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While Original Medicare has no limit on your annual costs, Medicare Advantage (MA) plans are federally required to have a Maximum Out-of-Pocket (MOOP) limit to protect you from catastrophic medical bills.
For 2026, the federal government has set the following absolute maximum limits for Medicare Advantage plans:
1. The Federal MOOP Limits (2026)
In-Network Max: $9,250 (a slight decrease from $9,350 in 2025).
Combined (In & Out-of-Network) Max: Typically capped around $13,950 for PPO plans.
2. “Most” Plans vs. The Federal Limit
While the numbers above are the legal maximums, most plans set their limits lower to remain competitive.
Average MOOP: Many popular HMO and PPO plans in the San Francisco Bay Area often set their in-network MOOP between $3,500 and $6,500.
Zero-Premium Plans: Often, plans with $0 monthly premiums will have a higher MOOP (closer to the $9,250 limit), while plans with a monthly premium might offer a lower MOOP.
3. What Counts Toward the MOOP?
It is important to understand what expenses actually trigger that safety net:
Included: Your deductibles, copayments, and coinsurance for all Part A and Part B services (doctor visits, hospital stays, lab work, etc.).
Excluded: Your monthly plan premiums, Part B premiums, and Part D prescription drug costs do not count toward this medical MOOP.
4. Part D Out-of-Pocket Cap (The “New” 2025/2026 Rule)
Thanks to the Inflation Reduction Act, there is now a separate, much lower cap for your medications:
Part D Cap: In 2026, the out-of-pocket maximum for covered prescription drugs is $2,100.
Once you spend $2,100 on your meds, you pay $0 for the rest of the year for covered prescriptions.
Summary Table: Out-of-Pocket Caps (2026)
| Expense Category | 2026 Out-of-Pocket Limit |
| Medical (In-Network) | Up to $9,250 (varies by plan) |
| Medical (Combined) | Up to $13,950 (for PPO plans) |
| Prescription Drugs | $2,100 (fixed for all plans) |
Pro Tip: If you reach your MOOP, the insurance company pays 100% of your covered medical costs for the remainder of the calendar year. This is one of the primary reasons people choose MA over Original Medicare without a Supplement.
Would you like me to look up the specific out-of-pocket limits for the top-rated plans in San Francisco Bayarea?
