Goodsurance
ES

Costs & IRMAA

Medicare Advantage Out-of-Pocket Limits Have Climbed Nearly 700 Dollars Since 2023

A KFF analysis finds the average in-network spending cap in Medicare Advantage reached 5,421 dollars in 2026, reversing a multi-year downward trend, with about 9 percent of enrollees in plans at the legal maximum of 9,250 dollars.

By the Goodsurance editorial teamJuly 6, 2026

The average in-network out-of-pocket spending limit in Medicare Advantage plans reached 5,421 dollars in 2026, up nearly 700 dollars from 4,685 dollars in 2023, according to a KFF analysis published in May 2026. The increase reverses a trend in which limits had generally declined from about 5,253 dollars in 2017 to that 2023 low.

CMS caps the in-network out-of-pocket limit for Medicare Advantage plans at 9,250 dollars in 2026. About 9 percent of enrollees, roughly 1.8 million people, are in plans set at that ceiling. About one in five enrollees overall are in plans with limits above 7,000 dollars. At the lower end, about 13 percent of enrollees, or roughly 2.8 million people, are in plans with limits of 3,000 dollars or less.

The average Medicare Advantage out-of-pocket limit hit 5,421 dollars in 2026, nearly 700 dollars higher than in 2023, with some plans at the 9,250-dollar ceiling.

Average limits vary by plan structure. Health maintenance organizations have an average in-network limit of 4,636 dollars, while preferred provider organizations average 6,592 dollars. The higher PPO figure reflects the broader network access PPO members receive.

The out-of-pocket limit is the maximum an enrollee can be required to pay for covered in-network services in a plan year before the plan assumes all remaining costs. A rising average limit means a beneficiary who needs extensive care could face a larger personal bill before reaching that full protection.

In plain words

Medicare Advantage plans have a limit on how much you pay each year for your health care. After you hit that limit, the plan pays the rest. In 2026, the average limit is 5,421 dollars. That is about 700 dollars more than it was in 2023. The highest limit any plan is allowed to set is 9,250 dollars. About 1 in 10 Medicare Advantage members is in a plan with that highest limit. HMO plans average around 4,636 dollars and PPO plans average about 6,592 dollars. A higher limit means you could end up paying more out of your own pocket if you need a lot of health care during the year.

Understand the basics first

Source: KFF
Read at the source →

More news

Other stories on what is moving in Medicare.

Costs & IRMAA

Medicare Will Pay 20 Percent Less for the Cheaper Service When a Doctor Bills Both a Visit and a Procedure on the Same Day Starting in 2027

A provision in the final 2027 physician pay rule, published today in the Federal Register, trims reimbursement when a physician furnishes an office visit and a minor procedure on the same date. CMS projects the change will prevent approximately 2.38 billion dollars in extra Medicare payments over the next 10 years.

November 9, 2026

Costs & IRMAA

Medicare Finalizes 2027 Outpatient Rule, Cutting Drug Costs for Patients at Hospital Clinics

CMS issued a final rule November 4 that sets a 2.3 percent hospital outpatient payment increase for 2027 and lowers what Medicare pays hospitals for 340B-acquired drugs, projecting average savings of about 900 dollars for beneficiaries who receive a qualifying drug at a hospital outpatient department.

November 5, 2026

Costs & IRMAA

Nearly All Medicare Stand-Alone Drug Plan Members Will Face a Deductible in 2027, With Averages Up Sharply

A KFF analysis of 2027 Part D plan designs finds average deductibles rising to 643 dollars for stand-alone plan enrollees and 489 dollars for Medicare Advantage drug plan members, while the share of enrollees subject to any deductible expanded in both plan types.

October 30, 2026

Costs & IRMAA

CMS Finalizes 2027 Medicare Dialysis Payment Rate at 297 Dollars and 52 Cents, With a Larger Add-On for Home Dialysis Training

A final rule issued October 28 sets the per-treatment base rate for kidney dialysis facilities and raises the payment designed to encourage training patients to do dialysis at home.

October 29, 2026

Costs & IRMAA

Medicare's Hospital Fund Is Projected to Fall Short of Full Payment Capacity by 2033, Trustees Report Finds

The 2026 Medicare Trustees Report projects the Part A Hospital Insurance fund will be partially depleted in 2033, at which point incoming revenues would cover only 89 percent of covered costs, absent new legislation.

October 26, 2026

Costs & IRMAA

KFF: Nearly Half of Traditional Medicare Beneficiaries Hold Medigap, as Average Monthly Premiums Reach 244 Dollars

A KFF analysis released two days before open enrollment finds 12.9 million people carry supplemental Medigap policies, that average premiums rose 7 percent in a single year, and that Plan G now covers nearly half of all policyholders.

October 15, 2026