medicare advantage

Maximum Out of Pocket on Medicare Advantage: Explained

Table of Contents


What is Medicare Advantage?

Medicare Advantage (Part C) is an “all in one” alternative to Original Medicare. It's like that swiss army knife you've always admired – it combines hospital insurance, medical services, and often includes prescription drug coverage. But like every tool, it has its nuances.

Why is MOOP Important?

Think of MOOP as a safety net. It's a feature that makes sure you don't end up in a free fall when it comes to healthcare costs. Ever wonder how high your medical bills could potentially go? MOOP sets that limit.

Understanding Maximum Out of Pocket (MOOP)

Defining MOOP

MOOP stands for Maximum Out-of-Pocket. Picture it as a spending cap, like the ceiling of a room, beyond which your Medicare Advantage plan begins to cover 100% of your costs.

How MOOP Works

Imagine you're filling a bucket with water (your medical expenses). Once it's full to the brim, you don't need to add any more. Similarly, once you reach your MOOP limit, you won't pay any more for covered services.

Differences Between MOOP and Traditional Deductibles

It's easy to confuse MOOP with traditional deductibles. Think of MOOP as the entire depth of a swimming pool, while the deductible is just the shallow end. Deductibles are the initial costs you pay, whereas MOOP is the absolute maximum for the year.

The Benefits of MOOP

Financial Protection

MOOP acts as a buffer. It's like having an umbrella during a rainstorm; even if it pours, you're shielded from the brunt of it.


Knowing there's a cap on your medical expenses offers peace of mind. It's akin to knowing there's a safety net while tightrope walking; you're secure, no matter what.

Encouraging Preventive Care

Because of MOOP, people are less likely to skip important medical appointments. It's like owning a car with a warranty; you're more likely to get regular check-ups, ensuring everything runs smoothly.

Limitations and Considerations

Coverage Gaps

Like any system, Medicare Advantage with MOOP isn't flawless. It's essential to understand what's covered and what's not. It's like knowing the zones of an umbrella; some areas shield you from rain, while others might let a few droplets through.

Network Restrictions

While Medicare Advantage offers a plethora of benefits, it may come with certain network restrictions. Think of it as a VIP event; it's fantastic, but you might need specific credentials to get the most out of it.


  1. What costs count towards MOOP? Most out-of-pocket costs related to covered services count towards MOOP. This includes deductibles, coinsurance, and co-pays.
  2. Do premiums count towards MOOP? No, monthly premiums don't count towards your MOOP.
  3. Is there a standard MOOP for all Medicare Advantage plans? No, MOOP limits can vary between plans, but there's a maximum limit set by Medicare each year.
  4. Can MOOP change year to year? Yes, the MOOP can be adjusted annually by Medicare.
  5. What happens if I switch Medicare Advantage plans halfway through the year? Your out-of-pocket expenses will reset, and you will need to meet the MOOP for your new plan.


Navigating the intricacies of Medicare Advantage and understanding MOOP can seem like unraveling a complex puzzle. But with the right guidance and insights, you can ensure you're adequately covered and financially protected. Remember, knowledge is power – and in this case, it's the key to sound health and peace of mind. Our office helps with all types of Medicare plans. Click here if you'd like our help.

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Medicare & You 2024 Guidebook

Medicare and You Book

The 2024 Medicare & You Guidebook is available and you can download it here.

When downloading the digital version, it will open in your Acrobat document reader, or in your browser. A tip for finding what you want, instantly, is to hit the Control and F button at the same time on your keyboard. This will bring up the FIND feature in your reader. 

Then, type in a word or phrase you are looking for. The reader should show you how many instances of that word or phrase exist in the entire book and you can click the down arrow to move from the first to the second, and so on.

This is how we zero in on things such as the Special Election Periods, Trial Right scenarios, Guarantee Issue Periods, and more. 

The 2024 Medicare & You book is slightly less controversial than those in the past.

 CMS (Center for Medicare and Medicaid Services) has been leaning more and more toward promoting Medicare Advantage plans and this bias has started to come through in their Medicare guide book.

In 2018, the non-profit Medicare Rights Center, in a joint letter with the Center for Medicare Advocacy and Justice in Aging, wrote a letter to the Administrator of CMS urging corrections in the proposed guidebook for 2019. 

They stated, “First, in several places, the Handbook suggests that Medicare Advantage is the less expensive alternative for beneficiaries. This is an overstatement. There are many variables determining whether enrollment in a Medicare Advantage plan may be more or less expensive for any particular Medicare beneficiary…. The repeated suggestion that Medicare Advantage can save beneficiaries money does not fairly represent these realities.”

The letter went on to point out that various descriptions throughout the book give the false impression that the benefits of Original Medicare are the same as the benefits in Medicare Advantage.

When the guidebook was first read by many of our clients, they found it to be confusing, contradictory, and inaccurate to their experience with Medicare. This again points to the benefit of using an independent Medicare professional who can interpret the realities of Medicare and how it works in the real world. This only comes from experience.

We are here to help and our service is always free.

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Diabetes and Medicare Advantage

Differences between Original Medicare vs. Medicare Advantage

If I have diabetes, should I choose Original Medicare or Medicare Advantage?

The answer to this question depends on how important individualized care is to you.

Medicare Advantage plans are typically bundled, all-in-one plans that are made as a ‘one size fits all’, with a prescription drug plan included.

However, Original Medicare is set up for you to choose a supplement plan along with a prescription drug plan tailored to your individual needs.

The American Journal of Managed Care published a study pertaining to the difference in treatment of diabetes between Original Medicare and Medicare Advantage.

In the study, they concluded that in order to achieve savings, Medicare Advantage enrollees are more likely to be treated with cheaper medications, such as Metformin and Sulfonylureas, rather than receive costly, newer medications, compared to Original Medicare. This means Original Medicare affords you the opportunity to have the drugs that might best suit you.

In this video, we review the study and explain some of the differences between Original Medicare and Medicare Advantage. We also discuss why this decision is so important if you or someone you know has diabetes and are searching for the best plan.

If you would like help finding the best Medicare plan for you, please reach out. Our help is 100% FREE to you.

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Go from Medicare Advantage to Medicare Supplement

North Carolina Medicare Plans

Seniors in North Carolina are facing more challenges with regard to Medicare Advantage plans.

Many are finding that Medicare Supplement (Medigap) is a far better way to go than the ever-shifting sands of Medicare Advantage, as shown in a recent story by the Charlotte Observer, which showed that over 57,000 North Carolina seniors are losing their Medicare Advantage plans in 2015.

Seniors on Medicare Supplement plans are guaranteed renewable, with the same benefits they signed for, for life. The benefits on Medigap plans cannot be changed, and this means stability.

Seniors who are 75, 80, 85 years old should not have to compare nuances of changing co-payments, doctor networks, and new requirements that are constantly changing on Medicare Advantage plans each time the one-year contract expire.

Seniors looking for a second opinion on their Medicare plans should call the Senior Savings Network at 1-800-729-9590.

Here is the article from the Charlotte Observer:
Turmoil in Medicare Advantage hits NC seniors hard.

North Carolina Medicare Plans Read More »

What does Medicare cover on Cancer?

Medicare Advantage Plans are often Restrictive on Cancer Treatment

Be sure to check the Medicare Advantage coverage on chemotherapy. Often, it is only of the cost. 

That's no better than just being on Medicare, because Medicare Part B already covers just 80% of the cost of chemo.

A Medicare SUPPLEMENT, however, is different than Medicare Advantage. The Medicare Supplement fully covers cancer and cancer treatments.

All of the Medicare Supplement plans are standardized. There are no hidden tricks or small print. They're accepted by every doctor that accepts Medicare.

See also:

SeniorSavingsNetwork.org helps seniors find the best Medicare Supplement plan by shopping the entire market.

We shop the market for the best Medicare Supplement rates in the market. We know the companies, the plans, and the best way to get the best rates.

Call us at 1-800-729-9590

Let us go to work for you. Our Medicare Supplement quoting service and help is free.

What does Medicare cover on Cancer? Read More »

Mount Pleasant Medicare Insurance | Medicare Insurance in Mt. Pleasant, SC

Are you looking for Medicare Insurance in Mount Pleasant, SC?

Then you have come to the right place. We specialize in the Mt. Pleasant marketplace for Medicare benefits.

SeniorSavingsNetwork.org is your one stop shop for medicare insurance quotes and agents. Whether you live in Mt. Pleasant, Hilton Head, Bluffton, Sun City, Summerville, Ladson, Ridgeville, North Charleston or elsewhere in South Carolina our agents can help you find and purchase that perfect insurance policy.

We are completely independent and can give you honest advice on the entire market, not just one company. We often save clients up to $100 per month on the same Medicare benefits, just by shopping the market for our clients.

Contact us at 1-800-729-9590 for a free, independent quote on your Medicare Supplement plan.

Mount Pleasant Medicare Insurance

Mount Pleasant Medicare Insurance | Medicare Insurance in Mt. Pleasant, SC Read More »

How will Obamacare Impact Medicare Advantage?

Obamacare will have a significant impact on Medicare Advantage, starting in the 2014 plan year.

Seniors should be cautious when considering staying on their existing Medicare Advantage plan, as many of the plans now have a different (higher) maximum out-of-pocket costs. Many plans have gone from $3,400 maximum out-of-pocket per year up to the max: $6,700 out-of-pocket.

This means if you have a catastrophic health event that requires multiple hospitalizations, doctor visits, physical therapy treatments, etc. these costs can quickly add up to the maximum, $6,700 before you are done with the cost sharing on the Medicare Advantage plans.

If this health event happens late in the year, you can see the reset of the $6,700 limit on January 1, meaning that you are on your own to hit that limit again, fully, before the health plan takes over all costs.

See these videos on the impact of Obamacare on Medicare Advantage:

These are specific ways that Obamacare will impact seniors on Medicare:

Seniors seeking to drop Medicare Advantage should first check on Medicare Supplement quotes before returning to original medicare.

This is easily done by visiting the Senior Savings Network, a free service to seniors that compares all available Medicare Supplement plans to find the best deal in the market.

How will Obamacare Impact Medicare Advantage? Read More »

What is Medicare Advantage?

A Medicare Advantage Plan, in general, is similar to an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization). Most of these plans require you to use the providers in their network, except emergency care, out-of-area urgent care, or out-of-area dialysis).

Medicare Advantage Plans are offered by private companies approved by Medicare. You will get your Part A (hospital insurance) and Part B (medical insurance) coverage from the Medicare Advantage Plan and not original Medicare.

These plans must cover all of the services that original Medicare covers except hospice care. In the case of hospice care, original Medicare covers it even if you're in a Medicare Advantage Plan. These plans are NOT supplemental coverage.

Medicare Advantage Plans may offer extra coverage that original Medicare does not cover, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the Plan, but not always.

You want to be sure and understand all the different aspects of each plan you are considering before making a final decision, as there are many variations in these plans. You may want to view the Medicare Plan Finder to find plans in your area. Remember the benefits are the same when comparing plan to plan. For instance, Plan G with one company is the same as Plan G with another company, even though the premiums differ.

If you are in a Medicare plan, review the EOC (Evidence of Coverage) and ANOC (Annual Notice of Change) your plan sends you each fall. The EOC gives details about what the plan covers, how much you pay, etc. The ANOC includes any changes in coverage, costs, or service area that will be effective in January. If you don't get these important documents, contact your plan, because any changes must be made from October 15 to December 7, unless there are special circumstances such as moving out of the plan's service area, obtaining Medicaid, moving to an institution (like a nursing home).

What is Medicare Advantage? Read More »

Medicare Advantage Plan Options

Choosing between Medicare Supplement and Medicare Advantage

Considering a Medicare Advantage Plan to save money?

Consider this…

The clients we help are usually on a FIXED INCOME.

This means that our senior clients do not like SURPRISES with their health plan.

As you can see, with a Medicare Supplement policy, you have consistent monthly premiums.

With a Medicare Advantage Plan, you could have a BIG surprise when you need hospital services.

Avoid the red line that's possible with Medicare Advantage.

Example includes Part B premium, four day hospital stay, outpatient procedure and doctor visits.


Compare Medicare Supplements to Medicare Advantage Plans:

Concerns of Seniors: Medicare
Restrictive Network of doctors and hospitals NO YES
Co-Payments to Providers NO YES
Up to $3,000 yearly
Out of Pocket Costs
Health Plan Decides What Test and Procedures Are Approved For You NO YES
Can Your Plan
Be Cancelled?

Cannot be cancelled as long as premiums are paid
YESPlans are approved yearly and can be dropped.
Ability to Travel the Country and Use Any Doctor or Hospital YES NO
Is Pre-Certification Required for some Treatments? NO YES

Penalties apply if pre-cert not done.

MD Anderson Cancer

Treatment Center Included?

MAYO Clinic Included?






Watch These Short Videos.
Things your agent won't tell you:


Good Morning America on Medicare Advantage.

Click on the video to start playback:

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A Doctor Discusses Medicare Advantage.

Click the video to start playback:

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President Obama's Changes to Medicare Advantage:
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    Please let us help you find the best plan for your situation.

Click here to get Medicare help.



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