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What is the Medicare Advantage maximum out pocket?

By on July 31st, 2012
Filed: Advice, Caregivers, Consumers, Disabled, Families, Parents, Research, Seniors, Tips

What is the Medicare Advantage maximum out pocket?

The Patient Protection and Affordable Care Act (health reform) placed maximum limit of $6,700 on all out of pocket medical costs a beneficiary can be responsible for on Medicare Advantage plans. This limit is referred to as the “Maximum Out of Pocket” or MOOP.

This MOOP doesn’t include prescription drug costs and monthly premiums. The Mandatory MOOP is $6,700 but Medicare allows for a “Voluntary MOOP” of $3,400 or less.

Here is how MOOP works:

Medicare Advantage plans must provide all of a person’s Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. And, Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. And, most plans include Medicare prescription drug
coverage (Part D).

In exchange for providing these services, Medicare pays the insurance company a fixed amount of money each month to provide these benefits. Some Medicare Advantage plans charge an additional fee, or “premium,” each month to provide these services, some plans don’t.

The insurers who offer Medicare Advantage benefits must follow rules set by Medicare. However, each Medicare Advantage plan can charge different out-of-pocket costs and have different rules for how care is provided. For example, they can determine whether or not you need a referral to see a specialist or if you
have access to a specific network of doctors and hospitals. These rules can change from year to year.

The Maximum Out of Pocket (MOOP) Benefit – How it works:

  • Mandatory MOOP: This refers to the dollar amount the Affordable Care Act sets as the highest limit for enrolled beneficiary in-network cost-sharing for Parts A and B services for the contract year.
  • Voluntary MOOP: This refers to an amount lower than the mandatory MOOP established by the Affordable Care Act. Plans may voluntarily adopt this limit or a lower amount in exchange for increased flexibility in establishing cost sharing amounts for Parts A and B services.
  • Catastrophic MOOP: This refers to the amount the Affordable Care Act sets as the highest limit charged by Local PPO Medicare Advantage plans (LPPOs) for the combined in-and out-of-network cost sharing for Parts A and B services for the contract year. The catastrophic MOOP amount is calculated as 1.5 times the mandatory or voluntary MOOP amount, as applicable to the plan.

*CY 2012 refers to the 2012 Calendar Year.

 CY 2012 Voluntary and Mandatory MOOP Amounts By Plan Type Voluntary Mandatory
HMO $3,400 $6,700
HMO POS $3,400 In-network $6,700 In-network
Local PPO $3,400 In-network and $5,100 Catastrophic* $6,700 In-network and $10,000 Catastrophic*
Regional PPO** $3,400 In-network and $5,100 Catastrophic* $6,700 In-network and $10,000 Catastrophic*
PFFS (full network) $3,400 In- and out-of-network $6,700 In- and out-of-network
PFFS (partial network) $3,400 In- and out-of-network $6,700 In- and out-of-network
PFFS (non-network) $3,400 $6,700

*Catastrophic MOOP is inclusive of in- and out-of-network Parts A and B services.

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Medicare has not reviewed or endorsed this information

About Ross Blair


Ross Blair has applied more than 26 years of technology experience to develop PlanPrescriber.com, a website that makes it easier for seniors and their caregivers to select and enroll in the best Medicare products for their specific needs. In his role as CEO, he has worked closely with pharmacists, insurers, physicians, caregivers and seniors to identify the most critical and complex aspects of Medicare and create a system that delivers this information to consumers in a format that is easy to use and understand.

1 Comment Add Your Comment

Rais Insurance on Wednesday, August 1 @ 2:57 am

MOOP has helped lot of my clients that would have to paid lot of money. I always promote it. Great informations.

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