Every Medicare Advantage plan has a number called the MOOP. It stands for Maximum Out-of-Pocket. It is the yearly cap on what you can spend on medical care. It matters more than the premium for anyone who ever gets sick. Here is how it works, what it does not cover, and the trap that catches PPO members.
The short answer
MOOP is the yearly cap on your medical copays, coinsurance, and deductibles on a Medicare Advantage plan. Once you hit it, the plan pays 100% of covered medical care for the rest of the year.
The federal limit for 2026 is around $8,850 in-network and $13,300 combined in-and-out-of-network. Individual plans often set lower MOOPs.
MOOP does NOT include your Part D drug costs, premiums, or dental and vision costs.
Why MOOP exists
Original Medicare has no yearly out-of-pocket cap. You pay 20% of every Part B service, forever. A serious illness could theoretically cost you tens of thousands.
Medicare Advantage was designed to fix that. By law, every Advantage plan must have a MOOP. It gives you a stop-loss that Original Medicare alone does not have.
This is one of the biggest points in Advantage's favor. It is also why a Medigap plan matters so much for people staying with Original Medicare. Medigap plans fill the 20% coinsurance gap and effectively cap your out-of-pocket costs there. See our Medicare Advantage vs Medigap comparison.
How the MOOP number is set
CMS sets a federal maximum each year. Plans can choose a lower MOOP but not a higher one.
For 2026, the numbers to check with your plan's summary:
- In-network MOOP: check current CMS rates, historically around $8,850
- Combined in-and-out-of-network MOOP (PPO only): check current CMS rates, historically around $13,300
Many plans set MOOPs well below the max. Common 2026 in-network MOOPs range from $3,500 to $6,500 depending on the plan and market.
What counts toward MOOP
These medical costs count:
- Primary care copays
- Specialist copays
- Emergency room copays
- Urgent care copays
- Hospital stays (inpatient copays)
- Skilled nursing facility copays
- Outpatient surgery
- Diagnostic tests, X-rays, MRIs, CT scans
- Lab work copays
- Ambulance
- Durable medical equipment coinsurance
- Rehab (physical, occupational, speech therapy)
- Radiation and chemotherapy
What does NOT count toward MOOP
These do NOT count:
- Monthly plan premium
- Prescription drug (Part D) copays
- Prescription drug deductibles
- Over-the-counter items
- Extra dental, vision, or hearing benefits
- Care from out-of-network providers on HMO plans (not covered, so not counted)
- Non-covered services (things Medicare does not cover)
- Balance billing from providers who go over MOOP-eligible amounts
HMO vs PPO: one MOOP or two?
This is where PPOs trip people up.
HMO plans: one MOOP
HMOs only cover in-network care (except emergencies). So there is one MOOP that applies to all your in-network costs.
PPO plans: two MOOPs
PPOs cover both in-network and out-of-network. They have:
- A lower in-network MOOP (like $6,500)
- A higher combined MOOP that includes out-of-network (like $10,500)
Out-of-network costs count toward the combined MOOP only. In-network costs count toward both.
If you use only in-network care, you cap out at the lower number. If you go out of network sometimes, you could pay up to the combined higher number.
Example of PPO MOOP math
Sam has a PPO with a $6,500 in-network MOOP and a $10,500 combined MOOP. He gets treated at:
- An in-network hospital: $4,000 in copays
- An out-of-network specialist for a second opinion: $3,000 in coinsurance
- In-network follow-ups: $2,000 in copays
In-network total is $6,000 (under $6,500 in-network MOOP, so he keeps paying).
Combined total is $9,000 (under $10,500 combined MOOP, so he keeps paying).
If Sam had stayed in-network, he would have capped at $6,500. Going out-of-network changed the math.
2026 MOOP numbers to expect
Actual plan MOOPs vary by insurer and county. General ranges for 2026:
| Plan type | Typical in-network MOOP | Combined MOOP |
|---|---|---|
| HMO $0 premium | $4,500 to $6,900 | N/A |
| HMO with premium | $3,500 to $5,900 | N/A |
| PPO $0 premium | $5,500 to $8,000 | $10,000 to $13,300 |
| PPO with premium | $4,500 to $6,900 | $9,000 to $12,500 |
| Federal 2026 max | ~$8,850 (check current CMS rates) | ~$13,300 (check current CMS rates) |
Lower MOOP usually means higher premium, higher copays somewhere, or a smaller network. Nothing is free.
How MOOP resets
MOOP is a calendar year total. It resets to $0 on January 1 every year. Whatever you paid last year does not carry over.
This is why people who have major surgery in November face a hard question. Some Advantage plans require you to hit MOOP again the next calendar year if the treatment continues.
Some plans offer "carry-over" credit if the same course of treatment spans a year change. Read your plan documents carefully.
MOOP and prior authorization
A common mistake: assuming that hitting your MOOP means the plan covers everything after that. It does not.
The plan still requires prior authorization for certain services. If a service is denied, it does not count toward MOOP and the plan does not pay for it.
MOOP protects you from copays on approved services. It does not turn every service into a covered one.
See our Medicare prior authorization guide.
How MOOP compares to Medigap
| Coverage type | Yearly out-of-pocket max (medical) |
|---|---|
| Original Medicare alone | No cap |
| Original Medicare + Medigap Plan G | Approximately $257 (Part B deductible only) |
| Original Medicare + Medigap Plan N | $257 deductible + copays up to about $50 total |
| Original Medicare + High-Deductible Plan G | Approximately $2,870 deductible then $0 |
| Medicare Advantage HMO | Plan MOOP, typically $3,500 to $6,900 |
| Medicare Advantage PPO (combined) | Combined MOOP, up to about $13,300 |
Medigap Plan G caps you at basically the Part B deductible. Medicare Advantage MOOP is a much bigger number in a bad year. That is a real cost difference on paper.
But Advantage has $0 or low premium, plus extras like dental. Medigap has a premium that runs $130 to $250 per month. The full cost comparison isn't just MOOP vs Medigap deductible. Both have trade-offs.
How to use MOOP when shopping plans
When comparing Advantage plans, do NOT just look at the premium. Do this:
- Note the in-network MOOP
- Note the combined MOOP (PPO only)
- Estimate your total copays for typical care (primary care, specialists, imaging, hospital)
- Consider a bad-year scenario (surgery + hospital + rehab)
- Add the premium × 12
- Compare total-cost estimates across plans
A plan with $0 premium but a $7,500 MOOP could cost more in a hospital year than a plan with a $40 premium and a $4,500 MOOP.
Real example: a hospital year
Jane's Medicare Advantage PPO has a $6,000 in-network MOOP and $10,000 combined MOOP. She has hip replacement surgery.
- Hospital copay (5 days at $400): $2,000
- Surgeon (in-network): $500 copay
- Skilled nursing rehab (20 days at $200): $4,000... but she hits MOOP at day 17
- Total after MOOP: $6,000
The plan pays 100% of remaining rehab and follow-up care that year. If Jane had stuck with Original Medicare and no Medigap, she could have paid over $10,000 in copays and coinsurance for the same year.
With Original Medicare + Medigap Plan G, she would have paid just the Part B deductible (~$257).
The mid-year MOOP decision
Say it is October and you have already spent $5,500 toward a $6,500 MOOP. A specialist recommends a procedure that will hit MOOP for sure. Two questions to ask:
- Can I do the procedure in this calendar year, so I hit MOOP now and everything else after is free?
- Or should I wait until January, when MOOP resets but I might spend less overall?
The right answer depends on how much more care you expect this year vs next. If you have follow-up visits, imaging, and therapy coming, doing the procedure in the current year usually saves money because everything else is $0 after MOOP.
Talk to your doctor and your billing team. A quick conversation can save real dollars.
MOOP and chronic conditions
People with chronic conditions like diabetes, heart failure, COPD, or cancer are more likely to hit MOOP. That is not bad. It is why MOOP exists.
If you know you use a lot of care every year, MOOP becomes your practical yearly medical budget. Pick a plan with a lower MOOP even if the premium is higher. On a bad year, you save.
Example: two plans available in the same county.
- Plan A: $0 premium, $7,900 MOOP
- Plan B: $45 premium, $4,500 MOOP
Yearly premium difference: $540. If you hit MOOP on Plan A but not Plan B, Plan B saves $3,400 minus the $540 in premium = $2,860 in a heavy-use year. Plan B wins if you use lots of care.
On a healthy year, Plan A wins by $540. The right pick depends on your health outlook.
Common mistakes
Only looking at the premium
A $0 premium plan can cost $8,000 in a bad year. Look at MOOP, not just premium.
Missing the PPO combined MOOP
The lower number is not your only exposure. Out-of-network costs push you toward the higher combined limit.
Confusing MOOP with drug costs
Two separate limits. Part D has its own $2,100 cap in 2026.
Assuming MOOP includes premium
Premium is separate. You pay it regardless.
Not thinking about MOOP crossing calendar years
MOOP resets January 1. Big surgery in December can start MOOP twice.
The bottom line
MOOP is the yearly ceiling on your medical costs in Medicare Advantage. It replaces the "no cap" problem of Original Medicare. But it only covers approved in-network medical services. Drugs are separate. Premium is separate. Out-of-network on PPO uses a higher limit.
When comparing Advantage plans, always compare MOOP. When comparing Advantage to Original Medicare + Medigap, remember Medigap's effective cap is much lower (about $257 with Plan G). Advantage's MOOP is a real number in a bad year.
Not sure which route protects your budget best? See what Medicare really costs in 2026 or book a free call. We will run your specific scenario side by side.
Frequently asked questions
What is MOOP in Medicare Advantage?
Maximum Out-of-Pocket. The yearly cap on your copays and coinsurance for covered medical care. Once you hit it, the plan pays 100%.
What is the maximum MOOP for Medicare Advantage plans in 2026?
Federal max is around $8,850 in-network and $13,300 combined for 2026 (check current CMS rates). Plans often set MOOPs lower.
Does the Medicare Advantage MOOP include prescription drug costs?
No. Medical and drug costs are separate. Part D has its own $2,100 cap in 2026.
Do PPO plans have two MOOPs?
Yes. A lower in-network MOOP and a higher combined MOOP that includes out-of-network care. Out-of-network only counts toward the higher one.
Does Original Medicare have a MOOP?
No. Original Medicare has no yearly cap. That is why most people add Medigap, which effectively caps your costs.