What’s the Medicare Advantage out-of-pocket maximum?

Medicare Advantage (MA) Plans (often called Part C) are offered by private companies and insurance companies approved by Medicare. These offer Part A and Part B with additional coverage, many offering coverage for prescription drugs.

Under a Part C Plan, you still have to pay your Part B monthly premium. Your part C costs differ based on your plan, which is usually an HMO, PPO, or PFFS plan. These costs include the plan’s monthly premium, deductible, copayments at the time of service, and coinsurance. The highest amount you pay for any service is 20%, whether that be a copayment or coinsurance.

Out-of-Pocket (OOP)

The maximum out-of-pocket (OOP) cost for Parts A and B spending is $6,700. HMO and PPO plans have their maximum out-of-pocket set to $6,700 for in-network care. However, PPO plans also include out-of-network in their policy. For in-network and out-of-network combined, the maximum out-of-pocket is $10,000. Spending toward Part D, prescription drug coverage, does not count toward this amount. 

However, keep in mind that these dollar amounts are the highest limits the plans can impose. Each plan and insurer are different, meaning they are free to choose their own out-of-pocket limits as long as it does not go over these maximum amounts.

Original Medicare, meaning Part A and Part B coverage directly from Medicare, does not have an out-of-pocket maximum. The advantage of Medicare Advantage plans is that your plan will cover any remaining costs once you reach the maximum for the year.

Why a limit?

The purpose of an out-of-pocket maximum is to set a certain limit for your out-of-pocket costs. Once you reach that limit, your Medicare Advantage Plan will begin paying 100% of your medical expenses for the remainder of the year. 

If you are considering a Medicare Advantage Plan, the plan you choose is obviously up to your own needs and wants. However, be aware of all your options. Would you rather have a lower out-of-pocket cost for a higher premium or vice versa?

At Turning 65 Solutions, we will answer your questions and give you all options available in your area. Contact us today to discuss your options with Medicare Advantage.

Turning 65 Solutions can help you plan for the future.