Medicare Advantage

Medicare Advantage Plans in Oregon

Although Original Medicare provides critical coverage for many healthcare services, some services and treatments are not covered. Original Medicare does not have a yearly cap on expenses. Medicare Advantage Plans, also referred to as Medicare Part C, are offered by private insurance companies and include the services of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance), and most plans also include Part D (prescription drug coverage). A Medicare Advantage plan must provide coverage for all the same services covered by Original Medicare, including emergency care and urgent care. In addition, a Medicare Advantage plan in Oregon has a yearly out-of-pocket maximum to provide a financial safety net. In Oregon, Medicare Advantage plans may also provide coverage for other services not included in Original Medicare such as routine dental, vision, hearing, and health and wellness programs.

Medicare Advantage Eligibility Requirements

In order to be eligible to enroll in a Medicare Advantage plan, you must have Medicare Part A & Medicare Part B, live in the plan’s service area, and not have End Stage Renal Disease (kidney failure).

  • Anyone entitled to Medicare Part A
  • Is enrolled in Medicare Part B
  • Permanently resides in the service area of the plan
  • Does not have End Stage Renal Disease

When Can You Enroll?

There are timeframes for enrollment in to Medicare Advantage and Prescription Drug Plans.

Initial Enrollment Period

Begins three months before and ends three months after the month of the individual’s Medicare eligibility date (typically 65th birthday). The beneficiary can choose any type of plan during the Initial Election Period (IEP).

Open Enrollment Period (or Annual Election Period)

October 15th to December 7th
Every year, Medicare has an open enrollment period when you can make a change using your annual election period. Since all plan contracts are annual, there may be changes. Between October 15th and December 7th you can make a new plan choice.

Medicare Advantage Disenrollment Period (MADP)

January 1st to February 14th
Medicare created this timeframe to help protect people that may have enrolled in a plan without knowing the details, so they give them the option to return to Original Medicare and enroll in a Stand Alone Part D, if they choose.

Special Election Period (SEP

In some cases you will have the right to change your coverage without waiting until the next annual election period. The following are a few common Special Election Periods:

  • Moved Outside of the Plan Service Area
  • Voluntary/Involuntary Loss of Employer Group Coverage
  • Qualify for or Loss of both Medicare and Medicaid
  • Qualify for or Loss of Low Income Subsidy
  • Qualify for Special Needs Plan
  • Enrolling into a Plan with 5 Stars


Different Types of Medicare Advantage Plans

There are several different types of Medicare Advantage plans.

  • Health Maintenance Organization (HMO)

    In most HMO plans, you can only go to doctors and hospitals in the plan’s network, except in urgent or emergency situations.
  • Health Maintenance Organization – Point of Service (HMO-POS)

    HMO-POS has a network of doctors and hospitals, however, they do have limited ability to go outside of the network, generally for higher costs, except in urgent or emergency situations.
  • Preferred Provider Organization (PPO)

    PPO plans allow you to go outside of their network of doctors and hospitals, but it will generally cost you more in copays and coinsurance, except in urgent or emergency situations.
  • Private Fee For Service (PFFS)

    PFFS plans generally allow you to go to any doctor that is willing to accept the terms of the plan, but the doctor may change their mind about accepting the plan at any time, even if you’ve seen them before, except in urgent or emergency situations.
  • Special Needs Plan (SNP)

    SNP plans generally require you receive care from a network of doctors and hospitals, except in urgent or emergency situations. SNP plans also carefully manage and coordinate your care to make sure your special needs and orders are being treated and adhered to properly. Not all plans are available in all areas. SNP plans are for specific groups of people, such as those with Medicare and Medicaid, those that live in a nursing home, or those that are diagnosed with certain chronic, disabling conditions such as diabetes and heart disease.

You Still Have Medicare

If you enroll in a Medicare Advantage plan, you still have Medicare and must continue to pay your Medicare Part B premium (and Part A premium if you have to pay one). You also have the same rights and protections as Original Medicare. The companies that offer Medicare Advantage Plans receive a fixed amount each month from Medicare to administer your coverage. In order to be contracted with Medicare, they must follow specific rules established by the Center for Medicare and Medicaid Services (CMS). Although each plan receives the same amount for administering your coverage, the plans may charge different amounts for premiums and other out-of-pocket costs and they may have different networks of doctors and hospitals. They also may have different rules for how you can obtain treatment – for instance, whether or not you need a referral to see a specialist or whether you’re required to see specific doctors or go to specific hospitals. These plans are annual contracts and may change every year. You will be notified by October 1st about the changes to the plans for the upcoming year so you can add, drop, or switch plans if necessary. Our agents schedule annual reviews with their clients so they can compare all of their options each year to make sure they are in the plan that works best for their needs.

Many people prefer the options offered by Medicare Advantage Plans; others may prefer Original Medicare coverage with a Medicare Supplement. To help determine which options may be best suited for your needs, call SeniorChoices NW today toll-free at 866-682-1878 or fill out our online contact form.

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Learn about the basics of Medicare, timeframes for enrolling, the differences between Medicare Supplement & Medicare Advantage, schedule individual appointments, and ask questions about the plans accepted by the provider.

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