What does the term maximum out-of-pocket (MOOP) represent in a health plan?

• A. The maximum deductible in a plan year.
• B. The maximum amount a member pays in a policy year before the plan covers 100% of allowed benefits.
• C. The annual premium charged by the plan.
• D. The maximum number of visits allowed per year.

Answer: (B)

MOOP is the maximum you would pay out of pocket in a policy year for covered health care services. It marks the point at which the plan begins paying 100% of allowed costs for those services for the rest of the year. This amount includes your deductible, coinsurance, and copayments for in-network, covered benefits, but does not include the monthly premium. Premiums don’t count toward reaching the MOOP. Some plans may have separate MOOPs for in-network vs out-of-network or individual vs family limits, and non-covered services typically don’t count toward the MOOP.