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Maximum Out-Of-Pocket Expense?
- Thread starter WayneRyan
- Start date
It does to a certain extent. Let me explain. If you do not qualify for a retiree plan that is secondary to Medicare, you can purchase an individual Medigap policy or Medicare Advantage plan. In either case, Part D drugs are considered separate and not included in the OOP.
If you choose original Medicare and Medigap plan G, all covered Medicare Part A and Part B expenses will be covered except the Part B deductible ($233 in 2022). So, the OOP max is $233 excluding Part D drug copays/coinsurance/deductible.
If you choose original Medicare and Medigap plan G-High Deductible (G-HD), Medicare still pays 80% and you pay 20% of the low Medicare approved amount until your 20% plus $233 totals $2490 (2022). Then, G-HD pays the 20%. The OOP max is $2490 plus Part D drug cost sharing. With original Medicare, you choose your Part D drug plan separately from the Medigap plan.
Medicare Advantage plans can be HMO or PPO and are more similar to your current group plan. The HMOs have an OOP max for in-network Part A/B services. You will be responsible for non-emergency out-of-network services plus Part D drug cost sharing. The PPOs have one OOP max for in-network services and a combined OOP max for in- and out-of-network services excluding Part D drug cost sharing. With Advantage plans, the Part D plan is already attached as a combined offering.
You can find more details on the Medicare Advantage plans in your area here.
www.medicare.gov
If you choose original Medicare and Medigap plan G, all covered Medicare Part A and Part B expenses will be covered except the Part B deductible ($233 in 2022). So, the OOP max is $233 excluding Part D drug copays/coinsurance/deductible.
If you choose original Medicare and Medigap plan G-High Deductible (G-HD), Medicare still pays 80% and you pay 20% of the low Medicare approved amount until your 20% plus $233 totals $2490 (2022). Then, G-HD pays the 20%. The OOP max is $2490 plus Part D drug cost sharing. With original Medicare, you choose your Part D drug plan separately from the Medigap plan.
Medicare Advantage plans can be HMO or PPO and are more similar to your current group plan. The HMOs have an OOP max for in-network Part A/B services. You will be responsible for non-emergency out-of-network services plus Part D drug cost sharing. The PPOs have one OOP max for in-network services and a combined OOP max for in- and out-of-network services excluding Part D drug cost sharing. With Advantage plans, the Part D plan is already attached as a combined offering.
You can find more details on the Medicare Advantage plans in your area here.
Find a Medicare plan
An update to the response in post #2. For 2024, Part D drug plans will no longer have a 5% coinsurance after the catastrophic cap is met. The catastrophic cap will be the OOP max.
In 2025, Part D plans will have a $2000 OOP max. The amount will be inflation adjusted in future years. These changes also apply to Part D plans attached to Medicare Advantage plans. The changes are the result of passage of the Inflation Reduction Act.
In 2025, Part D plans will have a $2000 OOP max. The amount will be inflation adjusted in future years. These changes also apply to Part D plans attached to Medicare Advantage plans. The changes are the result of passage of the Inflation Reduction Act.