Almost every conversation we have about comparing Medicare Advantage plans eventually lands on the same question: "What's the most this could cost me in a bad year?" That number has a name, the maximum out-of-pocket, or MOOP, and it's one of the most useful figures on a plan's Summary of Benefits, yet it's also one of the most overlooked. A plan can look attractive because of a low premium or a flashy flex card, and still leave you exposed to thousands more in a year with a surgery, a hospital stay, or a new diagnosis.
If you're comparing plans ahead of this year's Annual Enrollment Period, here's what the MOOP actually means, why it varies so much between plans in California, and how to weigh it against everything else on your comparison list.
What Is the Maximum Out-of-Pocket (MOOP) Limit?
Every Medicare Advantage plan is required by law to include an annual limit on what you pay out of pocket for covered medical services, meaning copays, coinsurance, and deductibles combined. Once your covered costs for the year reach that limit, the plan picks up 100% of covered, in-network care for the rest of the plan year. The limit resets every January 1, and it does not carry over or prorate if you enroll partway through the year.
For 2026, CMS caps how high any plan's in-network MOOP is allowed to be at $9,250 a year, with a combined in-network and out-of-network ceiling of $13,900 for PPO plans that cover care outside their network. Those are the maximums CMS allows, not what you should expect to actually pay. Most Medicare Advantage plans sold in California set their MOOP well under that ceiling, commonly somewhere between $3,000 and $7,500 depending on the plan, the carrier, and your county.
In-Network vs. Combined MOOP Limits
If you're comparing an HMO to a PPO, pay attention to which MOOP number you're looking at. HMO plans generally only have one limit, since out-of-network care usually isn't covered except for emergencies. PPO plans often list two numbers: a lower limit for in-network care and a higher combined limit that includes out-of-network costs. If you travel often, split time between two homes, or want the flexibility to see specialists outside the plan's network, that combined number matters more than the in-network figure alone.
Plan A: $0 premium, $7,500 MOOP
A common trade-off in California. The low or no monthly premium is attractive, but if you have a major medical event, you could owe several thousand dollars more out of pocket than a plan with a lower MOOP.
Plan B: modest premium, $3,400 MOOP
A smaller monthly cost, but a much lower ceiling on what you'd ever pay in a serious health year. Often the better fit if you're managing an ongoing condition or expect a procedure.
Why MOOP Matters More If You Have a Chronic Condition or a Planned Procedure
If you're healthy and rarely see a doctor beyond your annual wellness visit, the MOOP is more of a safety net than a number you expect to hit. But if you're managing diabetes, heart disease, or another chronic condition, or you know a surgery or procedure is likely this year, the MOOP stops being theoretical. A plan with a lower premium but a much higher out-of-pocket limit can end up costing more overall than a plan with a slightly higher monthly cost and a lower ceiling. This is exactly the kind of math worth running before AEP, not after a hospital bill shows up.
What Counts Toward Your MOOP, and What Doesn't
Not every dollar you spend on health care applies to the limit. Knowing what counts, and what doesn't, avoids a common surprise.
Usually counts toward your MOOP:
- Copays for doctor visits, specialist visits, and urgent care
- Coinsurance for hospital stays and outpatient procedures
- Plan deductibles for covered medical services
Usually does not count toward your MOOP:
- Your monthly plan premium, if the plan has one
- Most Part D prescription drug costs, which have a separate cap
- Costs for services the plan doesn't cover at all
- Out-of-network costs on an HMO plan, since those usually aren't covered outside emergencies
Because premiums and drug costs sit outside the medical MOOP, two plans with the same out-of-pocket limit can still leave you with very different total annual costs once you add those pieces back in. Our Medicare costs in California guide walks through how all these pieces fit together.
MOOP vs. Medigap: Two Different Ways to Cap Your Costs
If predictable costs matter to you more than a low premium, it's worth comparing Medicare Advantage's MOOP approach against Original Medicare paired with a Medigap policy. Medigap plans like Plan G cover nearly all of your out-of-pocket costs from the first dollar in most cases, rather than requiring you to spend up to a limit first. The trade-off is a higher monthly premium with Medigap versus paying as you go, up to the MOOP, with Medicare Advantage.
Worth comparing side by side: our Medigap in California guide breaks down how Medigap's cost structure differs from a Medicare Advantage MOOP, so you can decide which approach fits your budget and health needs.
If you're helping a Spanish-speaking parent or family member compare these numbers, our sister site Beneficios Medicare covers the same out-of-pocket maximum topic in Spanish.
Not sure how a plan's MOOP compares to what you're paying now?
A licensed Medicare specialist can walk through the real numbers for plans available in your county, at no cost to you.
Schedule a Free Plan ReviewFrequently Asked Questions
What is the Medicare Advantage out-of-pocket maximum for 2026?
CMS caps the in-network limit any plan can set at $9,250 for 2026, with a combined limit of $13,900 for PPOs. Most California plans set their actual MOOP well below that, often between $3,000 and $7,500.
Does the out-of-pocket maximum include my monthly premium?
No. The MOOP only counts copays, coinsurance, and deductibles for covered medical services. Your premium is paid separately, and most Part D drug costs don't count toward it either.
What happens once I reach my MOOP limit?
The plan pays 100% of your covered, in-network medical costs for the rest of the plan year. The limit resets to zero every January 1.
Is the out-of-pocket maximum the same for every Medicare Advantage plan in California?
No. Each plan sets its own MOOP within the CMS ceiling, and it can vary by thousands of dollars, even between two plans from the same carrier in the same county.
Does Original Medicare have an out-of-pocket maximum?
No. Original Medicare has no annual cap on out-of-pocket costs, which is why many people pair it with a Medigap policy or choose Medicare Advantage instead, since Advantage plans are required to include a MOOP.
One More Thought
The out-of-pocket maximum rarely gets the same attention as the premium or the extra benefits during AEP season, but it's the number that matters most in the year something goes wrong. Before you renew or switch, pull the MOOP for your current plan and for anything you're considering, and weigh it against your actual health picture, not just this year's premium.