The Medicare Advantage maximum out-of-pocket limit—often called the MOOP—is the annual limit on how much you can be responsible for in applicable cost sharing for covered Medicare Part A and Part B medical services under your plan. Once you reach your plan’s applicable limit, the plan generally pays 100% for covered health services for the rest of that calendar year.

That’s why the MOOP deserves much more attention when comparing Medicare Advantage plans.

Many shoppers begin with:

“What’s the monthly premium?”

That’s important.

But there’s another question you should put right beside it:

“What’s the maximum out-of-pocket limit?”

A Medicare Advantage plan with a $0 or relatively low monthly premium doesn’t mean you have $0 healthcare costs.

Depending on the plan and services you use, you may still have deductibles, copayments or coinsurance when you receive medical care.

So before choosing Medicare Advantage coverage, learn to compare:

PREMIUM + MEDICAL COST SHARING + MOOP

—not premium alone.

---

What Does MOOP Mean in Medicare Advantage?

MOOP stands for:

Maximum Out-of-Pocket

Medicare Advantage plans are required to limit how much members can pay in applicable cost sharing for covered Medicare Part A and Part B services during a calendar year.

Think of the MOOP as a financial boundary around certain covered medical expenses.

Depending on your plan, costs that may accumulate toward the applicable limit can include cost sharing for services such as:

• Primary care visits
• Specialist visits
• Emergency-room care
• Hospital services
• Outpatient procedures
• Diagnostic imaging
• Ambulance services
• Physical therapy
• Durable medical equipment
• Other covered Part A and Part B medical services

The exact costs and plan rules vary.

That’s why you should look at the MOOP listed for the specific Medicare Advantage plan you’re considering.

---

Premium vs. MOOP: They Answer Two Different Questions

This distinction is critical.

Number	What It Helps You Understand
Monthly Premium	What you pay each month for the plan
Deductible	What you may need to pay before certain coverage applies
Copay/Coinsurance	What you pay when you use certain healthcare services
MOOP	Your annual limit on applicable cost sharing for covered Part A and Part B medical services

A shopper who looks only at the premium is looking at only one piece of the financial picture.

Imagine seeing:

PLAN A

Monthly plan premium: $0

That number gets your attention.

But now imagine also seeing:

Specialist: $____

Hospital: $____

Imaging: $____

Outpatient surgery: $____

Ambulance: $____

MOOP: $____

Now you have a much more meaningful picture of how the plan works financially.

---

A $0 Premium Does Not Mean $0 Healthcare Costs

This is one of the most important Medicare Advantage concepts to understand.

Some Medicare Advantage plans have a $0 additional plan premium.

That does not necessarily mean:

• $0 specialist visits
• $0 hospital stays
• $0 imaging
• $0 ambulance
• $0 outpatient surgery
• $0 medical equipment
• $0 prescriptions
• $0 annual healthcare spending

You generally must also continue paying your Medicare Part B premium to remain enrolled in Medicare Advantage, although some plans may offer a Part B premium reduction benefit.

So when you see:

$0 PREMIUM

don’t interpret that as:

$0 RISK

Those are very different things.

---

What Counts Toward a Medicare Advantage MOOP?

Generally, applicable member cost sharing for covered Medicare Part A and Part B services counts toward the Medicare Advantage maximum out-of-pocket limit.

Depending on the plan and services involved, this can include applicable:

Copayments

and

Coinsurance

for covered medical services.

For example, imagine someone uses:

Medical Care	What the Member Pays
Specialist visits	$_____
Diagnostic imaging	$_____
Emergency room	$_____
Hospital care	$_____
Physical therapy	$_____
Outpatient surgery	$_____

Applicable cost sharing for covered Medicare Part A and Part B services can accumulate toward the plan’s MOOP according to the plan’s rules.

Once the applicable maximum is reached, the plan pays 100% for covered health services for the rest of that calendar year.

---

What Generally Does NOT Count Toward the Medical MOOP?

This is where people can get confused.

The Medicare Advantage medical MOOP is not necessarily a cap on every dollar you could spend on healthcare during the year.

One major example:

Part D prescription drug spending is separate.

If your Medicare Advantage plan includes Part D prescription coverage, your Part D drug costs generally don’t count toward the plan’s medical MOOP.

Part D has its own out-of-pocket structure.

Other amounts that generally aren’t part of the Medicare Advantage medical MOOP calculation can include things such as:

• Monthly plan premiums
• Medicare Part B premiums
• Part D prescription drug spending
• Costs for services that aren’t covered by the plan
• Certain supplemental or non-Medicare-covered services, depending on the plan

Always check the specific plan’s Evidence of Coverage for details.

---

Medical MOOP vs. Part D Drug Limit: Don’t Mix Them Up

Think of these as two separate buckets.

MEDICAL BUCKET	PRESCRIPTION BUCKET
Medicare Advantage medical MOOP	Medicare Part D out-of-pocket limit
Covered Part A & Part B services	Covered Part D prescription drugs
Specialist copays	Drug copays
Hospital cost sharing	Drug coinsurance
Imaging	Covered prescriptions
Outpatient procedures	Part D formulary drugs

For 2026, Medicare has a separate $2,100 annual out-of-pocket threshold for covered Part D prescription drugs.

Once that Part D threshold is reached through qualifying out-of-pocket spending and certain payments made on the beneficiary’s behalf, the beneficiary doesn’t pay additional copayments or coinsurance for covered Part D drugs for the remainder of that calendar year.

That is separate from your Medicare Advantage medical MOOP.

For 2027 plan comparisons, always use the confirmed limits and cost-sharing information for the upcoming plan year rather than assuming the previous year’s numbers remain unchanged.

---

Why MOOP Matters Even If You Rarely Go to the Doctor

You might be thinking:

“I’m healthy. Why should I care about the maximum?”

Because insurance isn’t only about what you expect to happen.

It’s also about what could happen.

You might have a year involving:

• An unexpected hospitalization
• Cancer treatment
• A cardiac event
• Surgery
• A serious accident
• Repeated specialist visits
• Extensive physical therapy
• Advanced imaging
• Durable medical equipment

You may never get close to your plan’s MOOP.

Many beneficiaries won’t.

But understanding the number tells you something important about your potential financial exposure under the plan.

---

Don’t Assume the Lowest MOOP Automatically Wins Either

There’s another side to this.

If Plan A has a lower MOOP than Plan B, that doesn’t automatically make Plan A the better plan for you.

Why?

Because Medicare Advantage needs to be evaluated as a package.

Plan A might have:

✓ Lower MOOP

but:

✗ Your specialist isn’t in-network

or:

✗ Your medications don’t fit as well

or:

✗ Your preferred hospital isn’t participating

or:

✗ The plan structure doesn’t fit your travel habits.

Meanwhile, another plan could have a different MOOP but fit other important healthcare needs better.

So don’t replace:

“Choose the lowest premium.”

with:

“Choose the lowest MOOP.”

Neither is a complete Medicare comparison.

---

A Better Way to Compare Two Medicare Advantage Plans

Suppose you’re deciding between two plans.

Instead of comparing only the premium, create this chart:

Cost Category	Plan A	Plan B
Monthly plan premium	$____	$____
Medical deductible	$____	$____
PCP	$____	$____
Specialist	$____	$____
Emergency room	$____	$____
Inpatient hospital	$____	$____
Outpatient surgery	$____	$____
Diagnostic imaging	$____	$____
Ambulance	$____	$____
Physical therapy	$____	$____
MOOP	$____	$____

Now add another layer:

Coverage Question	Plan A	Plan B
My PCP participates	☐	☐
My specialists participate	☐	☐
My hospital participates	☐	☐
My prescriptions fit	☐	☐
My pharmacy works well	☐	☐
Plan type fits my needs	☐	☐

That’s a much better Medicare Advantage comparison.

---

Low Premium vs. Lower Financial Exposure

Consider this hypothetical example.

Plan A

Premium: Lower

Specialist copay: Higher

Hospital cost sharing: Higher

MOOP: Higher

Plan B

Premium: Higher

Specialist copay: Lower

Hospital cost sharing: Lower

MOOP: Lower

Which plan is cheaper?

You can’t answer from this information alone.

It depends partly on how much healthcare the person uses.

A beneficiary who uses very little medical care could experience the plans differently than someone expecting:

• Multiple specialist visits
• Surgery
• Hospital care
• Physical therapy
• Frequent diagnostic testing

This is why:

LOWER PREMIUM ≠ AUTOMATICALLY LOWER TOTAL COST OR LOWER FINANCIAL RISK

You have to compare how the plan works when healthcare is actually used.

---

Three Medicare Advantage Cost Scenarios

Here’s another way to think about it.

🟢 Scenario 1: Light Healthcare Use

You may primarily have:

• Routine appointments
• Preventive care
• Occasional PCP visits

In a low-use year, the premium and routine cost sharing may receive more attention.

---

🟡 Scenario 2: Moderate Healthcare Use

You might have:

• Multiple specialists
• Diagnostic imaging
• Physical therapy
• Outpatient procedures

Now the individual copays and coinsurance become increasingly important.

---

🔴 Scenario 3: High Healthcare Use

Imagine:

• Hospitalization
• Surgery
• Frequent specialists
• Rehabilitation
• Imaging
• Other significant covered medical care

Now the MOOP deserves serious attention because you’re evaluating the plan under a higher-use scenario.

The same Medicare Advantage plan can look very different across these three situations.

---

The Question Most Shoppers Should Ask

Instead of asking only:

“What’s the cheapest Medicare Advantage plan?”

try asking:

“How would this plan affect me in a low-use, moderate-use and high-use healthcare year?”

That question forces you to look beyond the premium.

---

Find the MOOP in Your Plan Documents

If you already have Medicare Advantage coverage, review your:

Annual Notice of Change (ANOC)

and:

Evidence of Coverage (EOC)

Your ANOC helps identify changes coming for the next plan year.

Your Evidence of Coverage provides detailed information about your benefits, costs and plan rules.

If your MOOP is changing for 2027, that’s something worth circling when reviewing your ANOC.

Internal link: Medicare ANOC Guide
https://medicareplanassistance.com/medicare-anoc-2027-annual-notice-of-change/

---

Add MOOP to Your 2027 Medicare Comparison Checklist

Before choosing Medicare Advantage coverage for 2027, write down these numbers:

Monthly Costs

☐ Plan premium: $______

☐ Part B premium: $______

Routine Care

☐ PCP: $______

☐ Specialist: $______

Higher-Cost Care

☐ Emergency room: $______

☐ Hospital: $______

☐ Outpatient surgery: $______

☐ Imaging: $______

☐ Ambulance: $______

Financial Exposure

☐ MOOP: $______

Then compare your:

☐ Doctors

☐ Hospitals

☐ Prescriptions

☐ Pharmacy

☐ Plan type

☐ Prior authorization requirements

☐ Supplemental benefits

☐ Star Rating

Now you’re looking at the plan from several directions instead of choosing based on one attractive number.

---

What If Your MOOP Increases for 2027?

Don’t automatically switch plans.

First ask:

How much did it change?

Did my other medical copays change?

Did my providers change?

Did my prescriptions change?

Did my supplemental benefits change?

Are there other available plans that fit my needs better?

Your MOOP is an important comparison point.

It’s not the only one.

This is exactly why reviewing your Annual Notice of Change before Medicare Open Enrollment can be valuable.

---

Why MOOP Should Come Before Dental, OTC and Grocery Benefits

Extra benefits can be valuable.

But imagine comparing:

Plan A

Great dental allowance.

Attractive OTC benefit.

Lower MOOP.

Your cardiologist participates.

Your prescriptions fit.

Plan B

Even larger advertised supplemental benefits.

But your specialist doesn’t participate and your medical cost structure creates concerns.

Which plan should you choose?

That requires a broader comparison.

We recommend evaluating the foundation first:

1. Doctors

2. Hospitals

3. Prescriptions

4. Plan type

5. Medical costs

6. MOOP

Then evaluate:

7. Dental

8. Vision

9. Hearing

10. OTC and other supplemental benefits

Extras matter.

But they shouldn’t distract you from understanding your core medical coverage and potential financial exposure.

---

Medicare Advantage vs. Original Medicare: An Important MOOP Difference

There’s another reason MOOP matters.

Original Medicare by itself doesn’t have an annual out-of-pocket maximum for Part A and Part B services.

Medicare confirms that there’s generally no yearly limit on what you pay out of pocket under Original Medicare unless you have additional protection, such as supplemental coverage, or enroll in Medicare Advantage.

Medicare Advantage plans, by contrast, have an annual out-of-pocket limit for covered Part A and Part B medical services.

That doesn’t automatically make Medicare Advantage better than Original Medicare plus Medigap.

They’re different coverage structures.

But it’s an important distinction to understand when comparing Medicare options.

---

Don’t Confuse MOOP With What You Will Actually Spend

A MOOP of $_______ does not mean:

“I will spend $_______ this year.”

It means the plan has established that annual limit for applicable covered medical cost sharing.

Your actual spending could be much lower.

Someone with minimal healthcare use may never come remotely close.

Someone experiencing a serious medical year could accumulate much more cost sharing.

Think of MOOP as a:

RISK NUMBER

rather than a:

PREDICTION NUMBER.

That’s a useful distinction.

---

Compare Medicare Advantage Plans Beyond the Premium

When you’re comparing plans for 2027, don’t stop at:

“This one is $0.”

Write down:

Premium: $______

Specialist: $______

Hospital: $______

Imaging: $______

Outpatient surgery: $______

MOOP: $______

Then check:

Doctors: ✓ / ✗

Hospital: ✓ / ✗

Prescriptions: ✓ / ✗

Pharmacy: ✓ / ✗

Benefits I actually use: ✓ / ✗

That’s how you turn Medicare shopping into an actual comparison.

You can use our Compare Medicare Plans resources to learn what else should be part of your review.

Internal link:
https://medicareplanassistance.com/compare-medicare-plans/

---

Need Help Comparing Medicare Advantage Costs for 2027?

If you’re looking at two Medicare Advantage plans and wondering:

“Which one actually gives me better financial protection?”

don’t send us only the monthly premium.

Bring the whole picture.

Have your:

Plan options

Doctors

Specialists

Prescriptions

Preferred hospital

Expected healthcare needs

nearby.

Then we can help you compare the costs and coverage factors that matter.

Call Medicare Plan Assistance at (561) 808-9410.

Tell us:

“I want to compare the out-of-pocket costs on my Medicare Advantage options.”

We’ll start there.

Local Help. Clear Answers. Better Decisions.

---

Frequently Asked Questions

What is the maximum out-of-pocket limit in Medicare Advantage?

The maximum out-of-pocket limit, or MOOP, is the annual limit on applicable member cost sharing for covered Medicare Part A and Part B services under a Medicare Advantage plan. After reaching the applicable limit, the plan pays 100% for covered health services for the rest of the calendar year.

Does every Medicare Advantage plan have a MOOP?

Medicare Advantage plans are required to have an annual out-of-pocket limit for covered Medicare Part A and Part B services. The specific limit can vary by plan.

Do prescription drugs count toward my Medicare Advantage MOOP?

Part D prescription drug spending generally does not count toward your Medicare Advantage medical MOOP. Medicare Part D has a separate out-of-pocket structure and annual threshold for covered prescription drugs.

Does my Medicare Advantage premium count toward my MOOP?

No. Monthly premiums generally don’t count toward the Medicare Advantage medical maximum out-of-pocket limit.

Does the Medicare Part B premium count toward my MOOP?

No. Your Medicare Part B premium isn’t part of your Medicare Advantage plan’s medical MOOP calculation.

Does a $0-premium Medicare Advantage plan mean I have no healthcare costs?

No. A $0 additional plan premium doesn’t mean healthcare is free. Depending on the plan, you may still have deductibles, copayments, coinsurance and other costs when receiving healthcare. You also generally continue paying the Medicare Part B premium.

Is a lower MOOP always better?

A lower MOOP can reduce one aspect of potential financial exposure, but it doesn’t automatically make a plan the best fit. Provider networks, prescriptions, medical cost sharing, plan type and other coverage factors also matter.

Is MOOP the amount I will spend every year?

No. MOOP is a maximum applicable limit, not a prediction of your annual spending. Many beneficiaries may spend substantially less.

Can Medicare Plan Assistance help me compare MOOP between plans?

Yes. Medicare Plan Assistance can help you compare available Medicare Advantage plans based on premiums, medical cost sharing, MOOP, providers, prescriptions and other priorities. Call (561) 808-9410.