What is the Medicare Advantage out-of-pocket maximum for 2026?

CMS set the in-network MA MOOP ceiling at $9,250 for 2026. Individual plans may set a lower cap. Once you reach your plan's MOOP, covered in-network services cost $0 for the rest of the year. Prescription drug costs have a separate $2,100 Part D cap. Source: CMS 2026 MA and Part D Rate Announcement.

Do $0 premium Medicare Advantage plans mean Medicare is free?

No. Even with a $0 MA plan premium, you still owe the Medicare Part B premium — $202.90 per month ($2,434.80 per year) in 2026. This is deducted from your Social Security benefit or billed directly. The $0 refers only to the MA plan's own premium charged on top of Part B.

Does the Medicare Advantage MOOP cover prescription drug costs?

No. The $9,250 MOOP covers Part A and Part B medical cost-sharing only. Prescription drug costs under Part D have a completely separate $2,100 out-of-pocket cap in 2026 under the Inflation Reduction Act. In a true worst-case year you could owe both caps plus the Part B premium.

What happens if I need out-of-network care with Medicare Advantage?

HMO plans generally provide no coverage for non-emergency out-of-network care. PPO plans cover out-of-network care at higher cost-sharing, and may have a higher or separate out-of-network MOOP. Always review your plan's Evidence of Coverage before seeing an out-of-network provider.

Do I still pay the Part B premium with Medicare Advantage?

Yes, always. Every Medicare beneficiary on MA still owes the Part B premium — $202.90/month in 2026. Some plans offer a Part B premium giveback, but that is plan-specific and not guaranteed. If you owe IRMAA, your Part B cost is higher regardless of your MA plan.

What is the difference between HMO and PPO Medicare Advantage plans?

HMO plans require in-network providers and referrals for specialists, with lower premiums and more predictable costs. PPO plans allow out-of-network care without referrals, at higher cost-sharing. HMOs typically have lower MOOPs. Find plans at medicare.gov/plan-compare.

Can I switch from Medicare Advantage back to Original Medicare?

Yes. You can switch during Annual Enrollment (Oct 15 to Dec 7) or MA Open Enrollment (Jan 1 to Mar 31). However, switching back to Original Medicare makes getting Medigap coverage harder — most states allow medical underwriting outside your initial enrollment window.

How does IRMAA affect Medicare Advantage costs?

IRMAA surcharges apply to your Part B and Part D premiums — not to your MA plan premium. If your 2024 MAGI exceeded $109,000 (single) or $218,000 (joint), you owe $81.20 to $487.00 extra per month on Part B, on top of any MA plan costs.

Do Medicare Advantage costs change every year?

Yes. MA plans can change premiums, copays, MOOP amounts, drug formularies, and networks annually. Review your Annual Notice of Change letter every September and compare plans at medicare.gov/plan-compare during the Oct 15 to Dec 7 enrollment window each year.

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Last reviewed by the Seniors Audit research team on August 2026

Medicare Advantage Total-Cost Estimator 2026

See your realistic typical-year range and your worst-case in-network cap before you enroll.

Quick Answer

In 2026 the CMS-set Medicare Advantage in-network out-of-pocket ceiling is $9,250 — that is your worst-case medical cost, not counting the Part B premium ($202.90/mo) every beneficiary still owes. Most people in healthy years pay far less. Prescription drug costs have a separate $2,100 cap under the Inflation Reduction Act.

Medicare Advantage plans advertise $0 premiums prominently, which creates a common misunderstanding: that Medicare Advantage is free. It is not. You still owe the Part B premium every month, you pay copays on nearly every service, and if you have a serious health event you could owe up to $9,250 before your plan covers 100%. This tool shows you both numbers — the realistic middle and the hard worst case — so you can budget accurately.

What this tool covers:

Your typical-year estimated cost range based on expected healthcare and drug usage
Your verified worst-case in-network cap ($9,250 MOOP — a direct CMS number)
Why $0 premium plans still cost $2,434.80/year minimum in Part B premiums
Out-of-network cost warnings for HMO vs PPO plan types
How prescription drug costs interact with (but are separate from) the MOOP

Estimate Your Medicare Advantage Annual Costs

All calculations run in your browser. Nothing you enter is stored or transmitted. The $9,250 MOOP and $202.90 Part B premium are official CMS figures. Copay proxies are illustrative estimates, clearly labeled throughout.

FACT = Official government figure, cited. ESTIMATE = Illustrative proxy, varies by plan. DECISION SUPPORT = Educational range.

Important: This estimates a typical plan structure — not any specific plan. MA costs vary significantly by carrier and county. Always verify at medicare.gov/plan-compare using your ZIP code.

Your Date of Birth (used to calculate your age)

Month

Day

Year

Your State

MA plan availability and costs vary by county. See real plans in your ZIP at medicare.gov/plan-compare.

Expected Healthcare Usage This Year

Not sure? Read our guide to how Medicare Advantage works or compare options with the MA vs Original Medicare cost checker.

LowRoutine checkups and preventive care only — no specialist visits, procedures, or hospitalizations Moderate1–2 specialist visits or minor procedures expected — no hospitalization HighSurgery, hospitalization, or ongoing specialist management for a chronic condition expected this year

Do You Expect to Need Out-of-Network Care?

Traveling frequently, a key specialist not in any local MA network, or splitting time between two states? Read how MA networks work vs Original Medicare.

RarelyAll my doctors and specialists are in-network SometimesI may occasionally see an out-of-network provider or travel for care OftenI frequently travel, split time between states, or have a key specialist not in any local MA network

Expected Prescription Drug Usage

Drug costs under MA are tracked separately and have their own $2,100 cap. Read our guide to how Medicare Part D works. For exact costs, use medicare.gov/plan-compare with your medication list.

NoneNo regular prescriptions — drug proxy: $0/yr Low1–2 generic drugs — drug proxy: $200–$500/yr Moderate3–5 mixed generic and brand-name drugs — drug proxy: $800–$1,500/yr HighSpecialty drugs or 6+ medications — capped at 2026 Part D OOP limit: $2,100/yr

Cost Component	Typical Year	Worst Case	Type
Medicare Part B Premium	$2,434.80	$2,434.80	FACT
MA Plan Premium (baseline)	$0 (many plans charge more)	$0	ESTIMATE
Medical Copays / Coinsurance	—	Up to $9,250 MOOP	DECISION SUPPORT
Prescription Drugs (Part D)	—	Up to $2,100 (separate cap)	ESTIMATE
Total	—	—

Your Medicare Advantage Action Plan

Once you have reviewed your estimate, here are the specific steps to take before choosing a Medicare Advantage plan.

Verify every doctor and hospital in the plan's network. At medicare.gov/plan-compare, look up each of your current providers by name in the plan's directory before enrolling — not after.
Check your drug formulary before enrolling. Enter your exact medications at medicare.gov/plan-compare to see real drug costs for each plan. Do not assume your current drugs are covered.
Calculate your IRMAA first. If your 2024 MAGI exceeded $109,000 (single) or $218,000 (joint), your Part B cost is higher than the standard $202.90. Use our IRMAA calculator before finalizing your healthcare budget. Not sure of your MAGI? Use the MAGI for Medicare calculator.
Read the Evidence of Coverage for any plan you are seriously considering. Look specifically for the out-of-network MOOP — it may be much higher than the in-network MOOP, or unlimited for HMO plans.
Compare this estimate against Original Medicare + Medigap. Use our Original Medicare + Medigap + Part D Cost Estimator to see how the two paths compare for your specific situation. The right answer depends on your health, budget, and provider preferences.
Talk to a free SHIP counselor before enrolling. State Health Insurance Assistance Programs provide free, unbiased counseling on all plan options in your county. Find yours at shiphelp.org or call 1-877-839-2675.

How to Use This Tool

Enter your date of birth and state
Your age provides context for the estimate. Your state flags counties with limited MA plan availability or high-cost markets. Actual plan options depend on your specific ZIP code.
Select your expected healthcare usage level
Low = routine checkups only. Moderate = 1-2 specialist visits or minor procedures. High = surgery, hospitalization, or chronic specialist management expected this year.
Choose your out-of-network care frequency
This affects whether the $9,250 MOOP is your real worst case. HMO plans do not cover non-emergency out-of-network care. If you answered Often, read the OON warning in your results carefully.
Select your drug usage tier
Drug costs are tracked separately from medical costs under MA. They have their own $2,100 cap under the Inflation Reduction Act. This proxy gives you an estimated drug cost range.
Review your two numbers
Typical Year is a DECISION SUPPORT estimate using illustrative copay proxies. Worst Case is built from verified CMS facts — MOOP + Part B premium + Part D cap.

Three Hypothetical Scenarios

Fictional examples for educational purposes. They show how the same $9,250 MOOP plays out very differently depending on actual health events and plan structure.

Scenario 1 — Robert, 68, Low Usage, In-Network Only

Robert is in good health. He expects two routine checkups per year and takes one generic medication. He picks a $0 premium MA HMO in his county. His medical copay exposure runs about $200–$500 this year. His generic drug cost: about $200–$400. He still owes the Part B premium of $202.90/month = $2,434.80/year. His realistic total: roughly $2,800–$3,400 — well below the $9,250 MOOP.

Robert used this estimate to budget a healthcare reserve rather than assuming Medicare is free, and avoided a cash-flow surprise when his plan changed copay structures during Annual Enrollment.

Scenario 2 — Gloria, 74, High Usage, Hospitalization Year

Gloria has a hip replacement surgery this year. Her MA PPO covers the procedure in-network, but copays accumulate through the year: hospital admission, physical therapy, specialist follow-ups. By September she reaches her plan's specific $6,700 MOOP (lower than the $9,250 ceiling). After that, all in-network services cost her $0. Her total: $6,700 + $2,434.80 Part B = $9,134.80 — a predictable number she could plan for.

Gloria confirmed her specific plan's MOOP at medicare.gov/plan-compare before her surgery, and verified the hospital and surgeon were in-network. Her plan's MOOP was $6,700 — individual plans can and do set caps below the federal ceiling.

Scenario 3 — Frank, 71, Moderate Usage, Often Out-of-Network

Frank splits time between Florida and Maine. His Florida HMO does not cover non-emergency care in Maine at all. After one out-of-network specialist visit he owes the full bill — the MOOP did not protect him. Frank later switched during Annual Enrollment to a PPO plan covering out-of-network care at 60%, with a higher out-of-network MOOP but actual coverage when he needs it.

Frank's situation shows why the "Often" OON answer triggers the warning in this tool. For frequent travelers or part-year residents, Original Medicare's nationwide acceptance may be more predictable than any MA plan.

These are hypothetical examples for illustration only. Individual results vary based on plan selection, county, health events, provider network status, and enrollment dates. Verify at Medicare.gov before making enrollment decisions.

5 Common Medicare Advantage Cost Mistakes

Mistake 1 — Thinking a $0 Premium Means Medicare Is Free

The Part B premium ($202.90/month in 2026) is owed by every Medicare beneficiary on every plan. A $0 MA plan premium means you pay nothing extra to the plan insurer — you still owe $2,434.80/year to Medicare. This is the single most common budget error new enrollees make.

Always budget the Part B premium as a fixed line item. If you owe IRMAA, use our IRMAA calculator to find your actual Part B cost.

Mistake 2 — Not Verifying Doctors Are In-Network Before Enrolling

MA plan networks change every year. A physician in-network in 2025 may not be in 2026. Enrolling in an HMO without verifying your specific doctors and hospital creates the risk of losing access to providers you rely on, or paying out-of-network rates not capped by the MOOP.

Check the plan's provider directory at medicare.gov/plan-compare every year during Annual Enrollment (October 15 – December 7), not just when you first enroll.

Mistake 3 — Confusing the Medical MOOP With the Drug Out-of-Pocket Cap

The $9,250 MOOP covers medical services only. Drug costs under Part D have a completely separate $2,100 cap in 2026. In a true worst-case year you could owe both caps plus the Part B premium — up to $13,784.80.

Read our guide to how Part D works to understand how the two cost caps interact. The breakdown table in this tool shows both separately.

Mistake 4 — Choosing an HMO When You Need Out-of-Network Flexibility

HMO plans typically provide no coverage for non-emergency out-of-network care. If you travel frequently, see a specialist not in the local network, or split time between states, an HMO's low MOOP is meaningless for out-of-network expenses.

Use our MA vs Original Medicare cost checker if you travel often — Original Medicare's nationwide acceptance may be a better fit.

Mistake 5 — Not Reviewing Your Plan During Annual Enrollment Every Year

MA plans can change premiums, copays, MOOP amounts, drug formularies, and provider networks every year. Your 2025 plan terms may be very different in 2026. The Annual Notice of Change letter mailed in September lists every change your plan is making.

Read your Annual Notice of Change when it arrives in late September and compare alternatives at medicare.gov/plan-compare during the October 15 – December 7 window every year.

Official Sources Used in This Tool

Every government figure used in this tool is cited below. Links verified August 15, 2026. Copay proxies are illustrative estimates labeled throughout as ESTIMATE or DECISION SUPPORT.

Source	Figure Used	Verified	Link
CMS 2026 MA & Part D Rate Announcement	MA in-network MOOP ceiling: $9,250; Part D OOP cap: $2,100	August 15, 2026	CMS 2026 MA Rate Announcement
CMS 2026 Parts A & B Premiums Fact Sheet	Part B standard premium: $202.90/mo; Part B deductible: $283	August 15, 2026	CMS 2026 Parts A & B Fact Sheet
Medicare.gov — 2026 Cost Overview	Part B standard premium confirmation; cost-at-a-glance reference	August 15, 2026	Medicare.gov — 2026 Costs
SSA POMS HI 01101.020	IRMAA income brackets and Part D surcharge tiers (referenced in Action Plan)	August 15, 2026	SSA POMS — IRMAA Tables

Common Questions About Medicare Advantage Costs

What is the Medicare Advantage out-of-pocket maximum for 2026?: CMS set the in-network MA MOOP ceiling at $9,250 for 2026. Individual plans may set a lower cap. Once you reach your plan's MOOP, covered in-network services cost $0 for the rest of the year. Prescription drug costs have a separate $2,100 Part D cap. Source: CMS 2026 MA and Part D Rate Announcement.
Do $0 premium Medicare Advantage plans mean Medicare is free?: No. Even with a $0 MA plan premium, you still owe the Medicare Part B premium — $202.90 per month ($2,434.80 per year) in 2026. This is deducted from your Social Security benefit or billed directly. The $0 refers only to the MA plan's own premium charged on top of Part B.
Does the Medicare Advantage MOOP cover prescription drug costs?: No. The $9,250 MOOP covers Part A and Part B medical cost-sharing only. Prescription drug costs under Part D have a completely separate $2,100 out-of-pocket cap in 2026 under the Inflation Reduction Act. In a true worst-case year you could owe both caps plus the Part B premium.
What happens if I need out-of-network care with Medicare Advantage?: HMO plans generally provide no coverage for non-emergency out-of-network care. PPO plans cover out-of-network care at higher cost-sharing, and may have a higher or separate out-of-network MOOP. Always review your plan's Evidence of Coverage before seeing an out-of-network provider.
Do I still pay the Part B premium with Medicare Advantage?: Yes, always. Every Medicare beneficiary on MA still owes the Part B premium — $202.90/month in 2026. Some plans offer a Part B premium giveback, but that is plan-specific and not guaranteed. If you owe IRMAA, your Part B cost is higher regardless of your MA plan.
What is the difference between HMO and PPO Medicare Advantage plans?: HMO plans require in-network providers and referrals for specialists, with lower premiums and more predictable costs. PPO plans allow out-of-network care without referrals, at higher cost-sharing. HMOs typically have lower MOOPs. Find plans at medicare.gov/plan-compare.
Can I switch from Medicare Advantage back to Original Medicare?: Yes. You can switch during Annual Enrollment (Oct 15 to Dec 7) or MA Open Enrollment (Jan 1 to Mar 31). However, switching back to Original Medicare makes getting Medigap coverage harder — most states allow medical underwriting outside your initial enrollment window.
How does IRMAA affect Medicare Advantage costs?: IRMAA surcharges apply to your Part B and Part D premiums — not to your MA plan premium. If your 2024 MAGI exceeded $109,000 (single) or $218,000 (joint), you owe $81.20 to $487.00 extra per month on Part B, on top of any MA plan costs.
Do Medicare Advantage costs change every year?: Yes. MA plans can change premiums, copays, MOOP amounts, drug formularies, and networks annually. Review your Annual Notice of Change letter every September and compare plans at medicare.gov/plan-compare during the Oct 15 to Dec 7 enrollment window each year.

Related Tools You May Find Useful

Original Medicare + Medigap + Part D Cost Estimator

Compare the Original Medicare + Medigap path side-by-side with this MA estimate.

MA vs Original Medicare Cost Checker

A side-by-side comparison putting both Medicare paths in a single view.

Medicare IRMAA Calculator

Find your exact 2026 Part B and Part D IRMAA surcharges based on your 2024 income.

Medicare Enrollment Deadline Calculator

Find your exact enrollment windows: IEP, SEP, and General Enrollment dates.

Educational Disclaimer

This tool is for educational purposes only. Seniors Audit uses official figures published by the Centers for Medicare and Medicaid Services and the Social Security Administration, but results are estimates based on the information you entered. Medicare Advantage plan costs, networks, formularies, and MOOP limits vary significantly by plan, county, and year. The $9,250 MOOP is the CMS ceiling — individual plans may set a lower MOOP. Rules change annually. Always verify your specific plan details at medicare.gov/plan-compare and confirm with the plan's Evidence of Coverage before enrolling. A free State Health Insurance Assistance Program (SHIP) counselor can review your specific situation at no cost — find yours at shiphelp.org or call 1-877-839-2675. Seniors Audit is independent and not affiliated with any government agency, insurance carrier, or plan.