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What is MOOP or the Medicare Advantage maximum out-of-pocket limit?



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Question: What is MOOP or the Medicare Advantage maximum out-of-pocket limit?
Category: TrOOP and MOOP: Out of Pocket Costs

Answer: 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 medical services.  So when you have reached your 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.

Please note: Some types of Medicare Advantage plans (such as an HMO-POS) do not include out-of-network coverage as part of the plan's MOOP.  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."

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.

As background, 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.  The good news is that Medicare annually sets the maximum MOOP limit for all Medicare Advantage plans.

How do MOOP limits change or vary between plans?
MOOP limits can vary from $0 to the Medicare established maximum.  As an example, the most common 2019 Medicare Advantage plan MOOP limits are $6,700 and $3,400.

Percentage of Medicare Advantage Plans
Using Popular MOOP Limits*
Plan Year $6,700 $3,400 $0
2019 34% 13% 3%
2018 39% 14% 3%
2017 36% 14% 6%
2016 35% 17% 7%
2015 38% 23% 4%
2014 25% 26% 10%

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?"


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