Maximum Out of Pocket Limit – Center for Medicare and Medicaid Services (CMS) Contract Year 2023
Policy and Technical Changes

  November 29, 2022

CMS released the final rule effective 1/1/2023 which revises Medicare Advantage (MA) Part C programs to implement changes of communications in part, related to Maximum Out of Pocket (MOOP).

The MOOP limit in an MA plan (after which the plan pays 100 percent of MA costs) is calculated based on the accrual of all Medicare cost-sharing in the plan benefit, whether that Medicare cost-sharing is paid by the beneficiary, Medicaid, or other secondary insurance, or remains unpaid. This also includes when the cost-sharing is not paid because of state limits on the amounts paid for Medicare cost-sharing and dual eligible individuals’ exemption from Medicare cost-sharing

While enrolled, iCare dual eligible members are cost-share protected by Wisconsin Department of Health Services/ForwardHealth. Dual iCare members will not be responsible for copayments, coinsurance or deductibles and cannot be balance billed, even if a provider chooses not to bill iCare. iCare members will be notified when their MOOP has been met and a copy of the notification will be sent to the provider.