Medicare beneficiaries enrolled in Medicare Advantage plans will face a maximum out-of-pocket spending limit of $9,250 for in-network services in 2026, a federally mandated ceiling that Original Medicare does not provide on its own. The Centers for Medicare & Medicaid Services (CMS) set this cap through its CY 2026 MOOP and Cost Sharing Limit Calculations, released alongside final 2026 payment policy updates. For the roughly 30 million-plus Americans on Medicare Advantage, the cap means plans must cover 100% of covered services once a beneficiary hits the threshold. For those on Original Medicare without supplemental coverage, no such annual limit exists.
Why the $9,250 in-network cap changes the 2026 enrollment calculus
The gap between the two coverage structures is not new, but the specific dollar amount CMS attaches to the cap each year directly shapes how beneficiaries weigh their options during open enrollment. The CMS bid and rate materials list $9,250 as the mandatory in-network maximum out-of-pocket limit for 2026. Once a beneficiary’s cost sharing reaches that amount within a plan year, the plan pays the full cost of additional covered services. Original Medicare, by contrast, carries no equivalent annual ceiling. As Medicare.gov explains, there is no yearly limit on what someone pays out of pocket for Part A and Part B services unless supplemental coverage or a Medicare Advantage plan is in place.
That structural difference creates a concrete financial decision point. A beneficiary on Original Medicare who undergoes surgery, extended hospitalization, or a course of chemotherapy can face open-ended cost sharing through the 20% Part B coinsurance and hospital deductibles. A Medicare Advantage enrollee facing the same medical needs would stop paying once reaching $9,250 in-network, assuming the services are covered and the providers are within the plan’s network. The protection is automatic and does not require purchasing a separate Medigap policy, which itself can carry substantial monthly premiums depending on the plan letter, the enrollee’s age, and the state’s pricing rules.
However, the presence of a MOOP does not automatically make Medicare Advantage the better choice for every beneficiary. People who already hold comprehensive Medigap coverage effectively create their own cap by shifting most Part A and Part B cost sharing to the supplemental insurer, in exchange for a predictable monthly premium. For those individuals, the value of a $9,250 statutory ceiling is less pronounced, particularly if they prioritize broad provider access and are willing to pay higher premiums to avoid network restrictions and prior authorization requirements.
One hypothesis worth tracking is how future changes to the MOOP influence plan selection. If CMS raises the cap substantially in later years, the cost-certainty advantage of Medicare Advantage could narrow for beneficiaries who already own Medigap policies and are comparing overall spending, including premiums. County-level CMS enrollment files released after the 2026 open-enrollment period could reveal whether higher caps correlate with slower Medicare Advantage enrollment growth among people who previously switched from Original Medicare plus Medigap. That data does not yet exist for the 2026 plan year, but the question frames the competitive tension between the two coverage paths.
Federal rules and CMS documents behind the $9,250 ceiling
The cap is not a voluntary benefit that plans choose to offer. Federal regulation under 42 CFR 422.100 requires Medicare Advantage organizations to comply with CMS-specified MOOP limits and cost-sharing standards. CMS issues annual guidance that sets these limits, and plans must build their benefit designs within those boundaries before submitting bids for the coming contract year. Plans that propose higher in-network out-of-pocket maximums than CMS allows cannot be approved.
To operationalize the rules, CMS releases its annual rate announcement, technical guidance, and bid review memos that spell out the numerical MOOP thresholds and the maximum cost-sharing levels for different categories of services. The $9,250 figure for 2026 is the mandatory in-network ceiling, meaning no approved Medicare Advantage plan can expose enrollees to higher in-network cost sharing for Medicare-covered Part A and Part B benefits. Plans are permitted to offer a lower MOOP as a competitive feature, and many do so to attract enrollees who are particularly sensitive to catastrophic costs.
These requirements sit alongside other federal standards governing network adequacy, marketing practices, and supplemental benefits. Together, they define the basic framework within which private insurers can design Medicare Advantage products. While insurers retain flexibility to vary premiums, copays, and extra benefits such as dental or vision coverage, they cannot opt out of the MOOP requirement or substitute a higher limit in exchange for richer supplemental perks.
How the cap fits into broader coverage comparisons
For beneficiaries comparing coverage paths, the MOOP is one of several levers that affect financial risk. Medicare.gov’s comparison of Original Medicare and Medicare Advantage highlights that only Medicare Advantage plans are required to include an annual out-of-pocket maximum for Part A and Part B services. Original Medicare alone leaves beneficiaries exposed to unlimited cost sharing, though Medigap policies can substantially reduce that exposure, and separate Part D plans address prescription drug coverage.
In practice, the 2026 $9,250 cap will matter most to people who experience high-cost years-major surgeries, prolonged hospital stays, or intensive outpatient treatments. For healthier enrollees who rarely use services, the MOOP may never come into play, making premiums, networks, and extras like dental coverage more salient. As the 2026 plan year approaches, beneficiaries and advisors weighing options will need to consider not only the headline MOOP figure but also how it interacts with expected health needs, tolerance for network limits, and the cost of any supplemental coverage that would be required to approximate similar protection under Original Medicare.
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