Your Medicare Advantage plan’s Maximum Out-of-Pocket Limit (MOOP) is the total amount you will spend this year on in-network co-payments and co-insurance
for covered or eligible Medicare Part A and Medicare Part B medical services.
When you have reached your plan's annual MOOP limit, your Medicare
Advantage plan's eligible medical services are covered for the remainder of the
year at no cost to you.
What is my Medicare Advantage plan's MOOP limit?
Maximum out-of-pocket limits will vary from plan-to-plan and your Medicare Advantage plan's maximum out-of-pocket limits can be as little as $0 (for D-SNPs and MMPs) up to the Medicare-established annual maximum of $6,700 in 2020 (increasing to $7,550 in 2021
We show the MOOP levels for all Medicare Advantage plans in our MA-Finder
For more information, you can also call your plan's Member Services department to learn more about your plan's MOOP (the toll-free telephone number is found on your Member ID card) or you can look in your Medicare plan's Evidence of Coverage (EOC) document for text that may say something such as:
"As a member of the plan, the most you will have to pay out-of-pocket for in-network covered Part A and Part B services in 202[x] is $1,500. The amounts you pay for copayments and coinsurance for in-network covered services count toward this maximum out-of-pocket amount. . . . If you reach the maximum out-of-pocket amount of $1,500, you will not have to pay any out-of-pocket costs for the rest of the year for in-network covered Part A and Part B services."
In this example, if your Medicare Advantage plan has an annual MOOP limit of
$1,500 - and you have already spent $1,500 out-of-pocket for in-network,
eligible medical expenses - you will spend $0 for the remainder of the
year for your in-network, covered Part A and Part B medical costs.
As a note, the most common 2021
Medicare Advantage plan MOOP limits
are $7,550 and $6,700 (the most common 2020
Medicare Advantage plan MOOP limits
are $6,700 and $3,400).
|Percentage of Medicare Advantage Plans
Using Popular MOOP Limits*
Note: *Some Medicare Advantage plans do not have a MOOP limit. These plans are Medicare-Medicaid Plans and D-SNPs (Medicare Advantage Special Needs Plans for dual eligible Medicare/Medicaid beneficiaries) and are not included in the chart above.
You can click on the link in the chart above to see how MOOP limits can vary between Medicare Advantage plans each year.
Out-of-network Part A and Part B medical costs may be excluded from MOOP or your plan may have a separate higher out-of-network MOOP limit.
Some types of Medicare Advantage plans (such as HMOs) may not include out-of-network coverage as part of the plan's MOOP limit. Please look for language in your Medicare Advantage plan's (MA or MAPD) Summary of Benefits or Evidence of Coverage document that may read something like:
"Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs [MOOP], you keep getting
covered hospital [Medicare Part A] and medical [Medicare Part B]
services and we will pay the full cost for the rest of the year. Please
note that you will still need to pay your monthly premiums and
cost-sharing for your Part D prescription drugs."
"In addition, generally amounts you pay for non-authorized and/or non-plan directed out of network services, Non Medicare Covered Services and supplemental benefits such as, but not limited to: Dental, Hearing, Outpatient Blood Services, Over the Counter medications, Transportation and Vision do not count toward your maximum out-of-pocket amount."
However, some Medicare Advantage plans (such as HMO-POS plans) include out-of-network coverage as part of the plan's higher-costing MOOP. The Medicare-established annual maximum combined
out-of-network) MOOP limit will increase in 2021 to $11,300 from the
2020 combined MOOP of $10,000. Please look in your Evidence of Coverage (EOC) document for such language as:
As a member of our plan, the most you will have to pay out-of-pocket for in-network covered services in 202[x] is $6,700. . . . Your plan also has a combined maximum out-of-pocket amount of $10,000. This is the most you pay during the calendar year for covered plan services received from both in-network and out-of-network providers. The amounts you pay for deductibles, copayments and coinsurance for covered services count toward this combined maximum out-of-pocket amount. . . . If you have paid $10,000 for covered services, you will have 100% coverage and will not have any out-of-pocket costs for the rest of the year for covered services.
Remember: When you reach your MOOP, keep paying your Medicare plan premiums.
Once you reach your
MOOP limit, your Medicare Advantage plan will contact you and also remind you
that you will need to continue paying your Medicare Part B premiums (if paid by you) and your
Medicare Advantage plan premiums.
Please also remember that MOOP is only for medical services and
reaching your MOOP limit does not affect your Medicare Advantage plan’s
prescription drug coverage. In other
words, you will need to continue paying your prescription drug costs - even after you
meet your Medicare Part D out
of pocket limit or TrOOP
and enter your plan's Catastrophic Coverage.
Important: Part A & Part B MOOP is not Part D TrOOP!
To learn more, please read: "How are MOOP and TrOOP related? Does your TrOOP go towards meeting your MOOP?
Your Medicare Advantage plan's MOOP can change every year.
Medicare Advantage plans can change maximum out-of-pocket limits (MOOP) every year and the higher the MOOP, the more you will pay before your medical costs are covered by your plan. Medicare Advantage plans may also change the MOOP limits for in-network and out-of-network Part A and Part B coverage. The good news is that Medicare annually sets the maximum MOOP limit for all Medicare Advantage plans - and your Medicare plan's Annual Notice of Change letter (ANOC) will notify you about upcoming changes to your MOOP.