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What happens when I reach my Medicare Advantage plan maximum out of pocket limit (MOOP)?

Category: TrOOP and MOOP: Out of Pocket Costs
Updated: Aug, 23 2022

You do not pay anything more for your Medicare Part A and Medicare Part B covered services for the remainder of the year.

Your Medicare Advantage plan’s MOOP or Maximum Out-of-Pocket limit is the total amount you will spend this year on co-payments and co-insurance for covered or eligible Medicare Part A (hospitalization) and Part B (out-patient) medical services (and may include additional or supplemental benefits).

So when you have reached your annual MOOP limit, your Medicare Advantage plan's eligible, in-network medical services are covered for the remainder of the year at no cost ($0) to you.

For example, if your Medicare Advantage plan has an annual MOOP limit of $6,700, and you have already spent $6,700 out-of-pocket for in-network, eligible medical expenses, you will spend $0 for the remainder of the year for your in-network, covered Part A and Part B medical costs.

But, as a reminder:
  • Your Medicare Advantage plan’s MOOP limit can change every year.

  • The Centers for Medicare and Medicaid Services (CMS) set an annual maximum allowable MOOP for Medicare Advantage plans (in 2022 the MOOP is $7,550).

  • The most common 2022 Medicare Advantage plan MOOP limits are $7,550 and $6,700.

  • Depending on your type of Medicare Advantage plan, your out-of-network medical cost-sharing expenses may not count toward your MOOP limit or may fall into a higher “combined” MOOP -- so learn more before traveling.

  • If you reach your MOOP limit, your Medicare Advantage plan will contact you and remind you that you will need to continue paying your Medicare Part B premiums and Medicare Advantage plan premiums.

  • MOOP is only for covered Medicare Part A and Part B services and reaching your MOOP limit does not affect your Medicare Advantage plan’s Part D prescription drug coverage. In other words, you will need to continue paying your prescription drug cost-sharing. And, even after you meet your Medicare Part D prescription drug plan’s out-of-pocket limit or TrOOP, you will still continue to have minimal prescription drug cost-sharing in the Catastrophic Coverage phase.

  • If you have Original Medicare Part A and Medicare Part B, there is no limit in the amount of money that you can spend per year on Medicare costs.  In other words, Original Medicare Part A and Medicare Part B does not have a Maximum Out-of-Pocket limit.
Some background information . . .

As noted, Medicare Advantage plans can change MOOP limits every year and the higher the MOOP, the more you will pay before your medical costs are covered by your plan. The good news is that Medicare annually sets the maximum MOOP limit for all Medicare Advantage plans.

We have all the MOOP thresholds online for Medicare Advantage plans and they can be seen on our Medicare Advantage Plan Finder (MA-Finder.com). Here is an example of the Florida counties with Medicare Advantage plans: https://MA-Finder.com/FL

How do MOOP limits change or vary between plans?

MOOP limits can vary from $0 to the Medicare established maximum (around $7,550, depending on the year).

However, usually the $0 MOOP plans are Medicare Savings Account (MSA) plans or Medicare Advantage Special Needs Plans for dual Medicare/Medicaid eligible people (D-SNPs) and most Medicare Advantage plans have MOOP limits toward the allowed maximum amount.  As an example, the most common 2022 Medicare Advantage plan MOOP limits range from $0 to $7,550, with more plans having higher MOOP limits in 2022 as compared to prior years.

In-network and Out-of-network MOOP

Depending on your chosen Medicare Advantage plan, out-of-network cost-sharing expenses may fall into a higher MOOP.  For example, if you are enrolled in a Regional Medicare Advantage PPO may have a higher "combined" MOOP limit for in-network and out-of-network costs. With other Medicare Advantage plans, your out-of-network cost-sharing may not count at all toward your MOOP limit, as with the Medicare Advantage HMO-POS plan type. To repeat: with some Medicare Advantage plans, everything that you spend on out-of-network medical care, may not count toward your MOOP.

Where will my Medicare Advantage plan tell me more about MOOP?

In your Medicare Advantage plan's Evidence of Coverage document that you received when you enrolled in the plan.  If you no longer have this document, you can contact your Medicare plan's Member Services department and request another copy (the toll-free number is on your Member ID card).

The text in your Evidence of Coverage may vary slightly between Medicare plans, but , you will be able to find some explanation such as:

"What is the most you will pay for Medicare Part A and Part B covered medical services?

Because you are enrolled in a Medicare Advantage Plan, there is a limit to how much you have to pay out-of-pocket each year for in-network medical services that are covered under Medicare Part A and Part B (see the Medical Benefits Chart in Section 2, below [within the Evidence of Coverage]).  This limit is called the maximum out-of-pocket [MOOP] amount for medical services.

As a member of ABC Medicare Advantage plan, the most you will have to pay out-of-pocket for in-network covered Part A and Part B services in 201X is $4,000.  The amounts you pay for co-payments and coinsurance for in-network covered services count toward this maximum out-of- pocket amount. (The amounts you pay for your plan premiums and for your Part D prescription drugs do not count toward your maximum out-of-pocket amount.) If you reach the maximum out-of-pocket amount of $4,000 [or whatever your MOOP is] you will not have to pay any out-of-pocket costs for the rest of the year for in-network covered Part A and Part B services.  However, you must continue to pay your plan premium and the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party.)"

[emphasis added]

But ...

"If [healthcare] services are not covered by our plan, you must pay the full cost

ABC Medicare Advantage plan covers all medical services that are medically necessary, are listed in the plan’s Medical Benefits Chart (this chart is in Chapter 4 of this [Evidence of Coverage] booklet), and are obtained consistent with plan rules. You are responsible for paying the full cost of services that aren’t covered by our plan, either because they are not plan covered services, or they were obtained out-of-network and were not authorized.

If you have any questions about whether we will pay for any medical service or care that you are considering, you have the right to ask us whether we will cover it before you get it. You also have the right to ask for this in writing. If we say we will not cover your services, you have the right to appeal our decision not to cover your care.

Chapter 9 [of the Evidence of Coverage] (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) has more information about what to do if you want a coverage decision from us or want to appeal a decision we have already made. You may also call ABC Medicare Advantage plan Customer Service to get more information (phone numbers are printed on the back cover of this booklet.)

For covered services that have a benefit limitation, you pay the full cost of any services you get after you have used up your benefit for that type of covered service. If the covered service exceeds the benefit limit, the amount you pay will not count towards your out-of-pocket maximum. You can call ABC Medicare Advantage plan Customer Service when you want to know how much of your benefit limit you have already used."

[emphasis added]

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