Your Medicare Advantage plan’s MOOP or Maximum Out-of-Pocket
limit is the total amount you will spend this year on 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.
For example, if your Medicare Advantage plan has an annual MOOP limit of $6,700, and you have already spent $6,700 out of pocket for in-network, eligible medical expenses, you will spend $0 for the remainder of the year for your in-network, covered medical costs.
Out-of-network Part A and Part B medical cost may be excluded from MOOP or your plan may have a 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 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."
However, some Medicare Advantage plans (such as HMO-POS plans) include out-of-network coverage as part of the plan's higher-costing MOOP. 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 20[xx] 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.
When you reach your MOOP, keep paying your 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
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.
Your Medicare Advantage plan's MOOP can change every year.
Medicare Advantage plans can change MOOP limits 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.
How do MOOP limits change or vary between plans?
MOOP limits can vary from $0 to the Medicare-established annual maximum. As an example, 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 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.
You can also learn more at: "How are MOOP and TrOOP related? Does your TrOOP go towards meeting your MOOP?