The Medicare Advantage out-of-pocket maximum in 2026, explained
How the in-network out-of-pocket cap works, what counts toward it, the higher combined cap for PPO plans, and how a bad year compares with Medigap.
Every Medicare Advantage plan must cap what you pay for covered Part A and Part B services each year. For 2026, the federal ceiling for in-network services is $9,250. Many plans set a lower cap.
What counts toward the cap
- Copays and coinsurance for doctor visits, hospital stays, outpatient surgery, imaging and similar Part A and B services.
- The plan's medical deductible, if it has one.
What does not count
- Your monthly plan premium and your Part B premium ($203 in 2026).
- Prescription drug costs, which have their own $2,100 yearly cap under Part D; see the Part D cap.
- Extras such as dental, vision and hearing allowances.
- Out-of-network care in an HMO.
PPO plans have two caps
PPOs have an in-network cap and a higher combined cap for in-network and out-of-network care together.
A bad year side by side
In a healthy year a $0-premium Advantage plan usually costs less. In a year with surgery or cancer treatment, you can hit the cap, while a Plan G member pays the Part B deductible plus premiums. The trade-off is explained in Medigap vs Medicare Advantage.
For Washington residents comparing both, Maru Insurance can quote Advantage plans and Medigap side by side.
Questions people ask
What is the MA out-of-pocket maximum in 2026?
Up to $9,250 in network; many plans set lower caps.
Do premiums count toward the cap?
No.
Do drug costs count?
No, drugs have their own Part D cap.
Do PPOs have a different cap?
They also have a higher combined in- and out-of-network cap.
Independent educational site. Not affiliated with or endorsed by the U.S. government, the federal Medicare program, or any insurance company. Figures are 2026 amounts published by CMS unless noted; check Medicare.gov for your situation.