Medicare Advantage Out-of-Pocket Maximums: The $9,350 Ceiling Explained
The out-of-pocket (MOOP) maximum is Medicare Advantage’s defining safety feature: a hard annual ceiling on what in-network cost-sharing can cost you. The 2025 federal ceiling is $9,350 for in-network-only spending, or $14,000 where in- and out-of-network costs combine — but the majority of plans set their own max lower.
| MOOP concept | Rule | What it means |
|---|---|---|
| Federal in-network ceiling 2025 | $9,350 | No plan may set its in-network max higher |
| Combined ceiling (network + out) | $14,000 | Applies to PPOs counting both layers |
| Plan-set maximums | Often $3,000–7,500 | The number in your plan document is the binding one |
| What counts toward MOOP | Copays, coinsurance, deductibles for covered Part A/B services | Premiums and drug costs (Part D) do not count |
| What happens after MOOP | Plan pays 100% of covered in-network care for the rest of the year | Calendar-year reset |
MOOP versus the Medigap comparison
Medigap Plan G’s effective out-of-pocket ceiling is the $257 Part B deductible — a fraction of any MA MOOP. That gap is the true price of MA’s low premium: you are accepting up to $9,350 (or the plan’s lower max) of exposure in a bad year in exchange for $0 monthly plan cost. Healthy years never reach the ceiling, which is why the choice is really a forecast of your own claim volatility.
Reading the fine print that changes the number
Three details move the real ceiling: tiered MOOPs (some plans set separate lower maxima for in-network only), services excluded from MOOP counting (certain drug or supplemental benefits), and the PPO out-of-network layer, where cost-share can run 40–50% until a separate max. Compare plans on their specific MOOP, not the federal headline — a $4,500 MOOP plan is a materially different product from one at $9,350.
FAQ
Does the Part D drug out-of-pocket cap count toward MOOP?
No — since 2025 Part D has its own $2,000 cap; the two ceilings are separate.
Can my plan’s MOOP increase next year?
Yes — plans reset cost-sharing annually; carriers must notify members each fall of the coming year’s changes.
Is MOOP the same as a deductible?
No — MOOP is the annual ceiling on all cost-sharing combined; deductibles feed into it but are a component, not the ceiling.
Related reading: What is MA · MA vs Medigap · Part D cap details · Plan G contrast