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Out-of-Pocket Maximum Calculator
Find the month your plan's cap kicks in.
By Naomi Foster, Contributing Writer, Healthcare
Updated July 2, 2026
Updated July 2, 2026
Find the month your plan's cap kicks in.
Educational estimate. Not insurance advice, confirm with plan documents.
We divide your plan's out-of-pocket maximum by your average monthly cost-sharing to estimate the month you would reach the cap. After that, the plan covers 100% of covered in-network services for the rest of the year.
Using the calculator's own starting numbers, an $8,850 out-of-pocket maximum divided by $350 in average monthly cost-sharing comes to just over 25 months of spending, more than a full year, so the tool reports "Not this year": at that pace, the cap never gets hit, and 12 months of spending totals a projected $4,200.
Raise average monthly cost-sharing to $900, closer to what a chronic condition or a run of specialist visits can produce, and the math flips. $8,850 divided by $900 comes to about 9.8, which rounds up to month 10, and the running total for the year is capped at the full $8,850 rather than the $10,800 those months of raw spending would otherwise add up to.
Pair this cap check with the annual cost estimate for the full yearly picture.
See the full yearly picture, premiums included, in the Advantage cost calculator, or check whether Medigap would protect you better in a high-cost year with the Advantage vs Medigap comparison. The 2026 cost and enrollment reference has the CMS ceiling this cap is measured against.
The out-of-pocket maximum is the most an Advantage plan can charge you in copays and coinsurance in a calendar year. This tool makes that abstract cap concrete: at your typical monthly cost-sharing, which month do you actually hit it? After that point, the plan pays 100% for covered services.
If a serious diagnosis would push you to the cap quickly, that is a reason to weigh a lower-MOOP plan or Medigap. Compare options in the Advantage vs Medigap calculator linked above.
This estimate assumes your spending is spread evenly across the year, which real medical bills rarely do. A single surgery in February can hit the cap in one month rather than ten, so treat the month this tool reports as a rough pace, not a guaranteed date.
Copays and coinsurance you pay for covered Part A and Part B services from in-network providers count toward the cap. Your monthly plan premium, your Part B premium, and prescription drug costs are typically tracked separately and don't count toward this number.
Once your qualifying spending reaches the cap, your plan is required to pay 100% of the cost for covered in-network services for the rest of that calendar year. You can still owe premiums and drug costs, but medical cost-sharing effectively stops.
Yes. CMS sets a maximum a Medicare Advantage plan is legally allowed to charge for in-network out-of-pocket costs each year, and plans can set their own cap anywhere at or below that ceiling, so two plans in the same area can have very different real-world limits.
No, this tool just does the arithmetic on the numbers you provide. Your plan's actual out-of-pocket maximum is listed in its Evidence of Coverage or Summary of Benefits, and that document is the one to trust.