Every Medicare Advantage plan has an annual maximum out-of-pocket limit for covered Medicare Part A and Part B services.
Once your qualifying medical cost sharing reaches your plan’s applicable limit, the plan pays 100% of covered Part A and Part B services for the rest of the calendar year, subject to the plan’s rules.
The actual limit can vary among plans, so you should check the specific plan rather than assuming every Medicare Advantage plan has the same maximum.
Depending on plan rules, qualifying expenses commonly include your share of covered Medicare medical services such as:
Always use the plan’s Evidence of Coverage to determine exactly what counts.
Expenses that generally don’t count toward the Medicare Advantage medical maximum can include:
A $0-premium Medicare Advantage plan might look inexpensive.
But suppose the plan has significant cost sharing for:
Hospitalizations
chemotherapy
advanced imaging
or
outpatient surgery.
The maximum out-of-pocket amount tells you something about your potential medical exposure during a very expensive health year.
With an HMO, the key figure is typically your applicable in-network out-of-pocket maximum.
With a PPO, pay attention to both:
In-network maximum
and
combined in-network/out-of-network exposure, where applicable.
The Medicare Advantage Number Everyone Should Check
If you’re comparing Medicare Advantage plans and you look only at the premium, you’re missing one of the most important numbers.
I want to know:
What could this plan cost you in a bad health year?
A healthy person may pay almost nothing beyond Part B.
But serious illness can change the picture quickly.
The maximum out-of-pocket isn’t necessarily what you’ll spend.
It’s a way to understand your potential medical risk.
Medicare Advantage plans cover Medicare-covered cancer treatment, including qualifying chemotherapy, but plan networks, prior authorization rules and out-of-pocket costs can become especially important when someone has cancer.
Medicare’s Annual Enrollment Period, also commonly called Medicare Open Enrollment, runs, October 15 through December 7 each year.
