How Do I Qualify for Medicare and Oregon Health Plan?


medicare and oregon health planHealth Plans in Oregon has been helping Medicare beneficiaries in Oregon for over a decade and we’ve found that most people are confused on what Medicare is in relation to Oregon Health Plan (Medicaid) or are they one and the same? If you’re under 65 and do not have Medicare, then you may qualify for Oregon Health Plan alone. Medicare is only for Oregonians that are over 65 years old, disabled for at least 24 months by Social Security and have end stage renal disease. In Oregon, Medicare insurance is your primary insurance. Medicare generally covers about 80% of the medical bill and 20% of that would be paid by the beneficiary. Medicaid or better called Oregon Health Plan becomes the secondary insurance. Generally, Medicaid covers the 20% or whatever Original Medicare won’t cover. In Oregon, to qualify for Medicaid your income should be on certain limits.​

Medicare and Oregon Health Plan

MEDICARE

Medicare is a federally funded program available to seniors 65 years or older. People who are younger than 65 may also be Medicare eligible if they’ve been receiving Social Security disability check for at least 24 months or have end-stage renal disease.  Medicare enrollment in Oregon accounts more than 830,000 Oregonians currently enrolled in Medicare. Over half of them stay with Original Medicare and around 40% are enrolled on Medicare Advantage.

Medicare has four different parts:

  • Hospital insurance – Medicare Part A (inpatient hospital care, inpatient care in a Skilled Nursing Facility, hospice care, and some home health services);
    • Medical insurance – Medicare Part B (physician services, outpatient care, durable medical equipment, and many preventive services);
    • Medicare Advantage Plan – Medicare Part C or Medicare Advantage (Medicare-approved private insurance companies provide all Part A and Part B services and may provide prescription drug coverage and other supplemental benefits); and
    •  Prescription Drug Plan – Medicare Part D Medicare-approved private companies provide outpatient prescription drug coverage.

Related topics:  

All About Medicare

Medicare Enrollment [All Questions Answered]

MEDICAID

Medicaid better known as Oregon Health Plan (OHP) (link to our blog about OHP)  in the state of Oregon, is a joint venture funded by Federal and State governments that pays for medical costs for certain individuals and families with low income and limited resources.

Different Oregon Health Plan programs:
OHP Plus for children ages 0-18 and adults ages 19-64
OHP Plus Supplemental for pregnant adults women age 21 or older
OHP with Limited Drug for adults who qualify for both Medicaid and Medicare Part D
Other medical programs available include Citizen Alien Waived Emergent Medical (CAWEM) and Qualified Medicare Beneficiary (QMB).

Medicaid / Oregon Health Plan covers services like:

  • Hospital care
  • Mental health
  • Medical care such as a routine check-up or a general appointment
  • Medical transportation
  • Dental, Vision and Hearing
  • Laboratory and X-rays

OHP and Coordinated Care Organization (CCO)

You don’t need to sign up for a Coordinated Care Organization such as Healthshare but it’s highly beneficial to better coordinate your healthcare and billing. You need to be on full OHP or QMB+  to sign up. More on this later.

Medicare and Oregon Health Plan, what serves as your primary and secondary insurance?

If you’re under 65 and do not have Medicare, you may qualify for Oregon Health Plan alone. OHP covers your medical bills, hospital care, dental and other benefits (link to our blog about OHP) .

If you have Medicare, Medicare serves as your primary insurance and Medicaid /  Oregon Health Plan becomes your secondary insurance, depending on the level of OHP eligibility you qualify for.

Dual Eligible beneficiaries may receive full Medicaid benefits that cover will their Medicare premiums,  cost sharing and deductibles through “Medicare Savings Program” (MSP)

Types of OREGON Medicare Savings Program

medicare and ohp

1. OHP Plus or QMB Plus

Helps pay for Medicare Part A and/or Part B premiums, deductibles, coinsurance, and copays. It also covers dental care, some wrap around prescriptions, and transportation to healthcare appointments.

2. Qualified Medicare Beneficiary (QMB) Program

Helps pay for Medicare Part A and/or Part B premiums, deductibles, coinsurance, and copays.

3. Specified Low-Income Medicare Beneficiary (SLMB) Program

Helps pay for Medicare Part B premium.

4. Qualifying Individual (QI) Program

Helps pay for Medicare Part B premiums; and

5. Qualified Disabled Working Individual (QDWI) Program

Pays Medicare Part A premium for certain people who have disabilities and are working.

How Do I Qualify for Medicare and Oregon Health Plan?

To be Dual Eligible (meaning you qualify for both Medicare and Medicaid/OHP) and receive Medicaid benefits through “Medicare Savings Program” (MSP), you must be eligible or have Medicare Part A, hospital insurance coverage and your income and resources must be within the eligibility limit.  

2020 Medicare Savings Program’s income limits:

Medicare Savings Program
Program Name QMB* SLMB SMF/QI QDWI
Individual Income $1,041/mo $1,249/mo $1,406/mo $2,082/mo
Married Income $1,410/mo $1,691/mo $1,903/mo $2,819/mo

*Beginning January 1, 2016, there is no longer a resource limit for the QMB programs in Oregon.

To find out if you qualify for full Medicaid / OHP Plus / QMB plus, please contact your nearest Aging and Disability Office.

If you are enrolled on both Medicare and Medicaid (Dual Eligible beneficiary), remember that Medicare serves as your primary insurance and Medicaid or Oregon Health Plan becomes your secondary insurance. Medicare covers 80% of medical bills and Medicaid / OHP covers the deductibles and 20% co-insurance or whatever Original Medicare won’t cover.

To find out more or to apply, click here- Oregon Medicare and OHP

Also see: Oregon Medicare Annual Open Enrollment

If you have Medicare part A and part B and currently enrolled or wanting to enroll on a Medicare advantage plan, Medicare Advantage plan becomes the primary insurance and OHP becomes the secondary. If you qualify for QMB (look above the chart and remember this isn’t available in Oregon), then your copays and coinsurance on your Medicare Advantage will be covered by your OHP benefits through Medicare Savings Program.

Is your 2019 income below the eligibility limit?

Are you eligible or do you have Medicare Part A?

To apply and see if you are qualified for dual eligible Medicare and Medicaid / OHP, you need to contact your nearest Aging and Disability office.

If you’re eligible for Medicare and OHP, you can change your Medicare Plan every quarter. Unlike before, when you could switch Medicare plans every month. Starting in 2019, you can only use this Special Enrollment Period once every quarter: January-March, April- June and July – September. If you switch, it will take effect on the first day of the following month.

You also have one extra period to change during the Annual enrollment period from October 15- December 7 each year. Any changes take effect on January 1 the following year.

  • Original Medicare(primary insurance) + Part D(covers rx)+ OHP (secondary insurance)

 

  • Medicare Advantage (most plans cover part D) + OHP (good option for low income beneficiaries as it offers a minimum premium for additional benefits such as part D, vision, wellness, dental and hearing)
  • Original Medicare + Part D + Medicare Supplement Plan (most people that enroll in a Medicare supplement / Medigap policy don’t have their copays and coinsurance covered by OHP thus they enroll on a Medigap to fill in the gap of what Medicare won’t cover. Medigap policies in Oregon start at over $80 per month depending on the plan)

To know more about Medicare and Oregon Health Plan:

Call Health Plans in Oregon, we’ve been assisting Oregonians with their health insurance for over a decade. Our help is at no cost to you. Feel free to call us at 503-998-6169 or send an email to info@healthplansinoregon.com to get help.

 

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