Have You Heard: The Maximum Out-Of-Pocket Limit For Medicare Advantage Plans Will Be $7,550 In 2021?

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The Open Enrollment Period began October 15. It’s the time to pay attention to your Medicare Advantage plan. So many things can change—premiums, networks, copayments, coinsurance, networks, extra benefits and more. But the big change this year, one that many may not know about, could be the plan’s maximum out-of-pocket limit. 

The out-of-pocket maximum or limit is the most you will have to pay for covered services in a plan year. Once you have written checks up to the set limit, the Medicare Advantage plan will cover the costs of services for the remainder of the year. 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. But that will change as of January 1. The maximum limits will increase to $7,550 for in-network and $11,300 for in- and out-of-network combined.

Kidney failure driving the change 

Since the beginning of Medicare Advantage plans, individuals diagnosed with end-stage renal disease (ESRD), or kidney failure, have not been able to enroll in an Advantage plan. If they were already in a plan and then diagnosed, they could keep it. But beginning in January, those who have ESRD can enroll in a Medicare Advantage plan. Because these beneficiaries typically incur higher costs, the Centers for Medicare and Medicaid Services (CMS) will consider that when calculating plan limits.

Remember, the maximum limit does not apply to Part D prescription drug coverage, Original Medicare (Part A and Part B) or Medicare supplement plans (Medigap policies.)

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What should you do?

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  • Realize this may have an impact on you. There are almost 600 plans that will have the maximum limits in 2021. I found them from Connecticut to California. A family member in Arkansas just shared that the maximum limits in her PPO plan are increasing by $1,800 in-network and $6,200 for in- and out-of-network combined.
  • Read your plan’s Annual Notice of Changes. It will note the out-of-pocket maximum. 
  • Check the “maximum you pay for health services,” whether you’re electing Medicare Advantage for the first time or shopping for a new plan. In the Medicare Plan Finder, you’ll find this item on the plans available, plan comparison and plan details pages. Unfortunately, there is no filter for sorting by maximum limit. 
  • Look for a new plan, if you don’t want to face the $7,550/$11,300 maximum limits, and enroll by December 7.

This is a new and, for many, unexpected development. But, if you pay attention during Open Enrollment, you won’t be shocked in the New Year.

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