Can you explain the out-of-pocket limit?
Medicare Advantage plans must limit how much their members pay out-of-pocket for covered Medicare expenses. Medicare set the maximum but some plans voluntarily establish lower limits. After reaching the limit, Medicare Advantage plans pay 100% of eligible expenses.
Beginning in 2011, Medicare set the maximum out-of-pocket limit for in-network services at $6,700 and $10,000 for in- and out-of-network combined. In January 2021, the limits increased to $7,550 for in-network and $11,300 for in- and out-of-network combined. And, in 2023, the limits are even higher, $8,300 and $12,450.
There is an explanation for this change. For the first time, those diagnosed with end-stage renal disease (ESRD) or kidney failure will be able to enroll in a Medicare Advantage plan. Previously, if someone who had elected Medicare Advantage was diagnosed with ESRD, he could continue with the coverage. However, those with the condition could not enroll in a plan. The Centers for Medicare and Medicaid Services (CMS) now considers those costs when calculating the limits.
Here are some facts to know.
- This limit excludes monthly premiums and prescription medications.
- Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans have a limit on in-network care of $7,750. PPO plans also have a limit of $11,300 in- and out-of-network combined.
- Only Medicare-covered services count toward the out-of-pocket limit.
- Services not usually covered by Medicare, such as hearing, vision, and non-emergency transportation, and prescription medications are not counted in the limit.
- Each plan determines its maximum out-of-pocket limit and the limit can change every year.
Check the Medicare Advantage plan’s evidence of coverage for details on the out-of-pocket limit.
FYI: It's true that Original Medicare Part A and Part B do not have a limit on how much a beneficiary can spend out-of-pocket. However, those who have a Medigap policy (Medicare supplement insurance) don't have to worry. Any policy sold in the country covers the 20% Part B coinsurance. Plus, optional benefits can protect a beneficiary from other costs, such as the hospital deductible and skilled nursing facility copayment for days 21-100. For example, those who have Plan G are responsible for just the Part B deductible ($233) when they use providers who see Medicare patients.Last updated: 11-08-2022