Updated October 14, 2019 with CMS revised landscape data.
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.
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: TrOOP is not 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 2019 Medicare Advantage maximum out-of-pocket limits range from $0 to $6,700.
You can see each Medicare Advantage plan's MOOP using our 2019 Medicare Advantage Plan Finder (or MA-Finder.com/2019) or you can browse through the states/counties via our 2019 Overview by State.
A trend toward higher MOOPs
The table below illustrates some of the more frequently occurring 2019 MOOP limits across all types of Medicare Advantage plans. Notice the trend of Medicare Advantage plans moving to higher MOOP limits (about 77% of plans have a MOOP > $3,400) — meaning you will pay more out-of-pocket for your Medicare Part A and Medicare Part B covered services before reaching the annual maximum cost.
Top 2019 MOOP Limits for Medicare Advantage Plans |
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| Number of Medicare Advantage Plans (MA & MAPD) |
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| MOOP Limits |
2019 | 2018 | Change ’18 to ‘19 | 2017 | 2016 | |
| $6,700 | 947 | 911 | 36 | 4% | 761 | 722 |
| $3,400 | 365 | 318 | 47 | 15% | 296 | 359 |
| $5,900 | 189 | 142 | 47 | 33% | 114 | 76 |
| $4,900 | 160 | 104 | 56 | 54% | 104 | 95 |
| $5,500 | 130 | 79 | 51 | 65% | 60 | 45 |
| $4,500 | 107 | 84 | 23 | 27% | 71 | 65 |
| $5,000 | 89 | 75 | 14 | 19% | 69 | 70 |
| $0 | 75 | 69 | 6 | 9% | 131 | 143 |
| $3,900 | 57 | 42 | 15 | 36% | 43 | 27 |
Medicare Advantage plans may set their MOOP 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.
| 2019 Voluntary and Mandatory MOOP Range by Type of Medicare Advantage plan |
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| 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 |
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| Regional PPO | $0 - $3,400 In-network and $0 - $5,100 Combined |
$3,401 - $6,700 In-network and $3,401 - $10,000 Combined |
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| 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 2019 MOOP limits did not increase over the 2018 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.