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Max Out of Pocket Changes

Dec 16, 2022, 16:40 PM

This year, CMS passed a new D-SNP rule which changes how annual maximum out-of-pocket (MOOP) payments are applied by a member's Medicare Advantage Part A and B services. This change takes effect on January 1st, 2023.

An annual maximum out-of-pocket (MOOP) is a tool to protect a health plan enrollee from catastrophic medical costs that may occur despite the presence of health insurance coverage. Previously, Medicaid payments toward Medicare Advantage members’ MOOP were not counted toward the overall accumulation. Beginning in 2023, the new rule will require that all payments made by Medicaid be counted toward the member's MOOP.

Once the MOOP limit is met for a particular member, CareOregon Advantage Plus (COA) will pay 100%, rather than the current 80%. Since this significantly increases the cost of a member’s care after a member meets their MOOP, we’ve reevaluated our MOOP and made adjustments for 2023. COA will now set our MOOP at the federal limit of $8,300.

Medicaid coordination of benefits is limited to the Medicaid allowable, which is often less than the Medicare allowable amount. Once a member's annual MOOP is reached (we expect this to be a very small number of members each year), then all covered services will be paid by CareOregon Advantage at 100% of the Medicare allowable. This will mean a small increase in payment to providers. Services paid 100% will still be processed by the secondary Medicaid plan, however, since services were paid in full by the primary plan, there will be no additional payment. 

Anytime COA processes a claim for a member who has met their annual MOOP for that benefit year, we will note this on the remittance advice to ensure your billing teams are aware.

Please note that this does not impact pharmacy (Part D) copayments. Members will continue to pay Part D copayments until the catastrophic coverage limit of $7,400 (for benefit year 2023) is reached.

For more information on OHA's Medicaid billing guidelines, please review the Member Billing section of CareOregon Advantage's provider manual.

For more information from CMS regarding this change, please click here.

For any additional questions, please reach out to our Customer Service team at 800-224-4840 anytime from 8 am – 5 pm, Monday-Friday (closed on holidays).