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Q1Group 2016 MA/MAPD Analysis: A comparison of the Maximum Out-Of-Pocket Limit (MOOP) range for 2016 Medicare Advantage plans as compared to 2015 Medicare Advantage plans

Category: Out of Pocket: TrOOP and MOOP
Published: Oct, 16 2015 04:10:16

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.

Top 2016 MOOP Limits for Medicare Advantage Plans
MOOP Limit Nbr of 2016 MA Plans Nbr of 2015 MA Plans Change in Nbr of Plans Percent Change Nbr of 2014 MA Plans
 $6,700 722 938 -216 -23% 495
$3,400 359 565 -206 -36% 515
$0 143 90 53 59% 200
$4,900 95 60 35 58% 80
$5,900 76 104 -28 -27% 89
$5,000 70 106 -36 -34% 86
$4,500 65 66 -1 -2% 69
$5,500 45 37 8 22% 37
$6,000 41 31 10 32% 21
$3,000 35 64 -29 -45% 44

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.

2016 Voluntary and Mandatory
MOOP Range Amounts By Plan Type
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

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. 

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