Medicare Advantage Out-of-Pocket Maximum 2026

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Quick answer

Every Medicare Advantage plan must cap your in-network out-of-pocket spending each year. For 2026, CMS sets the federal maximum at $9,250 for in-network services, with a higher combined cap for plans that also cover out-of-network care. Many plans set lower limits than the federal ceiling.

The out-of-pocket maximum is one of Medicare Advantage's biggest advantages. Here is how the 2026 cap protects you.

How the out-of-pocket maximum works

The out-of-pocket maximum is the most you'll pay for covered medical services in a year before your Medicare Advantage plan covers 100% of further in-network costs. For 2026, CMS caps the in-network maximum at $9,250, though many plans choose lower limits to compete. Plans with out-of-network benefits (like PPOs) have a separate, higher combined cap. The maximum counts your copays, coinsurance, and deductibles for medical care, but not your monthly premiums or most prescription drug spending, which has its own separate cap under Part D. This protection is a key reason people choose Advantage. Call 1-800-MEDIGAP (1-800-633-4427) to compare caps.

Why the cap matters

Original Medicare has no out-of-pocket maximum, so a serious illness could leave you with unlimited bills unless you add a Medigap policy. Medicare Advantage builds in a cap, giving you a predictable worst-case for the year. Because plans set their own limits below the federal ceiling, a lower out-of-pocket maximum can be worth more than a slightly lower premium if you expect significant care. When comparing plans, always check both the in-network cap and, for PPOs, the combined cap. A licensed advisor at 1-800-MEDIGAP can line up the out-of-pocket maximums of your local plans so you choose the strongest protection for your budget.

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Frequently asked questions

What is the Medicare Advantage out-of-pocket maximum for 2026?+

For 2026, CMS sets the federal in-network out-of-pocket maximum at $9,250 for Medicare Advantage plans, with a higher combined cap for plans covering out-of-network care. Many plans set lower limits to compete. Call 1-800-MEDIGAP to compare the caps on plans in your area.

What counts toward the out-of-pocket maximum?+

Your copays, coinsurance, and deductibles for covered medical services count toward the out-of-pocket maximum. Monthly premiums do not count, and prescription drug costs have a separate cap under Part D. Once you hit the maximum, the plan covers 100% of further covered in-network care.

Does Original Medicare have an out-of-pocket maximum?+

No. Original Medicare has no annual out-of-pocket maximum, so costs can be unlimited without supplemental coverage. This is a major advantage of Medicare Advantage, which always includes a cap. Original Medicare beneficiaries typically add a Medigap policy for similar protection. Call 1-800-MEDIGAP to compare.

Do prescription drugs count toward the maximum?+

No. Prescription drug spending does not count toward the medical out-of-pocket maximum. Drugs have their own separate annual cap under Part D, which improved in recent years to limit what you pay for medications. Your medical and drug spending are tracked separately. Ask 1-800-MEDIGAP for details.

Can a plan have a lower out-of-pocket maximum than the federal cap?+

Yes. The $9,250 in-network figure is the maximum a plan can set for 2026, but many plans choose lower limits to attract members. A lower cap means stronger financial protection. When comparing plans, check each one's specific maximum. A 1-800-MEDIGAP advisor can line them up for you.

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