Every Medicare Advantage Plan has a yearly out-of-pocket maximum, the most you'll pay for covered Part A and Part B services in a calendar year. Once you reach it, Medicare's handbook says you pay nothing for Part A- and Part B-covered services for the rest of the year. CMS caps the in-network limit at $9,250 for 2026 and $9,850 for 2027, and plans can set lower limits.
What are the federal limits?
CMS publishes the highest limits plans are allowed to set:
| 2026 | 2027 | |
|---|---|---|
| In-network limit (highest allowed) | $9,250 | $9,850 |
| In- and out-of-network combined, for plans like PPOs (highest allowed) | $13,900 | $14,800 |
These are ceilings. Your plan's limit may be lower. Medicare.gov says the limit varies by plan, so check your plan's Evidence of Coverage, Summary of Benefits, or Annual Notice of Change for your exact number. See your Annual Notice of Change.
What counts toward the maximum?
In general, what you pay for covered Part A and Part B services counts, such as:
- Deductibles for medical care.
- Copays for doctor visits, specialists, the ER, and urgent care.
- Coinsurance for things like hospital stays, skilled nursing, outpatient surgery, and imaging.
In an HMO, that's usually in-network care. In a PPO, there may be one limit for in-network care and a higher, combined one for in- and out-of-network care.
What doesn't count?
Things that usually don't count toward the medical out-of-pocket maximum:
- Your monthly premiums, including the Part B premium and any plan premium.
- Part D drug costs. Drugs have a separate cap. Medicare.gov lists it at $2,100 in 2026 and $2,400 in 2027. See the Part D out-of-pocket cap.
- Services the plan doesn't cover.
- Many extra benefits, like some dental, vision, or hearing services. Check your plan's rules. See dental, vision, and hearing bills.
- Out-of-network care in an HMO, except emergencies and other cases the plan covers. See Medicare Advantage out-of-network bills.
How do I know how close I am?
Your plan's Explanation of Benefits (EOB) usually shows a running total toward your out-of-pocket maximum. Look for a line like "amount you've paid toward your out-of-pocket maximum." See how to read a Medicare Advantage Explanation of Benefits.
If you can't find it, call member services.
What to say:
"Can you tell me how much I've paid toward my in-network out-of-pocket maximum for this year, and how much is left? Are there any claims still being processed that would change that?"
What happens after I reach it?
Once you reach the limit, the plan pays 100% of covered Part A and Part B services for the rest of the calendar year. You'd still pay premiums, Part D drug costs until you reach the drug cap, and costs for anything that doesn't count.
The limit resets on January 1. If you've almost reached it and have a surgery planned for early January, you'll start the count over.