Medicare Out-of-Pocket Maximum Limits
Key Takeaways
- Medicare Part A doesn’t offer the protection of an out-of-pocket maximum.
- Medicare Part B also has no out-of-pocket maximum.
- Medicare Part C (Medicare Advantage) has a legally established out-of-pocket maximum for in-network and out-of-network healthcare.
- Medicare Part D plans now have an out-of-pocket maximum.
- Monthly premiums don’t count towards your out-of-pocket expenditures.
What Is the Maximum Medicare Out-of-Pocket Limit for 2025?
Many people are surprised to learn that Original Medicare doesn’t have out-of-pocket maximums. Original Medicare consists of two parts — Part A and Part B. If you have Original Medicare, there’s no ceiling on the amount of money you may have to pay for covered inpatient or outpatient services.
People on Original Medicare must enroll in a Medicare Part D prescription drug plan to get coverage for most medications. Medicare Part D plans have an out-of-pocket maximum that’s set each year by the federal government.
Medicare Advantage (Part C) plans are an alternative way to get coverage sold by Medicare-approved private insurers.
Unlike Original Medicare, a Part C plan is required to have out-of-pocket maximums, established by the insurer that manages the plan. This means there is a limit on the amount of money you will spend for covered healthcare during any given year. For in-network services in 2025, the highest Medicare out-of-pocket maximum allowed for a Part C plan is $9,350. Many Part C plans offer lower out-of-pocket limits.
There are several different types of Part C plans, including HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations). Both these types have provider networks, but PPO plans typically pay a percentage of your healthcare costs when you see an out-of-network provider. For that reason, Medicare Advantage PPO plans list one out-of-pocket maximum amount for in-network services and one out-of-pocket maximum amount that combines in-network and out-of-network healthcare costs.
What Is the Medicare Out-of-Pocket Maximum ?
Let’s face it, higher-than-expected medical bills can happen to anyone, even those in perfect health. That’s a scary reality we hope won’t happen to you, but life is unpredictable. If you’re concerned about the cost of healthcare, the Medicare out-of-pocket limit is an important dollar figure for you to know.
Your out-of-pocket maximum is the highest amount of money you will have to pay for covered healthcare services within a plan year. On a Part C plan, your deductibles, copays, and coinsurance all go toward your Medicare out-of-pocket maximum. Once you reach this dollar figure, your plan will pay 100% for all your covered healthcare costs for the remainder of the plan period.
If your Medicare Advantage plan includes Part D (prescription drug) coverage, the cost of your medications will not go towards your Part C out-of-pocket maximum. Neither will uncovered services your plan doesn’t cover.
Monthly premiums are another expenditure that won’t go towards meeting your Medicare out-of-pocket maximum. These include the Medicare Part B monthly premium you still are responsible for as well as your Part C monthly premium (if any).
Still have questions? GoHealth has the answers you need.
Call Today
Medicare Part A Out-of-Pocket Costs
Medicare Part A is the part of Original Medicare that pays for inpatient services. These include:
- Inpatient care you receive after being admitted into a hospital (excluding emergency room care).
- Hospice care.
- Home healthcare.
- Skilled nursing facility care.
- Non-custodial nursing home care.
Medicare Part A does not offer the protection of an out-of-pocket maximum.
About 99 percent of people don’t have to pay a Part A monthly premium. Whether you pay a monthly premium or not, Part A has coinsurance and deductible costs you can expect to pay out of pocket.
If you are hospitalized or spend time in a facility that is covered under Part A, you are responsible for an out-of-pocket deductible of $1,676 per benefit period in 2025. A benefit period begins on the day you go into a hospital or facility and ends after you have been discharged for 60 consecutive days. You can have multiple benefit periods during each calendar year. The Part A deductible will apply anew for each benefit period you incur during the same year.
In addition to your deductible, you may have coinsurance costs for each benefit period:
- Days 1-60 of your stay will have $0 coinsurance costs.
- Days 61-90 require a coinsurance cost of $419 per day in 2025.
- Days 91 and beyond require a coinsurance cost of $838 per “lifetime reserve day.” You have 60 lifetime reserve days that you can use over the course of your coverage.
- After exhausting your lifetime reserve days, you will be responsible for the full costs of every day you spend in the hospital.
Skilled Nursing Facility Costs
Part A will only cover a portion of your healthcare costs if you stay in a skilled nursing facility that is approved by Medicare. There also must be a medical need for you to be there. If you are in a skilled nursing facility solely due to your custodial care needs, Medicare will not pay for your stay. Custodial care includes help with bathing, dressing or eating that is not associated with a medical diagnosis or need.
Your Part A coinsurance costs for a stay in a skilled nursing facility in 2025 apply for each benefit period. Once approved by Medicare, you can expect to pay:
- Days 1-20 of your stay will have $0 coinsurance costs.
- Days 21-100 require a coinsurance cost of $209.50 per day in 2025.
- After 100 days, you will be responsible for the full cost of all additional days in the facility.
Medicare Part B Out-of-Pocket Costs
Medicare Part B is the part of Original Medicare that covers outpatient services, such as doctor’s appointments and preventive care. Unlike Part A, your Part B costs are not encapsulated into benefit periods.
Most people have to pay the standard Part B monthly premium, which was $185 in 2025. Other Part B out-of-pocket costs include the annual deductible and coinsurance. In 2025, the Part B deductible was $257. After your deductible has been met, you will typically pay 20% of the Medicare-approved amount for services covered under Part B. Medicare will pay the remaining 80%.
Still have questions? GoHealth has the answers you need.
Call Today
How Much Do Medicare Patients Pay Out-of-Pocket?
To summarize, Medicare beneficiaries pay varying out-of-pocket amounts, based upon the type of coverage they have.
- Most Medicare beneficiaries pay the Part B monthly deductible.
- With Part A, expect to pay $1,676 per benefit period plus coinsurance costs if you are an inpatient.
- With Part B, expect to pay a $257 deductible per year and then 20% of the Medicare-approved amount of your healthcare costs. This includes doctor’s visits, durable medical equipment, imaging and laboratory tests.
- If you add Medicare Supplement Insurance (Medigap), some or all of these costs may be paid by your plan, so you won’t have to pay for them out-of-pocket.
- If you have a standalone Part D (prescription drug) plan, you may have an additional monthly premium you will need to pay. You will also incur prescription drug copays.
- If you have Medicare Advantage (Part C), you may have an additional monthly premium which will be required, although many Part C plans are $0 monthly. Coinsurance costs will be determined by your plan. Your plan may also have deductibles you will have to meet before coverage begins.
Medicare Advantage Maximum Out-of-Pocket Costs
Medicare Advantage plans vary by state and zip code. What is available for your friend in a nearby county may not be available to you. Even so, most Medicare beneficiaries have several options they can choose between when they’re deciding on the right Part C plan.
Medicare Advantage plans are legally required to have a maximum out-of-pocket limit. Once you hit this dollar amount, your plan will pay 100% of covered services for the remainder of the plan period. This ensures every Part C beneficiary that their costs will remain under a certain dollar amount.
In 2025, the highest out-of-pocket limit a Part C plan could have was $9,350.
Many Part C plans offer a lower out-of-pocket maximum.
What’s Included in the Out-of-Pocket Maximum for Medicare Part C Plans?
The costs you pay for covered healthcare services all go towards your Part C out-of-pocket maximum. These include:
- Deductibles
- Copays
- Coinsurance
If your plan covers dental or other extras that Original Medicare doesn’t cover, it may include the out-of-pocket costs you incur for those services.
Medicare Part D Out-of-Pocket Maximums
Medicare Part D costs have gone through several changes since 2022. plans now have an out-of-pocket maximum set by the federal government. In 2025, you won’t pay more than $2,000 for covered drugs. This limit will be adjusted each year.
If your plan requires an annual deductible, you’ll pay the full costs of covered drugs until you reach that amount. In 2025, the Part D deductible is limited to $590.
Until 2024, Medicare Part D plans had a coverage gap known as the ” donut hole,” a temporary limit on your plans coverage after exceeding a certain amount. Once you exited the donut hole, you received catastrophic coverage. That meant you didn’t have to pay a copayment or coinsurance for covered Part D drugs for the rest of the year. As of 2025, the coverage gap has been eliminated.
Ready for a new Medicare Advantage plan?
Get Help Now
Medigap Supplement Out-of-Pocket Maximums
Medicare Supplement Insurance (Medigap) policies are sold by private insurers. They help pay some of the leftover costs that Original Medicare doesn’t pay. These include copayments, coinsurance and deductibles.
Some Medigap plans also cover some things that Original Medicare doesn’t, such as medical care when you travel abroad.
These plans are standardized and offer the same basic benefits. However, not every Medigap plan has an out-of-pocket limit.
In 2025, Medigap Plan K has an out-of-pocket limit of $7,220. Medigap Plan L has an out-of-pocket limit of $3,610.
After you meet these amounts plus your Part B deductible, your Medigap plan will pay 100% of your covered healthcare costs for the remainder of the plan year.
What to know about Medicare Savings Account Plans
Medicare Medical Savings Account (MSA) plans are a type of Medicare Advantage plan.
MSA plans combine a high-deductible insurance plan with a medical savings account. You use the funds in your medical savings account to pay for healthcare.
MSA plans often have deductibles you will have to meet. The deductible amount is established by the plan.
Like all Medicare Advantage plans, MSAs must cover everything Original Medicare does. Some MSAs also cover extras such as dental, vision and hearing.
Unlike many Medicare Advantage plans, MSAs do not cover prescription drugs. If you have an MSA, you will need to buy a standalone Part D plan to cover medications.
Sources
- Contract Year 2025 Medicare Advantage and Part D Final Rule. CMS.gov.
- What Part A covers. Medicare.gov.
- Costs. Medicare.gov
- Medicare costs at a glance. Medicare.gov.
- Skilled nursing facility (SNF) care. Medicare.gov.
This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money.
Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.