Introduction to Medicare Advantage in Oregon (Part C)

Medicare “replacement” (or Medicare Part C) are both alternative names for what most people know as Medicare Advantage. If you have Medicare, and you are worried about expensive coverage gaps, Medicare Advantage is a comprehensive supplement insurance policy which could help protect you from the gaps in Medicare Parts A and B. However, there are some drawbacks which you should learn about before you make a final decision.

Federal Regulations for Medicare Advantage

When you sign up for a Medicare Advantage policy, you are signing up for a private health insurance provider to take over responsibility for paying out claims on your Medicare benefits. For this reason, the government closely regulates such plans to make sure you are getting at least the coverage you deserve, if not better. By law, your Medicare Advantage plan must include the same benefits as Medicare Parts A and B. Fortunately, most plans include much more than that (which will be discussed in detail below).

Medicare Advantage Enrollment In Oregon

Medicare Advantage plans are actually quite common in Oregon. Around 44% of seniors in the state have replaced their Medicare with an Advantage plan. Below, you can take a look at which types of Advantage plans are the most popular among Oregon seniors:

Plan Type Enrollment Percentage
HMO Plans 59%
Local PPO Plans 13%
Special Needs Plans 11%
Regional PPO Plans 9%
Private Fee-For-Service Plans 5%
Other (Cost Plans, MSA’s, etc.) 3%

Plan Coverage & Cost

Below, we have a chart which displays estimated rates for Medicare Advantage plans near you. Keep in mind, though, that these are just estimates. Your individual quote and rate will vary greatly, based on attributes such as gender, health status, and even your zip code.

Most Popular Medicare Advantage Plans in Oregon

When you’re shopping around for a Medicare Advantage plan, it’s important to know what you’re getting into before you make a final decision. That’s why we make shopping easier with our five star rating system. It gives you the chance to consider all of the important factors about a plan – such as the company’s financial stability, their customer service record, and their history of managing care, among other things – and gives you a simple, easy to understand estimate of how much you can expect from them. This can help you make smarter healthcare decisions when it comes time to choose a plan.

Helpful Medicare Advantage Tips & Tricks

Doctor/Provider Network Restrictions

Depending on the Advantage policy you choose, your provider network could come with different restrictions on where, when, and how you can get your medical care. Limited Networks, such as HMOs, won’t let you see anyone outside of your network – unless you want to pay out-of-pocket, that is. Other networks will allow you to venture out for non-network care, but they will charge you more. Regardless of your network, nobody is legally allowed to deny you medical care in the event of a medical emergency.

  • HMO Plans – With an HMO plan, you agree to let your primary care doctor manage your care and to only go see other doctors or facilities if your primary gives you a referral. You can only go to other doctors or facilities that are in your network; going out -of-network will cost you out-of-pocket. There are exceptions if you must receive emergency medical attention from a hospital or doctor outside of your network. The reason HMO plans are so strict is because your insurance provider believes that their chosen network of doctors, hospitals, and facilities are best suited to give you the care you need at an affordable cost.
  • PPO Plans – PPO plans give you the freedom to see whatever doctor you want, whenever you want. but you may end up paying for that freedom – literally. PPO plan members will get financial assistance from their insurance company almost all of the time, but you will save substantially on your medical costs if you only see the doctors or visit the hospitals/outpatient centers which are in the network of preferred providers that your insurance company has handpicked for its clients.
  • PFFS Plans – PFFS stands for Private Fee-For-Service. These plans are defined by your insurance company and the care providers you select negotiating the cost of your care on a case-by-case basis. If the care provider you select refuses to comply with the terms of service offered by your insurance company, you either have to pay out-of-pocket or get care somewhere else. Keep in mind that providers change their minds frequently, and you have to stay on top of this status if you want to keep your costs low.
  • Special Needs Plans – Special Needs Plans are reserved for seniors with special needs only. And when we say special needs, we mean chronic and expensive-to-treat diseases like End Stage Renal Disease. They have limited networks similar to that of an HMO, and also similar exceptions for receiving out-of-network emergency care in the event of a real emergency. It is difficult to get care outside of your network if you have a SNP program, but your insurance company make grant you special out-of-network treatment if you can convince them it’s necessary.

Doctor/Providers List

  • HMO Plans – You can expect a Medicare Advantage HMO plan to work similarly to that of a regular HMO plan. You pick your primary care physician, they refer you to outside medical care when necessary, and you have to keep everything in-network unless you want to risk paying out-of-pocket. But there are exceptions for out-of-network emergency services.
  • PPO Plans – If you decide to go with a PPO plan under Medicare Advantage, you’ll get the freedom of choice when choosing care providers which you would get with a private PPO plan, but you’ll be getting the same benefits you would with Medicare Parts A and B (or better, if you choose to add additional coverage). Just remember that you going out of your preferred provider network will cost you more; but it won’t be nearly as expensive as it might be going out of network with an HMO.
  • PFFS Plans – PFS plans, even under Medicare Advantage, try to give you the freedom of choice you would get with a PPO; but they often fall short leaving you with the selection of an HMO. Your insurance company will try to negotiate with whichever care provider you choose, but the likelihood that everyone will agree to the same terms isn’t always guaranteed. And this is on a case-by-case basis – so even if your doctor agrees on your insurance company’s terms this week, you may try to make a follow-up appointment a month for now and come to find that they have changed their mind. A PFFS plan under Medicare Advantage will definitely keep you on your toes.
  • Special Needs Plans – Special needs plans are like HMOs for people with chronic medical conditions. When you combine a special needs plan with the expertise and affordability of Medicare, you get a Medicare Advantage Special Needs Plan which many chronically ill seniors with limited means can take advantage of. To keep costs as affordable as possible, make sure to stay in network and to listen to your primary care doctor. The only time you don’t have to worry about out-of-network care is in the event of a medical emergency, or if you negotiate with your insurance company for out-of-network care in advance.

Do you already have a doctor you prefer, and want to make sure you don’t lose them if you switch to Medicare Advantage? Then you should use the physician comparison Search tool available from Medicare.gov. This will help you see which doctors, hospitals, and facilities are available in your area with your chosen Medicare Advantage plan.

Drug, Vision and Dental Coverage

Do you want vision coverage with your Medicare Advantage plan? Odds are good that you will be able to get it if you request it. It will likely cost extra to purchase the coverage, but it’s not an option you would get with a Medicare supplement insurance plan or Original Medicare. You can get your own private vision insurance plan if you decide not to go with Medicare Advantage, but these plants give you the option of adding vision and bundling it with your current health insurance plan for added convenience.

The same thing goes for dental insurance coverage. All you have to do is talk to your Medicare Advantage insurance representative, request that dental coverage be added to your policy, and then choose someone in your dental network of dentists and orthodontists depending on what your oral health needs are. Just keep in mind that dental insurance isn’t available in all areas, so be sure to double-check before deciding on a plan if this is important to you.

Enrollment Options & Best Time To Enroll

Enrolling within your Initial Enrollment Period (or, in most cases, during a Special Enrollment Period) should result in your request for coverage getting approved without a physical exam or a health survey. Should you enroll outside of those special periods, you may have a more difficult time getting approved. People with serious health conditions (ESRD among them) will have an even greater challenge getting approved. But your state department of insurance is there to help, as well as your local insurance agent. You can also visit our Medicare Advantage Enrollment Options page for more information.

  • Initial Enrollment Period: Within your first 6 months of Medicare enrollment, you can enroll in a Medicare Advantage policy.
  • Annual Enrollment Period (AEP): From October 15th through December 7th each year, you are free to change or cancel your Medicare Advantage and part D drug plan.
  • Special Enrollment Period (SEP): Any sort of special circumstance in which you may need to change or get new coverage outside of a regular enrollment period, such as moving out of your service area, losing your employer/plan coverage, or your provider ceasing coverage in your area.

What Medicare Advantage Plan Is Best For Me?

Ideally, all seniors want a Medicare Advantage health plan with affordable premiums, lots of benefits, and they want it from an insurance provider that is good at managing their clients’ needs. There are lots of companies to choose from, and not all of them can offer you the care you need at a price you can afford. Finding the Medicare Advantage plan that can is going to require some detective work on your part.

But we can help alleviate that burden for you. With our help, you can see who the best providers are in your area, compare quotes between companies, and find an affordable and effective Medicare Advantage plan that’s right for you – all within your enrollment period window! Finding the Medicare Advantage plan you need has never been easier.

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