Can you help me understand Maximum Out-of-Pocket (MOOP) limits in Medicare plans, from your experience as an agent?
Answered by 8 licensed agents
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.
Answered by Sandra Teel on April 7, 2025
Broker Licensed in WV, AZ, CA & 13 other states
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.
Answered by Diana Garner on April 8, 2025
Broker Licensed in KY, FL, IN, OH & TN
Answered by Shelly Hefley on April 17, 2025
Broker Licensed in IN, AL, IL, KY & TN
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.
Answered by Michael Crocker on April 12, 2025
Broker Licensed in SC
Answered by Kelly Linster on April 8, 2025
Agent Licensed in ND, AZ, CO, IA & SD
Answered by Bob Nunn on April 16, 2025
Agent Licensed in FL, AL, AR & 36 other states
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!
Answered by Tonya Mowan on April 8, 2025
Agent Licensed in AR
Answered by Kimberly McPherson on April 15, 2025
Broker Licensed in AR, AL, AZ & 14 other states
Tags: Agent Interview New To Medicare The Medicare System
Agents: Share Your Expertise
Have insights or experiences related to this topic? Help others by sharing your knowledge and answering this question.
Add Your Answer