What are out-of-pocket expenses in Medicare Advantage plans?
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Medicare Advantage plans are subject to the same out-of-pocket expenses as original Medicare (Parts A and B).
BUT… The Affordable Care Act (Health Care Reform) requires all Medicare Advantage plans to have a $6,700 cap or limit on what you could be required to pay out of pocket for covered medical expenses. This limit is referred to as the “Maximum Out of Pocket” or MOOP and it does not include prescription drugs and monthly premiums.
The Mandatory Maximum Out of Pocket (MOOP) is $6,700 for Medicare Advantage, but Medicare allows for a “Voluntary MOOP” of $3,400 or less.
Before you reach the MOOP, Medicare Advantage plans are subject to the same out-of-pocket expenses as original Medicare, which means you have out-of-pocket costs associated with the following benefits:
Part A and Medicare Advantage Out-of-Pocket Costs for Hospital Services
- Deductible: There is a $1,132 deductible tied to a 60-day benefit.
- Hospital Stays: Hospital stays are covered and there are out-of-pocket cost-sharing tied to a hospital visit. Levels of cost-sharing change after the first 60 days and again after 90 days.
- Skilled Nursing Facilities: Care at a skilled nursing facility is covered and there are out-of-pocket costs and cost-sharing associated with it. Cost-sharing levels change after the first 20 days and again after 100 days.
- Hospice Care: Hospice care is also covered and there is cost-sharing associated with this benefit.
- Blood (for transfusions) and Home Health Care: These benefits are also covered with some cost-sharing associated with each.
Part B and Medicare Advantage Out-of-Pocket Costs for Medical Services
- Monthly Premiums: A person on Original Medicare or Medicare Advantage will still pay the Part B premium, which varies based on a person’s income. The standard Part B premium is $115.40.
- Deductibles: The annual deductible for Medical services is $162.
- Coinsurance: With coinsurance, the insurance companies pay a certain percentage of each bill, and the beneficiary pays the rest. For the majority of Part B-related services, Medicare or your insurance company will pay 80% of each bill (after deductible) and you will pay 20%. However, coinsurance levels can vary depending upon the benefits you’re receiving.
Medicare has not reviewed or endorsed this information