Definition. An out-of-pocket maximum is the most you pay in a year for covered services before your coverage pays 100%. Original Medicare has none. Medicare Advantage plans must have one (no more than $9,250 in-network in 2026), and Part D caps covered drug costs at $2,100 in 2026.
What it means
- Original Medicare alone has no out-of-pocket maximum. After the Part B deductible you generally pay 20% of the Medicare-approved amount, with no ceiling.
- Medicare Advantage plans must cap what you pay for covered Part A and Part B services. For 2026, Medicare's limit is $9,250 for in-network services and $13,900 for in- and out-of-network services combined in plans that cover both. Each plan sets its own amount within those limits; check the plan's Summary of Benefits.
- Part D has a yearly cap on what you pay for covered drugs: $2,100 in 2026. After you reach it, you pay nothing more for covered Part D drugs that year.
- Medigap Plans K and L have yearly out-of-pocket limits ($8,000 and $4,000 in 2026). Other Medigap plans have no stated limit but pay some or all of Original Medicare's deductibles and coinsurance.
In Oregon
The same federal limits apply in every Oregon county. When you compare a Medicare Advantage plan with Original Medicare and Medigap, look at the plan's out-of-pocket maximum, its network and whether your doctors and hospitals take it. You can see plans for your ZIP code or request a call from a licensed insurance agent.
Sources
- Medicare.gov — Medicare costs
- Medicare.gov — Costs for Medicare drug coverage
- Medicare.gov — Compare Medigap plan benefits
Frequently asked questions
Does Original Medicare have an out-of-pocket maximum?
No. With Original Medicare alone, your 20% coinsurance has no yearly limit. That's one reason people add a Medigap policy or choose Medicare Advantage.
Do premiums count toward the out-of-pocket maximum?
No. Monthly premiums, including your Part B premium, don't count. For Part D, what you pay for drugs your plan doesn't cover doesn't count either.
Is the Part D cap going up for 2027?
Yes. CMS has published the 2027 Part D amounts; see Medicare costs in 2027 on this site for the new cap.
Medicare in your Oregon county
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