Your Medicare out-of-pocket maximum is the most you will pay in a calendar year for covered services under Part A (hospital) and Part B (doctor visits and outpatient care). Once you reach that limit, Medicare covers 100 percent of your may be able to access services for the rest of that year. The exact amount changes each year and depends on which type of Medicare coverage you have.

Key Takeaways

  • Original Medicare (Part A and Part B combined) has a Part B deductible you pay first, then coinsurance on services, but no annual out-of-pocket cap — your costs can continue indefinitely.
  • Medicare Advantage plans (Part C) must have an annual out-of-pocket maximum set by federal law, and costs stop once you hit that limit.
  • The out-of-pocket maximum for Medicare Advantage varies by plan and region, typically ranging from $6,700 to $10,000 or more for in-network services.
  • Prescription drug costs under Part D have a separate out-of-pocket maximum, after which the plan covers most remaining drug costs.
  • Costs that do not count toward any out-of-pocket maximum include premiums, balance billing from out-of-network providers, and services Medicare does not cover.

How Original Medicare Differs From Medicare Advantage on Out-of-Pocket Costs

Original Medicare (Part A and Part B) does not have an annual out-of-pocket maximum. You pay a Part B deductible once per year, then coinsurance on most services — typically 20 percent of the approved amount for doctor visits and outpatient care. Hospital stays under Part A involve copayments per day after your deductible. Because there is no cap, your total out-of-pocket costs can grow without limit if you need extensive care.

Medicare Advantage plans (Part C) are required by federal law to set an annual out-of-pocket maximum for in-network services. Once you reach that limit in a calendar year, the plan covers 100 percent of your may be able to access in-network services for the rest of the year. This cap provides a ceiling on your costs that Original Medicare does not offer. Out-of-network services in Medicare Advantage plans often have a separate, higher out-of-pocket maximum.

Many people choose Medicare Advantage specifically because of this spending cap. If you have unpredictable health needs or worry about catastrophic costs, the maximum out-of-pocket limit can provide peace of mind. However, Medicare Advantage plans typically have narrower provider networks and may require referrals for specialists.

What the Out-of-Pocket Maximum Covers and Does Not Cover

The out-of-pocket maximum in Medicare Advantage includes deductibles, copayments, and coinsurance for covered services delivered in-network. Once you hit the limit, the plan pays the full cost of additional covered services for the remainder of the calendar year.

Several costs do not count toward your out-of-pocket maximum, even in Medicare Advantage. Your monthly premium is never included. Balance billing — charges from out-of-network providers that exceed Medicare's approved amount — does not count. Services Medicare does not cover at all, such as routine dental, vision, or hearing care, do not count. If you receive care from an out-of-network provider in a Medicare Advantage plan, those costs typically go toward a separate out-of-pocket maximum for out-of-network services, which is usually higher or unlimited.

This distinction matters because your actual spending can exceed the in-network out-of-pocket maximum if you use out-of-network providers or receive non-covered services. Always check your plan documents to understand which costs explore to your specific maximum.

Medicare Advantage Out-of-Pocket Maximums by Year and Plan Type

The federal government sets a minimum and maximum limit for what Medicare Advantage plans can charge as an out-of-pocket maximum. The exact amount your plan uses depends on the insurance company and the specific plan you choose. Plans in the same region often have different out-of-pocket maximums, so comparing plans side by side is essential.

In recent years, in-network out-of-pocket maximums for Medicare Advantage plans have typically ranged from around $6,700 to $10,000 or higher, though the federal limits change annually. Some plans offer lower maximums to attract enrollees, while others set higher ones. Out-of-network maximums, where they exist, are often double the in-network maximum or may be unlimited.

You can find the exact out-of-pocket maximum for any Medicare Advantage plan you are considering by reviewing the plan's Summary of Benefits and Coverage document, available on the plan's website or by calling the plan directly. This document lists deductibles, copayments, coinsurance, and the annual out-of-pocket maximum for in-network and out-of-network services.

Part D Prescription Drug Out-of-Pocket Maximum

Part D prescription drug coverage has its own separate out-of-pocket maximum. This limit applies only to the cost of covered drugs and does not include your Part D premium. Once you reach the Part D out-of-pocket maximum in a calendar year, your plan covers most of the cost of any additional covered drugs for the rest of the year.

The Part D out-of-pocket maximum amount changes each year. After you reach it, you typically pay only a small copayment or coinsurance for covered drugs. This cap protects you from unlimited drug costs, which is especially important if you take multiple medications or expensive specialty drugs.

If you have a Medicare Advantage plan that includes Part D coverage (called an MA-PD plan), the Part D out-of-pocket maximum is separate from your medical out-of-pocket maximum. You could reach both limits in the same year, meaning you would have two different spending caps protecting you.

Strategies to Manage Your Out-of-Pocket Costs

Understanding your out-of-pocket maximum helps you budget for healthcare, but several strategies can help you keep costs lower. First, stay in-network whenever possible if you have a Medicare Advantage plan. In-network providers are bound by your plan's out-of-pocket maximum; out-of-network care often is not.

Second, use preventive services that Medicare covers at no cost. Annual wellness visits, screenings for cancer and heart disease, and vaccinations are covered with no deductible or coinsurance under both Original Medicare and Medicare Advantage. Taking advantage of these services can catch problems early and reduce larger expenses later.

Third, if you have Original Medicare and are concerned about unlimited out-of-pocket costs, consider a Medigap (supplemental insurance) policy. Medigap plans help pay the deductibles and coinsurance that Original Medicare does not cover, providing a more predictable spending limit. Medigap has its own costs and rules, so compare options carefully.

Fourth, keep track of your out-of-pocket spending throughout the year. Once you are close to your maximum in a Medicare Advantage plan, you know that additional covered services will be fully covered. This can help you plan elective procedures or catch-up care near the end of the year.

How to Find Your Plan's Out-of-Pocket Maximum

If you have a Medicare Advantage plan, your out-of-pocket maximum should be listed in your plan documents, which you receive when you enroll. Look for the Summary of Benefits and Coverage or the Evidence of Coverage document. These explain your deductibles, copayments, coinsurance, and annual out-of-pocket maximum for both in-network and out-of-network services.

You can also call your plan's customer service number, listed on your insurance card, and ask directly: "What is my annual out-of-pocket maximum for in-network services?" Have your member ID ready. The representative can tell you the exact amount and explain which services count toward it.

If you are comparing Medicare Advantage plans during the annual enrollment period (October 15 to December 7), use Medicare.gov's plan comparison tool. Enter your zip code and current medications, and the tool will show you the out-of-pocket maximum for each plan available in your area, along with other costs and coverage details.

Frequently Asked Questions

Does my Part D premium count toward my out-of-pocket maximum?

No. Your monthly Part D premium is separate and never counts toward your out-of-pocket maximum. Only the actual cost of covered drugs you purchase counts toward the limit.

What happens if I go to an out-of-network doctor in a Medicare Advantage plan?

Out-of-network costs typically go toward a separate out-of-pocket maximum, which is often higher or unlimited. You may also face balance billing. To avoid surprises, ask your doctor's office whether they are in-network before your visit, or call your plan to confirm.

If I have Original Medicare, can I get an out-of-pocket maximum like Medicare Advantage has?

Original Medicare itself does not have an out-of-pocket cap, but you can add a Medigap supplemental insurance policy that limits your costs. Medigap plans vary in what they cover, so compare plans to find one that fits your budget and health needs.

Does my out-of-pocket maximum reset on January 1st?

Yes. The calendar year runs from January 1 to December 31. Your out-of-pocket spending resets to zero on January 1st each year, and you start working toward your new annual maximum.

Are dental and vision costs included in my Medicare out-of-pocket maximum?

Original Medicare does not cover routine dental, vision, or hearing care, so those costs do not count toward any maximum. Some Medicare Advantage plans offer dental or vision benefits as an extra feature; if they do, those costs may count toward your out-of-pocket maximum. Check your plan documents to see what is included.