What the limit covers
The out-of-pocket maximum (often called the MOOP) is the most you pay in a year for covered Part A and Part B services: copays, coinsurance and deductibles. Once you reach it, the plan pays 100% of covered in-network care for the rest of the year.
Premiums don’t count toward it. Neither do Part D drug costs, which have their own yearly cap: $2,100 in 2026 and $2,400 in 2027.
CMS’s three limit levels
CMS sets three ranges each year: lower, intermediate and mandatory. The mandatory limit is the ceiling no plan can go above. Plans that choose a lower limit get more room in how they set some copays.
For 2027, the in-network ranges are $0 to $4,450, $4,451 to $7,150, and $7,151 to $9,850. PPO plans also carry a combined limit for in- and out-of-network care, up to $14,800 in 2027.
| Limit level | 2026 | 2027 |
|---|---|---|
| Lower (in-network) | $0 to $4,200 | $0 to $4,450 |
| Intermediate (in-network) | $4,201 to $6,750 | $4,451 to $7,150 |
| Mandatory ceiling (in-network) | $6,751 to $9,250 | $7,151 to $9,850 |
| PPO combined ceiling (in- and out-of-network) | $13,900 | $14,800 |
Why it matters
Original Medicare has no yearly out-of-pocket limit unless you add a Medigap policy. With Medicare Advantage, the plan’s limit is your worst case for covered care in a bad year, so read it before the premium.
Our county guides, such as Duval County and St. Johns County, list every 2027 plan’s out-of-pocket limit. One conversation is usually enough to know whether this matters for your situation.