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2023 Medicare Advantage plan Maximum Out-Of-Pocket (MOOP) limits are changing and can reach $8,300 -- with 1.4 million members seeing a MOOP increase from $50 to $4,850

Category: Annual Medicare plan changes
Published: Sep, 26 2022 04:09:34

Your Medicare Advantage plan's Maximum Out-of-Pocket (MOOP) threshold limits how much you will spend on healthcare copayments and coinsurance 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 spend more out-of-pocket for your Medicare Part A and Medicare Part B covered services before reaching the annual maximum cost threshold.

Each year MOOP limits can change and, starting back in 2021, the Centers for Medicare & Medicaid Services (CMS) began increasing the Maximum Out-of-Pocket limits for Medicare Advantage plan health benefit.  In 2023, Medicare Advantage plans can increase their Maximum Out-of-Pocket limit to $8,300.  Based on these annually established MOOP limits, each Medicare Advantage plan then sets their plan's MOOP (see below for an explanation) — with the approval of CMS.

And this means:  If you have high healthcare expenses, you may want to watch out for an increase in your Medicare Advantage plan's out-of-pocket spending limit.  If you find that your MOOP is increasing, you may wish to search for another Medicare Advantage plan having a lower MOOP limit ($3,650 or less). In short, the higher the MOOP limit, the higher your covered healthcare total expenses can be for the year. However, on a positive note, your Part A & Part B expenses will not exceed $8,300 for in-network Medicare cost-sharing (remember, this does not include Part D prescription drug expenses).

How many people will see an increase in their in-network MOOP?

About 1.4 million Medicare Advantage plan members will see an increase in their in-network MOOP in 2023.  The MOOP increase can range from $50 to $4,850.

2023 Medicare Advantage Plans In-Network MOOP Limit Increases

MOOP Limit Increase Range Members Affected
$4,000 to $4,850 10,485
$3,000 to $3,999 34,749
$2,000 to $2,999 38,925
$1,000 to $1,999 223,951
$500 to $999 431,999
less than $500 638,040

For example, the members of the Wellcare Plus Open PPO in Vermont will see an increase of $4,850 in the in-network MOOP and members of the Louisiana Blue Advantage (HMO) will see a MOOP increase of $4,400.

In-network vs. Out-of-network MOOP

The MOOP limit is a cap on your out-of-pocket expenses and applies to in-network Medicare Part A and Medicare Part B eligible medical cost-sharing.  Please note that local and regional PPO Medicare Advantage plans can have a combined maximum MOOP of $12,450 (for in-network and out-of-network coverage).

The range of in-network 2023 MOOP thresholds

The 2023 Medicare Advantage MOOPs range from $0 to $8,300 — and often Medicare Advantage plans with a MOOP of $0 are Medicare Advantage PFFS plans, MSAs, or Cost plans.  The following chart shows how the MOOP range has changed from 2019 through 2023.  Our chart excludes $0 MOOP plans. Remember, starting in 2021 Medicare began to increase the allowable voluntary and mandatory MOOP limits, and for 2023, Medicare has renamed the voluntary MOOP to "lower" MOOP and added a third intermediate MOOP limit between the two MOOPs -- so the MOOP limits are now "lower", "intermediate", and "mandatory" MOOP. 

Analysis of how Maximum out of pocket limits have changed for Medicare Advantage plans

As reference, you can see each Medicare Advantage plan's MOOP using our 2023 Medicare Advantage Plan Finder (MA-Finder.com/2023) or you can browse through the states/counties via our 2023 Overview by State.

The 2023 MOOP dispersion:  Different out-of-pocket limits for different Medicare Advantage plans

We found that across all 2023 Medicare Advantage plans, only 392 plans increased their MOOP, 2,254 plans kept the same MOOP as last year, and 952 plans reduced the plan's MOOP limit.

When MOOP is evaluated across all Medicare Advantage plans (excluding MMPs and SNPs which do not have a MOOP), we see a decrease in the average 2023 MOOP limit.  The 2023 average MOOP is around $5,061 as compared to $5,164 in 2022.

The table below illustrates some of the more frequently occurring 2023 MOOP limits across all types of Medicare Advantage plans.  Note that 74% of 2023 Medicare Advantage plans have a MOOP over the $3,650 lower MOOP as compared to 76% over the 2022 voluntary MOOP of $3,450.

Top 2023 MOOP Limits for Medicare Advantage Plans and
new low, intermediate, and mandatory MOOP limits

  Number of Medicare Advantage Plans
MOOP Limits 2023 2022 Change '22 to '23 Percent 2021 2020
$6,700 421 520 -99 -19% 572 979
$7,550 318 513 -195 -38% 575
$5,900 223 250 -27 -11% 216 232
$4,900 210 207 3 1% 220 167
$3,400 207 267 -60 -22% 267 410
$4,500 206 203 3 1% 164 121
$5,500 196 186 10 5% 153 142
$3,900 182 163 19 12% 117 96
$5,000 149 134 15 11% 121 92
$3,450 123 184 -61 -33% 178 1
2023 lower, intermediate, and mandatory MOOP limits
$3,650 59 3 56 1,867% 2
$6,000 87 57 30 53% 57 64
$8,300 129
129 0%

Comparison of the number of plans falling into the MOOP ranges.

Medicare Advantage Plans per CMS Defined MOOP Limits

2023 2022
MOOP Limit Range Nbr of Plans % of Plans MOOP Limit Range Nbr of Plans % of Plans
$0 to $3,650
1,165 26% Voluntary:
$0 to $3,450
992 24%
$3,651 to $6,000
1,955 44%

$6001 to $8,300
1,307 30% Mandatory:
$3,451 to $7,550
3,197 76%

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 $8,300; however, an HMO plan that sets MOOP within the lower ($0 - $3,650) or intermediate ($3,651 - $6,000) range is granted greater flexibility for individual service category cost-sharing. 

2023 Lower, Intermediate and Mandatory
MOOP Range by Type of Medicare Advantage plan
Plan Type Lower (Voluntary) Intermediate Mandatory
HMO $0 - $3,650 $3,651 - $6,000 $6,001 - $8,300
HMO POS $0 - $3,650 In-network $3,651 - $6,000 $6,001 - $8,300 In-network
Local PPO $0 - $3,650 In-network and
 $0 - $5,450 Combined
$3,651 - $6,000 In-network and
$3,651 - $8,950 Combined
$6,001 - $8,300 In-network and
$6,001 - $12,450 Combined
Regional PPO $0 - $3,650 In-network and
$0 - $5,450 Combined
$3,651 - $6,000 In-network and
$3,651 - $8,950 Combined
$6,001 - $8,300 In-network and
$6,001 - $12,450 Combined
PFFS (full network) $0 - $3,650
$3,651 - $6,000 $6,001 - $8,300 Combined
PFFS (partial network) $0 - $3,650 $3,651 - $6,000 $6,001 - $8,300 Combined
PFFS (non-network) $0 - $3,650 $3,651 - $6,000 $6,001 - $8,300

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 lower, intermediate and mandatory MOOP limits now change yearly and the 2023 limits are slightly higher than the 2022 figures. 

Question:  How are the lower, intermediate and mandatory MOOP limit set?

The lower, intermediate 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 $8,300 or more in Parts A and B deductibles, copayments and coinsurance.  The lower MOOP amount of $3,650 represents approximately the 85th percentile of projected Original Medicare out-of-pocket costs.  The voluntary MOOP was renamed to lower MOOP in 2023 when the intermediate MOOP was added. The intermediate MOOP is set at the numeric midpoint of the mandatory and lower MOOP limits.

MOOP and Special Needs Plans (and MMPs)

You may notice 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 Medicare Advantage MOOP and Part D Drug Plan 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 Question: TrOOP is not MOOP.)

Bottom Line:  Please review your 2023 Medicare Advantage plan's coverage information to learn more about your plan's MOOP.  You should be able to find your 2023 MOOP in your plan's 2022/2023 Annual Notice of Change letter (ANOC).  You can also telephone your current Medicare Advantage plan using the toll-free Member Services number found on your Member ID card for more information.

Need additional assistance?  Please call Medicare at 1-800-633-4227 and speak with a Medicare representative about Medicare plans that are available in your service area.

You can see more 2023 Medicare Part D plan changes using our MA-Compare tool found at: MA-Compare.com/2023 or Browse Medicare Advantage or Part D plans by state and county.

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