Medicare in Oregon

Medicare is the national health insurance program, available for people aged 65 and older as well as those with specified disabilities. Oregon had enrolled almost 880,000 people in Medicare as of 2020, an increase of more than 20,000 compared with the previous year. Around 20.8% of the state’s total population receive Medicare, with more than 468,000 and almost 411,000 people enrolled in Original Medicare and Medicare Advantage, respectively. In 2019, Oregon spent almost $4 billion on Medicare, with an average spend of $8,443 per beneficiary.

There are two parts to Original Medicare: Part A and Part B. In general, Part A covers expenses for inpatient care in a hospital, nursing facility care, some home health care services and hospice care. Individuals who, or whose spouse, paid Medicare taxes for a certain period receive free Part A coverage. Those who don’t qualify for free coverage can purchase coverage. Part B Medicare pays for preventative health services, necessary medical services and essential medical supplies. Part B premiums depend on a person’s income, with a standard monthly premium of $170.10.

Private insurance companies also offer tailored coverage through private policies called Medicare Advantage. Also referred to as Part C Medicare, plans include the same benefits as Parts A and B (except for hospice care, which is covered by Part A). Medicare Advantage plans usually offer additional benefits, such as prescription drug coverage, eye care and telehealth services. 

Oregon has almost 655,000 enrollees in Part D, which lets beneficiaries add prescription drug coverage to Original Medicare. Most Medicare Advantage plans have prescription drug coverage (Part D) included. Additionally, private health insurance companies offer supplemental plans, also known as Medigap, which help lower out-of-pocket expenses for Original Medicare users. 

This guide details Medicare in Oregon, with information about the various plans available across the state. It also includes resources that help individuals make informed decisions about health insurance.

Options for Medicare Coverage in Oregon

Original Medicare provides standard coverage, which is suitable for many older adults. However, there are occasions where individuals require additional coverage. Oregon’s seniors have several health insurance options, helping them select the best policy for their health care needs. As well as the regular Medicare program, private insurance firms offer extra options or alternate plans.

Original Medicare (Parts A & B)

Original Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) and is open to seniors aged 65 and over, along with those under 65 years old, but with certain disabilities or end-stage kidney disease. It includes two parts. Part A covers inpatient hospital care, nursing home and skilled nursing care, hospice and home health care. Part B, or medical coverage, pays for medically necessary goods and services such as durable medical equipment, mental health services and emergency medical transportation. 

Unlike most private Medicare plans, Original Medicare’s provider network isn’t limited to the beneficiary’s geographic region, making it easier to obtain services while traveling within the country. In most cases, Medicare doesn’t pay for health services the individual receives outside the United States. 

Under this program, seniors pay for services as they receive them. They must pay an annual deductible, which is $1,556 for Part A and $233 for Part B in 2022. After they’ve paid this amount, Medicare covers all eligible services at 80%. Beneficiaries pay the remaining 20% out of pocket.

Who Should Consider Original Medicare

Original Medicare may be a good option for those who:

• Travel frequently within the United States
• Don’t need extra benefits such as home-delivered meals and coverage for over-the-counter medication
• Want to choose their own prescription drug coverage

Medicare Advantage (Part C)

Medicare Advantage plans, or Medicare Part C, are private plans that provide personalized insurance options. Almost 411,000 Oregonians were enrolled in Medicare Advantage in 2020. Aside from hospice care, policies include at least the same benefits as Parts A and B. Most Advantage plans cover prescription drugs (Part D). Many plans also offer extra coverage, which may include dental, vision and hearing care, wellness programs, over-the-counter drugs, transportation to medical appointments and home-delivered meals following a hospital stay. Some plans offer lower costs, including premiums and deductibles, and many limit a policyholder’s maximum personal expenditure each year.

The four most common types of Medicare Advantage plans are health maintenance organization (HMO), preferred provider organization (PPO), private fee-for-service plans (PFFs) and special needs plans (SNPs). Medicare medical savings account plans (MSAs) and HMO point-of-service plans (HMOPOs) are less common. Eligibility criteria and costs vary and are set by providers.

Who Should Consider Medicare Advantage

Part C plans might be well-suited for older adults who:

• Need extra health care coverage beyond the benefits provided by Original Medicare
• Are comfortable receiving managed care
• Are typically in good health and want lower premiums
• Would appreciate greater control over their annual health care costs

The Top 10 Medicare Advantage Plans in Oregon 

Oregon seniors can choose between many highly rated Part C plans. The below table lists the top providers based on the number of people enrolled in each plan. It also shows available plan types and typical monthly costs. More details about Part C plans are provided on the Medicare Advantage Plans in Oregon page.

Medicare Prescription Drug Coverage (Part D)

Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later.

Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.

Who Should Consider Medicare Prescription Drug Coverage

Seniors who may benefit from prescription drug coverage include those who:

• Currently take prescription medication or expect to in the future
• Want to avoid late enrollment penalties
• Want to reduce out-of-pocket prescription drug expenses

Medicare Supplement Insurance (Medigap)

While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.

For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2022 page.

Who Should Consider Medicare Supplement Insurance

Good candidates for Medigap may be those who:

• Have ongoing health issues and expenses
• Travel overseas often
• Want to access an expanded network of health care providers
• Expect to need health services not covered by Original Medicare

Medicare Resources in Oregon

Understanding the numerous Medicare and private health insurance options can be challenging, and enrollment processes can feel overwhelming. Luckily, Mississippi’s aging individuals can access assistance from several programs and agencies. Resources aim to help individuals understand their options and find the best coverage for their needs. Advisors assist seniors compare plans, understand benefits and costs, enroll for coverage, identify fraud and appeal adverse decisions.