All Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plans must set an annual limit on your out-of-pocket costs Out-of-pocket costs are health care costs that you must pay because Medicare or other health insurance does not cover them. , known as the maximum out-of-pocket (MOOP) The maximum out-of-pocket (MOOP) is an annual limit on your out-of-pocket costs for Medicare Advantage Plans. Once you reach this amount, you will not owe cost-sharing for Part A or Part B covered services for the remainder of the year. All Medicare Advantage Plans are required to set a maximum out-of-pocket. . This limit is high but it may protect you from excessive costs if you need a lot of care or expensive treatments. After reaching your MOOP, you will not owe cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs. for Part A or Part B covered services for the remainder of the year. Some plans may also apply the MOOP to supplemental benefits, such as vision, hearing, or dental.
The out-of-pocket costs that help you reach your MOOP include all cost-sharing (deductibles, coinsurance, and copayments) for Part A and Part B covered services that you receive from in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. providers. Part D cost-sharing does not count towards your plan’s MOOP.
In 2025, the MOOP for Medicare Advantage Plans is $9,350, but plans may set lower limits. If you are in a plan that covers services you receive from out-of-network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received. providers, such as a PPO, your plan will set two annual limits on your out-of-pocket costs. One limit is for in-network costs and the other is for combined in-network and out-of-network costs.
Call your plan directly if you have questions about your annual out-of-pocket limit.