Medicare AdvantageReimbursementMedium impact
CMS Final Rule: CY2023 Medicare Advantage Plans' Maximum Out-of-Pocket (MOOP) Limits
Healthfirst·Provider Update
Effective date
Jan 1, 2023
We identified it
Jun 20, 2026
Summary
Effective January 1, 2023, Medicare Advantage plans will calculate maximum out-of-pocket (MOOP) limits based on all Medicare-covered cost sharing, not supplemental benefits. Once members reach their MOOP limit, reimbursement responsibility shifts from Medicaid/secondary insurers to the Medicare Advantage plan, which will then pay 100% of covered costs.
Action Required
Immediately: Billing team must update workflows to track Medicare Advantage members' MOOP status and identify when the limit is reached. Coordinate with Medicare Advantage plans to ensure proper reimbursement source after MOOP is met - expect payment from MA plan instead of Medicaid/secondary insurance. Update billing system notes to flag members who have reached MOOP limits.