Medicare Advantage Plans in Oregon

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans include Part A (hospital) and Part B (medical) coverage, and most also include Part D (prescription drug coverage). Many plans offer added benefits like routine dental, vision, hearing, and fitness programs.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first sign up for Original Medicare (Parts A and B). Most people become eligible for Medicare enrollment at age 65, although individuals with disabilities or conditions like ALS or ESRD may qualify earlier. Be aware of key enrollment periods—Initial, General, and Special Enrollment—and the potential for penalties if you enroll late or don’t qualify for premium-free Part A.

What Types of Medicare Advantage Plans Are Available in Oregon?

Oregon offers several Medicare Advantage plan types:

• Health Maintenance Organizations (HMOs): Require you to see in-network providers and obtain referrals for specialists. These plans typically have lower premiums.
• Preferred Provider Organizations (PPOs): Offer access to out-of-network providers at higher costs and usually don’t require referrals for specialists.
• Private Fee-for-Service (PFFS) Plans: Let you see any provider who agrees to the plan’s payment terms, though some may have networks offering lower costs.
• Special Needs Plans (SNPs):
  • C-SNPs: For people with chronic conditions such as diabetes, HIV/AIDS, or heart disease.
  • I-SNPs: For individuals living in institutions or needing nursing care.
  • Dual Eligible Special Needs Plans (D-SNPs): For individuals eligible for both Medicare and Medicaid. These plans offer additional benefits like drug coverage, dental, and care coordination—often at little or no cost.
• Medical Savings Accounts (MSAs): Combine a high-deductible health plan with a medical savings account funded by the insurer. Oregon currently offers MSAs from one insurer.

What Are Your Prescription Drug Options with Medicare Advantage?

Most Medicare Advantage plans include Part D drug coverage. However, MSAs and some PFFS plans do not.

If your plan doesn’t offer drug coverage, you can:

• Enroll in a separate Part D plan (only for certain plan types).
• Face a late enrollment penalty if you don’t obtain coverage when first eligible and lack creditable coverage.

How Do You Choose a Medicare Advantage Plan?

Before selecting a plan, understand Medicare Advantage costs:

• Premiums: Many plans have $0 premiums; others charge a monthly fee.
• Deductibles, Coinsurance & Copays: Review what you’ll pay for services and prescriptions.
• Out-of-Pocket Maximums: Caps your annual spending on covered care.
• Extra Benefits: Evaluate coverage for dental, vision, hearing, fitness, telehealth, over-the-counter products, and meal delivery.

When and How Do You Enroll in a Medicare Advantage Plan?

You can enroll in Medicare during specific enrollment periods:

• Initial Enrollment: 3 months before to 3 months after your 65th birthday month.
• Annual Open Enrollment (Oct 15–Dec 7): Join, switch, or drop a plan.
• General Enrollment (Jan 1–Mar 31): For individuals enrolling in Part B.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch MA plans or return to Original Medicare.
• Special Enrollment Periods: Triggered by life changes such as:
  • Moving out of your plan’s area
  • Losing employer or union coverage
  • Plan discontinuation
  • Certain qualifying health conditions

What If You Want to Change Your Medicare Advantage Plan?

You can switch during:

• Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

Understanding Medicare Advantage Star Ratings

The CMS star ratings system is how the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) plans using a 5-star quality scale. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

CMS Star Ratings Overview

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

What Are Medicare Resources in Oregon?

• Senior Health Insurance Benefits Assistance (SHIBA): Provides free Medicare counseling.
• Oregon SMP Program: Educates beneficiaries on avoiding healthcare fraud.
• Oregon Insurance Division: Assists with coverage complaints.
• For low-income residents, the Oregon Health Plan (OHP) helps with medical costs. Visit www.oregon.gov/oha or call 1-800-699-9075. Learn more about the differences between Medicare and Medicaid.

Other Medicare Plan Options to Help with Out-of-Pocket Costs

Medicare Supplement Plans, or Medigap, help pay expenses not covered by Original Medicare, like deductibles and coinsurance.

To buy a Medigap plan, you must have Parts A and B. The best time to enroll is during your six-month Medigap Open Enrollment Period, which begins when you enroll in Part B. After that, you may be subject to medical underwriting.

These plans don’t include drug coverage, so a separate Part D plan may be necessary.

There are 10 standard Medigap plans; Plans F, G, and N are the most popular. Medicare Supplement Plan G had the highest enrollment in 2023 and is among the fastest-growing. Plan F is unavailable to new Medicare enrollees as of 2020.

Medigap plans offer predictable costs, no referrals, and nationwide coverage from any provider that accepts Medicare.

Learn more about Medicare Supplement plans in Oregon.

Next Steps

If a Medicare Advantage plan in Oregon seems right for you, compare plans in your area. Review provider networks, premiums, out-of-pocket limits, and extra benefits. When you’re eligible, be ready to enroll and take advantage of the coverage that fits your needs.