If you qualify for Original Medicare, or Medicare Part A (hospital care) and Part B (outpatient care), you may be concerned that the federal program doesn’t offer enough coverage. Original Medicare doesn’t cover prescription drugs or limit your out-of-pocket costs. One option is a Medicare Advantage plan. Medicare Advantage (MA), or Medicare Part C, plans are provided by private insurers and offer the same coverage as Original Medicare, as well as other benefits like prescription drug coverage and a cap on your out-of-pocket expenses.
What You Need to Know
Medicare Advantage plans are offered by private insurance companies but must provide the same basic protections as Original Medicare.
Prescription drug coverage is included in most Medicare Advantage plans.
You have multiple enrollment periods each year to join an MA plan.
What Types of Medicare Advantage Plans Are Available in Oregon?
Oregon has 78 Medicare Advantage plans1 offered by 15 private insurers.2 These plans generally contract with a network of medical providers for services. There are several different types of MA plans. Here are some details on each:
Health maintenance organization (HMO)
You’ll likely pay the lowest per month for an HMO plan. Except for emergencies, you’ll be limited to seeing in-network providers. You’ll also need to pick a primary care physician (PCP) and get referrals to see specialists.3
Preferred provider organization (PPO)
PPOs tend to have larger provider networks than HMOs. You’ll have higher premiums, but you’ll be able to see out-of-network doctors. You generally won’t need to pick a PCP or get referrals for specialists.4
Special needs plans (SNP)
SNP plans are for people with specific situations. Except in emergencies, you must see in-network providers and get referrals for specialists. You have access to an SNP at any time if you qualify.5
The two types of SNPs in Oregon are:6
- Dual eligible (D-SNP), in which you’re eligible for both Medicare and Medicaid.
- Institutional (I-SNP), in which you live in an institution (such as a nursing home) or require in-home nursing care.
Private fee-for-service (PFFS)
Of all MA plans, PFFS plans offer the greatest flexibility. You can get care from any provider that accepts your plan’s payment terms, but you may pay less to see a provider from your network. You don’t need to pick a PCP or get referrals for specialists.7
Medical Savings Account (MSA)
These plans combine a high-deductible health plan with a Medicare MSA, which you use to pay costs until you meet your deductible. You choose your services and providers.8 One insurer currently offers MSA plans in Oregon.9
In Network Saves
You’ll save money on Medicare Advantage plans by using in-network providers and services.
How Can You Get Prescription Drug Coverage with Medicare Advantage?
Under Original Medicare, you’d need to buy a separate prescription drug plan, or Medicare Part D. Most Medicare Advantage plans in Oregon cover prescriptions. When you’re looking at plans, check their formulary, or list of covered medications, to make sure your prescriptions are included.
PFFS and MSA plans generally don’t cover prescriptions, so you would need separate Part D coverage with those plans.
How Do You Choose a Medicare Advantage Plan in Oregon?
See what plans are available in your area and whether your medical providers accept them. Then check the costs involved, what benefits are included and what the plans cover.
Your premium is the amount you pay monthly for coverage. It doesn’t include the Medicare Part B premium ($148.50 for most people in 2021). There are zero-premium MA plans available, but your other costs may be higher as a result.
Here are some other costs to consider:10
Deductible: The amount you pay per year for services before your coverage begins.
Coinsurance: The portion of the cost you pay for a covered service after you’ve met your deductible. For example, if your plan’s coinsurance is 15%, you pay 15% and the insurer pays 85% of covered expenses.
Copayment: A fixed amount (for example, $20) you pay for a covered service or prescription drug.
Out-of-pocket maximum: The total out-of-pocket amount you pay in a year.
Medicare Advantage covers everything that Original Medicare covers, including inpatient hospital and skilled nursing facility care, emergency and urgent care, doctor’s visits, surgery, preventive care and some vaccines and medical equipment.
Most MA plans offer additional benefits, including:
- Vision care, such as eye exams and glasses
- Dental care, such as cleanings
- Hearing aids
- Gym membership
- Telehealth visits with providers
- Over-the-counter healthcare products
- Meals, such as meal delivery
Most Medicare Advantage plans offer additional benefits like vision and dental coverage.
When and How Do You Enroll in a Medicare Advantage Plan in Oregon?
To qualify for a Medicare Advantage plan, you must have Medicare Part A and B. You also must have lived legally in the U.S. for five years or longer.11 As of October 2020, if you have end-stage renal disease, you can enroll in an MA plan during the Medicare Annual Election Period, or Open Enrollment Period.12
Initial Enrollment Period (IEP): You’re first eligible for Medicare during this period, which starts three months before and ends three months after the month you turn 65.
Annual Election Period (AEP), or Open Enrollment Period: This period goes from October 15 through December 7 each year. You can enroll in an MA plan for the first time or switch to a different MA plan.
Medicare Advantage Open Enrollment Period (OEP): Between January 1 and March 31 of each year, you can switch back to Original Medicare or change to a different Medicare Advantage plan.
General Enrollment Period (GEP): If you enrolled in Medicare Part B for the first time between January 1 and March 31 (during the Medicare Advantage OEP), you can join an MA plan between April 1 and June 30.
Special Enrollment Period (SEP): In certain situations, you can make changes to your Medicare Advantage plan outside of regular enrollment periods. These situations include moving out of your plan’s service area, losing coverage, or gaining coverage through an employer or union.14
How Much Do Medicare Advantage Plans Cost in Oregon?
In 2021, the average monthly premium in the U.S. for a Medicare Advantage plan is $21. In Oregon, it is $44.04, which is 8.6% lower than in 2020 and down more than one-quarter compared to 2017.15
Your costs depend on your plan type and where you live. For example, one ZIP code in Portland offers 44 plans with premiums ranging from $0 to over $452. One in Eugene has 28 available plans ranging from $0 to $201.16
What Are Alternatives to Medicare Advantage?
PACE: Oregon’s Program for All-Inclusive Care for the Elderly offers community-based care for those who qualify.17
Original Medicare: If Medicare Part A and B offer enough coverage for you, you can stay with it.
Medicare Supplement with a Part D plan: You may need a separate Medicare Part D plan for prescription drug coverage with your Medigap policy.
What Medicare Resources Are Available in Oregon?
The Senior Health Insurance Benefits Assistance (SHIBA) program provides free and unbiased information on Medicare and Medicaid.18
Oregon’s Qualified Medicare Beneficiaries program can help people living on a limited income pay Medicare costs.19
The Oregon Health Plan (OHP) is the state Medicaid program. Medicaid is a federal-state partnership that provides healthcare assistance to those with low income or disability.20
If a Medicare Advantage plan is the best fit for your health needs, compare plans and costs in your area to find the right amount of coverage for the right price. That way, you’ll be ready to sign up once you’re eligible for Medicare.