covered services aren't subject to MOOP.
- Out-of-network costs in HMO plans — typically not covered at all (except emergencies).
- Out-of-network costs in PPO plans — typically count toward a higher combined MOOP, not the in-network MOOP.
- Penalties for late enrollment or other CMS-imposed charges.
2026 Medicare Advantage MOOP limits
CMS sets a maximum allowable MOOP that plans cannot exceed:
| Category | 2026 Maximum | Notes |
|---|---|---|
| In-network MOOP | $9,250 | Down from $9,350 in 2025 |
| Combined (in/out-of-network) MOOP | ~$14,000 | Applies to PPO plans |
| Median plan MOOP (estimated) | ~$5,900 | Most plans set MOOP below the maximum |
The $9,250 figure is the CMS maximum — plans can (and many do) set lower MOOPs to compete for customers. The CMS-published median MA MOOP for 2026 is approximately $5,900. Many plans offer MOOPs in the $3,000-$5,500 range as a competitive feature, particularly for HMO plans.
When comparing MA plans, MOOP is a critical comparison point. A plan with $0 premium and $9,250 MOOP looks different from a plan with $30 premium and $4,500 MOOP — the lower MOOP costs $360/year in premium but caps your medical exposure at less than half the worst-case high-MOOP plan.
Why Original Medicare has no MOOP
Original Medicare (Parts A and B alone) has no annual cap on your out-of-pocket spending. This is a major distinction from Medicare Advantage and a primary reason most Original Medicare beneficiaries pair it with Medigap:
- Part A: has a per-benefit-period deductible ($1,736 in 2026) plus daily copays for extended hospital stays (over 60 days) and SNF stays (over 20 days). Multiple hospitalizations in a year can produce multiple deductibles.
- Part B: 20% coinsurance applies to almost all Part B services with no cap. A year of extensive Part B services (cancer treatment, dialysis, repeated outpatient procedures) can produce $10,000-$50,000+ in 20% coinsurance liability.
- No safety net in Original Medicare alone. Beneficiaries with major medical events face significant out-of-pocket costs.
Medigap policies fill this gap by paying the cost-sharing Original Medicare doesn't cover. Plans G and N are most popular; Plan G covers everything except the Part B deductible, producing near-$0 out-of-pocket for medical services after the deductible.
Medigap K and L have MOOPs
Unusually among Medigap plans, K and L have explicit out-of-pocket maximums. Plan K covers 50% of cost-sharing until you hit $8,000 in out-of-pocket, then 100%. Plan L covers 75% until you hit $4,000, then 100%. Plans A, B, C, D, F, G, M, and N cover specific items at 100% without an explicit MOOP structure — they don't need one because they cover the cost-sharing fully.Medigap K and L MOOP
Plans K and L are the two cost-sharing Medigap plans with explicit MOOPs:
| Medigap Plan | 2026 MOOP | Coverage structure |
|---|---|---|
| Plan K | $8,000 | 50% of Part A coinsurance, 50% Part B coinsurance, 50% of Part B preventive coinsurance until MOOP; 100% after |
| Plan L | $4,000 | 75% of Part A coinsurance, 75% Part B coinsurance, 75% of Part B preventive coinsurance until MOOP; 100% after |
K and L premiums are lower than full-coverage plans (F, G) but you pay more out-of-pocket for routine services. For beneficiaries comfortable with somewhat higher cost-sharing in exchange for lower premium, K and L are reasonable choices. For most retirees, Plans G or N produce simpler budgeting with predictable costs.
PPO MA plans: combined MOOP
Medicare Advantage PPO plans (Preferred Provider Organization) allow you to use out-of-network providers at higher cost-sharing. PPO plans typically have two MOOPs:
- In-network MOOP: typically $4,000-$9,250 — the cap for services received from in-network providers.
- Combined MOOP: typically $10,000-$14,000 — the cap for in-network AND out-of-network services combined. Out-of-network services typically count toward both your in-network MOOP and the combined MOOP simultaneously, but at higher cost-sharing rates.
If you anticipate using out-of-network providers regularly (vacation home elsewhere, specialists out of state, snowbird patterns), the combined MOOP is your real worst-case exposure under a PPO MA plan. Verify both numbers when comparing PPO plans.
Strategic implications for choosing coverage
MOOP is one of the most important factors when choosing Medicare coverage:
- Anticipating a high-cost year (planned surgery, new diagnosis, etc.): a lower-MOOP MA plan or Medigap-paired Original Medicare can cap your exposure significantly.
- Generally healthy retiree: a higher-MOOP, $0-premium MA plan may save money in years with low utilization but expose you in a bad year.
- Tendency to use out-of-network providers: PPO MA plans with reasonable combined MOOP are typically better than HMO plans that don't cover out-of-network at all.
- Long-term predictability: Medigap G or N with Original Medicare produces highly predictable annual costs (premium + Part B deductible + maybe small Part N copays), regardless of utilization.