Medicare Advantage Plans can be used in replace of Original Medicare that may offer more benefits that may not be covered by Original Medicare. It’s a type of a Medicare health insurance that’s government approved offered by private insurance carriers. There are different types of Medicare Advantage Plans in Oregon to suit different needs. Some health plans include more coverage of services like dental, vision care or wellness programs and more importantly maximum out of pocket. These type of health plans may offer a lower copay, coinsurance and out of pocket costs than Original Medicare unless you’re also on Medicaid that can cover some to all copays or coinsurance. It’s important to know what you’re eligible for, coverage you need and what each plan covers.
Medicare Advantage has certain service areas and providers networks where you can receive healthcare and services. It’s important to check your providers if they participate or accept Medicare Advantage plans. Most plans also cover worldwide coverage for urgent and emergency visits if you travel in another country or around the states.
Medicare Advantage Plans and Medicaid (Oregon Health Plan)
Medicare Advantage plans can work alongside the Oregon Health Plan. There are different levels of medical help for low-income Oregonians that have Medicare. You may qualify to have your part B premium paid for, copays and coinsurance and prescription drugs assistance. Find out and qualify for these Medicare Savings Programs in Oregon by calling 1-800-282-8096.
Medicare Advantage Plans and Employer Insurance
If you have both Medicare Advantage and Employer insurance, coordination of benefits apply. Primary insurance(payer) pays the majority of the bill and the secondary insurance pays the rest of the bill. If your employer has 20 or more employees, your employer insurance may pay first. For more questions about this topic, call the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 (TTY: 1-855-797-2627)
Medicare Advantage Plans and Veterans Benefits (VA)
You can use choose which healthcare to use to receive services. In order for U.S. Department of Veterans Affairs (VA) to pay for services, you must go to a VA facility or have the VA authorize services in a non-VA facility. Your Veteran benefits can’t pay for the same service that was covered by Medicare.
Want to compare Medicare Advantage plans in Oregon?
Medicare.gov is the best tool to compare Medicare advantage plans side by side. Taking the time to look at available plan options in your area can result in thousands of dollars in savings. And even though Medicare Advantage plans in Oregon vary in costs and availability, there are still some Medicare plans that have monthly premiums as low as $0. On the other hand, you have to remember that even though some MA plans may not have a premium, there are other health plan costs — copayments, coinsurance, and deductibles.
In addition, you’ll to continuously pay your Medicare Part B. Needless to say, it’s always a smart idea to have a licensed and certified health plan consultant that can guide you on which plan may fit your needs and budget. We will review the cost of insurance plans, benefits, enrollment and eligibility so you’ll get the most out of your Medicare and what you qualify for.
Is Medicare Advantage Plan same as Medicare Supplement (Medigap)?
No. They’re a totally different type of plans and coverage. Medicare Advantage is a private health plan that may offer lower out of pocket and more benefits than Original Medicare. It may also cover prescriptions, dental, vision, and annual exam. On the other hand, Medicare supplement acts as secondary insurance to Original Medicare. It covers most if not all of Original Medicare’ s out of pocket expense. Original Medicare and Medicare Supplement don’t cover prescriptions so you will have to enroll in a prescription drug plan.
Now, let us compare Original Medicare and Medicare Advantage Plans:
You probably know by now that Original Medicare is made up of Medicare Part A and Medicare Part B. Moreover, most Americans know that when a person turns 65, he/she becomes eligible for particular health care benefits coming from the government. However, not all are familiar with Medicare Advantage Plans. The difference is that Medicare Advantage plans offer more coverage than Original Medicare.
|ONLY covers medical and hospital costs
|covers medical and hospital costs — most plans also cover dental, vision, hearing and prescription drugs
|out of pocket cost has no cap — only pays for a certain number of days in the hospital or nursing facility
|out of pocket cost has a maximum per year — pays 100% of the cost for most medical services once you hit a certain dollar amount
|almost all the time, Original Medicare won’t cover your medical needs when you’re out of the country
|Medicare Advantage may cover emergency care when you’re out of the country
|Coinsurance / Copay
|for common health services like office visits or outpatient surgery, you pay 20 percent of the cost (coinsurance)
|for common health services like office visits or outpatient surgery, you pay the fixed cost (copay)
|you can go to any doctor or hospital that accepts Medicare
|has fixed networks of doctors and hospitals and may require additional cost when you go outside your network
2023 Oregon Medicare Advantage Plans Statistics
Let’s go straight to the facts!
- Average costs of Medicare in Oregon: In 2023, Medicare Advantage premiums decreased 14.1% from $39.28 to $33.74. The lowest Part D plan in Oregon is $1.60.
- Average expenditure per enrollee: In Oregon, the average Medicare spending per enrollee is $9,290.
- Number of enrollees in Oregon: As of 2023, 909,151 individuals are enrolled in Medicare in the state of Oregon. Approximately 440,949 million individuals are on a Medicare Advantage Plan.
- Medicare Advantage availability: Oregon has had a 6.1% decrease in Medicare Advantage Plans since 2022.There are 124 Oregon Medicare Advantage Plans available in 2023, which is an increase from 132 plans in 2022.
Medicare Advantage Providers in Oregon
Fifteen private health insurance providers offer Medicare Advantage plans in Oregon, including:
- Aetna Medicare
- AllCare Advantage
- ATRIO Health Plans
- Kaiser Permanente
- Lasso Healthcare
- Moda Health Plan, Inc.
- PacificSource Medicare
- Providence Medicare Advantage Plans
- Regence BlueCross BlueShield of Oregon
- Samaritan Advantage Health Plan
- Summit Health Plan, Inc.
- Wellcare by Health Net
Plan availability varies by ZIP code, so not all providers listed above offer Medicare Advantage plans in all counties in Oregon.
Medicare Advantage Enrollment Period
Initial Enrollment Period (IEP)– this is the period when you are first eligible for Medicare A and B. It starts 3 months before, the month of your birthday and 3 months after your birth month.
Annual Enrollment Period– this is the yearly enrollment period for anyone on Medicare. It starts Oct. 15- Dec.7 every year.
Open Enrollment Period– this period is new this year 2019. Anyone who’s currently enrolled with Medicare Advantage can switch to another Medicare Advantage, go back to Original Medicare with or without prescriptions and Medicare supplement.
Special Election Period:
You may sign up for / change your Medicare Advantage plan outside of the open enrollment period if you qualify for a Medicare Special Enrollment Period that allows you to enroll outside of the normal enrollment period. There are different circumstances and programs for those who qualify. Certain life events allow you to enroll or modify outside of open enrollment.
You move to a new location
There are several ways that changing where you live can allow you to change your Medicare Advantage plan outside of the open enrollment period.
If you relocate to somewhere that isn’t in your current plan’s service area, you’re free to switch plans or convert to original Medicare. If you tell your current plan about your move in advance, you’ll have two months after your move to switch plans. And if you tell your current plan of your new address after you move, you’ll have two months to switch from when you let the plan know.
Even if you move to a new address that’s in your current plan’s service area, you could potentially still change plans — but only if there are new plan options in your new location. Note, however, in this situation, you can change Medicare Advantage plans but you can’t switch to original Medicare. The time period in which you’re allowed to change plans is the same as if you had moved to an address, not in your current plan’s service area.
What if you move back to the U.S. after living in another country? You can join a Medicare Advantage plan for two full months after the month you return to the U.S.
If you move into or out of a skilled nursing facility or long-term care hospital, you can also join a new Medicare Advantage plan. You can make changes as long as you live in the institution. This is for two full months after the month you leave.
If you were in jail and are released, you can join a Medicare Advantage plan. Your window for enrolling extends for two months after the month you’re released from jail.
You lose your current coverage Medicare Advantage enrollment
If you’re no longer eligible for Medicaid, you can change Medicare Advantage plans or enroll in one if you had not already done so. You could also switch to original Medicare and get a prescription drug plan. Changes can be made for two months after the month you find out you’ve lost Medicaid eligibility. If you lose coverage for the next year, you must make any changes between Jan. 1 and Feb 28.
Moreover, if you drop coverage from an employer or union plan (including COBRA) or from a Program of All-Inclusive Care for the Elderly (PACE) plan, you have two months after the month your coverage ends to enroll in a Medicare Advantage plan.
If you involuntarily lose other Medicare prescription drug coverage that’s as good as Medicare drug coverage or your current drug coverage is no longer “credible” (equivalent to Medicare drug coverage), you can either join a Medicare Advantage plan with drug coverage or enroll in a Medicare Part D prescription drug plan. The window for enrolling is two months after the month you lose your coverage or when you find out your drug coverage is no longer credible, whichever is later.
You have an opportunity to get other coverage
If you have the chance to enroll in coverage from your employer, your union, or PACE, you can drop your current Medicare Advantage plan at any time during the year to go to the new coverage.
Your current plan’s status with Medicare changes
If Medicare sanctions your current Medicare Advantage plan or ends the contract with the plan for some reason, you’re free to switch to a new Medicare Advantage plan. In situations where your current plan has its contract with Medicare canceled, you can change to a new plan. It starts two months before the contract ends and one month after it ends. The period allowed for changes varies on a case-by-case basis when Medicare Advantage plans are sanctioned.
Also, if your current Medicare Advantage plan doesn’t have its contract renewed, you’ll have from Dec. 8 to the last day in February to enroll in a new Medicare Advantage plan.
You’re dual eligible for Medicare and Medicaid
You can join, switch, or drop your Medicare Advantage Plan at any time during the year if you’re eligible for both Medicare and Medicaid or better known as Oregon Health Plan .
There are different types of Medicare Advantage Plans:
- HMO (Health Maintenance Organization plan)
Lets you see doctors and other health professionals who participate in its provider network. Out of network are normally not covered unless it’s an urgent or emergency visit.
- PPO (Preferred Provider Organization plan)
Covers both in- and out-of-network providers, giving you the freedom to choose any doctor that accepts Medicare assignment, which can work if you prefer that kind of flexibility. Although, out of network may cost you a higher copay, coinsurance or out of pocket.
- PFFS (Private Fee-for-Service plan)
The plan determines how much it will pay providers and how much you must pay when you receive care. The treating doctor has to accept the plan’s payment terms and agree to treat you. If the doctor doesn’t agree to those terms, then the PFFS plan will not cover services through that doctor or provider.
- SNP (Special Needs Plans) — more about this below
Are especially for people who have certain special needs. The three different SNP plans cover Medicare beneficiaries living in institutions, those who are dual-eligible on Medicaid and Medicare, and those with chronic conditions such as diabetes, End Stage Renal Disease (ESRD), or HIV/AIDS. This type of plan always includes prescription drug coverage.
- HMO-POS (Health Maintenance Organization – Point of Service plan)
Covers both in- and out-of-network health services, but at different rates. You pay less out-of-pocket when you go to in-network doctors, labs, hospitals, and other health care providers.MSA (Medical Savings Account plan)Includes both a high deductible and a bank account to help you pay that deductible. The amount deposited into the account varies from plan to plan. The money is tax-free as long as you use it on IRS-qualified medical expenses, which include the health plan’s deductible.
Access Rules on major types of Medicare Advantage plans:
|— Needs a referral before seeing an in-network specialist
|— Allows you to go to out-of-network providers
|No, unless you have a POS (Point of Service) option that allows you to use providers that are not in the plan’s network. Another exemption is when an emergency happens and you’re going to need urgent care
|Yes, but the cost is higher unless it is an emergency
|Yes, but the cost is higher unless it is an emergency and the provider must agree to treat you
Did you know that there are Medicare Special Needs Plans?
Medicare Advantage plans (Part C) may be used alongside Medicare Parts A and B. These Medicare SNP plans may cover more benefits than original Medicare. Medicare Advantage Plans SNP (Special Needs Plans) are catered for people with certain special needs. Medicare SNPs limit the membership to people with specific diseases or chronic conditions and characteristics such as people on both Medicare and Medicaid or OHP. Moreover, Special Needs Plans tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.
In addition, the three different SNP plans cover Medicare beneficiaries living in institutions or senior home facilities, those who are dual-eligible that qualify for both Medicaid and Medicare, and those with chronic conditions such as diabetes, heart condition and or End Stage Renal Disease (ESRD), or HIV/AIDS. Moreover, this type of plan always includes coverage for prescription drugs and most have vision coverage, nurse helpline, worldwide coverage and more. Unlike regular Medicare Advantage Plans, you need to meet the criteria to enroll in this type of Medicare Advantage plans.
Qualifications for Medicare Advantage SNP:
- You have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).
- You live in the plan’s service area.
- You meet the plan’s eligibility requirements, like one of these:
- Chronic Condition SNP (C-SNP) — You have one or more of these severe or disabling chronic conditions:
- Chronic alcohol and other dependence
- Autoimmune disorders
- Cancer (excluding pre-cancer conditions)
- Cardiovascular disorders
- Chronic heart failure
- Diabetes mellitus
- End-stage liver disease
- End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis) Medicare special needs plans
- Severe hematologic disorders
- Chronic lung disorders
- Chronic and disabling mental health conditions
- Neurologic disorders
- Institutional SNP (I-SNP): You live in an institution (like a nursing home), or you require nursing care at home.
- Dual Eligible SNP (D-SNP): You have both Medicare and Medicaid.
- Chronic Condition SNP (C-SNP) — You have one or more of these severe or disabling chronic conditions:
How about paying for Medicare SNP?
If you have both Medicare and Medicaid, most of the costs of joining a Medicare SNP will be covered for you. Contact your Medicaid office for more information and to see if you qualify for Medicaid benefits.
Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you.
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