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January 24, 2022

Medicare Program Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs: Summary of Proposed Changes to Maximum Out-of-Pocket (MOOP) Limits

This Bulletin is brought to you by AHLA’s Payers, Plans, and Managed Care Practice Group.
  • January 24, 2022
  • Christopher Lim , Fresenius Medical Care North America

In the Proposed Rule, CMS seeks to make it easier for Medicare Advantage (MA) Plan enrollees, particularly those who are dually eligible for Medicaid, to reach their Maximum Out-of-Pocket (MOOP) limits. Under the Medicare Advantage Program, CMS requires that all MA Plans establish limits on enrollee out-of-pocket cost sharing for Parts A and B services (e.g., deductibles, copays, and coinsurance) that do not exceed the annual limits established by CMS. In addition, MA Plans with preferred provider networks are required to have two MOOP limits: (a) an in-network limit, and (b) a total catastrophic limit that includes both in-network and out-of-network items and services under Parts A and B. After an enrollee reaches the MOOP limit, the MA Plan is 100% responsible for reimbursing providers for the items and services covered under Parts A and B that are furnished to the MA Plan’s enrollee.

  • Payers, Plans, and Managed Care
  • Government Reimbursement

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