The Medicare Advantage plan Maximum Out-of-Pocket (MOOP) threshold limits how much you will spend on co-payments and co-insurance for covered or eligible Medicare Part A (in-patient or hospitalization) and Medicare Part B (out-patient or doctor visits) medical services (plus the plan may include additional or supplemental benefits).

Reminder: 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).

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 2016 Medicare Advantage maximum out-of-pocket limit can range from $0 to $6,700.  Typically, Medicare Advantage plans with a MOOP of $0 are Special Needs Plans for Dual Medicare/Medicaid eligible beneficiaries (D-SNPs).

As reference, we have all available MOOP thresholds online for Medicare Advantage plans and they can be seen on our 2016 Medicare Advantage Plan Finder (or MA-Finder.com) or you can browse through the states/counties via our 2016 Overview by State.

The table below illustrates the most frequently occurring 2016 MOOP limits across all types of Medicare Advantage plans.


Medicare Advantage plans may set their MOOP as any amount within the ranges shown in the CMS table below. This table shows that MOOP limits may be lower than the CMS- established maximum amounts and what MOOP amounts qualify as mandatory and voluntary MOOP limits.


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 2016 MOOP limits did not increase over the 2015 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.  Stated differently, 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.