In the Medicare context, your Maximum Out-of-Pocket,” or “MOOP,”  is the greatest amount of money you may need to pay out of your own resources in any given plan year.

What is the Maximum Out-of-Pocket in Medicare Plans

Once you reach your maximum out-of-pocket limit, your Medicare Advantage, Medicare Part D prescription drug plan, or Medigap  plan will typically cover 100% of your covered medical expenses for the rest of the plan year.

In simpler terms, your Medicare plan’s maximum out-of-pocket limit effectively sets a cap on the amount you’ll spend on healthcare services in a given year.

It’s like having a safety net for your medical expenses. It sets an upper limit on your risk.

What are the Medicare Plan Maximum Out-of-Pocket Limits?

Here’s what you need to know:

  • Original Medicare (Medicare Parts A and B) does not have any maximum out-of-pocket limits at all. Furthermore, you must pay 20% of all your expenses under Part B. Without additional protection, your potential risk is theoretically unlimited. That’s why it’s important to have some additional protection, whether in the form of Medigap or a Medicare Advantage plan.
  • All Medicare Advantage plans are required to set an annual MOOP. Your MOOP may vary with each individual Medicare Advantage plan. But as of 2023, Medicare Advantage plan MOOPs cannot exceed $8,300 for covered in-network services, and $12,450 for covered in-network and out-of-network services combined. For Medigap plans, your maximum out-of-pocket limit depends on the plan you select.
  • For Plan F, which is closed to new Medicare enrollees, the maximum out-of-pocket limit is zero. Plan F covers all deductibles, copays, and co-insurance costs under Medicare Parts A and B.

Plan G:

  • The most comprehensive Medigap plan currently available to new Medicare enrollees is Plan G.
  • It has a maximum out of pocket exposure of $216 as of 2023. That’s the Part B deductible for the year. All other out-of-pocket expenses under Medicare Parts A and B are included in Plan G.
  • For Medicare Part D prescription drug plans, the 2024 MOOP is $8,000. However, the Part D MOOP is set to fall to $2,000 in 2025 (source:

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MOOP: Maximum Out-of-Pocket Explained

Generally, privately-purchased health insurance policies don’t cover everything.

If you need medical care, you will have to pay a certain amount of money yourself, in the form of deductibles, co-insurance, and copays.

This is where MOOP comes into play.

How Your Max Out-of-Pocket Limit Works:

Let’s break down how MOOP works with a hypothetical scenario:

You have a Medicare Advantage plan with a MOOP limit of $8,300.

  1. You get sick and require various medical services throughout the year.
  2. You pay copayments, deductibles, and coinsurance for these services, and these amounts accumulate throughout the plan year.
  3. As you continue to receive care and pay for it, your plan tracks the amount of medical expenses for covered services that  you take on yourself.
  4. Once your cumulative out-of-pocket spending reaches the MOOP limit of $8,300, you have no further out-of-pocket expenses. You pay no more deductibles, copays, or co-insurance. Your health plan will cover 100% of your covered healthcare expenses for the remainder of the year.
  5. You no longer have to worry about paying copays, deductibles, or coinsurance.

What Expenses Don’t  Count Towards MOOP?

The following expenses will not count toward your MOOP:

  • Your monthly premiums
  • Anything you spend for services your plan doesn’t cover
  • Out-of-network care and services
  • Costs above the plan’s allowed amount for a service that a provider may charge

Can maximum out-of-pocket limits change from year to year in Medicare Advantage and Part D plans?

Yes, maximum out-of-pocket limits in Medicare Advantage and Part D plans can change from year to year, so it’s important to review plan documents annually during the open enrollment period.

Is the maximum out-of-pocket limit the same for all Medicare Advantage plans?

No, the maximum out-of-pocket limit can vary between different Medicare Advantage plans.

However, they cannot exceed the maximum out-of-pocket limit established by Congress.

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Final Thoughts on Maximum Out of Pocket Limits

  1. MOOP limits can vary depending on your insurance plan.
  2. Not all healthcare expenses count toward your MOOP. Typically, if a given medical service or product is not covered under your plan, your expenses won’t count toward either your deductible or your MOOP. Make sure to understand which services are covered and which aren’t.
  3. While MOOP sets a cap on out-of-pocket spending, it doesn’t apply to premiums – the monthly cost you pay for your insurance plan.

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Here are few more blogs for further reading: What Kind of Medicare Plan is Best for Me? (Quiz) | When Can You Switch from Medicare Advantage to Medigap? | Can I Change or Switch My Medigap Plan? | Medicare Penalties and How to Avoid Them

Here are some additional pages related to this article: Medi-Share 65+ | Medicare Part D Prescription Drug Coverage

Mike Montes is a Personal Benefits Manager at MediGap Advisors. Mike has a passion for bringing clarity to those confused about Medicare. He is an authority on Medicare, Medicare supplement plans, Medicare Advantage plans, and Part D prescription drug plans. Read more about Mike on his Bio page.