Medicare Advantage Must Cap Patient Expense Starting in 2011
In 2011, Medicare will require every Medicare Advantage plan to have an annual maximum-out-of-pocket (MOOP). This is good news for 30,000 or so seniors in Tucson whose Advantage plan does not have a MOOP.
A MOOP is a cap on expenses for co-pays and co-insurance, and the maximum limit is expected to be $6,700. However, CMS (Centers for Medicare and Medicaid) encourages Advantage plans to have lower MOOPs and will reward plans that voluntarily cap members’ expenses at a lower amount, such as $3,400.
A MOOP is important when someone has a chronic illness or multiple hospitalizations during a given year. Co-pays for specialists ($35-$45 for each visit), co-pays for MRIs ($150), and hospitalization at $200 per day, can add up. So Medicare is going to require every Advantage plan to set a cap for its members’ annual co-pays.
Cancer is an illness that requires large co-pays for chemo and radiation treatment (20% of the bill) and can quickly add up to five or even ten thousand dollars. An Advantage plan with a MOOP of $3,400 means that after the member has paid this amount “out of his own pocket”, he will have no more co-payments or co-insurance for the rest of the year. (Some plans have a MOOP but still require co-pays for doctor visits and labs after the MOOP is met.)
The Medicare Advantage plan with the largest enrollment in Tucson (over 28,000 members) does not have a MOOP. I recently got a call from a woman whose mother-in-law is in this plan and is being treated for breast cancer. The co-pay for chemotherapy under every Medicare Advantage plan in Tucson is 20% of the bill. So a person enrolled in a plan with a $3,400 MOOP would have their chemo cost capped at $3,400 through the end of the year. A person in a plan with a $5,000 MOOP will stop paying at $5,000. A person in a plan with no MOOP can only wait and see what their total bill will be. I have heard of people whose 20% co-pay was $10,000.
Please see my post from last fall in which I compared the benefits and costs of 2010 Advantage plans in southern Arizona. I addressed the MOOP for several plans.
LOWEST MOOP: Health Net has introduced a $3,400 MOOP for all of its Ruby plans. Universal also has a $3,400 MOOP.
NO MOOP: Secure Horizon Medicare Complete Plan 1 has no MOOP. CareMore plans have no MOOP.