What is an out of pocket maximum?
In short: An out of pocket maximum is the most you pay for covered care in a plan year. After that, the plan pays the rest. In 2026, Medicare Advantage caps it at $9,250 in-network, and Original Medicare has no cap at all.
That last part is what catches families. Your mother gets a hospital bill, and you assume there's a ceiling somewhere. With Original Medicare alone, there isn't one. If a bill is bigger than it should be, or a claim was denied, Navigate Care explains how a navigator can follow through on it, and what that may cost, on its what you will pay page.
HealthCare.gov defines the term as the most you have to pay for covered services in a plan year. It's a ceiling, not a bill. Most years your parent never reaches it. It matters in the bad year: the surgery, the long stay, the cancer treatment.
How it fills up
Every dollar your parent pays toward covered care adds to the running total. Deductibles, copayments and coinsurance are cost sharing, and plans usually count them, though you should confirm. When the total hits the limit, your parent pays nothing more for covered care until the plan year ends. Then it resets.
Here's an example with round numbers. It is illustrative and not a Medicare figure. Say a plan has a $1,000 deductible and a $10,000 limit. Your parent pays the first $1,000 in full. After that the cost is shared. Once everything your parent has paid adds up to $10,000, the plan pays 100% of covered care for the rest of the year.
What doesn't count toward it
This is the part nobody explains. HealthCare.gov lists four things that don't count toward the limit: monthly premiums, services the plan doesn't cover, out-of-network care, and charges a provider bills above the plan's allowed amount.
So the limit isn't the most your parent will spend on health care in a year. It's the most they'll pay for covered, in-network care, on top of the premium. Check your parent's own plan documents for how each item is treated, since rules differ plan to plan.
Where Medicare has one, and where it doesn't
Medicare isn't one plan, so it isn't one answer. There are three.
Out of pocket limits across Medicare in 2026
| Coverage | Yearly limit in 2026 | What it covers |
|---|---|---|
| Original Medicare (Parts A and B) | None | Hospital and doctor costs |
| Medicare Advantage (Part C) | Up to $9,250 in-network, $13,900 combined | Part A and B services only |
| Part D drug plan | $2,100 | Covered prescription drugs |
Source: KFF, Medicare.gov
Original Medicare. In 2026 your parent pays a $283 Part B deductible, then usually 20% of each covered service. Medicare.gov says plainly that there's no yearly limit on what you pay out-of-pocket, unless you have supplemental coverage. Medigap or a Medicare Advantage plan can provide that protection. They don't work together: it's one or the other. Our guide to Medicare insurance plans compared shows how.
Medicare Advantage. Every plan has a limit. KFF reports that in 2026 it may not exceed $9,250 for in-network services and $13,900 for in-network and out-of-network services combined, though plans can set lower limits. So the number on your parent's plan may be well under the cap. Look for it in the plan's summary of benefits. More on this in our Medicare Part C guide.
Part D. Drugs have their own, separate limit. Medicare.gov says that once out-of-pocket spending on covered drugs reaches $2,100 in 2026, your parent pays nothing more for covered Part D drugs for the rest of the calendar year. It doesn't count toward the Advantage limit, and the Advantage limit doesn't count toward it. Read more in Medicare Part D.
Who to ask before you decide
Choosing between a cap and an open network is a real trade, and we don't give financial advice. SHIP, the free State Health Insurance Assistance Program, will walk through it with you and doesn't sell plans. If your parent is already in a plan and a bill looks wrong, check the plan's own running total first. Then ask the plan or SHIP what has been counted.
Frequently asked questions
Is an out of pocket maximum the same as a deductible?
No. A deductible is what your parent pays before the plan starts sharing costs. The out of pocket maximum is the ceiling on everything they pay in the year. Ask the plan whether the deductible counts toward it.
Does Original Medicare have an out of pocket maximum?
No. Medicare.gov says there's no yearly limit on what you pay out-of-pocket, unless you have supplemental coverage. In 2026 that means the $283 Part B deductible and then usually 20% of each covered service, with no stop.
Do premiums count toward the out of pocket maximum?
Generally no. HealthCare.gov lists monthly premiums among the costs that don't count. Check your parent's plan documents to see how their plan treats each cost.
What happens when my parent reaches the limit?
For covered, in-network care, the plan pays the rest of the plan year. For Part D, your parent pays nothing more for covered drugs for the rest of the calendar year. Care outside the plan's coverage still has to be paid for.
Does the limit reset every year?
Yes. The limit applies to a plan year, so the running total starts again at zero when a new year begins.
