The 2025 Out-of-Pocket Maximum for Medicare Part A and Part B

In 2025, the maximum out-of-pocket limit for Original Medicare (Part A and Part B combined) is $7,550 for in-network care. Once you reach this amount in a calendar year, Medicare covers 100% of your may be able to access services for the rest of that year. This limit applies only to costs you pay toward your deductible and coinsurance — it does not include your monthly premiums or charges for services Medicare does not cover.

The limit breaks down into two parts: Part A (hospital insurance) has a deductible of $1,676 per benefit period, and Part B (medical insurance) has a deductible of $240 per year. After you meet these deductibles, you typically pay 20% coinsurance on most Part B services. Once your combined out-of-pocket spending reaches $7,550, that 20% coinsurance drops to zero for the remainder of the calendar year.

This limit is different from what you pay in a Medigap or Medicare Advantage plan. If you have supplemental coverage, your out-of-pocket costs may be lower because your supplemental plan may cover some or all of the costs that Original Medicare leaves to you.

Key Takeaways

  • The 2025 out-of-pocket maximum for Original Medicare is $7,550 per calendar year for in-network care.
  • This limit covers only deductibles and coinsurance, not premiums or services Medicare does not cover.
  • Medicare Advantage plans have their own out-of-pocket maximums, which vary by plan and may be lower or higher than Original Medicare.
  • Once you reach the out-of-pocket maximum, Medicare covers 100% of may be able to access services for the rest of that calendar year.
  • Medigap plans can reduce your out-of-pocket costs by covering some or all of the deductibles and coinsurance that Original Medicare requires you to pay.

How the Out-of-Pocket Maximum Works in Practice

The $7,550 limit is a cumulative total across all your may be able to access Medicare services in a single calendar year. If you have a hospital stay in January that costs you $2,000 in coinsurance, and then outpatient surgery in June that costs you $1,500 in coinsurance, both amounts count toward your $7,550 limit. Once your total reaches $7,550, you stop paying coinsurance on covered services.

The limit resets on January 1 each year. If you reach your maximum in November, you still pay zero coinsurance for December, but on January 1 the counter starts over at zero. This means your out-of-pocket costs can spike in January and early February as you work toward meeting the new year's deductible.

Important: the out-of-pocket maximum does not include your monthly Part B premium (currently $174.70 for most people in 2025, though higher earners pay more). It also does not include Part D prescription drug costs, which have their own separate out-of-pocket maximum of $8,000 in 2025.

Medicare Advantage Out-of-Pocket Maximums

If you have a Medicare Advantage plan (Part C), your out-of-pocket maximum is set by your individual plan and can range from around $4,000 to $10,000 or higher, depending on the plan and your location. Medicare Advantage plans are required to have an out-of-pocket maximum, but the amount varies widely. Some plans have lower maximums to attract members; others have higher ones.

When you reach your Medicare Advantage plan's out-of-pocket maximum, the plan covers 100% of your in-network care for the rest of that year. Out-of-network care may have a separate, higher out-of-pocket maximum or may not be covered at all, depending on your plan's rules.

To find your specific plan's out-of-pocket maximum, check your plan documents or call the plan's customer service number. The amount is also listed on Medicare.gov when you compare plans during the annual enrollment period.

What Counts Toward Your Out-of-Pocket Maximum

Your deductibles and coinsurance count toward the limit. This includes the Part A hospital deductible, Part B deductible, and the 20% coinsurance you pay on most Part B services like doctor visits, lab tests, and imaging. Copayments for certain services (such as some mental health visits) also count.

What does not count: your monthly premiums for Part B, Part D, or Medigap; charges for services Medicare does not cover; balance billing from providers who do not accept Medicare assignment; and any costs above what Medicare allows for a service. If a provider charges more than Medicare's approved amount and does not accept assignment, you may owe the difference, and that overage does not count toward your out-of-pocket maximum.

Medigap Plans and Out-of-Pocket Costs

A Medigap (supplemental insurance) plan can significantly reduce your out-of-pocket costs by covering some or all of the deductibles and coinsurance that Original Medicare requires. For example, Medigap Plan G covers your Part B deductible and 20% coinsurance on most services, meaning you may have very little out-of-pocket cost once you meet the plan's premium.

Medigap plans do not have an out-of-pocket maximum in the same way Medicare Advantage does. Instead, they cover specific costs up to 100%. Your total out-of-pocket expense depends on which Medigap plan you choose and what your plan covers. Plans with broader coverage (like Plan G or Plan F, if you are may be able to access) typically have higher premiums but lower out-of-pocket costs when you use care.

If you are considering Medigap, compare the monthly premium against the out-of-pocket maximum you might reach with Original Medicare alone. For someone who uses a lot of medical services, a Medigap plan with higher premiums may save money overall.

Part D Prescription Drug Out-of-Pocket Maximum

Part D (prescription drug coverage) has its own separate out-of-pocket maximum of $8,000 in 2025. This limit applies only to your drug costs, not to your medical costs under Part A and Part B. Once you reach $8,000 in out-of-pocket drug spending, your Part D plan covers 100% of your prescription costs for the rest of that year.

The $8,000 limit includes your deductible (if your plan has one), copayments, and coinsurance on covered drugs. It does not include your monthly Part D premium. After you reach the limit, you pay nothing for covered prescriptions for the remainder of the calendar year.

If you have a Medigap plan, it may cover some or all of your Part D costs, which can help you reach your out-of-pocket maximum more slowly or avoid it altogether.

Planning for Out-of-Pocket Costs

To estimate your out-of-pocket costs for 2025, start by listing the services you expect to use: doctor visits, hospital stays, imaging, lab work, and prescriptions. Then check your plan documents or Medicare.gov to find the deductibles and coinsurance rates. Multiply the coinsurance rate (usually 20%) by the estimated cost of each service, and add up the totals.

If you expect to reach your out-of-pocket maximum, consider whether a Medigap plan might save you money in the long run. If you use very few services, Original Medicare with no supplemental coverage may be cheaper overall because you avoid paying a Medigap premium.

Keep receipts and track your out-of-pocket spending throughout the year. Once you reach your maximum, you can stop worrying about coinsurance for the rest of that year. Some people find it helpful to set aside money each month in a health savings account or separate fund to cover their expected out-of-pocket costs.

Frequently Asked Questions

Does my monthly Medicare premium count toward the out-of-pocket maximum?

No. Your Part B premium, Part D premium, and any Medigap premium do not count toward the out-of-pocket maximum. Only deductibles and coinsurance count. This means you pay your premiums on top of your out-of-pocket costs.

What happens to my out-of-pocket maximum if I switch plans mid-year?

If you switch from Original Medicare to a Medicare Advantage plan (or vice versa) mid-year, your out-of-pocket spending does not carry over. Your new plan's out-of-pocket counter starts at zero on the date your new coverage begins. Any costs you paid under your old plan do not count toward your new plan's maximum.

If I have both Original Medicare and a Medigap plan, do I still have an out-of-pocket maximum?

You still have an out-of-pocket maximum under Original Medicare ($7,550 in 2025), but your Medigap plan covers most or all of the costs that would count toward it. Your actual out-of-pocket expense depends on your Medigap plan's coverage and premium.

Can my out-of-pocket maximum change during the year?

No. The out-of-pocket maximum for 2025 is fixed at $7,550 for Original Medicare and does not change mid-year. Medicare Advantage plans also lock in their out-of-pocket maximums for the year. The amounts change only on January 1 of the following year.

Are there any services that do not count toward my out-of-pocket maximum?

Yes. Services Medicare does not cover (like routine dental, vision, or hearing aids) do not count. Balance billing from out-of-network providers also does not count. Charges above Medicare's approved amount do not count unless your provider accepts assignment.