6.4 MA Benefits, MOOP & Supplemental Benefits

Why This Topic Matters

Beyond plan type (HMO, PPO, SNP, etc.), every Medicare Advantage plan operates under the same floor of required benefits and the same cost-protection guardrail: the maximum out-of-pocket (MOOP) limit. This is one of the most concrete, numbers-driven parts of Module 2 — the exam wants agents to know exactly what a plan must cover, what a client's worst-case annual cost exposure looks like, and which extra benefits a plan can restrict to specific enrollees versus which it must offer to everyone.

Quick Answer: MA plans must cover everything Original Medicare Parts A and B cover (except hospice), and must cap in-network cost-sharing at a CMS-mandated MOOP — $9,250 for 2026. Supplemental benefits beyond that floor are either open to all enrollees (if "primarily health related") or, for chronically ill enrollees only, offered as Special Supplemental Benefits for the Chronically Ill (SSBCI).

The Minimum Benefit Floor

Every MA plan must provide, at minimum, all benefits covered under Original Medicare Part A (hospital insurance) and Part B (medical insurance) — this is the core statutory promise of Medicare Advantage: an enrollee cannot receive less coverage than Original Medicare provides. There is one well-known and heavily tested exception: hospice care generally continues to be billed through Original Medicare Part A even for a beneficiary enrolled in an MA plan, rather than through the MA plan itself. This trips up agents who assume the MA plan handles every Part A/B service without exception — hospice is the standard carve-out to memorize.

Beyond that floor, plans commonly add:

• Reduced cost-sharing (lower copays than Original Medicare for some services)
• Extra benefits Original Medicare doesn't cover at all, such as routine dental, vision, and hearing exams and hardware
• Care coordination extras, like a nurse hotline or case management for complex conditions

Maximum Out-of-Pocket (MOOP): The 2026 Numbers

CMS requires every MA plan to set an annual cap on in-network cost-sharing — once an enrollee hits that number, the plan pays 100% of covered Part A/B services for the rest of the year. This is a real, quantifiable protection Original Medicare alone does not have (Original Medicare has no cap; a Medigap policy is the traditional way to protect against that gap).

Two details the exam likes to test:

1. Plans can set a lower MOOP than the mandatory maximum (and most do — the average in-network MOOP across MA enrollees is well below $9,250), but no plan can set one higher.
2. Only Part A/B in-network cost-sharing counts toward the MOOP. Part D drug cost-sharing (deductibles, copays in the coverage phases) does not count toward the MA plan's MOOP — Part D has its own separate out-of-pocket cap, covered in Chapter 7.

For a PPO, out-of-network spending only counts toward the higher combined limit, not the in-network limit — so a PPO enrollee who exclusively sees in-network providers will hit the $9,250 ceiling and stop paying, while one who mixes in- and out-of-network care tracks against the $13,900 combined ceiling.

Supplemental Benefits: Two Different Rulebooks

Not every extra benefit follows the same rule, and this distinction is a common source of exam confusion:

SSBCI exists because Congress recognized (via the CHRONIC Care Act of 2018) that certain non-traditional benefits — home-delivered meals, transportation, healthy food, home safety modifications — can measurably improve outcomes for high-risk chronically ill members specifically, even though they wouldn't qualify as "primarily health related" benefits for the general population.

The 2026 Shift: VBID Sunset, SSBCI Expansion

A detail agents recertifying from a prior year's AHIP training will want to update: the Value-Based Insurance Design (VBID) demonstration model — which many plans used to fund benefits like grocery or utility allowances — ended after CY2025. For 2026, plans are increasingly shifting those same kinds of benefits into the SSBCI framework instead, meaning access is now tied to a documented qualifying chronic condition rather than being available demonstration-wide. One other 2026 guardrail worth remembering: SSBCI cannot be used to offer $0 cost-sharing on prescription drugs — that restriction is new for plan year 2026.

Exam Scenario

A client without any chronic condition asks whether her MA plan's $0-copay grocery allowance (which she saw advertised last year) still applies to her. Because that benefit was funded through the now-ended VBID demonstration and has likely been restructured as an SSBCI benefit for 2026, she would need a qualifying chronic condition and documented health need to access it — it is no longer a benefit available to the general enrolled population the way it may have been under VBID.