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 copayments and coinsurance
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 2024 the MOOP is $8,850).
- The most common 2024
Medicare Advantage plan MOOP limits are $6,700 and $4,900.
- 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, in 2023, you will still continue to have minimal prescription drug
cost-sharing in the Catastrophic Coverage phase.
- Keep in mind that 2023 is the last year that Medicare Part D
beneficiaries will pay cost-sharing in the Catastrophic Coverage phase.
For plan year
2024 and beyond,
the Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing in the Catastrophic Coverage phase, so plan members will not have any out-of-pocket costs for formulary drugs after reaching the plan's 2024 total out-of-pocket threshold (TrOOP); therefore, TrOOP becomes the Rx maximum out-of-pocket threshold (RxMOOP).
- 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:
MA-Finder.com/FL
Question: How do MOOP limits change or vary between plans?
MOOP
limits can vary from $0 to the Medicare established maximum (around $8,850, 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
2024
Medicare Advantage plan MOOP limits range from $0 to $8,850, with 46% of plans falling in the $3,851 to $6,350 "Intermediate" MOOP limit range.
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.
You can check your plan documentation to learn more about your MOOP and
out-of-network MOOP (if any). For example, you may read:
"In-network maximum out-of-pocket amount $6,500
Your costs for covered medical services (such as copays) from network
providers count toward your in-network maximum out-of-pocket amount.
Your plan premium and your costs for [Medicare Part D] prescription
drugs do not count toward your maximum out-of-pocket amount.
Once you have paid $6,500 out-of-pocket for covered Part A and Part B
services, you will pay nothing for your covered Part A and Part B
services from network providers for the rest of the calendar year.
Combined [in-network and out-of-network] out-of-pocket amount $10,000
Your costs for covered medical services (such as copays) from in-network
and out-of-network providers count toward your combined maximum
out-of-pocket amount. Your plan premium and costs for outpatient
[Medicare Part D] prescription drugs do not count toward your maximum
out-of-pocket amount for medical services.
Once you have paid $10,000 out-of-pocket for covered Part A and Part B
services, you will pay nothing for your covered Part A and Part B
services from network or out-of-network providers for the rest of the calendar year." [emphasis added]
You may also find that if your out-of-network healthcare
does not receive prior authorization from your Medicare Advantage plan
then you may not have the cost included in your annual MOOP limit. For
example, in your Medicare Advantage plan's Evidence of Coverage
document, you may read:
“In addition, generally amounts you pay for non-authorized
and/or non-plan directed [no prior authorization] out-of-network
services, Non Medicare Covered Services and supplemental benefits such
as, but not limited to: Dental, Hearing, Outpatient Blood Services, Over
the Counter medications, Transportation and Vision do not count toward
your maximum out-of-pocket amount.”
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 copayments 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]