Medicare Advantage Max Out-of-Pocket (MOOP): What Counts and What Doesn’t?

Understanding the Medicare Advantage Max Out-of-Pocket Limit

When comparing Medicare Advantage coverage options, one of the critical features to grasp is the Maximum Out-of-Pocket (MOOP) limit. This annual ceiling determines how much you pay for Medicare Advantage out-of-pocket costs before your plan covers 100 % of in-network services.

Unlike Original Medicare, which does not include a spending cap, MOOP offers protection from runaway expenses. As you read on, you’ll see how MOOP works, what expenses count toward it, and how to use that knowledge to choose or evaluate your plan.

What Is MOOP in Medicare Advantage?

The Medicare Advantage MOOP is the maximum amount you must pay in a plan year for covered in-network services. After you hit this limit, your plan pays 100 % of Medicare-approved services for the rest of the year.

Here’s what usually counts toward MOOP:

• Copayments for doctor visits, specialists, and hospitals

• Coinsurance for outpatient procedures, lab tests, and imaging

• Deductibles (if your plan includes one)

• Emergency and urgent care received within the U.S.

For 2025, federal regulations cap the in-network MOOP at $9,350.

Plans may choose lower limits, but not higher. If you’re curious about how Medicare costs in general are trending, you may also want to check our update on 2025 Medicare cost changes.

What Doesn’t Count?

Keep in mind: not every dollar you spend goes toward your MOOP. Key exclusions include:

• Prescription drugs, since Part D costs are tracked separately

• Monthly premiums for your MA plan

• Top Medicare Advantage benefits such as routine Dental, vision, or hearing services outside of core Medicare coverage

• Elective or non-covered services (e.g., cosmetic procedures)

• Out-of-network expenses, unless your plan (e.g. PPO) allows partial credit

FAQ highlight: Do drug costs count toward MOOP?
No. Even when bundled, your prescription drug spending is managed via Part D.

Medicare Advantage vs. Original Medicare: Out-of-Pocket Costs

If you’re weighing between sticking with MA or switching back, see how Medicare Advantage compares to Original Medicare.

FAQ

What counts toward Medicare Advantage MOOP?
Costs such as copays, coinsurance, and deductibles for covered services.

Do drug costs count toward MOOP?
No, your prescription costs fall under Part D, and are handled separately.

What expenses don’t count toward MOOP?
Premiums, services not covered by Medicare, and extras like dental/vision.

Does the MOOP reset every year?
Yes. MOOP resets on January 1 each calendar year.

How is MOOP different from general MA plan costs?
MOOP is one component of the total cost. MA plans also involve premiums, deductibles, and cost sharing—you can learn more about those in our costs overview for Medicare Advantage plans.

How to Plan Around Medicare Advantage Out-of-Pocket Maximums

• Compare plan MOOPs carefully: Lower MOOPs often come with higher premiums.

• Track your expenses through your plan dashboard or finance app.

• Stick to in-network providers so your spending actually counts toward the MOOP.

• Consider long-term care needs: If you anticipate needing assisted living or nursing home care, see how that intersects with MA coverage for these services.

• Get expert help: A knowledgeable Medicare insurance agent can help you compare MOOPs, premiums, and extras.

Bottom Line

The Medicare Advantage max out-of-pocket limit is a crucial tool in protecting you from unbounded expenses—but it doesn’t include every cost. By knowing what counts and what doesn’t, you can better compare plans, budget your spending, and choose coverage that fits your needs.