Understanding Medicare Costs
Medicare MOOP vs. Deductible: What Is the Difference?
A deductible determines when certain cost sharing begins; a maximum out-of-pocket limit caps covered Part A and Part B spending under Medicare Advantage.
The Quick Explanation
Think of the deductible as a possible starting requirement and the MOOP as a medical spending ceiling.
Deductible
A deductible is an amount you may need to pay for certain covered services or prescriptions before the plan begins paying its portion of those costs.
- Can be $0 or more
- May apply only to certain services
- Medical and drug deductibles can be separate
- Usually resets at the start of each plan year
- Does not mean every service is full price beforehand
Maximum Out-of-Pocket Limit
A Medicare Advantage MOOP is the most you pay during the calendar year in qualifying cost sharing for covered Part A and Part B medical services under the plan’s rules.
- Includes qualifying medical cost sharing
- Does not include monthly premiums
- Does not include Part D prescription costs
- May have separate network-based limits
- Resets every January 1
MOOP vs. Deductible Side by Side
| Question | Deductible | Medical MOOP |
|---|---|---|
| What does it do? | Determines when the plan begins sharing certain covered costs | Caps qualifying Part A and Part B cost sharing for the year |
| Must every plan have one? | No. A Medicare Advantage plan may have a $0 medical deductible | Medicare Advantage plans must have a medical out-of-pocket limit |
| Do premiums count? | No | No |
| Do covered medical copays count? | Not toward satisfying the deductible unless specified | Generally yes |
| Do Part D drug costs count? | Only toward a separate Part D deductible | No—Part D has a separate out-of-pocket system |
| Does it reset? | Generally each plan year | Every calendar year |
| What happens after it is reached? | You normally begin paying the plan’s copays or coinsurance | The plan generally pays all covered Part A and Part B costs for the rest of the year |
How a Medicare Advantage Deductible Works
A Medicare Advantage plan can have no medical deductible, one overall medical deductible or a deductible that applies only to particular services. Always read the plan’s Summary of Benefits and Evidence of Coverage.
$0 Medical Deductible
Many plans begin using their listed copayments or coinsurance immediately without requiring an overall medical deductible.
Service-Specific Deductible
A deductible might apply to certain hospital, outpatient or out-of-network services while office visits use a copayment from the beginning.
Separate Drug Deductible
An MAPD plan may have a $0 medical deductible but still have a Part D prescription deductible. Some drug tiers may be excluded from that deductible.
What Counts Toward a Medicare Advantage MOOP?
Costs That Generally Count
- Medical deductibles for covered Part A and Part B care
- Primary care and specialist copayments
- Emergency and urgent care copayments
- Hospital and outpatient medical cost sharing
- Coinsurance for durable medical equipment
- Cost sharing for Part B-covered drugs
- Other qualifying Part A and Part B cost sharing
Costs That Generally Do Not Count
- Your Medicare Part B premium
- The Medicare Advantage plan premium
- Part D premiums, deductibles or drug copayments
- Services the plan does not cover
- Routine benefits used beyond the plan’s allowance
- Amounts paid for noncovered out-of-network care
- Costs caused by failing to follow plan rules
In-Network vs. Combined MOOP Limits
The way the out-of-pocket limit works depends partly on the Medicare Advantage plan type.
HMO Plans
An HMO generally uses an in-network medical MOOP. Except for emergencies, urgent care and certain authorized situations, non-network services may not be covered at all.
Paying for noncovered out-of-network care usually does not move you closer to the plan’s MOOP.
PPO Plans
A PPO may show an in-network limit and a higher combined limit for in-network and covered out-of-network care.
Out-of-network cost sharing is usually higher, and an out-of-network provider must agree to treat you and follow applicable Medicare rules.
How the Deductible and MOOP Work Together
The Plan Year Begins
Deductible and MOOP tracking generally begins again at zero on January 1.
You Receive Covered Care
You pay the deductible, copayment or coinsurance assigned to each covered service.
Qualifying Costs Accumulate
The plan credits eligible Part A and Part B cost sharing toward your medical MOOP.
You Reach the MOOP
The plan generally pays 100% of additional covered Part A and Part B services for the rest of the calendar year.
Simple Example
Imagine a Medicare Advantage plan with a $300 medical deductible and a $5,000 in-network MOOP.
- You pay $300 toward services subject to the deductible.
- You then continue paying listed copayments and coinsurance.
- Qualifying medical payments accumulate toward the $5,000 MOOP.
- After the plan records $5,000 in qualifying in-network medical cost sharing, covered Part A and Part B services are generally paid in full for the rest of the year.
You must still pay applicable premiums and Part D prescription costs.
The Separate 2026 Part D Out-of-Pocket Cap
Medicare Part D prescription drug spending does not count toward a Medicare Advantage medical MOOP. Part D has its own deductible and annual out-of-pocket protection.
2026 Part D Deductible
In 2026, a Part D plan may have a deductible as high as $615. A plan may use a lower deductible or no deductible, and it may exclude certain drug tiers from the deductible.
2026 Part D Out-of-Pocket Cap
In 2026, beneficiaries pay no more than $2,100 in credited out-of-pocket spending for covered Part D drugs during the year.
After reaching the cap, the beneficiary generally pays $0 for additional covered Part D drugs for the remainder of the year.
Learn more in the Medicare Part D guide .
MOOP Under Original Medicare and Medigap
The term MOOP is most commonly used when discussing Medicare Advantage. Original Medicare and Medicare Supplement insurance operate differently.
Original Medicare Alone
Original Medicare does not have one annual medical maximum out-of-pocket limit. Part A uses benefit periods, and Part B generally leaves beneficiaries responsible for 20% coinsurance after the annual deductible.
Most Medigap Plans
Most Medigap plans do not use a traditional MOOP. Instead, the policy pays specified portions of Original Medicare’s deductibles, copayments or coinsurance.
Plans K and L
Medigap Plans K and L use partial cost sharing and annual out-of-pocket limits. For 2026, those limits are $8,000 for Plan K and $4,000 for Plan L.
Learn more about Medicare Supplement insurance .
Why a Low MOOP Is Not the Only Factor
A lower out-of-pocket maximum provides stronger protection during a high-cost medical year, but it does not automatically make a plan the best overall fit.
Also Compare
- Your doctors and hospitals
- Specialist and hospital copayments
- Part B drug coinsurance
- Outpatient surgery costs
- Skilled nursing cost sharing
- Prescription formulary and pharmacy network
- Prior authorization requirements
- Travel and out-of-area coverage
Common Comparison Mistakes
- Comparing only monthly premiums
- Assuming a $0 deductible means $0 medical costs
- Believing Part D spending counts toward the medical MOOP
- Ignoring the out-of-network limit on a PPO
- Assuming every service is covered before the deductible
- Choosing extra benefits over medical-network access
Our guide to choosing a Medicare Advantage plan explains the other factors that deserve attention.
Frequently Asked Questions
Is the deductible added on top of the MOOP?
Generally, no. A medical deductible paid for covered Part A or Part B services normally contributes toward the plan’s medical out-of-pocket limit. Review the Evidence of Coverage for the specific plan.
Does a $0 deductible mean my health care is free?
No. A plan with no medical deductible may still charge copayments or coinsurance for office visits, hospital care, outpatient surgery, medical equipment and other services.
Do monthly premiums count toward the MOOP?
No. Medicare Part B premiums, Medicare Advantage premiums, Part D premiums and IRMAA do not count toward the Medicare Advantage medical MOOP.
Do prescription costs count toward my medical MOOP?
Part D prescription costs do not count toward the Medicare Advantage medical MOOP. Part D has a separate out-of-pocket cap, which is $2,100 in 2026.
Do Part B drugs count toward the medical MOOP?
Cost sharing for covered Part B drugs generally counts toward the Medicare Advantage medical MOOP because those drugs are covered under Part B rather than Part D.
What happens after I reach the MOOP?
The Medicare Advantage plan generally pays 100% of covered Part A and Part B services for the rest of the calendar year, provided you follow the plan’s network, authorization and coverage rules. Premiums and Part D costs continue.
Does out-of-network spending count toward an HMO MOOP?
Usually not when the service is outside the HMO network and is not covered. Emergency, urgent, authorized and certain other protected services may be treated differently.
Does Original Medicare have a MOOP?
No. Original Medicare alone does not have one annual maximum out-of-pocket limit for Part A and Part B services. Medigap coverage can reduce this financial exposure.
Does the MOOP carry into the next year?
No. Medicare Advantage medical MOOP tracking resets on January 1. Amounts paid during one calendar year do not carry into the next.
Where to Find Your Plan’s Numbers
- Summary of Benefits: Provides a shorter overview of the deductible, MOOP and common copayments.
- Evidence of Coverage: Contains the controlling details about what counts toward each limit.
- Explanation of Benefits: Shows claims, your cost-sharing responsibility and the amount credited toward your limit.
- Annual Notice of Change: Explains how the deductible, MOOP and other plan costs will change next year.
Read more about reviewing your Medicare Annual Notice of Change .
Medicare amounts and plan benefits can change each year. Always review the official documents for your particular plan.
Want Help Comparing Your Real Medicare Costs?
I will help you look beyond the monthly premium and compare the deductible, MOOP, hospital costs, provider network, prescriptions and other details that determine what a plan could actually cost you.
Thompson Medicare Brokerage is not connected with or endorsed by the U.S. government or the federal Medicare program.