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A comparison of the Maximum Out-Of-Pocket Limit (MOOP) range for 2020 Medicare Advantage plans as compared to 2019 Medicare Advantage plans

Category: Annual Medicare plan changes
Published: Sep, 27 2019 04:09:40

The Medicare Advantage plan Maximum Out-of-Pocket (MOOP) threshold limits how much you will spend on co-payments and co-insurance for eligible Medicare Part A (in-patient or hospitalization) and Medicare Part B (out-patient or doctor visit) coverage.  A higher MOOP limit means you will pay more out-of-pocket for your Medicare Part A and Medicare Part B covered services before reaching the annual maximum cost threshold.

Each Medicare Advantage plan sets their plan's MOOP (see below for an explanation) — with the approval of the Centers for Medicare & Medicaid Services (CMS).

The range of in-network MOOP

The 2020 Medicare Advantage MOOPs range from $0 to $6,700 — and often Medicare Advantage plans with a MOOP of $0 are Medicare Advantage PFFS plans, MSAs, or Cost plans.

As reference, you can see each Medicare Advantage plan's MOOP using our 2020 Medicare Advantage Plan Finder (or MA-Finder.com/2020) or you can browse through the states/counties via our 2020 Overview by State.

2020 MOOP dispersion

We found that across all 2020 Medicare Advantage plans, 152 plans increased MOOP, 1,156 MOOPs remained unchanged, and 256 plans reduced the plan's MOOP threshold.

When MOOP is evaluated across all Medicare Advantage plans, we see a decline in the average 2020 MOOP limit.  The 2020 average MOOP is around $4,993 as compared to $5,089 in 2019.

The table below illustrates some of the more frequently occurring 2020 MOOP limits across all types of Medicare Advantage plans.  Note that 76% of 2020 Medicare Advantage plans have a MOOP over $3,400.

Top 2020 MOOP Limits for Medicare Advantage Plans

  Number of Medicare Advantage Plans
2020 2019 Change ’19 to ‘20 2018 2017
$6,700 979 947 32 3% 911 761
$3,400 410 365 45 12% 318 296
$5,900 232 189 43 23% 142 114
$4,900 167 160 7 4% 104 104
$5,500 142 130 12 9% 79 60
$4,500 121 107 14 13% 84 71
$5,000 92 89 3 3% 75 69
$0 80 75 5 7% 69 131
$3,900 96 42 54 129% 42 43

Medicare Advantage plans may set their MOOP threshold as any amount within the ranges shown in the CMS table below.  As an example, HMO plans can set their plan's MOOP as high as $6,700; however, an HMO plan that sets MOOP within the voluntary range ($0 - $3,400) is granted greater flexibility for individual service category cost-sharing. 

2020 Voluntary and Mandatory
MOOP Range by Type of Medicare Advantage plan
Plan Type Voluntary Mandatory
HMO $0 - $3,400 $3,401 - $6,700
HMO POS $0 - $3,400 In-network $3,401 - $6,700 In-network
Local PPO $0 - $3,400 In-network and
 $0 - $5,100 Combined
$3,401 - $6,700 In-network and
$3,401 - $10,000 Combined
Regional PPO $0 - $3,400 In-network
$0 - $5,100 Combined
$3,401 - $6,700 In-network and
$3,401 - $10,000 Combined
PFFS (full network) $0 - $3,400 Combined $3,401 - $6,700 Combined
PFFS (partial network) $0 - $3,400 Combined $3,401 - $6,700 Combined
PFFS (non-network) $0 - $3,400 $3,401 - $6,700

Important: In-network MOOP and out-of-network MOOP

As can be seen in the table above, out-of-network cost-sharing expenses may fall into a higher MOOP (for example, see Regional PPO above with a higher "combined" MOOP limit) or (IMPORTANT!) your out-of-network cost-sharing may not count toward your MOOP limit, as with the HMO POS plan type.  Please notice that the voluntary and mandatory 2020 MOOP limits did not increase over the 2019 figures. 

How are the voluntary and mandatory MOOP limit set?

The voluntary and mandatory MOOP limits are set by the Centers for Medicare and Medicaid Services (CMS).  Per CMS, the mandatory MOOP amount represented approximately the 95th percentile of projected beneficiary out-of-pocket spending.  In other words, five percent of Original Medicare beneficiaries are expected to incur approximately $6,700 or more in Parts A and B deductibles, co-payments and coinsurance.  The voluntary MOOP amount of $3,400 represents approximately the 85th percentile of projected Original Medicare out-of-pocket costs.

MOOP and Special Needs Plans (and MMPs)

You may note that Medicare Advantage MMP (Medicare-Medicaid plans) and Special Needs Plans, such as for dual Medicare/Medicaid eligible beneficiaries (D-SNPs),  do not have a MOOP.

Reminder about MOOP and TrOOP

Your Total Out-of-Pocket Limit (TrOOP) for your Medicare Part D prescription drug coverage is not the same as your Medicare Part A and Medicare Part B Maximum Out-of-Pocket (MOOP).  (For more information, please see our Frequently Asked Quesiton: TrOOP is not MOOP.)

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