Can you help me understand Maximum Out-of-Pocket (MOOP) limits in Medicare plans, from your experience as an agent?

Question

Sandra Teel · Accepted Answer

There are two maximums out of pocket limits to consider.

The first one is on prescription drugs.
In 2024, Medicare changed the way prescription drug plans work. Out with the old and in with the new $2,000 maximum amount you will pay for your covered prescription drugs. Our prescription drug plan insurance company keeps track of how much you've paid for your prescriptions and when you have reached your maximum, your covered prescriptions will drop to zero amount for the rest of the year.

The second maximum out of pocket to know about is with the Medicare Advantage plans.
If you have a Medicare Advantage Plan, commonly known as a Part C, the insurance company keeps track of how much you pay for co-pays and co-insurance through the year. Once you reach the plans maximum out of pocket amount, then the insurance company pays the remaining co-pays and co-insurance for the rest of the year. Each plan has a different Maximum out of pocket amount, so knowing what that amount is important.

Make note that if you only have original Medicare, there is no maximum out of pocket amount for your 20% co-insurance.

Diana Garner · Answer

The maximum out-of-pocket, also referred to as MOOP, is a limit on the amount of money you are responsible for paying when receiving covered medical services in a plan year. Once the limit is met, your plan will cover 100% of your covered health care costs for the remainder of the plan year.

The MOOP resets each year and is subject to change. All Medicare Advantage plans must set an annual limit on your out-of-pocket costs.

Shelly Hefley · Answer

That is the maximum amount you could be responsible for in a given year. These are important and not always discussed, particularly by telemarketers. Everyone should know what their max out of pocket could be.

Answered by Shelly Hefley on April 17, 2025

Broker Licensed in IN, AL, IL, KY & TN

Answered by Shelly Hefley Medicare Insurance Agent

Michael Crocker · Answer

The MOOP for your Medicare Advantage plan is your "worst case scenario." It specifies the most you are personally liable for in a given calendar year, assuming you have a host of medical issues throughout the year and are paying co-pays for doctor visits, outpatient surgeries, hospital stays, cancer treatments, etc. Add all of these up and you can not be billed for more than your MOOP.

There are a few MOOP-related issues to be aware of: 1) a very small percentage (less than 2%) of Medicare recipients hit the MOOP in a given year; 2) the MOOP for your Advantage plan is for medical services only, and does not include drug costs. There is a separate $2000 drug MOOP for 2025; 3) If you are on a PPO, there will be two MOOP: one for in-network expenditures and a second, higher figure that includes both in-and-out-of-network expenditures.

Fred Manas · Answer

The Maximum Out-of-Pocket (MOOP) limit in Medicare Advantage (Part C) plans is an annual cap on how much you pay for covered services, excluding premiums. It protects you from excessive healthcare costs, ensuring you don't spend more than a set amount on deductibles, copayments, and coinsurance. 
Elaboration:
What it is:
The MOOP is a yearly limit on your out-of-pocket expenses for covered services in Medicare Advantage plans. 
What it covers:
It applies to deductible, copay, and coinsurance costs for in-network and, in some cases, out-of-network services. 
How it works:
Once you reach your MOOP, your plan pays 100% of the remaining covered expenses for the rest of the year. 
What it doesn't cover:
It doesn't cover monthly premiums, charges for non-covered services, or costs above the Medicare-allowed amount. 
Annual Limit:
The MOOP for Medicare Advantage plans is set annually by the government, and for 2025, it is $9,350. However, individual plans can set lower limits, according to Medical News Today and the National Council on Aging (NCOA). 
PPO plans:
PPO plans may have higher MOOP limits that also include out-of-network services.

Kelly Linster · Answer

It’s the worst it could be if you have a terrible health year. It’s the cumulation of copays and possible coinsurance cost sharing. Think of it as a stop loss!

Bob Nunn · Answer

There is co insurance ,paying part of the service like initial days in hospital and copayments like 20 for a specialist visit . Max out of pocket or Moop is what you pay per year with coinsurance and copayments , it does not include premium payments . So try to get procedures done at end of year because Moop resets beginning of next year. Please note there is a separate Moop 2000 for drug cost that does not apply to health care Moop.

Answered by Bob Nunn on April 16, 2025

Agent Licensed in FL, AL, AR & 36 other states

Answered by Bob Nunn Medicare Insurance Agent

Tonya Mowan · Answer

The Maximum Out-of-Pocket (MOOP) limit is the highest amount of money you will have to pay for covered healthcare services in a Medicare Advantage plan during a given year. Once you hit this limit, the plan will pay 100% of your covered medical expenses for the rest of the year. This includes deductibles, copayments, and coinsurance, but it does not include things like premiums or non-covered services (like cosmetic surgery or out-of-network care).

Let’s say someone’s Medicare Advantage plan has a $5,000 MOOP. If that person receives treatment for a chronic condition and their total out-of-pocket costs for things like doctor visits, tests, and hospital stays reach $4,800, they’ll only need to pay $200 more for the rest of the year. After that, the plan would cover all additional costs for the year, even if more treatments are needed.

The MOOP is a safety net for Medicare Advantage beneficiaries, protecting them from potentially high medical costs in any given year. It’s important to compare the MOOP limits of different plans when selecting coverage, as a higher premium plan with a lower MOOP might be better for someone with frequent healthcare needs, while a plan with a higher MOOP and lower premiums could suit someone who is generally healthy.

It’s a balancing act between premiums, MOOP, and overall healthcare needs that will vary depending on the individual!

Kimberly McPherson · Answer

Maximum out of pocket (MOOP) is the most you pay out of pocket for the year for your medical bills. If you are on a Medicare Advantage plan, you will have a MOOP, for example, $5,000. You will have copays for everything throughout the year, such as $300 per day for days 1-6 for a hospital stay, $30 to see a specialist, $80 for x-rays, etc. These copays add up towards your MOOP. Once you have paid that maximum amount out of pocket (in this example $5,000), you have met your MOOP for the calendar year and evertyhing else beyond that is covered at 100%. If you have original Medicare with a Medicare Supplement (Medigap) plan and Part D prescription drug plan, here is what you can expect: Starting in 2025, the MOOP for Medicare Part D drug plans is $2,000. That is the most you will pay out of pocket for your prescriptions for the year. Once you hit that, your prescriptions are covered at 100% as long as they are on your plan "formulary". For the medical side, there is not a MOOP with Original Medicare; however, your Medicare A and B combined with your Medigap plan limits what you owe out of pocket. If you have Medigap Plan F or C, you will owe nothing for medical expenses. If you have Medigap Plan G or N, you will owe the Part B deductible out of pocket ($257 in 2025) and then you are covered at 100%. Plan N has some additional copays associated with it as well.

Answered by Kimberly McPherson on April 15, 2025

Broker Licensed in AR, AL, AZ & 14 other states

Answered by Kimberly McPherson Medicare Insurance Agent

Can you help me understand Maximum Out-of-Pocket (MOOP) limits in Medicare plans, from your experience as an agent?

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