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.

Robert Pennington · Answer

The Max Out Of Pocket (MOOP) applies to the monies that are paid for copays for medical services during the year.  If the MOOP is met during the year then you pay no more.  Rx copays do not apply.

Ray McCauley · Answer

once you reached the limit you no longer have  the responsibility to pay medical expenses. different plans have different max limits

David Wynne · Answer

The Maximum Out-of-Pocket (MOOP) limit is the most you’ll have to pay in a calendar year for covered services under a Medicare Advantage plan. Once you reach this limit, your plan covers 100% of the costs for the rest of the year. MOOP includes your deductibles, copayments, and coinsurance for medical services covered by your plan. It does not include your monthly premiums, prescription drug costs or services not covered by Medicare.

From an agent’s perspective, I always advise clients to compare MOOP limits when reviewing plan options. Lower MOOPs can offer peace of mind, especially for those with chronic conditions. Also, some plans like PPOs, have separate in-network and out-of-network MOOPs, so it’s important to understand how that applies to your situation.

Steven Bleicher · Answer

This has to do with the free of premium Medicare Advantage plans. Since each private insurance company has the right to determine its maximum deductible amount, if yours is $2,900.00 per calendar year, the MOOP for you is that same figure. Bear in mind that it starts all over again next year. I presume you know that these have little or no premiums due to the Federal government subsidy.

Answered by Steven Bleicher on May 25, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

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.

Steve Houchens · Answer

Maximum out out pocket or MOOP is referring to medical cost and the most you will spend out of pocket for the year. This doesn't include prescription cost as that is a totally different issue. MOOP is after any deductibles and copays have been met it will be the most you will have to pay for any medical cost.

Answered by Steve Houchens on May 27, 2025

Agent Licensed in KY & TN

Answered by Steve Houchens Medicare Insurance Agent

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

Cleo Martin · Answer

That is that maximum amount of money you can spend in a year. I haven't had anybody reach that yet. I would imagine you would have to be really, really sick to hit that amount.

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.

Alan &quot;AL&quot; Minthorn · Answer

MOOP’s apply to Part A & B cost sharing - it is the maximum you should pay in total cost shares before the plan covers 100% of Part A & B costs the remainder of year. Greater than 90% hit their MOOP via chemo or other Part B medications, or radiation treatments.

Answered by Alan "AL" Minthorn on June 1, 2025

Broker Licensed in ME, FL, GA, NC & NH

Answered by Alan "AL" Minthorn Medicare Insurance Agent

Crystal Burney · Answer

In simplified terms MOOP or Max Out of Pocket cost is the most you will have to pay for COVERED healthcare services in a year under your Medicare plan. This means as your copays, coinsurance and deductibles are paid throughout the year, and they meet the MOOP amount, you will not pay out of pocket anymore throughout the year. 
For example, if your Medicare Advantage plan has a MOOP of 5,000.00 and you hit that amount in medical costs Copays, Coinsurance and deductibles, during the year, you will not pay anything more for covered services the rest of the year.

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.

Vachik Chakhbazian · Answer

The MOOP is the limit on annual out-of-pocket expenses that you'll pay for medical services that are covered by your Medicare plan. Once you reach this limit, your insurance pays 100% of the covered costs for the rest of the policy year. This limit helps protect you from excessive healthcare expenses.

Answered by Vachik Chakhbazian on June 1, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Andrew Kramer · Answer

MOOP's on Medicare Advantage plans are the total of annual co-pays and co-insurance on the plan. Rx drug costs are excluded from the MOOP because they have a separate MOOP of $2,000/yr from the 2024 Inflation Reduction act. From my experience, it's very rare to reach the MOOP from just the co-pays. The rare exception from my clients have been those on chemo therapy infusions, because those are always 20% co-insurance of the Medicare allowable cost for the medication, which adds up.

Answered by Andrew Kramer on May 12, 2025

Agent Licensed in FL

Answered by Andrew Kramer Medicare Insurance Agent

Jerry Cohen · Answer

MOOP refers to the highest amount a person can be asked to pay for covered expenses on a Medicare Advantage plan. The Federal government estableshes the MOOP each year but insurance companies are permitted to use a lower figure if they wish. The MOOP includes network expenses for deductibles; CoPays; and hospital related expenses.

Answered by Jerry Cohen on May 22, 2025

Broker Licensed in NY

Answered by Jerry Cohen Medicare Insurance Agent

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!

Richard Balistreri · Answer

Part B has a medical deductible that everyone pays regardless of what plan you are on. Medicare does not have a maximum out-of-pocket. If you elect to stay on Medicare only, you are exposing yourself to costs that could be devastating. For that reason, you should consider a Supplement plan or an Advantage plan. A supplement plan does not have a maximum out-of-pocket, so after you pay your Part B deductible, Medicare-allowed charges are covered at 100%.

Medicare Advantage plans do have a maximum out-of-pocket, but it can range from $1,000 to $14,000 if you go out of network.

Out-of-pocket refers to the amount you would need to pay before your plan will pay 100% of the Medicare-allowed charges.

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

Robert Rowe · Answer

Maximum Out-of-Pocket limits are pretty much what they look like. They are the most possible costs you can be charged for a calendar year assuming all care is within network. Typically it will take a catastrophic health crisis to hit a MOOP or multiple serious health concerns within a short period of time. If you ever have a plan with a high MOOP I would recommend looking at hospital indemnity plans to cover that large gap in Medicare.

Answered by Robert Rowe on May 29, 2025

Broker Licensed in MI

Answered by Robert Rowe 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

Christopher Hepburn · Answer

Maximum Out-of-Pocket (MOOP) limits are caps on the amount of money that Medicare beneficiaries must pay out of pocket for covered medical services within a calendar year. Once this limit is reached, the plan covers 100% of the costs for covered services for the rest of the year.  

Medicare Advantage plans, also known as Part C, are required to set MOOP limits to protect beneficiaries from excessive medical expenses. These limits vary by plan but are regulated by the Centers for Medicare & Medicaid Services (CMS).

MOOP limits provide significant financial security by capping annual out-of-pocket expenses. This is particularly beneficial for individuals with chronic conditions or unexpected health emergencies, ensuring that they are not burdened by unmanageable healthcare costs.

Medigap plans, which are designed to cover some of the costs not covered by Original Medicare, do not have MOOP limits. Instead, they help pay for expenses such as copayments, coinsurance, and deductibles. While Medigap plans provide considerable financial protection, beneficiaries should compare the benefits and costs carefully to choose the best plan for their needs.

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

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

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