Medicare Advantage plans are required by law to cap your out-of-pocket costs each year, but the specific limit varies by plan. CMS sets a maximum ceiling that plans cannot exceed, though many plans set their caps lower than that ceiling.
Original Medicare (Parts A and B) has no out-of-pocket maximum. You could theoretically face unlimited costs in a bad year. That's one reason Medicare Advantage exists. By law, every Medicare Advantage plan must include an annual out-of-pocket maximum, which is a cap on what you pay before the plan covers 100 percent of covered costs for the rest of the year.CMS sets a ceiling on how high that cap can go, and it adjusts most years. For recent plan years, that ceiling has been in the range of $8,000 to $9,000 for in-network costs, with a higher cap allowed for combined in-network and out-of-network spending. The specific numbers for the current plan year are published by CMS and can change, so always verify the current figures.Here's the important nuance. Plans can set their caps lower than the CMS ceiling, and many do, sometimes significantly lower. A plan might cap your costs at $4,000 or $5,000 in-network. That's a meaningful difference if you have a serious health event.Also worth knowing: out-of-pocket maximums typically apply to Medicare-covered services only. Drug costs, dental, vision, and hearing may or may not count toward the cap depending on the plan. Read the plan documents carefully, or ask an agent to walk you through exactly what counts.
Utah Medicare Advantage plans from carriers like SelectHealth, Regence, and others vary considerably in their out-of-pocket maximums. Plans tied to Intermountain Health networks sometimes offer competitive caps for in-network care. Always compare the Summary of Benefits for each plan during Open Enrollment.
For you, this means a lower out-of-pocket maximum is a concrete form of financial protection, and it's worth comparing caps just as carefully as premiums when choosing a plan.
Our Commitment to Reliable Medicare Information
At Resting Sycamore Advisors, we work to provide accurate, current, and trustworthy information about Medicare Advantage, Medicare Part D, and Special Needs Plans.
To do that, we use data published by the Centers for Medicare & Medicaid Services (CMS), which is the official source for Medicare plan and enrollment information.
Our Medicare plan pages and comparison tools are powered by CMS datasets, including:
When possible, we link to the original CMS resources so you can review the source material directly.
We follow the CMS release schedule and update our website as new data becomes available.
We load new plan year Landscape and PBP files before the Medicare Annual Enrollment Period (October 15 through December 7). We also monitor CMS.gov for updates or revisions and refresh our content when needed.
We update enrollment and performance data as CMS publishes revised files, which are typically released monthly or quarterly.
We routinely monitor CMS announcements for corrections, reissued files, or other changes and update our pages accordingly.
Each plan page includes a Last Accessed date so visitors can see when the source information was most recently reviewed.
CMS data can be difficult to read in raw form. To make it easier to use, we format and organize the data for clarity.
This includes:
All data values come from CMS. We do not change the underlying values beyond formatting, organization, and presentation.
We keep internal records of the CMS dataset versions used on our site.
If CMS issues corrected or revised files, we update our website to reflect the latest available version.
Please keep the following in mind:
For personalized Medicare assistance, please use these official resources: