Medicare Advantage plans limit how much their members have to pay out-of-pocket for their covered Medicare expenses. Medicare has set the maximum out-of-pocket (MOOP) limit at $6,700 for in-network services and $10,000 for out-of-network services. However, some plans will voluntarily establish even lower limits. After reaching these limits, Medicare Advantage plans will pay 100% of the eligible expenses.
Here are some helpful facts to be aware of.
- This limit does not include the monthly premium, or prescription medication.
- Health Maintenance Organization (HMO) plans only have a limit on in-network care. Preferred Provider Organization (PPO) plans have a limit for in-network as well as $10,000 for in- and out-of-network combined.
- Only Medicare-covered services count toward this out-of-pocket limit.
- Services not usually covered by Medicare, such as hearing, vision, and non-emergency transportation, will not be counted in the limit.
- Each plan determines its maximum out-of-pocket limit, which can change every year.
You may check your Medicare Advantage plan’s evidence of coverage (EOC) for details on the out-of-pocket limit.
Note: Although Original Medicare Part A and Part B do not have a limit on how much a beneficiary can spend out-of-pocket, those who have a Medigap policy (Medicare supplement insurance) have no need to worry. All policies sold in this country will cover the 20% Part B coinsurance. Additionally, optional benefits may protect beneficiaries from other costs, such as the Part A hospital deductible and the skilled nursing facility copayment for days 21-100.
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