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Out-of-Pocket Maximum

Provider Type

  • Participating Physician Groups (PPG)
  • Hospitals 
  • Ancillary

The Centers for Medicare and Medicaid Services (CMS) mandates that health plans include an out-of-pocket maximum (OOPM) on Medicare Advantage (MA) plans. The OOPM benefit mandate affects capitated participating physician groups (PPGs), dual-risk hospitals and capitated ancillary providers, and applies to all Part A and Part B medical covered services, including behavioral health and substance abuse services. The OOPM does not apply to supplemental benefits and Part D prescription medication benefits.

In order to meet this regulatory requirement, the plan's capitated medical groups, facilities and ancillary providers must include member-paid copayment amounts on all professional and institutional Medicare claims and encounter data. In addition, any rejected Medicare encounter data must be corrected and resubmitted in order for correct member-paid copayment amounts to be captured and accumulated.

Last Updated: 10/30/2019