Costs
MOOP (Maximum Out-of-Pocket)
Quick answer
MOOP stands for Maximum Out-of-Pocket. It's the yearly cap on what you pay for covered in-network medical services in a Medicare Advantage plan. Once you hit it, the plan pays 100% of covered Part A and Part B care for the rest of the calendar year.
Plain-English definition
Original Medicare has no MOOP. Every Medicare Advantage plan must have one, and CMS caps how high it can go each year.
Why it matters
MOOP is the true financial ceiling in a bad year. Two plans with the same premium can have very different MOOPs.
A simple example
Your MA plan has a $4,500 in-network MOOP. After a hospital stay pushes you to $4,500, the plan pays 100% of covered in-network services the rest of the year.
Common mistakes & misconceptions
- Assuming premiums are what protect you — the MOOP is the true ceiling.
- Confusing the medical MOOP with the Part D drug out-of-pocket cap.
Parent topics
Related terms
Medicare Advantage (Part C)
Medicare Advantage, also called Part C, is a way to receive your Medicare benefits through a private insurance plan approved by Medicare. Plans bundle Part A and Part B, usually include Part D drug coverage, and often add dental, vision, and hearing.
Medicare Part B
Medicare Part B is the medical insurance half of Original Medicare. It covers doctor visits, outpatient care, preventive screenings, mental health services, and durable medical equipment.
Medicare Part D
Medicare Part D is prescription drug coverage sold by private insurance companies approved by Medicare. You get it either as a stand-alone drug plan (PDP) with Original Medicare or bundled inside most Medicare Advantage plans.
Coinsurance
Coinsurance is your share of a covered service as a percentage, not a fixed dollar amount. Original Medicare's Part B coinsurance is 20% after the deductible.
Deductible
A deductible is the amount you pay out of pocket for covered services before your plan starts to pay. Part A, Part B, Part D, and many Medicare Advantage plans each have their own deductibles.
Frequently asked questions
Does Original Medicare have a MOOP?+
No. Only Medicare Advantage plans do.
Do prescription drugs count toward the MOOP?+
No — Part D has its own separate out-of-pocket cap.
People also ask
Is a low MOOP always better?
A lower MOOP means stronger worst-case protection, often paired with a higher premium or narrower network.
Sources & references
📚 Where this information comes from
- Medicare.gov — official U.S. government site for people with Medicare ↗Primary source for benefits, enrollment periods, and plan comparison.
- CMS.gov — Centers for Medicare & Medicaid Services ↗Federal rulemaking, program updates, and official guidance.
- Social Security Administration — Medicare enrollment & premiums ↗Enrollment, premium withholding, and IRMAA determinations.
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Medicare Caddies is an independent insurance agency. We are not affiliated with, endorsed by, or connected to the U.S. government, the federal Medicare program, or the Centers for Medicare & Medicaid Services (CMS). We help compare Medicare Advantage plans from the insurance companies we represent, and we don't offer every plan available in your area.