Page Reviewed / Updated - May 18, 2020
Medicare Advantage is a Medicare program that lets seniors enroll in a health care plan of their choice through a private insurance company. Participants still pay their Plan B premiums and receive all of the benefits of Original Medicare Parts A and B but have access to additional coverage such as hearing, vision and dental care. Unlike Original Medicare plans, Medicare Advantage plans may vary in price, in-network providers, rules and specific benefits provided.
In Oregon, Medicare Advantage enrollments comprise 42% of the state's total Medicare enrollment. This is one of the highest Medicare Advantage enrollment rates in the country, with higher rates in only three other states and Puerto Rico. Among Oregon's neighboring states, California has the next highest enrollment rate at 40%, followed by Nevada at 35%.
Below, we look at the five types of Medicare Advantage plans Oregon insurance companies provide to seniors across the state, with options likely varying slightly by region. Oregon's plan types include HMO and HMO-POS plans, PPOs, PFFS plans and SNPs. Additionally, we include information on how to enroll, the ways Medicare Advantage participants can obtain prescription drug coverage and resources that can help Oregon seniors better understand their plan options.
Oregon's Medicare Advantage program allows insurance companies to offer senior Medicare recipients up to five different plan types. These include Health Maintenance Organizations (HMOs), HMOs with a Point-of-Service option (HMO-POS), Preferred Provider Organizations (PPOs), Private Fee-for-Service plans (PFFS) and Special Needs Plans (SNPs).
Health Maintenance Organizations (HMOs)
Health Maintenance Organization plans, or HMOs, allow seniors to visit a list of specified in-network providers. Participants receive full plan benefits if they remain within the network but likely receive no coverage for services received outside of the network. HMOs often require enrollees to select a primary care physician (PCP) for their basic medical needs such as checkups and undiagnosed conditions. These plans also typically require participants to obtain specialist referrals from their PCP.
Health Maintenance Organization Point-of-Service (HMO-POS)
HMO plans with a Point-of-Service option are similar to an HMO plan in that they have a list of in-network providers seniors must use to obtain full coverage, but it also allows participants to use its Point-of-Service out-of-network option. Through this option, seniors may be allowed to pay a higher rate to visit out-of-network providers for certain types of treatment.
Preferred Provider Organization (PPO)
On average, Preferred Provider Organizations (PPOs) offer seniors greater flexibility at slightly higher costs, depending on the specific plan selected. PPOs also have a list of preferred in-network providers, but they also often allow participants to pay more and receive some coverage if they prefer to visit an out-of-network provider. PPOs generally do not require participants to select a PCP or request referrals before seeing a specialist.
Private Fee-for-Service (PFFS)
Private Fee-for-Service (PFFS) plans also offer seniors flexibility in choosing what doctors and facilities they would like to visit. PFFS plans set their rates for area providers, and a participant may visit any provider that agrees to the plan's terms. Additionally, some PFFS plans may have a list of providers that have agreed to honor the plan's rates and terms ahead of time. This way, participants can anticipate their costs and know their care will be covered if they opt to visit a provider on the list.
Special Needs Plans (SNPs)
Special Needs Plans (SNPs) are similar to HMOs in that they require participants to receive care from in-network providers to obtain full coverage of benefits. SNP participants must also select a PCP and request a referral to see a specialist. Unlike HMOs, however, SNPs are only available to certain qualified individuals who either have a chronic illness, live in a nursing home or receive both Medicare and Medicaid. Seniors should also note that each individual SNP plan is designed to serve only one of these groups.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
In Oregon, many HMO and PPO Medicare Advantage plans include Medicare Part D, a federally funded prescription drug coverage administered through private insurance companies. These combined plans are known as MAPD, and if an Oregon senior chooses an HMO or PPO plan, they must select an MAPD plan health if they wish to obtain prescription drug coverage. Oregon Medicare does provide stand-alone prescription drug plans, however, for those not enrolled in an HMO or PPO plan. PFFS plans are slightly more flexible in that they offer seniors a choice of a bundled health and prescription drug plan or enrollment in a stand alone prescription drug plan, and seniors with VA prescription drug coverage are allowed to combine this coverage with permitting health-only Medicare Advantage plans. Participants in MAPD plans pay one premium for combined health and prescription drug coverage, and those with standalone prescription drug plans pay a separate premium with rates ranging from $14.94 to $117 per month, as of 2019.
For Oregon seniors looking to select a Medicare Advantage plan, the process of researching, understanding and enrolling in a plan can be a daunting task. While Original Medicare and Medicare Advantage plans can provide invaluable and comprehensive health care options at affordable rates, it's important that seniors are able to choose a plan that allows them easy access to their preferred medical providers, includes the types of coverage they need and works within their budgetary and flexibility concerns. That's why we've included a list below of numerous resources available locally and throughout the state.
Oregon's Senior Health Insurance Benefits Assistance (SHIBA) program provides free, one-on-one Medicare counseling services to seniors interested in enrolling and those who have questions, issues or concerns about their plan. Trained volunteers answer questions and can assist with enrollment applications, helping a senior understand a plan's benefits and compare all types of Medicare and prescription drug plans. Volunteers can also help seniors file claims or appeals with their Medicare plan.
Seniors can contact SHIBA by calling its free helpline at 1-800-722-4134 or completing the online contact form.
The Oregon Senior Medicare Patrol (SMP) program aims to empower seniors enrolled in Medicare to recognize and report fraudulent activity related to their health care. Highly trained volunteers educate seniors to help them understand their Medicare documents and bills so they can more easily spot errors or scams. The Oregon SMP partners with other state organizations such as SHIBA and the Association for Oregon Centers for Independent Living (AOCIL).
To contact SMP, Oregon seniors can call 1-855-673-2372 or contact their local Aging and Disability Resource Connection (ADRC).
Oregon's Services for Seniors and People with Disabilities office is part of the state's Department of Human Services (DHS). The office provides information on state medical programs including Medicare and the Prescription Drugs Assistance Program that gives interested Oregon residents of any age and income a discount card for prescription drugs. Through the office's website, seniors can apply for benefits and access information on services such as in-home support, reporting abuse, caregiver support and disability benefits.
Seniors can find the contact information of their local Seniors and People with Disabilities office here or call DHS at 503-945-5600.
The YWCA of Greater Portland is a nonprofit women's organization that offers programs and services to improve the lives of women and their families. The YWCA's Senior Services program provides resources, information and referrals to low-income seniors ages 60 and older who wish to remain in their homes. Services include insurance and benefits counseling, care management and legal assistance. Seniors can also stay active through the YWCA's fitness programs and shop for clothes and home goods at its affordable thrift store.
To contact the YWCA of Greater Portland, seniors can call (503) 294-7400, email [email protected] or visit the corporate office at 4610 SE Belmont St., Portland, OR 97215.
Oregon's numerous Aging and Disability Resource Connection (ADRC) offices are located throughout the state, each serving designated counties. Oregon seniors and people with disabilities can contact their local ADRC to be connected to resources and support programs that fit their needs. Options counselors can help individuals plan for their futures by discussing their short- and long-term goals and assessing their needs related to insurance, health care, in-home care and caregiver support.
Seniors can call the Oregon ADRC toll-free at 1-855-673-2372 or find the contact information for their local office on the ADRC website here.
Throughout Oregon, 17 Area Agencies on Aging serve seniors and their loved ones through advocacy and support programs geared to help seniors receive the long-term care they need while remaining in the community. These agencies are members of O4AD, the Oregon Association of Area Agencies on Aging and Disabilities. This associate promotes the long-term care needs of seniors across the state and supports member programs including home-delivered meals and ADRC services.
Seniors and caregivers can find the contact information for their local Area Agency on Aging on the O4AD website here.