Medicare Advantage Plans in Oregon
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: February 17, 2021
Medicare Advantage plans, sometimes called MA plans or Medicare Part C, offer Oregon residents an alternative to Original Medicare Parts A and B. Many Medicare Advantage plans are bundled with prescription drug coverage, or Medicare Part D. They may also include vision, dental, and hearing care and extras, such as gym memberships and transportation for medical appointments. Each plan provides its own specific coverage, and costs vary accordingly. Medicare Advantage plans are offered by Medicare-approved private insurance companies, so they are required to adhere to the agency's standards.
- 1 In 2019, there were 78 Medicare Advantage plans available in Oregon.
- 2 43% of the total Medicare population in Oregon is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $7,816 per beneficiary in Oregon, which is 23% lower than the national average.
- 4 Available Medicare Advantage plans range from two to 42 across Oregon’s 36 counties.
Oregon seniors interested in enrolling in Medicare Advantage can compare the available coverage types and costs before deciding on the most beneficial plan for their needs. While plans may have specific requirements, all provide the same protections and rights as Original Medicare. Depending on the carrier’s availability and the enrollee’s geographic location, plans may include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-For-Service (PFFS) plans, and Special Needs Plans (SNPs).
Medicare Advantage Plans in Oregon
Types of Medicare Advantage Plans
Oregon’s Medicare Advantage program includes HMOs, PPOs, PFFSs, and SNPs offered by various insurance companies within the state. Each plan stipulates its own eligibility and enrollment rules, according to Medicare’s guidelines. Comparing the similarities and differences can be time-consuming and confusing. Fortunately, there are local resources available to help seniors understand their options and choose a plan that best suits their needs.
Health Maintenance Organizations (HMO)
HMO plans have a network of providers, including physicians, hospitals, and other healthcare professionals and facilities. HMOs offer the most affordable coverage option, such as low premiums and copays; however, they’re also the least flexible. HMO members must select a primary care physician from within their plan’s network, who supervises their routine medical care and is responsible for writing referrals for specialist care. Members must obtain all services within the network to receive full coverage. Allowable exceptions include emergency care and out-of-area dialysis. Most HMOs include prescription drug coverage. It’s important to choose a plan that provides prescription coverage if that’s one of the enrollee’s requirements. Medicare doesn’t allow beneficiaries to enroll in both a Medicare Advantage HMO and a separate Plan D plan.
Preferred Provider Organizations (PPO)
PPOs are generally more expensive than HMO plans; however, they offer more flexibility. While PPO plans have a network of providers, beneficiaries may also opt to go out of network. However, they realize the greatest savings by choosing in-network care. Another advantage of a PPO is that members aren’t required to select a primary care physician, and they can see a specialist without needing a referral. While many PPO plans include prescription drug coverage, not all of them do. As with HMO plans, enrollees aren’t permitted to purchase a separate Plan D. They will be dropped from Medicare Advantage and reinstated in Original Medicare if they attempt to purchase both types of plans.
Private Fee-For-Service Plans (PFFS)
A PFFS plan determines the rate it will pay its providers and the beneficiary’s financial responsibility. Some PFFSs have a network of providers who’ve agreed to the plan’s terms. Seniors enrolled in a PFFS plan may see any physician, including specialists, they want to as long as the provider accepts the plan’s payment terms. While members are free to choose either in- or out-of-network care, they can expect to pay more with out-of-network providers. Most PFFSs plans include prescription drug coverage. If it’s not included, enrollees can purchase separate Medicare Part D prescription drug coverage without penalty.
Special Needs Plans (SNP)
SNPs are specifically designed to provide coverage for individuals with special needs, and the plans are tailored to accommodate particular health concerns or circumstances. An SNP may offer coverage for those with chronic or disabling health conditions, such as dementia, heart failure, HIV/AIDS, or end-stage renal disease (ESRD). They may also accommodate seniors and others living in nursing homes, as well as those who qualify for both Medicare and Medicaid benefits. All SNPs are required to include prescription drug coverage. These plans are limited by geographic location, so they may not be available statewide. Each SNP has a predetermined network of providers, and their premiums are generally higher than other Medicare Advantage plans.
Enrollment & Eligibility for Medicare Advantage Plans in Oregon
Individuals may enroll in one of Oregon’s Medicare Advantage plans if they meet the following requirements:
- They qualify for Medicare Parts A and B.
- They’re at least 65 years old. Younger candidates may also be eligible if they have a chronic disease or disability.
- They live within the geographic area where plan services are offered.
- They’re U.S. citizens or permanent residents with a minimum of five consecutive years of documented residency.
- They’re not enrolled in a Medigap plan.
Medicare automatically enrolls seniors in Parts A and B on their 65th birthday if they’re receiving Social Security or Railroad Retirement benefits. Enrollees may opt to change plans or switch to Medicare Advantage during an appropriate enrollment period.
Adhering to Medicare’s enrollment periods ensures access to the plans that best meet individual needs and avoids penalties.
- Seniors have a seven-month initial coverage election period, which includes the three months before and after their 65th birthday month, to enroll in Original Medicare or a Medicare Advantage plan.
- October 15th through December 7th is the annual election period. Current Original Medicare beneficiaries can submit an initial Medicare Advantage application, and those currently enrolled in a Medicare Advantage plan can change plans during this period.
- January 1st through March 31st is the open enrollment period, during which current Medicare Advantage members can change plans or reenroll in Original Medicare.
- April 1st through June 30th is the annual general enrollment period. It’s limited to individuals who currently have Medicare Part A, completed Part B enrollment during the open enrollment time period and want to switch to Medicare Advantage.
Prescription Drug Coverage
Medicare-approved private insurance companies in Oregon offer Medicare Advantage prescription drug coverage plans, also known as MA-PDs. Each plan bundles the benefits of Medicare Plans A, B and D differently. As mentioned above, most HMOs and PPOs include a prescription drug component, and enrollees should consider one of these plans if they require this coverage. Neither HMOs nor PPOs permit dual enrollment with stand-alone Medicare Part D plans. Those enrolling in both will be removed from Medicare Advantage and reinstated in Original Medicare. PFFS plans may or may not include prescription drug coverage, and members are permitted to enroll in a separate Part D plan if necessary. All SNPs must include prescription coverage.
Medicare Advantage Resources in Oregon
Oregon’s Medicare Advantage plans offer seniors and other eligible individuals a variety of health insurance coverage choices. New enrollees, in particular, can often feel overwhelmed when trying to navigate the various options. Oregon offers free state and local resources to help seniors understand the available types of plans, their eligibility requirements and the enrollment process.
Senior Health Insurance Benefits (SHIBA)
SHIBA’s certified Medicare counselors are available to provide seniors with unbiased information and advice regarding Original Medicare and Medicare Advantage plans. They evaluate the individual’s situation and provide educational guidance about the available options that best meet their specific needs. Assistance is available by phone and at counseling sites statewide.
Contact Information: Website | 800-722-4134
Portland Regional Office – Legal Aid Services of Oregon
The team at the Portland Regional Office of Legal Aid Services of Oregon serves seniors in five counties by providing free and low-cost assistance with their legal concerns, including government benefits. The legal staff offers unbiased advice regarding the most beneficial Original Medicare and Medicare Advantage products for seniors’ specific needs. It provides multilingual services in Spanish, Russian, and American Sign Language, with other languages available on request. In addition to individualized assistance, the facility also distributes self-help materials.
Contact Information: Website | 800-520-5292
Friendly House, Inc.
Friendly House Inc. is a nonprofit community center centrally located in Portland. Its programs and social services provide assistance for all ages. The center’s team of trained volunteers work in conjunction with Multnomah County Aging & Disability Services to empower seniors in making educated decisions about their health care. These volunteers can assist seniors in evaluating and comparing policies and completing their initial Medicare enrollment. They also help those currently receiving benefits with filing claims, complaints and appeals.
Contact Information: Website | 503-224-2640
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