Understanding Your Medicare Advantage MOOP Limit

Posted on March 8, 2024 By Jeff Snyder

When it comes to your Medicare insurance coverage, there’s a lot that Original Medicare or Medicare Advantage will pay for. But, as with any insurance, there are certain out-of-pocket costs that you’ll be expected to pay.

If you have a year that necessitates using your plan frequently, it’s reasonable to worry that your out-of-pocket (OOP) costs may grow exponentially. Luckily, the Medicare program has protections in place to make sure that your OOP costs don’t get out of hand!

What is the Medicare Advantage MOOP?

Your MOOP is the Medicare insurance maximum out-of-pocket cost for medical services that you’re expected to pay over the course of a year in your Medicare Advantage plan. In other words, it’s the limit to how much you will spend in out-of-pocket costs for medical services in a calendar year. Other popular names for MOOP are the maximum OOP, maximum OOPC, or out-of-pocket maximum.

MOOP is the limit on how much you can spend in out-of-pocket costs for medical services in a calendar year before your plan covers these costs.

Maximum OOPs vary by plan, up to a maximum that’s established by Medicare insurance, and may change each year. Plans may have two different MOOP levels — one for in-network and one for out-of-network. In 2025, Medicare requires all these plans to cap their MOOP at $9,350 in-network and $14,000 out-of-network.

What Happens When You Reach Your Limit?

Once you surpass your MOOP Medicare insurance limit, your Medicare Advantage plan will cover the remainder of your OOP costs for eligible services. So, let’s say your plan has a $9,350 out-of-pocket maximum. Once your expenditures surpass that amount, you’re generally not expected to cover anymore costs for in-network, Medicare insurance-covered services.

Once your expenditures surpass that amount, you’re generally not expected to cover anymore costs for in-network, Medicare insurance-covered services.

When you hit your maximum OOP limit, you’ll get a letter from your plan informing you of such. This letter should also let you know what costs (exceptions to the out-of-pocket maximum) you’ll still be responsible for.

What are the Exceptions?

For the most part, you’ll still be on the hook for costs that don’t count toward your limit. For example, you’ll still pay premiums, like the Part B premium that may be part of your Medicare insurance plan. (Your monthly Medicare Advantage premiums don’t count toward your limit.) You’ll also still be expected to pay for drug costs, since they don’t count toward your maximum OOP limit either.

Even after you hit the out-of-pocket maximum, your plan may not cover services outside of your plan’s network.

Another common exception to Medicare Advantage out-of-pocket maximum spending is a result of your plan’s network. Even after you hit the out-of-pocket maximum, your plan may not cover services outside of your plan’s network. Some plans also have a higher maximum OOP that includes out-of-network costs. When you meet this type of limit, your plan will then cover eligible out-of-network costs. Furthermore, if a service isn’t covered by your Medicare Advantage plan, your plan still won’t cover those costs.

What Counts Toward Your MOOP Medicare Insurance Limit?

At this point, you may be wondering what actually counts toward your MOOP Medicare insurance limit. There are three types of payments that count toward your maximum OOP costs.

There are three types of payments that count toward your out-of-pocket maximum: copayments, coinsurances, and deductibles.

The first type is a copayment. Copayments are set fees you pay per use of a certain Medicare insurance-approved service. These services can be anything from a doctor’s visit to transportation.

The second type are coinsurances. The difference between coinsurances and copayments is that coinsurances are usually a percentage of the total cost of a service.

The third and final type of payment that counts toward your out-of-pocket maximum is a deductible, which is a set amount you pay for a service, or services, before your plan begins to cover costs. The difference between copayments and deductibles is that copayments are paid each time, while deductibles add up each time you use the service(s) over the course of a set timeframe (often a year) — much like the maximum OOP limit.

Please note, any costs associated with outpatient drugs don’t count toward your Medicare Advantage MOOP limit.

Please note, any costs associated with outpatient drugs don’t count toward your Medicare Advantage MOOP limit. There is a separate Medicare Part D out-of-pocket limit for drug costs.

Ultimately, Medicare insurance will always have some costs associated with it. Luckily, for anyone that uses their plan a lot, MOOP limits are in place to protect beneficiaries from crippling expenses that can occur with long-term medical conditions or services..

This entry was posted in Medicare Insurance and Tagged Chastain Agency LLC, Gainesville GA