Oregon Guide to
Medicare Insurance Plans
Second Edition
2017
S
HIBA
Terms are dened in the glossary on Pages 77-81.
Information supplied in this guide is in the public domain and may be copied and distributed
without permission.
This guide is produced by the Division of Financial Regulation, and SMP Senior Medicare Patrol .
If a company is not listed, it may not be authorized
to sell insurance in Oregon, it is new, it is
suppressed, or information was unavailable by
Feb. 1, 2017, for this consumer guide.
SHIBA is a statewide network of certied counselors
volunteering in their community to help all Oregonians make
educated Medicare decisions.
To get help
Call SHIBA: 800-722-4134 (toll-free). You will be asked to use the phone keypad
to enter your ZIP code. Depending on where you live, your call may be routed
to a local agency in your area or will be returned by one of the state SHIBA staff
members.
If you need to talk to state SHIBA staff, do not enter your ZIP code and your call
will be directed to the Salem ofce.
Learn more about SHIBA at
oregonshiba.org
.
New to Medicare? Check out
medicarestartsat65.org.
Be sure to get your Medicare information from a reliable source (rather than
family or friends) and document the contact to protect yourself with date, time,
number you called from (calls are recorded), representative with whom you
spoke, and what was said.
• Social Security, 800-772-1213 for Medicare Parts A & B questions
• 1-800-Medicare (800-633-4227) for Part D questions
To give help
Become a SHIBA certied counselor. Call SHIBA at 800-722-4134 (toll-free).
Counselors must complete an application, go through our training program, and
work with a SHIBA coordinator in their community.
To apply online, go to
oregon.gov/DCBS/shiba/volunteers/Pages/volunteer.aspx.
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Table of contents
The Basics .................................. 6-19
Your Medicare options ......................................... 7
Part A – Original Medicare hospital insurance .... 8
Part B – Original Medicare medical insurance .... 9
The ABCs – and D – of Medicare ..................... 10
Enrollment periods ..............................................11
Part B Medicare preventive services ................. 13
Preventive Visits ................................................ 14
Original Medicare –ABN and DMEPOS ............ 15
Veterans’ benets and Medicare ....................... 16
Retiree Plans and Medicare .............................. 17
Medicare and the Marketplace .......................... 18
Part D prescription
drug coverage .......................... 20-27
Medicare Part D ................................................ 20
Do I need prescription drug coverage? ............. 20
What if I have prescription coverage? ............... 20
The late penalty ................................................. 20
Where do I get help choosing a prescription
drug plan? .......................................................... 20
Can I switch plans?............................................ 21
Things to look for in a drug plan ........................ 21
What are the out-of-pocket costs for Part D? .... 22
Can I have more than one prescription
drug plan at a time? ........................................... 22
Extra Help and the Medicare Savings Program .. 23
More ways to pay for prescription drugs ............ 24
Part D standard benet coverage terms ............ 24
Part D standard benet, what you pay
for drugs ............................................................ 25
2017 stand-alone prescription drug plans .......... 26
About Medigap plans ..............28-47
What is Medigap? .............................................. 28
What do Medicare Supplement SELECT
plans offer? ........................................................ 28
What is an Medicare Supplement
Innovative plan? ................................................. 28
Plan costs differ ................................................. 29
When can I buy a Medigap policy? ................... 29
Medigap for enrollees younger than age 65 ...... 30
Will I have to wait to use my Medigap? .............. 30
Medigap waiting periods .................................... 30
Medigap coverage outside the United States .... 31
Guaranteed Issue .............................................. 32
What do Medigaps cover? ................................. 33
Medicare Supplement (Medigap)
policy information .............................................. 34
Medigap policies by plan type ........................... 37
Medigap vs. Medicare Advantage
Comparison chart .............................................. 47
About Medicare
Advantage plans ...................... 48-73
Medicare Advantage .......................................... 48
Who can join a Medicare Advantage plan? ....... 48
Medicare Advantage election periods and
enrollment actions ............................................. 48
Special Enrollment Periods (SEP) ..................... 49
Help comparing plans ........................................ 49
How do I select a plan? ..................................... 50
Prescription drug coverage ................................ 50
About Medicare Advantage dental coverage ..... 51
Medicare Advantage Disenrollment Period ....... 51
Medicare Special Needs Plans (SNPs) ............. 52
Medicare Advantage plan contact information .. 54
Medicare Advantage plans by County ............... 55
Medicare Advantage plans ................................ 56
Appeals ..........................................74
Resources and publications ........ 76
Glossary ........................................ 77
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If you have other
coverage
available
and need more
information,
contact
the source of
your benets
May also
choose
Private-Fee-for-
Service plans
(PFFS)
With or without
drug coverage
Pages 48-73
Managed care
(HMOs, PPOs,
etc.)
With or without
drug coverage
Pages 48-73
If you also want
drug coverage
If you
want to add
just drug
coverage
Stand-alone
prescription
drug plans
Pages 26-27
Stand-alone
prescription
drug plans
Pages 26-27
Medigap
Pages 28-47
Stand-alone
prescription
drug plans
Pages 26-27
If you want
supplemental
medical
coverage
● Employer or union group plan: Plan customer service
● Military benets: Your county Veterans Service Ofcer 800-692-9666
● Medicaid: Your case manager or DHS, 800-282-8096
START HERE: Choose one option
Original Medicare
Part A Hospital and/or Part B Medical
If you want other options for coverage
Medicare Advantage
(Private Medicare)
Note: Must have Medicare
Parts A and B to enroll
Option 1 or Option 2
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Your Medicare options
Enrolling in Medicare
If you are turning 65 and have already
applied for Social Security or Railroad
Retirement Board benets, you should get a
Medicare card and packet in the mail about
three months before your birthday.
If you have not yet applied for retirement
benets, you must contact Social Security
to enroll in Medicare or to see if you can
delay enrolling without penalty. You have
seven months surrounding your 65th birth
month to enroll, but benets are delayed the
longer you wait. See the table on Page 11
for details.
If you miss the seven-month enrollment
period at age 65, you can enroll from Jan. 1
through March 31 each year, with benets
beginning July 1. However, you may be
penalized for late enrollment.
Social Security is the agency that deter
-
mines eligibility, premiums, and penalties.
If you have questions about enrollment into
Medicare, call Social Security at 800-772-
1213 (toll-free). Always keep a record of the
date, time, and name of the service repre
-
sentative. Remember to take accurate notes.
What is Medicare Part A
and Part B?
Medicare Parts A and B, also known as
Original Medicare, cover basic hospital and
medical services, but leave part of the cost
for you to share. This guide also explains
additional Medicare options for health and
prescription drug coverage.
Whichever Medicare path is best
for you, please:
1. Make sure your providers, including
hospitals, accept your insurance. Call
your plan.
2. Make sure your plan covers your pre
-
scription drugs. Use the Medicare
Health and Drug Plan Finder at
medicare.gov or call your plan to
nd out.
3. Keep records. Document phone calls
with the date, time, number from which
you called, name of person with whom
you spoke, and the information you
received.
4. Call Social Security for information
on enrolling in Parts A and B. Call
Medicare at 800-MEDICARE or (800-
633-4227 toll-free) for information on
benets, claims, or Part D drug cov
-
erage. ALWAYS document the date
and name of the customer service
representative.
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2017 Part A Premium
Fewer than 30 credits, $413; 30-39 credits, $227.
Most people have no premium if they have 40 or more work
credits. Check with Social Security for work credits.
Service Benet
You pay
Hospitalization
Inpatient, not observation;
semiprivate room and board,
general nursing, and
miscellaneous hospital
services and supplies.
First 60 days
$1,316 deductible per benet
period. You could pay multiple
deductibles in a calendar year. A
deductible is required if another
hospitalization occurs after the
beneciary has been discharged
from the hospital or skilled nursing
facility for 60 consecutive days.
Days 61-90 $329 a day
Days 91-150 $658 a day
Beyond 150 days All costs
Skilled Nursing Facility (SNF)
After three midnights of inpatient
hospitalization, within 30 days of
discharge, in a facility approved
by Medicare.
Days 1-20 $0
Days 21-100 Up to $164.50 a day
More than 100 days All costs
Home health care
With a Medicare-certied agency.
Visits limited to part-
time or intermittent
skilled nursing care
Nothing for services
Hospice care
Available only to the terminally ill.
As long as a
doctor certies
medical need
Limited cost-sharing option for
outpatient drugs and inpatient
respite care.
Blood
Blood If the hospital has to buy blood for
you, you must pay for the rst 3
units or have the blood donated.
Remember: Medicare pays only for Medicare-approved charges, not for all costs of medical
services provided.
Part A – Original Medicare hospital insurance
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Part B – Original Medicare medical insurance
Covered services You pay monthly Part B premium plus:
• Physician services
• Emergency room, urgent care
• Diagnostic tests; lab tests, MRIs, CT
scans, and X-rays
• Part B covered drugs administered in
outpatient facility
• Ambulance transportation
20 percent of Medicare-allowed amount
after annual deductible.
• Diabetes supplies
• Durable medical equipment, prosthetics/
orthotics
See Page 15 for details.
Hospital observation stay
Co-payment determined by Medicare
payment formula, after annual deductible.
Occupational therapy
20 percent of Medicare-allowed amount after
annual deductible; annual limit ($1,960-2016)
on amount Medicare covers.
Physical and speech therapy
20 percent of Medicare-allowed amount after
annual deductible; annual limit ($1,960-2016)
on amount Medicare covers.
Home health care (same as in Part A)
Nothing for covered services.
Preventive services, some clinical lab
services (blood tests, urinalysis)
Nothing for most tests or procedures; fees for
ofce visits or other costs may apply.
Mental health
20 percent of Medicare-allowed amount after
annual deductible.
2017 Part B
Premium
Most people pay $104.90 each month in 2016. The standard Part B
premium amount in 2017 will be $134 (or higher depending on your
income). However, most people who get Social Security benets will
pay less than this amount ($109 on average).
2017 Part B
Cost Share
After paying the annual deductible of $183, Medicare generally pays 80
percent of the Medicare-allowed amount for covered services and you
pay the other 20 percent. There is no out-of-pocket maximum.
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The ABCs – and D – of Medicare
What is Medicare?
Medicare is health insurance for:
● People age 65 years and older
● People younger than 65 receiving Social Security Disability Insurance (SSDI)
income for more than 24 months
● People with end-stage renal disease (ESRD) or amyotrophic lateral
sclerosis (ALS)
This guide contains information on the areas of Medicare coverage:
● Part A: Hospital insurance*
● Part B: Medical insurance*
● Medicare supplements, also called Medigap plans
● Part C: Medicare Advantage plans; private Medicare health insurance plans
● Part D: Prescription drug coverage
Because Medicare is health insurance, you share the costs of your care.
*Some of the items not covered by Parts A or B
● Long-term care
● Dental care and dentures
● Outpatient prescription drugs
● Hearing aids/exams for tting hearing aids
● Routine vision and eyeglasses
● Routine annual physical exams with lab tests
● Travel outside the U.S., with limited exceptions
● Alternative care (acupuncture / naturopathic)
● Medical transport services (not ambulance)
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Enrollment periods
Initial Enrollment Period (IEP)
The Initial Enrollment Period is a seven-
month period surrounding your 65th
birth month (the three months before your
65th birth month; the month of your 65th
birthday; and the three months following
your 65th birth month).
People who are not auto-enrolled, or those
who must pay a premium for Part A
coverage, can sign up for Medicare during
the Initial or General Enrollment Periods
(IEPs or GEPs).
Initial Enrollment Period & Effective Dates
If you enroll in this month of your IEP... ...then your Medicare coverage
starts the 1st day of this month:
1st month, (3 months before birth month) Month of 65th birthday
2nd month, (2 months before birth month) Month of 65th birthday
3rd month, (1 month before birth month) Month of 65th birthday
4th month, (birth month) Month after birth month
5th month, (1 month after birth month) 2nd month after enrollment
6th month (2 months after birth month) 3rd month after enrollment
7th month (3 months after birth month) 3rd month after enrollment
Exception: If your birthday is on the rst day of the month, then your IEP starts one month earlier.
Everyone is eligible for Medicare at age 65 so long as they have resided legally in the U.S.
for ve years or longer. For people older than age 65 who have not yet met this legal resi
-
dency time period, the 60th month would be treated the same as their 65th birth month.
The Initial Enrollment Period would then start on the 57th month and end on the 63rd
month of their legal residency.
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Enrollment periods and deadlines
AEP: Annual Enrollment Period, EGHP: Employer Group Health Plan, GI: Guaranteed Issue, IEP: Initial Enrollment
Period, GEP: General Enrollment Period, MA: Medicare Advantage, MADP: Medicare Advantage Disenrollment Period,
MAPD: Medicare Advantage with Prescription Drug, OEP: Open Enrollment Period, SEP: Special Enrollment Period,
SSDI: Social Security Disability Income
Plan IEP/OEP AEP/GEP SEP/GI MADP Late penalty
Medicare
Part A
The 7 months
that begin 3
months before
age 65, or
auto-enrolled
after 24 months of
receiving SSDI.
GEP:
January,
February, and
March each
year; coverage
effective
July 1.
Any time while covered
by an EGHP through
active work (self or
spouse), or up to 8
months after active work
ends.
None, unless pre
-
mium is not free
– penalty is 10 per
-
cent of premium;
lasts twice as long
as enrollment was
delayed.
Medicare
Part B
The 7 months
that begin 3
months before
age 65, or
auto-enrolled
after 24 months if
already receiving
SSDI.
GEP:
January,
February, and
March each
year; coverage
effective
July 1.
Any time while covered
by an EGHP through
active work (self or
spouse), or up to 8
months after active work
ends.
Premium penalty
is 10 percent of
current Part B
premium per
year of delayed
enrollment;
continues for
lifetime.
Medigap
May purchase as
soon as you have
both Part A and
Part B. OEP w/GI
for rst 6 months
of Part B, regard
-
less of age (under
or over 65).
Any time, but
at plan’s
discretion;
company may
underwrite or
deny for pre-
existing health
conditions.
63-day GI period from
date previous plan ends
through no fault of your
own.
30-day GI period (start
-
ing on current policyhold-
er’s birthday) to switch to
a different company.
May cost more.
If beyond OEP
and GI periods,
plan may refuse
to insure due to
health conditions.
Medicare
Advantage
The 7-month
period that begins
3 months before
turning age 65, or
before the date
of qualifying for
Medicare due to
SSDI.
AEP:
Oct. 15-Dec. 7
Effective Jan. 1.
GEP: If enrolling
in Part A and
B during GEP,
then MA
enrollment
April 1-June 30;
effective July 1.
60 days after
moving out of a plan’s
service area or plan is
discontinued, or after
EGHP ends. This includes
ve-star and low-perform
-
ing plan SEPs.
Continuous for those
receiving Extra Help or
Medicaid.
See Page 49.
If in MA plan,
may switch
to Original
Medicare,
Jan. 1-
Feb. 14.
See Page 51.
None for health
coverage. Delayed
drug enrollment
may incur Part D
penalty added to
premium.
Medicare
Part D
The 7-month
period that begins
3 months before
age 65, or before
the date of qualify
-
ing for Medicare
due to SSDI.
AEP:
Oct. 15-Dec. 7
Effective Jan. 1.
GEP: If enroll
-
ing in Part A
and B during
GEP, then PDP
enrollment
April 1-June 30;
effective July 1.
60 days after
moving out of a plan’s
service area or plan is
discontinued, or after
EGHP ends. This includes
ve-star and low-perform
-
ing plan SEPs.
Continuous for those
receiving Extra Help or
Medicaid.
See Page 49.
If in MA plan,
may switch to
Original
Medicare
and add a
stand-alone
Part D plan,
Jan. 1-
Feb. 14.
See Page 51.
Penalty for each
month enroll
-
ment was delayed
is 1 percent of
a benchmark
premium; e.g. 24
months of delay
becomes 24 per
-
cent penalty; con-
tinues for lifetime
unless you qualify
for Extra Help.
See Page 20.
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Medicare offers some preventive services
at reduced cost if you get them from a
provider who accepts assignment. Certain
facilities’ fees or ofce visit charges may
apply to some benets. Ask your doctor
which services are right for you.
Before receiving any preventive service,
ask your doctor’s billing ofce if the service
is a Medicare-covered expense for you.
Restrictions apply to all benets — be sure
to keep an accurate record of all preventive
services received.
Tip: If you use Original Medicare, you can
keep track of your preventive services
by creating your own mymedicare.gov
account.
• Abdominal aortic aneurysm screening
• Alcohol misuse screenings and
counseling
• Bone mass measurements (bone
density)
• Cardiovascular disease screenings
• Cardiovascular disease (behavioral
therapy)
• Cervical and vaginal cancer screening
• Colorectal cancer screenings
• Depression screenings
• Diabetes screenings
• Diabetes self-management training
• Glaucoma tests
• Hepatitis C screening test
• HIV screening
• Mammograms (screening)
• Nutrition therapy services
• Obesity screenings and counseling
• One-time Welcome to Medicare
preventive visit
• Prostate cancer screenings
• Sexually transmitted infections
screening and counseling
• Shots:
– Flu shots
– Hepatitis B shots
– Pneumococcal shots
• Tobacco use cessation counseling
• Yearly Wellness visit
• HPV screening
Medicare Advantage plans must provide
these preventive screenings, as well.
Check your with your plan for any facility or
other fees.
Part B Medicare preventive services
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Preventive visits (Applies only to Original Medicare)
The Welcome to Medicare
preventive visit
You can get this free visit within the rst 12
months you have Part B. This visit includes
a review of your medical and social his
-
tory related to your health and education
and counseling about preventive services,
including certain screenings, shots, and
referrals for other care, if needed. It also
includes:
● Height, weight, and blood pressure
● Calculation of your body mass index
● Simple vision test
● Review of your potential risk for
depression and your level of safety
● An offer to talk with you about creating an
advance directive
● A written plan to let you know about what
screenings, shots, and other preventive
services you need
This is a one-time visit; you are not
required to get this visit in order to have
your Yearly Wellness visit covered. The
visit may not be covered if any other
services are provided that day. Make
sure when you call to set up the appoint
-
ment that you inform them you want the
Welcome to Medicare visit. This is NOT an
annual physical.
The yearly Wellness visit
If you have had Part B longer than
12 months, you can get this free visit
to develop or update a personalized
prevention help plan to prevent disease
and disability based on your current health
and risk factors. Your provider will ask you
to ll out a Health Risk Assessment as part
of the visit, which will help you and your
provider develop a personalized prevention
plan to help you stay healthy. The visit also
includes:
● Review of your medical and family history
● Developing and updating a list of current
providers and prescriptions
● Height, weight, blood pressure, and other
routine measurements
● Detection of any cognitive impairment
● Personalized health advice
● List of risk factors and treatment options
for you
● A screening schedule for appropriate
preventive services
This visit is covered once every 12 months
(11 months must have passed since the
last visit).
I appealed Medicare’s decision not to
cover the yearly Wellness visit – and
Medicare still won’t cover it. Why?
If you received services outside the scope
of the yearly Wellness visit, Medicare will
not cover it, no matter how many times you
appeal. If you decide to receive the yearly
Wellness visit, you may want to take this
guide to your doctor.
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Advance Beneciary Notices
(ABN) Mandatory and Voluntary
Sometimes medical providers or suppliers
must notify you in writing (with an ABN) if
they believe Medicare will not cover a par
-
ticular service. The ABN should identify the
specic service that is not covered and your
costs.
If you do not get the notice to sign and it was
required, you may not have to pay the bills.
The ABN is not required for items and ser
-
vices that are never covered by Medicare.
Also, the notices apply to people in Original
Medicare and not those with Medicare
Advantage plans. Never sign a blank ABN.
Routine ABNs (a practice of obtaining
beneciary signatures on blank forms and
then completing them later) are a violation
of Medicare rules. Telling the patient “we
need you to sign because we never know
if Medicare will pay” is not allowed either.
The provider should know based on medical
codes used if Medicare will cover a service.
Durable Medical Equipment,
Prosthetics, Orthotics, and
Supplies (DMEPOS)
Under the DMEPOS Competitive Bidding
Program, beneciaries with Original
Medicare as the primary payer who obtain
specic items covered by Part B in a
Competitive Bidding Area must obtain these
items from a competitively contracted sup
-
plier. If you live in the Portland metro area,
you must get your DMEPOS items from a
Medicare competitively contracted supplier.
To nd a supplier go to
medicare.gov/sup-
plierdirectory/search.html
This rule affects Original Medicare bene
-
ciaries residing in or purchasing durable
medical equipment items in Clackamas,
Multnomah, Washington, and parts of
Columbia counties. If you do not use
contracted suppliers for required items,
Medicare will not pay its portion.
Note: Medicare will not reimburse you if
you pay a supplier the full amount up front.
Make sure you are receiving supplies from
a Medicare-contracted supplier that bills
Medicare directly.
Mail-Order Diabetic Supplies
Medicare will reimburse only contracted
suppliers for diabetic testing supplies deliv
-
ered to beneciaries’ residences. Mail order
means items shipped or delivered to the
beneciaries’ residence, including home
deliveries offered through some pharma
-
cies. If the pharmacy does not have a
competitive bid contract with Medicare, the
delivered diabetic supplies won’t be covered
by Medicare.
If you have a Medicare Advantage plan,
contact the plan to nd out the suppliers
your plan contracts
with to obtain all your
DMEPOS.
To nd a Medicare competitive bid or other
supplier, go to medicare.gov/what-medicare-
covers/part-b/competitive-bidding-program-
where-to-get-supplies.html
Original Medicare – ABN and DMEPOS
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Veterans’ benets and Medicare
Veterans need to understand how
Veterans Affairs (VA) and Medicare
work together in their case. Veterans
who have Medicare and VA may receive
services through either program. However,
they must choose which benet they
will use each time they see a doctor or
receive health care (e.g., in a hospital).
Medicare will not pay for the same service
that was authorized by the Department
of Veterans Affairs; similarly, veterans’
benets will not make primary payment
for the same service that was covered by
Medicare. Some veterans receive their
health care for free, including prescriptions.
Others may be responsible for making
co-payments. Medicare will not reimburse
such co-payments.
To receive services under VA benets, a
person must receive his or her health care
at a VA facility or have the VA authorize
services in a non-VA facility.
Veterans could be subject to a penalty for
enrolling late for Medicare Part B, even if
they are enrolled in VA health care.
VA drug coverage is considered Medicare
creditable, which protects against the
penalty for delayed enrollment in Medicare
Part D. To avoid penalty when enrolling
in a Medicare drug plan, proof of VA drug
coverage is required. To request a letter of
creditable coverage or information regard
-
ing current benet status, contact the VA
Health Revenue Center at 866-290-4618
(toll-free).
Some veterans benet from using both
their VA drug benet and enrolling in a
Medicare plan for drugs the VA may not
cover. When a Medicare drug plan is
used, VA does not reimburse out-of-pocket
expenses and VA is not a secondary payer.
Every county is assigned a Veterans
Service Ofcer (VSO) to help you with
your VA benets. To nd your local VSO:
oregon.gov/odva/Pages/contact_us.aspx
.
Phone: 800-828-8801 (toll-free)
TRICARE for Life is for military retirees
and their dependents. You must have
Medicare Part A and Part B to receive
TRICARE for Life.
For eligibility information, call the
Department of Defense at 866-773-0404
(toll-free) or visit
tricare4u.com
.
T
i
p
s
&
H
i
n
t
s
If you rent medical equipment, such
as a walker, return the item to the
medical equipment dealer when you
are nished. Always get a dated
receipt for the return.
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Retiree Plans and Medicare
If you are eligible for group health plan (retiree)
coverage from a former employer, and are
approaching or older than 65, in most cases
you must be enrolled in Medicare Parts A and
B in order to enroll in or continue with any of
the retiree plan options. Also, exercising your
option to enroll in the retiree plan once you are
Medicare eligible will most likely have a dead
-
line. Check with your employer’s plan adminis-
trator for the timelines and rules for eligibility.
Not enrolling timely may prohibit you from
enrolling in the future.
Once you are retired and have Medicare and
group health plan (retiree) coverage from a
former employer, be sure you know whether
your group health plan pays after Medicare
(secondary) or is a managed care plan that
pays primary.
How your retiree group health plan coverage
works depends on the terms of your specic
plan. If you can get group health plan cover
-
age after you retire, it might have different
rules and might not work the same way after
you have Medicare.
5 things to know about retiree coverage
1. Find out if you can continue your employer
coverage after you retire. Generally,
when you have retiree coverage from an
employer or union, it controls this cover
-
age. Employers are not required to provide
retiree coverage, and they can change
benets or premiums, or even cancel
coverage.
2. Find out the price and benets of the
retiree coverage, including whether it
includes coverage for your spouse. Your
employer or union may offer retiree cover
-
age for you, your spouse, or both that limits
how much it will pay. It might provide only
“stop loss” coverage, which starts paying
your out-of-pocket costs only when they
reach a maximum amount.
3. Find out what happens to your retiree cov
-
erage when you are eligible for Medicare.
For example, retiree coverage might not
pay your medical costs during any period
in which you were eligible for Medicare but
did not sign up for it. When you become eli
-
gible for Medicare, you may need to enroll
in both Medicare Part A and Part B to get
full benets from your retiree coverage.
4. Find out what effect your continued cover-
age as a retiree will have on both your and
your spouse’s health coverage. If you are
not sure how your retiree coverage works
with Medicare, get a copy of your plan’s
benet booklet or look at the summary plan
description provided by your employer or
union. You can also call your employer’s
benets administrator to ask how the plan
pays when you have Medicare. You may
want to talk to a SHIBA counselor for
advice about whether to buy a Medicare
Supplement Insurance (Medigap) policy.
5. If your former employer discontinues your
coverage, in Oregon, you have the right
to buy a Medigap policy with Guaranteed
Issue within 63 days even if you are no
longer in your Medigap open enrollment
period.
Since Medicare pays rst after you retire, your
retiree coverage is likely to be similar to cover
-
age under Medicare Supplement Insurance
(Medigap). Retiree coverage is not the same
thing as a Medigap policy, but, like a Medigap
policy, it usually offers benets that ll in
some of Medicare’s gaps in coverage, such
as co-insurance and deductibles. Sometimes,
retiree coverage includes extra benets, such
coverage for extra days in the hospital, routine
vision exams, or dental benets.
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CONTENTS
Medicare and the Marketplace
If you have Medicare, you should not
need to buy coverage through the Health
Insurance Marketplace (healthcare.gov). The
Marketplace is for individuals, families, and
employees of small businesses to get health
coverage — either through private insur
-
ance companies or the Oregon Health Plan.
Below are frequently asked questions about
Medicare and the Marketplace.
Can I get a Marketplace plan in addition
to Medicare?
No. It is against the law for someone who
knows that you have Medicare to sell you
a health plan through the Marketplace or
an insurance company. This is true even if
you have only Part A or Part B. Instead of
a Marketplace plan, there are plans speci
-
cally designed to work with Medicare. Go to
Pages 28-47 to learn about Medigap policies
and Pages 48-73 to learn about Medicare
Advantage plans. You can also call SHIBA or
visit medicare.gov for more information.
Can I choose the Marketplace coverage
instead of Medicare?
Generally, no; however, there are a few
exceptions:
You may be able to get a plan through the
Marketplace if you are eligible for Medicare
but have not enrolled because you would have
to pay a premium for Part A or because you
are not collecting Social Security benets.
If you:
• Are paying a premium for Part A. You can
drop your Part A and Part B coverage.
• Do not have ve years documented legal
resident status to qualify for Medicare or
Medicaid.
Your household income will determine whether
you qualify for nancial help to pay for the plan
through the Marketplace. For more information
about Marketplace coverage, visit healthcare.
gov or call 800-318-2596 (toll-free).
Before making a choice, there are two points
to consider:
1. If you enroll in Medicare after your initial
enrollment period ends, you may have to
pay a late enrollment penalty for as long as
you have Medicare.
2. Outside of the initial enrollment period, you
can usually enroll in Medicare only during
the Medicare general enrollment period
(from Jan. 1 to March 31). Your coverage
will not begin until July of that year.
See Page 12 for enrollment periods and
deadlines.
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What if I become eligible for Medicare
after I join a Marketplace plan?
You can get a health insurance plan through
the Marketplace before your Medicare begins.
You can then cancel your Marketplace plan
when your Medicare coverage starts.
Once you are eligible for Medicare, you will
have an initial enrollment period to sign up. For
most people, the initial enrollment period for
Medicare starts three months before their 65th
birth month and ends three months after their
65th birth month.
In most cases, it is to your advantage to sign
up when you are rst eligible because:
• Once you are eligible for Medicare, you
will not be able to get lower costs for a
Marketplace plan based on your income.
• If you enroll in Medicare after your initial
enrollment period ends, you will have to
pay a late enrollment penalty for as long as
you have Medicare.
Note: You can keep your Marketplace plan
after your Medicare coverage starts. However,
once your eligibility for premium-free Part
A coverage starts, whether you are actually
enrolled or not, any nancial help you get
through the Marketplace will stop.
Can I get a stand-alone dental plan
through the Marketplace?
No, you cannot buy a dental plan through the
Marketplace if you have Medicare. However,
you may purchase a dental plan directly from
a health insurance company. Contact your
agent.
T
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p
s
&
H
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t
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Save Medicare Summary Notices and Part D
Explanations of Benets. Shred the
documents when they are no longer useful.
20
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CONTENTS
Part D prescription drug coverage
Medicare Part D
Medicare offers prescription drug insurance
to all Medicare beneciaries, regardless of
income or health. Medicare Part D plans
cover generic and brand-name prescription
drugs.
Private insurance companies contracted with
Medicare offer the plans, which may require
monthly premiums, co-pays, co-insurance,
and deductibles.
Part D coverage is available through stand-
alone Prescription Drug Plans (PDPs) that
cover only drugs, as well as from Medicare
Advantage with Prescription Drug (MAPD)
plans that combine health and drug
coverage.
If you want prescription drug coverage, you
must take an action to enroll in a plan.
Do I need prescription
drug coverage?
Medicare Part D is like all insurance. It
covers you if you need it now and it pro
-
tects you against future prescription costs.
If you do not enroll in Part D when you are
rst eligible, you may have a late enroll
-
ment penalty later.
What if I have prescription
coverage?
If you already have a Part D stand-alone pre-
scription plan, your insurance company must
send you a packet in early October describing
the changes for the coming year. Carefully
read the documents.
If you already have prescription coverage
through an employer, a union, or a govern
-
ment agency (such as Veterans Affairs), you
may want to stay with your existing plan if
the drug benets are creditable – as good
as or better than Medicare’s standard Part D
benet. If you do not have a letter telling you
whether your coverage is creditable, contact
your benets administrator and request one.
Always save any proof of creditable coverage.
The late penalty
You will face a penalty if you are eligible for
Part D, but not enrolled in creditable drug
coverage. The penalty amount is 1 percent
of the Part D National Base Beneciary
Premium for every month you did not have
creditable prescription drug coverage. If you
have other drug coverage, that plan’s ben
-
ets administrator must issue a letter stat-
ing whether your coverage is as good as or
better than Medicare’s basic PDP benet.
The late penalty may be waived if you qualify
for Extra Help (see Page 23), or are on
Medicare due to disability and you turn 65.
Where do I get help choosing
a prescription drug plan?
● Visit
medicare.gov
● Call SHIBA (Senior Health Insurance
Benets Assistance program) at
800-722-4134 (toll-free)
● Call Medicare at 800-633-4227
(toll-free)
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CONTENTS
Part D prescription drug coverage, continued
Can I switch plans?
Yes. Plans change every year. Medicare
recommends that you review your pre
-
scription drug plan each fall. You may join,
drop, or switch plans during the Annual
Enrollment Period (AEP) from Oct. 15 to
Dec. 7.
To switch plans:
● Enroll in a new prescription drug plan
or a Medicare Advantage plan that
includes prescription drug coverage.
Your new plan will replace your old
plan starting Jan. 1. You do not need
to take any other action to end your
prior plan.
● If you take more than one enrollment
action during the fall Annual Enrollment
Period, the last action received by
Medicare before the period closes is the
one that will become effective. Do not
make more than one enrollment action
on the same day.
If you move to a new state, you must
enroll in a new plan in your new state,
even if you are enrolled in a national
plan.
Things to look for in a drug plan
Drug list: Also known as a formulary.
Each drug plan has a list of prescription
drugs it covers. Plans differ by formularies,
rules governing access, and costs.
Restrictions
All the plans are allowed to apply restric
-
tions to their drug formulary. Types of
restrictions and limitations imposed are:
● Prior authorization: Your doctor must
contact the plan and request authoriza
-
tion to write the prescription for the drug
or the plan will not cover its share of
the cost. This usually applies to nonpre
-
ferred or very expensive drugs.
● Quantity limits: For cost, safety, or
legal reasons, some plans limit the
quantity of drugs that they cover over a
period of time. If you require more than
the allowed amount, your doctor must
submit proof that it is medically neces
-
sary and the plan may grant an excep-
tion to the limit.
● Step therapy: The plan requires that
you must rst try certain less-expensive
drugs on its formulary before you can
get a more expensive brand-name drug
covered. If you have previously tried
the drug and it did not work, or if your
doctor believes because of your medi
-
cal condition it is medically necessary
for you to be on a specic drug, the
doctor can contact the plan to request
an exception. If the plan approves the
request, then the drug will be covered.
Picking a plan with the fewest or no restric-
tions – even if you end up paying a some-
what higher price overall – may be a good
choice. It will lessen the amount of delay and
paperwork to receive your preferred drugs.
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T
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What are the out-of-pocket
costs for Part D?
Drug plan premiums have a wide range of
costs. Higher premium plans do not neces
-
sarily cover your medications better than
lower premium plans. The real determining
factor is the specic medications on your
personal list. The Plan Finder on
medicare.
gov
is the best tool for doing a cost com-
parison and choosing the plan that works
best for you.
There are two ways of determining the
cost share that is paid for each medica
-
tion: co-pay and co-insurance. Co-pays,
a set dollar amount, tend to be on the
lower-tiered medications. Co-insurance,
a percentage of cost, is often applied to
the higher-tiered drugs. Co-pays will be a
consistent cost share throughout the year.
Co-insurance cost shares change along
with market uctuation. Medicare.gov
Plan Finder drug plan detail (View Drug
Benet Summary) provides the information
whether your drug list requires co-pays or
co-insurance.
Cost share is also greatly affected by
whether the pharmacy you use is a
preferred pharmacy.
Drug plan benets are not available if you
use an out-of-network pharmacy. You pay
the retail cost, as if you had no insurance.
If you travel out of state, you may need to
make sure you are enrolled in one of the
national plans.
Can I have more than one
prescription drug plan at a time?
It depends. If you are enrolled with
Veterans Affairs drug benets or Indian
Health Services pharmacy, you are in a
special group that has creditable coverage
and you can have either one or both types
of coverage. Whether it will be a benet to
have both options depends on your drug
list. However, people with creditable union,
employee, or retiree coverage could end
up canceling their benets by signing up
for a Medicare Part D plan.
Part D prescription drug coverage, continued
If you have questions about
information on your Medicare
Summary Notice or Part D
Explanation of Benets, call
your provider or plan rst.
23
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CONTENTS
Extra Help and the Medicare Savings Program
Help with Part D
The federal government’s Extra Help pro-
gram, also called the Low Income Subsidy
(LIS), saves qualifying beneciaries money on
their Medicare Part D plans.
Extra Help:
● Reduces the monthly premium,
often to $0
● Cuts the yearly deductible,
often to $0
● Greatly reduces pharmacy co-pays, even
on expensive medications
● Eliminates the coverage gap (“donut hole”)
for all participants
You must be enrolled in a Part D plan. Your
level of assistance depends on your income
and resources. Once approved for Extra
Help, you must choose a plan. If you do not
choose a plan, you will be automatically
enrolled in a random $0 premium plan that
may not cover your specic needs.
How to apply:
1. Call Oregon Medicare Savings Connect
at 855-447-0155 (toll-free)
2. Online at BenetsCheckUp
benetscheckup.org/Oregon
3. Call your local SHIBA counselor at 800-
722-4134 (toll-free)
In addition, you can nd a variety of patient-
assistance programs online for help with
drug costs or for specic diseases or condi
-
tions. A good place to start is needymeds.org.
Help with the Part B premium and other
Medicare costs
The Medicare Savings Programs (MSP) can
help pay for the Medicare Part B premium,
co-insurance, and deductible depending
on your level of income. MSP automatically
qualies you for Extra Help.
To see if you qualify, apply at your local
ofce of Aging and People with Disabilities.
This ofce is part of Oregon’s Department
of Human Services (DHS). To nd your local
ofce, call DHS at 800-282-8096 (toll-free)
or go to
oregon.gov/dhs/spwpd/Pages/ofces.aspx.
Ask about the Medicare Savings Program or
QMB (Qualied Medicare Beneciary).
If you get Supplemental Security Income
(SSI), you automatically receive this nancial
help.
Estate Recovery
● No estate recovery for MSP (Partial
Medicaid)
● No estate recovery for Extra Help
● Estate recovery continues for Full
Medicaid
● For more information, call Estate
Administration, 800-826-5675 (toll-free).
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More ways to pay for
prescription drugs
Drug manufacturers’ discount pro-
grams or patient-assistance programs.
Some are available if you enrolled in Part
D and still cannot afford your drugs. For a
list of programs and links to applications,
visit
needymeds.org
.
Many employer group health plans
cover prescription drugs. Check with
your benets administrator for your cover
-
age information.
Oregon Prescription Drug Program
(OPDP), a bulk-purchasing pool, is free
to all residents in Oregon. Apply at
opdp.
org
. Most (Walgreens is not contracted
with OPDP) major pharmacy chains are
included in the bulk-purchasing pool
network. You may have both Part D and
an OPDP discount card, but can use only
one for a purchase. The OPDP discount
card is not insurance.
Part D Standard benet terms:
● Monthly premium: Plans have a pre-
mium. This is the amount you pay every
month even if you do not buy any pre
-
scription drugs. Oregon stand-alone
drug plan premiums in 2017 range from
$14.60 to $163 monthly.
1. Yearly deductible: Some plans have a
yearly deductible. You pay this amount
before the insurance plan pays its part
of your prescript
i
on drug costs. This
amount can be up to $400. After you
have paid your plan’s deductible, the
plan typically pays 75 percent of your
drug costs up to a point.
2. Initial benet period: When the insur
-
ance plan starts to pay for covered
drugs, you still
p
ay a percentage or a
co-pay amount (such as a $15 co-pay at
the pharmacy).
3. Coverage gap: Health-care reform is
phasing out the “donut hole.” In 2017,
after your total drug value reaches
$3,700, you will pay 40 percent of
the cost of brand-name drugs and 51
percent of generic drug costs. This does
not apply to people receiving Extra
Help.
4. Catastrophic coverage: Once you have
spent $4,950 out of pocket in 2017, you
are out of the coverage gap and auto
-
matically receive catastrophic coverage.
When you reach catastrophic coverage,
you pay the higher amount of 5 percent
or $3.30 for generic or $8.25 for other
drugs for the rest of the year.
T
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H
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If you are not comfortable
calling your provider or plan
or you are not satised with
the response you get, call
your local Senior Medicare
Patrol at 855-673-2372
(toll-free).
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Part D standard benet, what you pay for drugs
Diagram shows standard prescription drug plan benet. Coverage begins Jan. 1, 2017. The
costs shown below are in addition to any monthly premium charged by the drug plan.
In 2017, when in Stage 3 Coverage Gap, 90 percent of the full price of a brand name and
51 percent of the full price of a generic goes toward True Out Of Pocket (TrOOP) expense.
Once this amount reaches $4,900, then Stage 4 – Catastrophic coverage – is reached.
Standard Benet 2017
1.
Yearly
Deductible
2.
Initial Benet
Period
3. Coverage Gap
(aka “donut hole”)
4. Catastrophic
Coverage
Brand-name Generic
$3,700 Total value of drugs
10%
49%
Plan pays 15%
Medicare pays 80% =
95% covered by
Medicare and plan
100%
($400)
Maximum
(can be less)
Insurance
pays 75%
(~$2,475)
50%
Manufacturer
discount
51%
40%
25%
Co-insurance
(~$825)
Greater of 5%
Co-insurance or
$3.30 generic / $8.25
minimum
$400 +$825 +$3,675
$4,900 TrOOP
Beneciary pays
Plan pays
26
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
2017 stand-alone prescription drug plans
Parent company name,
contract, and phone
numbers
Plan name
and plan number
Premium
Annual
deductible
Additional
coverage in
gap
Plan
premium with
100% Extra
Help
Aetna Medicare S5810*
M – 877-238-6211
NM – 855-338-7030
TTY – 711
Aetna Medicare Rx
Saver 064
$35.20 $400 No $0.40
Asuris Northwest Health
S5609
M – 800-541-8981
NM – 844-278-7472
TTY – 711
Asuris Medicare Script
Basic 001
$99.50 $210 No $64.70
Asuris Medicare Script
Enhanced 002
$163.00
$0
Yes
$128.20
Cigna-HealthSpring Rx
S5617**
M – 800-222-6700
NM – 800-735-1459
TTY – 711
Cigna-HealthSpring Rx
Secure 148
$21.20 $400 No $0
Cigna-HealthSpring Rx
Secure - Extra 275
$31.30 $50 Yes $9.80
EnvisionRx Plus S7694*
M & NM – 866-250-2005
TTY – 711
EnvisionRxPlus 030 $14.60 $270 No $0
Express Scripts Medicare
S5660*
M – 800-758-4574
NM – 866-477-5704
TTY – 800-716-3231
Express Scripts
Medicare - Value 132
$49.00 $400 No $14.20
Express Scripts
Medicare - Choice 215
$81.50 $350 No $46.70
First Health Part D S5768*
M – 844-233-1938
NM – 855-389-9688
TTY – 711
First Health Part D
Value Plus 153
$37.40 $0
Yes
$8.70
First Health Part D
Premier Plus 192
$101.80 $0 Yes $67.00
Humana Ins. Co. S5884*
M – 800-281-6918
NM – 800-706-0872
TTY – 711
Humana Enhanced 028 $62.10 $0 Yes $27.30
Humana Preferred Rx
Plan 113
$30.30 $400 No $0
Humana Walmart Rx
Plan 176
$17.00 $400
No
$7.70
SilverScript S5601*
M – 866-235-5660
NM – 866-552-6106
TTY – 711
SilverScript Choice 060 $32.30 $0 No $0
SilverScript Plus 061 $72.90 $0 Yes $38.10
* Nationwide plans **Plan is sanctioned at time of publication
Key: NM – nonmember, M – member, TTY – TeleTYpewriter
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2017 stand-alone prescription drug plans, continued
Parent company name,
contract, and phone
numbers
Plan name
and plan number
Premium
Annual
deductible
Additional
coverage in
gap
Plan
premium with
100% Extra
Help
UnitedHealthcare
S0522*
M- 866-870-3470
NM – 800-753-8004
TTY - 711
Symphonix Value Rx
030
$26.00 $400 No $0
AARP MedicareRx
Walgreens 063
$22.40 $400 No $2.10
UnitedHealthcare S5820*
M – 888-867-5575
NM – 888-867-5564
TTY – 711
AARP MedicareRx
Preferred 029
$72.70 $0 No $37.90
UnitedHealthcare S5921*
M – 866-460-8854
NM – 888-867-5564
TTY – 711
AARP MedicareRx
Saver Plus 374
$34.80
$400 No $0
WellCare S4802*
M – 800-316-2273
NM – 888-900-4307
TTY – 711
WellCare Classic 020 $26.10 $400 No $0
WellCare Extra 126 $74.90 $0 No $40.10
* Nationwide plans **Plan is sanctioned at time of publication
Key: NM – nonmember, M – member, TTY – TeleTYpewriter
T
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H
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t
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Avoid telephone or email offers of “free”
medical tests or supplies in exchange for a
“peek” at your Medicare or Medicaid card.
28
Note: Rates vary per
individual factors.
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
What is Medigap?
Medigap is another name for Medicare
Supplement Insurance. With Original
Medicare, Medicare beneciaries must pay
some of the costs (deductibles and co-
insurance) of their medical care. Because
of these gaps in Parts A and B coverage,
private insurance companies sell Medicare
Supplement Insurance policies, also
known as Medigap plans.
You must have
Medicare Parts A and B to purchase a
Medigap plan.
If you are in Original Medicare (Parts A and
B) and buy a Medigap policy, Medicare will
pay its portion of your medical costs rst,
then your Medigap policy will pay its portion.
Medigap plans are named by letter, Plan
A through Plan N. (These are not to be
confused with Medicare Parts A, B, C,
and D; they are different.) Medigap plan
benets are standardized and regulated
by the Division of Financial Regulation. A
Medigap policy cannot pay if you also
enroll in a Medicare Advantage plan.
What do Medicare Supplement
SELECT plans offer?
These are essentially limited versions of
standardized Medigap insurance that cost
less.
SELECT plans are almost identical to regu
-
lar Medigap policies, but they limit which
clinics, doctors, and hospitals are covered
for nonemergency and nonurgent care.
If you use only the in-network providers, a
SELECT plan can give you Medigap cover
-
age at a lower cost. If you need an out-of-
network specialist, Medicare will still pay
for 80 percent of its predetermined amount,
but your SELECT plan may not pay for any
of the remaining 20 percent or deductibles.
What is a Medicare
Supplement Innovative plan?
Medicare Supplement Innovative plans
must follow federal and state laws and
must be clearly identied as Medicare
Supplement Insurance on the policy and
attached documents. The insurance com
-
pany can offer some additional benets at
no extra cost to the Medicare beneciary.
With the approval of the state, Innovative
plan benets cannot be used to change or
reduce the standardized benets, including
a change of any cost-sharing provision.
Medicare Supplement Innovative plan
benets can include, but are not limited to:
● Nurse hotline
● Annual physical exam
● Preventive dental care
● Preventive vision care
● Routine hearing exam
● Drug discount card
If an insurance company offers the
Innovative plan, the insurance company will
determine which benets will be offered.
About Medicare Supplement (Medigap) plans
29
Note: Rates vary per
individual factors.
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
Plan costs differ
The monthly premium for the same policy
varies by insurance company. Factors that
affect premium rates include age, gender,
health history, tobacco use, direct bill, elec
-
tronic funds transfer (EFT), ZIP code, and,
most importantly, the number of members in
the insurance policy pool.
Areas
When a company states that its rates vary
by ZIP code, the pool of members with that
policy is divided into smaller sizes. Smaller
pool groups may have more volatile pre
-
mium increases because plans can increase
rates once a year based on medical claims
payments not by individuals but for the entire
membership pool. Plans may increase pre
-
miums only once in a 12-month period for
the pool medical loss ratio.
Type
The majority of Medigap plans available in
Oregon are attained age rated. This means
your plan premium may also increase each
year because you are a year older.
There are a couple of community rated
plans and issue age rated plans available
in Oregon. The community rated plan quits
increasing premium cost due to age at 75
years old. The issue age rated plans never
increase due to aging. Both may increase
each year based on medical cost payments
within the membership pool.
When can I buy a Medigap policy?
You can apply for a Medigap policy at any
time. Insurance companies may consider
your medical history (underwrite) and may
refuse your application. However, the com
-
panies must sell you a Medigap policy during
your Medigap open enrollment period and
guaranteed issue periods and cannot under
-
write you.
● Medigap open enrollment period: Your
open enrollment period for Medigap plans
begins the day your Medicare Part B
begins and ends six months later.
● Guaranteed issue: Certain special
circumstances trigger guaranteed issue
(GI) situations. At these times, you are
entitled to purchase a Medigap plan with
no underwriting. These GI protections last
for 63 days. See Page 32 for all GI situa
-
tions available.
● Loss of Medicaid: If you lose full
Medicaid or Qualied Medicare
Beneciary (QMB) Medicaid eligibility, you
have 63 days to buy a Medigap policy.
You might want to do this to afford expen
-
sive medical treatments such as dialysis,
chemo treatments, and infused medica
-
tions or immunosuppressants.
● Your birthday: In Oregon, if you are an
existing Medigap policyholder, you have a
30-day shopping period with GI beginning
on your birthday if you want to compare
different companies’ prices for the same
(or lesser) Medigap benets.
About Medicare Supplement (Medigap), continued
30
Note: Rates vary per
individual factors.
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
T
i
p
s
&
H
i
n
t
s
Medigap for enrollees
younger than age 65
People younger than 65 who receive
Medicare due to a disability and those with
ESRD (permanent kidney failure) have
additional opportunities for guaranteed
issue open enrollment rights for Medigap
insurance:
● When they turn 65, for six months.
● During the six-month period after a
person receives notice of retroactive
enrollment into Medicare. If a person
younger than 65 applies for enrollment
in Medicare Part B due to a disability –
and is awarded Medicare retroactively
– the initial six-month open enrollment
period to elect a Medicare supplement
without underwriting begins on the rst
day of the rst month after receiving
notice of retroactive enrollment.
Will I have to wait to
use my Medigap?
Medigap policies can have a pre-existing
conditions look-back/waiting period of up
to six months before the policy will pay
certain benets or before the policy covers
previously diagnosed conditions. On the
plan rate pages, a 0/0, 6/6, or 2/6 refers to
how many months back the company looks
for pre-existing conditions and how many
months you must wait before the Medigap
policy will cover those pre-existing condi
-
tions. Not all companies’ policies have
waiting periods.
Medigap waiting periods
Can I get credit for my prior coverage?
If you apply for a Medigap policy that has
a waiting period for pre-existing conditions
during your open enrollment period, your
previous insurance may qualify for credit.
Qualifying coverage must be from one of
the following:
● Group or individual health care pro
-
gram, including an employer plan or
COBRA policy
● Medicare or Medicaid
● Military-sponsored health care program
● Indian Health Service benets
● Certain public health plans
● Federal Employees Health Benets
Program (FEHB)
● Peace Corps health benet plan
About Medicare Supplement (Medigap), continued
Elder nancial abuse is estimated at
$2.8 billion a year. Be aware of fraud
scams!
31
Note: Rates vary per
individual factors.
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
T
i
p
s
&
H
i
n
t
s
Medigap coverage outside
the United States
Except in limited situations, Medicare does
not pay for health care services you get
outside the U.S. However, Medigap plans
C, D, F, F High Deductible, G, M, and N will
cover emergency care outside the U.S. in
certain circumstances.
Medigap Plans C, D, E, F, F High Deductible,
G, M, and N pay 80 percent of the billed
charges for certain medically necessary
emergency care outside the U.S. after you
meet the plan’s deductible plus a $250
deductible for the year. These Medigap
policies cover foreign travel emergency care
if it begins during the rst 60 days of your trip,
and if Medicare does not otherwise cover the
care but would if the policyholder had been in
the U.S. Foreign travel emergency coverage
with Medigap policies has a lifetime limit of
$50,000. The intent of this benet is not to
provide robust coverage. Anyone planning
on extensive traveling should research
travel insurance. Remember, when traveling
on a cruise ship, you are in a foreign
country. Cruise ships sail under foreign
ags.
Ask questions – ask your provider or plan*
WHEN you don’t understand the charges billed
WHEN you don’t think you received the service
WHEN you think the service was unnecessary
*If your provider or plan does not help you, contact your local
Senior Medicare Patrol at 855-673-2372 (toll-free).
The rates published on Pages 37-46 are starting rates, at the time of publication.
They are the lowest rate available in the state and include rate factors such as
gender, ZIP code, nonsmoking status or electronic funds transfer (EFT). Contact the
insurance companies for specic individual quotes.
About Medicare Supplement (Medigap), continued
32
Note: Rates vary per
individual factors.
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
Guaranteed Issue Medigap plan choices
You joined a Medicare Advantage plan or PACE program when
you were rst enrolled in Medicare at age 65, but within the
rst 12 months of joining the plan, you want to leave. (N)
ALL PLANS
You are awarded retroactive Medicare enrollment due to disability.
The six-month open enrollment period begins on the rst day of
the rst month after you receive written notice of retroactive
enrollment. (OR)
ALL PLANS
You terminated a Medigap policy to enroll in a Medicare Advantage
(MA) plan, Medicare Select policy, or PACE program for the rst
time and now you want to terminate the MA plan after no more
than 12 months of enrollment. (N)
Original plan.
If not available then
ALL PLANS
Your Medicare Advantage plan or PACE program coverage ends
because the plan is leaving the Medicare program or stops giving
care in your area.* (N)
ALL PLANS
Your employer group health plan coverage (including COBRA and
retiree coverage) (N), Medicaid (OR), or your Medigap (N) coverage
ends through no fault of your own.*
ALL PLANS
Your employer group health plan, Medicare Advantage plan,
PACE, Medigap, or Medicare SELECT health coverage ends
because you move out of the plan’s service area.* (N)
ALL PLANS
You leave any plan — Medicare Advantage plan, PACE, Medicare
SELECT, or Medigap — because the plan committed fraud. For
example, marketing materials were misleading or quality standards
were not met.* (N)
ALL PLANS
Your Medicare SELECT insurer had its certication terminated,
stopped offering the plan in your area, substantially violated a
material provision of the organization’s contract in relation to the
individual, or misrepresented the plan’s provisions.* (N)
ALL PLANS
You are a current Medigap policyholder wanting to change to a
different Medigap insurance company within 30 days following your
birthday. (OR)
oregon.gov/DCBS/shiba/Documents/4845-31_
medicare-bday-rule.pdf. Does not apply to retiree group policies
(e.g., PERS).
Same plan as current
policy or one with fewer
benets
*63-day deadline; (N) National rule; (OR) Oregon-only rule
About Medigap plans, continued
33
Note: Rates vary per
individual factors.
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
What Medigap plans cover
Medigap plans help pay the deductibles, co-payments, and co-insurance in Medicare Parts A
and B. These standardized plans offer the same benets from company to company. Costs
may vary by ZIP code; call for a rate quote. Rate comparisons begin on Page 37.
Original Medicare Gaps
A B C D F
F
High
G K L M N
Hospital cost share
—
Cost share for days 61-90 and days
91-150 in hospital; payment in full for
365 additional lifetime days.
X X X X X X X X X X X
Part B co-insurance
—
Co-insurance for Part B services, such
as doctors’ services, laboratory and
X-ray services, durable medical equip
-
ment, hospital outpatient services, and
Medicare-covered preventive services.
X X X X X X X
50% 75%
X X*
First three pints of blood,
per
calendar year.
X X X X X X X
50% 75%
X X
Hospice care —
Co-insurance for
respite care and other Part A-covered
services.
X X X X X X X
50% 75%
X X
Hospital (Part A) deductible
Covers deductible in each benet
period.
X X X X X X
50% 75% 50%
X
Skilled Nursing Facility (SNF)
daily co-insurance —
Covers co-
insurance for days 21-100 each benet
period.
X X X X X
50% 75%
X X
Part B deductible —
Covers the
annual deductible.
X X
Part B excess charges —
Covers the 15 percent excess charge
when a physician or hospital does not
accept Medicare’s full charge as pay
-
ment in full.
X X X
Emergency care outside the
United States —
See Page 31 for
more information.
80% 80% 80% 80% 80% 80% 80%
Out-of-pocket maximum —
Pays 100 percent of Parts A and B
co-insurance after annual maximum
out-of-pocket has been spent.
$5,120 $2,560
High deductible —
Once you
have paid the deducible in cost shar
-
ing, the coverage will begin.
$2,200
* Pays the Part B co-insurance, except you pay up to a $20 co-pay per physician visit and a $50 co-pay per
emergency room visit.
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
34
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Insurer Phone Website
Available Plan
Types
Home State Rate Factors
Aetna Life Ins. Co. 866-465-1023
aetnaseniorproducts.com A, B, F, G, N Connecticut
Female nonsmoker, EFT
AllCare Health Plan, Inc. 888-460-0185 allcarehealth.com/medigap A, F Oregon Preferred female,
nonsmoker, area 1,
EFT
American Republic Corp Ins. Co. 866-705-9100
americanenterprise.com A, F, FH, K, L Nebraska Preferred single
female, PAC, rates
vary by ZIP code
American Republic Ins. Co. 800-247-2190
americanenterprise.com A, C Iowa Preferred single
female, PAC, rates
vary by ZIP code
Assured Life Association 877-223-3666
assuredlife.org
A, B, C, D, F, G, N
Colorado
Female nonsmoker, EFT,
rates vary by ZIP code
Central States Indemnity Co. of
Omaha
866-644-3988 csi-omaha.com A, F, G, N Nebraska Female nonsmoker,
rates vary by ZIP code
Colonial Penn Life Ins. Co. 800-800-2254
bankerslife.com/products/
medicare-supplement/insurance/
A, B, F, FH, G,
K, L, M, N
Pennsylvania Preferred female bank
draft
Combined Ins. Co. of America 800-544-5531
combinedinsurance.com A, F, N Illinois Preferred female, PAC
Continental Life Ins. Co. of
Brentwood, Tennessee
800-264-4000
aetnaseniorproducts.com A, B, F, FH, G,
N
Tennesse Preferred female,
rates vary by ZIP code
Equitable Life & Casualty Ins. Co. 877-358-4060
equilife.com A, F, N Utah Female nonsmoker,
ultimate rate
Everence Association, Inc. 800-348-7468
everence.com A, C, F, L, N Indiana Female nonsmoker
First Health Life & Health Ins. Co. 855-369-4835
aetnaseniorproducts.com A, B, F, G, N Texas Female nonsmoker,
rates vary by ZIP code
Gerber Life Ins. Co. 888-534-3257 not available A, F, G New York Female nonsmoker,
EFT, rates vary by ZIP
code
Globe Life and Accident Ins. Co. 888-534-3257
globecaremedsupp.com A, B, C, F, FH Nebraska EFT
Key: I (Innovative), S (SELECT), PAC (preauthorized check), EFT (electronic funds transfer), FH (F High)
Medicare Supplement (Medigap) policy information
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
35
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medicare Supplement (Medigap) policy information, continued
Insurer Phone Website
Available Plan
Types
Home State Rate Factors
Government Personnel Mutual
Life Ins. Co.
866-242-7573
gpmlife.com A, C, F, G, N Texas Female nonsmoker,
EFT, Area 1, rates
vary by ZIP code
GPM Health and Life Ins. Co. 866-242-7573
gpmhealthandlife.com A, F, G, N Washington Female nonsmoker
Humana Healthly Living 800-866-0581
humana.com A(I), F(I), FH(I),
K(I), N(I)
Wisconsin Preferred female,
rates vary by ZIP code
Humana Ins. Co. 800-866-0581
humana.com A, B, C, F, FH,
K, L, N
Wisconsin Preferred female,
rates vary by ZIP code
Individual Assurance Co., Life,
Health & Accident
844-502-6780
iaclife.com A, F, G, N Oklahoma Female nonsmoker,
rates vary by ZIP code
Liberty National Life Ins. Co. 800-331-2512
libertynational.com A, B, F, FH, N Nebraska Preferred female
Loyal American Life Ins. Co. 866-459-4272
cignasupplementalbenets.com A, B, C, D, F,
G, N
Ohio Preferred female,
rates vary by ZIP code
The Manhattan Life Ins. Co. 800-877-7703
manhattanlife.com/Individuals/
Policies/MedicareSupplement.aspx
A, C, F, G, N Texas Preferred female,
rates vary by ZIP code
Medico Corp Life Ins. Co. 866-891-9365
completeplus.com A, F, FH Iowa Preferred single
female, PAC, rates
vary by ZIP code
Medico Ins. Co. 800-228-6080
gomedico.com/or.htm A, D, F Iowa Preferred female,
PAC, rates vary by ZIP
code
Moda Health Plan, Inc. 877-277-7073
modahealth.com A, F, FH, N Oregon Preferred female
Omaha Ins. Co. 800-667-2937
mutualofomaha.com A, F, FH, G, N Nebraska Female nonsmoker,
EFT, rates vary by ZIP
code
Oxford Life Ins. Co. 800-308-2318
oxfordlife.com/Products/
medicare/medicare.aspx
A, F, N Arizona Female nonsmoker,
rates vary by ZIP code
Key: I (Innovative), S (SELECT), PAC (preauthorized check), EFT (electronic funds transfer), FH (F High)
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
36
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medicare Supplement (Medigap) policy information, continued
Insurer Phone Website
Available Plan
Types
Home State Rate Factors
Philadelphia American Life Ins.
Co.
800-552-7879
neweralife.com
A, F, FH, G, N Texas Female nonsmoker,
Area 2, bank draft
Regence BlueCross BlueShield
of Oregon
844-734-3623
or.regence.com A, C, F, G, K, N Oregon EFT
Sentinel Security Life Ins. Co. 800-247-1423
sslco.com
A, B, C, D, F, N
Utah Female nonsmoker,
rates vary by ZIP code
Standard Life and Accident Ins. Co.
888-350-1488 slaico.com A, B, C, D, F,
FH(I) G, N
Texas
Female nonsmoker, PAC,
rates vary by ZIP code
State Farm Mutual Automobile
Ins. Co.
866-855-1212 statefarm.com/insurance/health/
medsupp.asp
A, C, F Illinois Female nonsmoker,
territory 1, contact
local agent, rates vary
by ZIP code
State Mutual Ins. Co. 888-212-0475
statemutualinsurance.com A, B, C, D, F,
FH, G, M, N
Georgia Preferred females,
rates vary by ZIP code
Thrivent Financial for Lutherans 800-847- 4836
thrivent.com A, B, C, D, F,
FH, G, L, M
Wisconsin Nonsmoker, PAC,
rates vary by ZIP code
Transamerica Life Ins. Co. 800-752-9797
transamerica.com A, B, C, D, F,
G, K, L, M, N
Iowa Female nonsmoker,
PAC
Transamerica Premier Life 888-272-9272
transamerica.com A , F,G ,N Iowa Female nonsmoker,
rates vary by ZIP code
United American Ins. Co. 800-331-2512
unitedamerican.com A, B, C, D, F,
FH, G, K, L, N
Nebraska Preferred female
United Commercial Travelers of
America (The Order of)
800-848-0123
uct.org A, F, G, N Ohio
Female nonsmoker, EFT,
rates vary by ZIP code
UnitedHealthcare Ins. Co.
(AARP)
800-523-5800 aarpmedicaresupplement.com A, B, C(S), F(S),
K, L, N
Connecticut Nonsmoker
USAA Life Ins. Co. 800-515-8687
usaa.com A, F, N Texas Nonsmoker, PAC
Key: I (Innovative), S (SELECT), PAC (preauthorized check), EFT (electronic funds transfer), FH (F High)
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
37
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medigap policies by plan type
Insurance Company Name
Age at time of purchase
SELECT/
Innovative
Pre-existing
look-back/
waiting period
Type
Application
fee
Member.
Require.
0-65 70 75 80 85
Plan A
Aetna Life Ins. Co. $118 $141 $162 $175 $185 6/6 A None No
AllCare Health Plan, Inc. $89 $110 $130 $150 $163 6/6 A None No
American Republic Corp Ins. Co. $116 $130 $155 $174 $192 0/0 A None No
American Republic Ins. Co. $97 $109 $129 $145 $161 0/0 A None No
Assured Life Association $141 $167 $185 $197 $205 0/0 A $25 No
Central States Indemnity Co. of Omaha $105 $119 $141 $160 $174 0/0 A $25 No
Colonial Penn Life Ins. Co. $152 $186 $226 $263 $299 0/0 A None No
Combined Ins. Co. of America $94 $122 $149 $168 $177 0/0 A None No
Continental Life Ins. Co. of Brentwood, Tennessee $106 $120 $141 $155 $165 0/0 A $20 No
Equitable Life & Casualty Ins. Co. $111 $135 $156 $171 $184 0/0 A $20 No
Everence Association, Inc. $118 $128 $134 $142 $149 0/0 I None Yes
First Health Life & Health Ins. Co. $106 $121 $135 $143 $148 0/0 A None No
Gerber Life Ins. Co. $116 $137 $155 $175 $190 0/0 A $25 No
Globe Life & Accident Ins. Co. $74 $101 $108 $109 $109 2/2 A None No
Government Personnel Mutual Life Ins. Co. $132 $145 $172 $198 $220 0/0 A $25 No
GPM Health and Life Ins. Co. $113 $125 $151 $177 $203 0/0 A None No
Humana Healthy Living $148 $172 $197 $222 $244 I 6/3 A None No
Humana Ins. Co. $127 $151 $175 $198 $219 6/3 A None No
Individual Assurance Co., Life, Health & Accident $119 $133 $153 $171 $188 0/0 A $25 No
Liberty National Life Ins. Co. $128 $155 $164 $164 $164 2/2 A None No
Loyal American Life Ins. Co. $99 $112 $133 $151 $165 6/6 A None No
Manhattan Life Ins. Co. (The) $109 $123 $141 $158 $176 0/0 A $25 No
Medico Corp Life Ins. Co. $103 $115 $137 $154 $171 0/0 A None No
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
38
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medigap policies by plan type, continued
Insurance Company Name
Age at time of purchase
SELECT/
Innovative
Pre-existing
look-back/
waiting period
Type
Application
fee
Member.
Require.
0-65 70 75 80 85
Plan A, continued
Medico Ins. Co. $107 $120 $140 $151 $160 0/0 A None No
Moda Health Plan $98 $114 $126 $139 $141 6/6 A None No
Omaha Ins. Co. $117 $134 $162 $186 $218 0/0 A None No
Oxford Life Ins. Co. $115 $137 $162 $177 $185 0/0 A $15 No
Philadelphia American Life Ins. Co. $96 $104 $120 $139 $179 *Unk A $20 No
Regence BlueCross BlueShield of Oregon $138 $169 $195 $206 $209 0/0 A None No
Sentinel Security Life Ins. Co. $136 $156 $174 $191 $203 0/0 A $25 No
Standard Life & Accident Ins. Co. $200 $205 $220 $261 $332 0/0 A None No
State Farm Mutual Automobile Ins. Co. $90 $113 $131 $148 $154 0/0 A None No
State Mutual Ins. Co. $137 $163 $193 $220 $239 0/0 A None No
Thrivent Financial for Lutherans $97 $115 $133 $142 $145 0/0 A None Yes
Transamerica Life Ins. Co. $80 $100 $122 $144 $162 6/6 IA None No
Transamerica Premier Life Ins. Co. $98 $103 $120 $133 $154 6/6 A $25 No
United American Ins. Co. $93 $113 $120 $120 $120 2/2 A None No
United Commercial Travelers of America
(The Order of) $146 $183 $214 $236 $251 0/0 A None Yes
UnitedHealthcare Ins. Co. (AARP) $79 $96 $124 $124 $124 3/3 C None Yes
USAA Life Ins. Co. $138 $161 $192 $223 $246 0/0 A None No
*Unknown – contact plan for details
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
39
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medigap policies by plan type, continued
Insurance Company Name
Age at time of purchase
SELECT/
Innovative
Pre-existing
look-back/
waiting period
Type
Application
fee
Member.
Require.
0-65 70 75 80 85
Plan B
Aetna Life Ins. Co. $130 $159 $189 $215 $247 6/6 A None No
Assured Life Association $153 $181 $203 $219 $232 0/0 A $25 No
Colonial Penn Life Ins. Co. $146 $177 $214 $250 $286 0/0 A None No
Continental Life Ins. Co. of Brentwood, Tennessee $134 $152 $178 $195 $208 0/0 A $20 No
First Health Life & Health Ins. Co. $121 $141 $160 $176 $190 0/0 A None No
Globe Life & Accident Ins. Co. $111 $148 $164 $167 $167 2/2 A None No
Humana Ins. Co. $139 $164 $190 $216 $239 6/3 A None No
Liberty National Life Ins. Co. $178 $221 $243 $247 $247 2/2 A None No
Loyal American Life Ins. Co. $115 $131 $155 $177 $192 6/6 A None No
Sentinel Security Life Ins. Co. $151 $172 $195 $217 $234 0/0 A $25 No
Standard Life & Accident Ins. Co. $228 $234 $250 $297 $378 0/0 A None No
State Mutual Ins. Co. $160 $190 $226 $257 $279 0/0 A None No
Thrivent Financial for Lutherans $109 $131 $154 $171 $182 0/0 A None Yes
Transamerica Life Ins. Co. $105 $132 $161 $190 $214 6/6 IA None No
United American Ins. Co. $140 $174 $190 $193 $193 2/2 A None No
UnitedHealthcare Ins. Co. (AARP) $129 $156 $202 $202 $202 3/3 C None Yes
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
40
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medigap policies by plan type, continued
Insurance Company Name
Age at time of purchase
SELECT/
Innovative
Pre-existing
look-back/
waiting period
Type
Application
fee
Member.
Require.
0-65 70 75 80 85
Plan C
American Republic Ins. Co. $134 $150 $179 $201 $222 0/0 A None No
Assured Life Association $190 $225 $253 $273 $291 0/0 A $25 No
Everence Association, Inc. $177 $210 $236 $254 $270 0/0 A None Yes
Globe Life & Accident Ins. Co. $129 $166 $190 $201 $201 2/2 A None No
Government Personnel Mutual Life Ins. Co. $175 $193 $232 $273 $312 0/0 A $25 No
Humana Ins. Co. $180 $213 $247 $280 $310 6/3 A None No
Loyal American Life Ins. Co. $142 $161 $194 $220 $240 6/6 A None No
Manhattan Life Ins. Co. (The) $144 $161 $188 $218 $253 0/0 A $25 No
Moda Health Plan $153 $179 $197 $218 $221 6/6 A None No
Regence BlueCross BlueShield of Oregon $172 $219 $261 $293 $317 0/0 A None No
Sentinel Security Life Ins. Co. $185 $212 $241 $270 $294 0/0 A $25 No
Standard Life & Accident Ins. Co. $259 $266 $285 $338 $430 0/0 A None No
State Farm Mutual Automobile Ins. Co. $136 $171 $198 $223 $232 0/0 A None No
State Mutual Ins. Co. $191 $228 $274 $311 $339 0/0 A None No
Thrivent Financial for Lutherans $129 $152 $181 $212 $242 0/0 A None Yes
Transamerica Life Ins. Co. $124 $156 $190 $224 $253 6/6 IA None No
United American Ins. Co. $148 $185 $209 $229 $229 2/2 A None No
UnitedHealthcare Ins. Co. (AARP) $149 $180 $233 $233 $233 3/3 C None Yes
UnitedHealthcare Ins. Co. (AARP) $121 $147 $190 $190 $190 S 3/3 C None Yes
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
41
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medigap policies by plan type, continued
Insurance Company Name
Age at time of purchase
SELECT/
Innovative
Pre-existing
look-back/
waiting period
Type
Application
fee
Member.
Require.
0-65 70 75 80 85
Plan D
Assured Life Association $163 $193 $218 $237 $253 0/0 A $25 No
Loyal American Life Ins. Co. $121 $137 $163 $185 $201 6/6 A None No
Medico Ins. Co. $144 $164 $198 $223 $247 0/0 A None No
Sentinel Security Life Ins. Co. $144 $166 $189 $212 $232 0/0 A $25 No
Standard Life & Accident Ins. Co. $156 $160 $171 $203 $259 0/0 A None No
State Mutual Ins. Co. $167 $199 $236 $269 $292 0/0 A None No
Thrivent Financial for Lutherans $111 $134 $162 $192 $221 0/0 A None Yes
Transamerica Life Ins. Co. $115 $145 $176 $207 $234 6/6 IA None No
United American Ins. Co. $142 $181 $206 $227 $227 2/2 A None No
Plan F
Aetna Life Ins. Co. $151 $187 $224 $257 $301 6/6 A None No
AllCare Health Plan, Inc. $132 $162 $195 $233 $257 6/6 A None No
American Republic Corp Ins. Co. $164 $184 $219 $246 $273 0/0 A None No
Assured Life Association $201 $238 $268 $290 $308 0/0 A $25 No
Central States Indemnity Co. of Omaha $152 $171 $204 $231 $250 0/0 A $25 No
Colonial Penn Life Ins. Co. $189 $229 $278 $331 $390 0/0 A None No
Combined Ins. Co. of America $134 $175 $213 $240 $252 0/0 A None No
Continental Life Ins. Co. of Brentwood, Tennessee $157 $176 $203 $219 $233 0/0 A $20 No
Equitable Life & Casualty Ins. Co. $162 $198 $230 $253 $275 0/0 A $20 No
Everence Association, Inc. $194 $210 $223 $241 $260 0/0 I None Yes
First Health Life & Health Ins. Co. $141 $166 $190 $211 $231 0/0 A None No
Gerber Life Ins. Co. $162 $192 $220 $254 $281 0/0 A $25 No
Globe Life & Accident Ins. Co. $130 $167 $191 $202 $202 2/2 A None No
Government Personnel Mutual Life Ins. Co. $180 $198 $238 $280 $319 0/0 A $25 No
GPM Health and Life Ins. Co. $147 $162 $196 $230 $263 0/0 A None No
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
42
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medigap policies by plan type, continued
Insurance Company Name
Age at time of purchase
SELECT/
Innovative
Pre-existing
look-back/
waiting period
Type
Application
fee
Member.
Require.
0-65 70 75 80 85
Plan F, continued
Humana Healthy Living $200 $233 $268 $303 $333 I 6/3 A None No
Humana Ins. Co. $184 $217 $252 $286 $316 6/3 A None No
Individual Assurance Co., Life, Health & Accident $140 $156 $182 $209 $241 0/0 A $25 No
Liberty National Life Ins. Co. $202 $252 $286 $314 $314 2/2 A None No
Loyal American Life Ins. Co. $147 $166 $198 $224 $242 6/6 A None No
Manhattan Life Ins. Co. (The) $146 $163 $190 $220 $255 0/0 A $25 No
Medico Corp Life Ins. Co. $139 $155 $185 $208 $230 0/0 A None No
Medico Ins. Co. $174 $196 $234 $262 $289 0/0 A None No
Moda Health Plan $163 $190 $209 $230 $234 6/6 A None No
Omaha Ins. Co. $154 $177 $213 $245 $287 0/0 A None No
Oxford Life Ins. Co. $144 $170 $201 $232 $266 0/0 A $15 No
Philadelphia American Life Ins. Co. $129 $140 $165 $194 $249 *Unk A $20 No
Regence BlueCross BlueShield of Oregon $173 $221 $262 $294 $318 0/0 A None No
Sentinel Security Life Ins. Co. $189 $217 $247 $277 $301 0/0 A $25 No
Standard Life & Accident Ins. Co. $203 $208 $223 $264 $337 0/0 A None No
State Farm Mutual Automobile Ins. Co. $137 $173 $200 $225 $235 0/0 A None No
State Mutual Ins. Co. $199 $234 $280 $316 $342 0/0 A None No
Thrivent Financial for Lutherans $129 $153 $182 $213 $243 0/0 A None Yes
Transamerica Life Ins. Co. $125 $157 $191 $226 $254 6/6 IA None No
Transamerica Premier Life Ins. Co. $165 $175 $202 $225 $260 6/6 A $25 No
United American Ins. Co. $162 $202 $228 $250 $250 2/2 A None No
United Commercial Travelers of America
(The Order of) $216 $263 $303 $327 $348 0/0 A None Yes
UnitedHealthcare Ins. Co. (AARP) $149 $181 $235 $235 $235 3/3 C None Yes
UnitedHealthcare Ins. Co. (AARP) $122 $148 $191 $191 $191 S 3/3 C None Yes
USAA Life Ins. Co. $153 $178 $212 $246 $272 0/0 A None No
*Unknown – contact plan for details
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
43
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medigap policies by plan type, continued
Insurance Company Name
Age at time of purchase
SELECT/
Innovative
Pre-existing
look-back/
waiting period
Type
Application
fee
Member.
Require.
0-65 70 75 80 85
Plan F High
American Republic Corp Ins. Co. $50 $56 $67 $75 $84 0/0 A None No
Colonial Penn Life Ins. Co. $34 $41 $50 $59 $70 0/0 A None No
Continental Life Ins. Co. of Brentwood, Tennessee $61 $69 $79 $85 $91 0/0 A $20 No
Globe Life & Accident Ins. Co. $28 $38 $48 $52 $52 2/2 A None No
Humana Healthy Living $71 $82 $93 $104 $113 I 6/3 A None No
Humana Ins. Co. $53 $63 $73 $83 $91 6/3 A None No
Liberty National Life Ins. Co. $33 $43 $53 $59 $59 2/2 A None No
Medico Corp Life Ins. Co. $51 $57 $68 $77 $85 0/0 A None No
Moda Health Plan $36 $41 $46 $50 $51 6/6 A None No
Omaha Ins. Co. $42 $49 $59 $68 $79 0/0 A None No
Philadelphia American Life Ins. Co. $31 $35 $42 $52 $66 *Unk A $20 No
Standard Life & Accident Ins. Co. $29 $29 $31 $37 $47 0/0 A None No
Standard Life & Accident Ins. Co. $43 $52 $53 $57 $68
I
0/0 A None No
State Mutual Ins. Co. $78 $92 $110 $124 $135 0/0 A None No
Thrivent Financial for Lutherans $35 $43 $53 $64 $76 0/0 A None Yes
United American Ins. Co. $26 $35 $43 $47 $47 2/2 A None No
Plan G
Aetna Life Ins. Co. $136 $169 $203 $235 $281 6/6 A None No
Assured Life Association $165 $195
$220 $239 $255
0/0 A $25 No
Central States Indemnity Co. of Omaha $117 $132 $158 $178 $193 0/0 A $25 No
Colonial Penn Life Ins. Co. $136 $167 $206 $249 $295 0/0 A None No
Continental Life Ins. Co. of Brentwood, Tennessee $129 $145 $167 $180 $191 0/0 A $20 No
First Health Life & Health Ins. Co. $130 $153 $176 $197 $217 0/0 A None No
Gerber Life Ins. Co. $137 $162 $187 $216 $240 0/0 A $25 No
*Unknown – contact plan for details
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
44
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medigap policies by plan type, continued
Insurance Company Name
Age at time of purchase
SELECT/
Innovative
Pre-existing
look-back/
waiting period
Type
Application
fee
Member.
Require.
0-65 70 75 80 85
Plan G continued
Government Personnel Mutual Life Ins. Co. $120 $132 $160 $188 $215 0/0 A $25 No
GPM Health and Life Ins. Co. $118 $130 $157 $185 $212 0/0 A None No
Individual Assurance Co., Life, Health & Accident $114 $129 $153 $177 $205 0/0 A $25 No
Loyal American Life Ins. Co. $121 $137 $163 $185 $201 6/6 A None No
Manhattan Life Ins. Co. (The) $124 $140 $165 $193 $226 0/0 A $25 No
Omaha Ins. Co. $131 $150 $181 $208 $244 0/0 A None No
Oxford Life Ins. Co. $119 $126 $146 $167 $190 0/0 A $15 No
Philadelphia American Life Ins. Co. $105 $114 $136 $158 $203 *Unk A $20 No
Regence BlueCross BlueShield of Oregon $162 $207 $245 $275 $298 0/0 A None No
Standard Life & Accident Ins. Co. $157 $161 $173 $205 $261 0/0 A None No
State Mutual Ins. Co. $169 $200 $238 $270 $294 0/0 A None No
Thrivent Financial for Lutherans $111 $135 $163 $194 $223 0/0 A None Yes
Transamerica Life Ins. Co. $115 $144 $176 $207 $234 6/6 IA None No
Transamerica Premier Life Ins. Co. $129 $136 $158 $175 $203 6/6 A $25 No
United American Ins. Co. $145 $191 $210 $231 $231 2/2 A None No
United Commercial Travelers of America
(The Order of) $178 $223 $261 $287 $306 0/0 A None Yes
Plan K
American Republic Corp Ins. Co. $69 $78 $92 $104 $115 0/0 A None No
Colonial Penn Life Ins. Co. $51 $62 $77 $94 $113 0/0 A None No
Humana Healthy Living $94 $109 $124 $139 $153 I 6/3 A None No
Humana Ins. Co. $75 $88 $102 $116 $129 6/3 A None No
Regence BlueCross BlueShield of Oregon $93 $115 $138 $155 $169 0/0 A None No
Transamerica Life Ins. Co. $57 $72 $88 $103 $117 6/6 IA None No
United American Ins. Co. $84 $112 $124 $131 $131 2/2 A None No
UnitedHealthcare Ins. Co. (AARP)
$44 $53 $69 $69 $69 3/3 C
None Yes
*Unknown – contact plan for details
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
45
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medigap policies by plan type, continued
Insurance Company Name
Age at time of purchase
SELECT/
Innovative
Pre-existing
look-back/
waiting period
Type
Application
fee
Member.
Require.
0-65 70 75 80 85
Plan L
American Republic Corp Ins. Co. $94 $106 $126 $141 $157 0/0 A None No
Colonial Penn Life Ins. Co. $115 $138 $168 $200 $235 0/0 A None No
Everence Association, Inc. $97 $106 $113 $123 $132 0/0 I None Yes
Humana Ins. Co. $106 $126 $146 $165 $183 6/3 A None No
Thrivent Financial for Lutherans $79 $96 $116 $138 $159 0/0 A None Yes
Transamerica Life Ins. Co. $85 $107 $130 $153 $173 6/6 IA None No
United American Ins. Co. $118 $157 $175 $184 $184 2/2 A None No
UnitedHealthcare Ins. Co. (AARP) $82 $100 $129 $129 $129 3/3 C None Yes
Plan M
Colonial Penn Life Ins. Co. $132 $164 $203 $243 $284 0/0 A None No
State Mutual Ins. Co. $151 $180 $213 $242 $263 0/0 A None No
Thrivent Financial for Lutherans $105 $126 $152 $178 $202 0/0 A None Yes
Transamerica Life Ins. Co. $105 $132 $160 $189 $213 6/6 IA None No
Plan N
Aetna Life Ins. Co. $108 $135 $163 $191 $232 6/6 A None No
Assured Life Association $130 $154 $174 $188 $202 0/0 A $25 No
Central States Indemnity Co. of Omaha $96 $108 $129 $146 $158 0/0 A $25 No
Colonial Penn Life Ins. Co. $90 $116 $149 $185 $225 0/0 A None No
Combined Ins. Co. of America $94 $122 $149 $168 $177 0/0 A None No
Continental Life Ins. Co. of Brentwood, Tennessee $108 $123 $143 $158 $168 0/0 A $20 No
Equitable Life & Casualty Ins. Co. $99 $121 $140 $154 $168 0/0 A $20 No
Everence Association, Inc. $91 $109 $123 $134 $144 0/0 A None Yes
First Health Life & Health Ins. Co. $101 $119 $138 $155 $173 0/0 A None No
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
46
CONTENTS
Key: I - Innovative, S - SELECT, IS - Innovative SELECT
A - Attained age, C - Community rated, IA - Issue age
See Pages 28-31 for more information on Medigap plans.
Medigap policies by plan type, continued
Insurance Company Name
Age at time of purchase
SELECT/
Innovative
Pre-existing
look-back/
waiting period
Type
Application
fee
Member.
Require.
0-65 70 75 80 85
Plan N, continued
Government Personnel Mutual Life Ins. Co. $109 $120 $146 $172 $198 0/0 A $25 No
GPM Health and Life Ins. Co. $95 $105 $127 $149 $170 0/0 A None No
Humana Healthy Living $135 $157 $180 $202 $222 I 6/3 A None No
Humana Ins. Co. $114 $135 $157 $178 $197 6/3 A None No
Individual Assurance Co., Life, Health & Accident
$91 $102 $121 $141 $166 0/0 A $25 No
Liberty National Life Ins. Co. $154 $197 $227 $253 $253 2/2 A None No
Loyal American Life Ins. Co. $97 $110 $131 $148 $160 6/6 A None No
Manhattan Life Ins. Co. (The) $100 $113 $134 $158 $186 0/0 A $25 No
Moda Health Plan $118 $137 $151 $166 $168 6/6 A None No
Omaha Ins. Co. $96 $110 $133 $153 $179 0/0 A None No
Oxford Life Ins. Co. $100 $119 $144 $169 $199 0/0 A $15 No
Philadelphia American Life Ins. Co. $89 $96 $114 $134 $172 *Unk A $20 No
Regence BlueCross BlueShield of Oregon $135 $172 $204 $229 $248 0/0 A None No
Sentinel Security Life Ins. Co. $122 $140 $160 $180 $197 0/0 A $25 No
Standard Life & Accident Ins. Co. $103 $105 $113 $134 $171 0/0 A None No
State Mutual Ins. Co. $139 $164 $196 $221 $239 0/0 A None No
Transamerica Life Ins. Co. $98 $124 $151 $178 $200 6/6 IA None No
Transamerica Premier Life Ins. Co. $127 $135 $156 $173 $201 6/6 A $25 No
United American Ins. Co. $128 $164 $188 $210 $210 2/2 A None No
United Commercial Travelers of America
(The Order of) $150 $183 $210 $227 $241 0/0 A None Yes
UnitedHealthcare Ins. Co. (AARP) $101 $122 $158 $158 $158 3/3 C None Yes
USAA Life Ins. Co.
$92 $107 $128 $148 $164 0/0 A None No
*Unknown – contact plan for details
47
Note: Rates vary per
individual factors.
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
Medigap vs. Medicare Advantage comparison chart
Original “Fee-for-Service”
Medicare
with a Medigap (Example: Plan F)
Comparison
point:
Medicare Advantage:
HMO, PPO, or PFFS
(Private Medicare Plans)
Must have Parts A and B. Companies may deny,
but must accept all applicants, all ages, during
Medigap Open Enrollment and Guaranteed Issue
periods.
Eligibility
Must have Parts A and B and live in service
area. Takes all applicants except those with
end-stage renal disease.
Premium may vary with gender and health, and
may go up with age. Companies may underwrite
(add to premium).
No co-pay costs, with some exceptions, at time of
service. Out-of-pocket maximum for K and L only.
Costs:
Premiums, co-pay,
co-insurance, and
out-of-pocket max
All plan members pay same premium, regard-
less of age, gender, or health. Cost sharing
(co-pays) must be paid for most medical
services. Plans have an out-of-pocket annual
maximum.
No network: Go to any provider that accepts
Medicare. No referrals required for specialist visits.
May be hard to nd providers accepting new
patients with Original Medicare in some areas.
May be used for treatments at specialty medical
facilities, such as Mayo Clinics, OHSU, etc.
Provider choice
and availability
Always ask your
providers what
insurance they
accept
Maintain provider networks; they must have
available providers in order to accept new
members.
HMOs: Generally cover in-network only.
Referrals may be required for specialist visits.
PPOs: Cover out-of-network, but then costs
may be higher. No referrals required.
PFFSs: Set their own reimbursement rates with
contracted doctors.
Not included. If you want drug coverage, you may
enroll in any stand-alone Medicare prescription
drug plan available.
Prescription drug
coverage
To make sure your
plan covers your
drug, use
medicare.gov
If you want drug coverage, you must enroll in
the included drug coverage if choosing an HMO
or PPO (VA-eligible excepted).
With PFFS, you may choose the plan’s drug
coverage, if offered, or a stand-alone Medicare
prescription drug plan.
Yes, guaranteed renewable as long as you pay the
premium and the application was correct. Benets
never change. No election season for Medigaps.
May change company each year on birthday with
Guaranteed Issue.
Is it renewable?
No, benets may change yearly. However, you
usually remain in a plan unless you disenroll at
election times or your plan terminates in your
area.
Covers only same as Original Medicare. No
routine dental, vision, except “innovative” plans; no
alternative medicine.
Extras
Some plans include routine dental, hearing, or
vision. Some offer additional alternative
therapy coverage or gym memberships.
Good for travelers or “snow birds.” May save
money for people needing high-cost or frequent
care. Customize elements of your Medicare
picture – choose doctors and drug plan.
For whom it may
be best
Network plans may be good for people who
otherwise can’t nd a Medicare provider. May
save money unless you need frequent
appointments or treatments.
Having a packaged plan may simplify choices.
Because Medigaps are standardized, price
and customer service are the only difference.
Try calling a few competitively priced plans.
Regulated by Division of Financial Regulation. Use
oregonshiba.org to view rate increase
histories of the Medicare supplement plans.
How to
comparison shop
Who regulates it?
Plans are not standardized. To compare, see
Pages 59-78 of this guide or the medicare.
gov Plan Finder. Plans regulated by Medicare/
CMS; sales agents licensed by Division of
Financial Regulation.
48
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
About Medicare Advantage plans
Medicare Advantage
Private insurance companies contract with
Medicare to offer coordinated care and
private fee-for-service health insurance
plans. Medicare pays these plans to pro
-
vide all your Medicare-approved services.
When you join a Medicare Advantage (MA)
plan, you agree to that plan’s terms and
conditions.
● You will receive the same benets as in
Original Medicare, but not at the same
payment rates.
● You will still pay the Part B premium,
plus a premium to the plan (unless
the plan has a $0 premium) and co-
payments or co-insurance for certain
services.
● Medicare Advantage plans may offer
additional coverage, such as routine
annual physicals, preventive vision, or
dental.
Medicare Advantage plans renew their
contracts annually with the Centers for
Medicare and Medicaid Services (CMS).
This means the policies are not guaran
-
teed renewable. However, if you join a plan
that decides to not renew its contract with
CMS, you have protection under the law
that enables you to join another plan or
purchase a Medigap policy.
Where you live (based on your ZIP code)
often determines which Medicare
Advantage plans are available to you.
You can nd out if a plan covers your
area by calling the company or by
reviewing the plan on Medicare’s website,
medicare.gov
, or the chart on Page 54.
Who can join a Medicare
Advantage plan?
Most people who have both Medicare Part
A and Part B and live in the plan’s service
area can join a plan.
Beneciaries with end-stage renal dis
-
ease (ESRD) are not eligible to join a plan.
However, if you are already in a plan and
develop ESRD, you may stay in the plan.
If you had a successful kidney transplant,
you may be able to join a plan. For more
information on what is offered to bene
-
ciaries with ESRD, see Medicare publica-
tion 10128, Medicare coverage of Kidney
Dialysis and Kidney Transplant Services.
Medicare Advantage election
periods and enrollment actions
If you take more than one action during
any of the enrollment periods, the last
action received by Medicare before the
effective date ends the enrollment period.
You may join, leave, or switch Medicare
Advantage plans during:
● Initial Enrollment Period (IEP) when you
are new to Medicare; usually the three
months before, the month of and three
months after your 65th birthday.
49
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
● Annual Enrollment Period (AEP), Oct.
15 to Dec. 7, also referred to as Fall
Open Enrollment. Enroll in your new
plan; you will be automatically disen
-
rolled from your old plan. Medicare
Advantage Disenrollment Period
(MADP) happens from Jan. 1 to Feb. 14
every year. See more on Page 51.
Special Enrollment Periods (SEP)
Special enrollment periods are opportuni-
ties to make plan changes outside of the
standard enrollment periods.
● Moving permanently outside your plan’s
service area.
● Qualifying for any limited-income
assistance.
SEPs are generally 60 days, but may vary.
At these times, you may use your SEP to:
● Join a different Medicare Advantage
plan.
● Switch to using only Original Medicare.
● Switch to Original Medicare and pur
-
chase a Medigap. Insurance companies
may require that you undergo underwrit
-
ing unless you have guaranteed issue.
Star-rated SEPs – Medicare uses a star
rating system based on complaints that
they receive. Five stars is excellent and
one star is poor.
● Five-star SEP – You may enroll in a
plan with ve stars once from Dec. 8 to
Nov. 30.
● Low-performing plan SEP – If you are
in a low-performing plan you will receive
a letter in late October. You must call
800-MEDICARE to enroll in another
plan.
Help comparing plans
A SHIBA counselor can help you under-
stand plan options and plan rules, such as
how and when you may make changes.
For a SHIBA contact in your area:
● Call 800-722-4134 (toll-free)
● Visit oregonshiba.org
● Call 800-MEDICARE (800-633-4227)
About Medicare Advantage plans, continued
Medicare Advantage plan types:
HMO: Health Maintenance Organization
HMO-POS: HMO with Point-of-Service
option
PFFS: Private Fee-for-Service plan
PPO: Preferred Provider Organization
SNP: Special Needs Plan
MSA: Medicare Savings Account (not
available in Oregon)
(See Glossary for denitions)
50
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
Choosing a Medicare Advantage plan
How do I select a plan?
● What plans are offered in my area?
Refer to the
by-county chart
on Page
55 to see which plans are available to
you.
● Will your doctor and hospital accept
the plan?
Ask the business ofces of your doc
-
tors and hospital if they are in the
network for a plan you are considering.
Even though a plan may be offered
in your area, providers do not have
to participate. In some plans, if your
doctor is not part of the preferred
network, you will have to pay more to
see that doctor. It is very important
to know if the plan you are considering
includes your doctors and hospital of
choice.
Call for the above information for
yourself. Webpages and printed mate
-
rials can be incorrect and an agent
wanting to sell you a plan may be
misinformed.
● Can I afford the plan?
Make sure you understand the cover
-
age, including premiums and co-pays.
The plan description pages list some
of your costs. Here are some of the
words you need to understand:
– Premiums: The amount you pay monthly
for a plan. In a few cases there is a $0
premium.
– Deductible: The amount you pay before
the plan starts paying (some exceptions
apply).
– Maximum out-of-pocket costs: This is
the most you would have to pay in a year
for covered services, excluding the pre
-
mium and Part D drugs, before the plan
starts paying 100 percent.
Caution: Not all covered services may
count toward the out-of-pocket maximum.
– Co-pays: A xed amount you pay for a
service.
– Co-insurance: A percentage of the cost
of a service.
Prescription drug coverage
● Do I want prescription drug
coverage with my Medicare
Advantage plan?
Most HMO/PPO plans include inte-
grated prescription drug coverage
(MAPD). Your drug coverage must be
this “bundled” package.
PFFS plans allow you to choose a
stand-alone prescription drug plan or
enroll in their bundled package.
Exception: If you have VA drug coverage
available, you can use it with the health-
only MA plan, if the plan allows.
51
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
T
i
p
s
&
H
i
n
t
s
Medicare Advantage Disenrollment Period: Jan. 1 - Feb. 14
During the Medicare Advantage
Disenrollment Period (MADP), from
Jan. 1 to Feb. 14, you may disenroll from
a Medicare Advantage plan and switch to
Original Medicare.
The key to using this period is that you
must enter January enrolled in a Medicare
Advantage plan.
You may disenroll from a Medicare
Advantage plan and switch to Original
Medicare.
Note: This disenrollment will not, by itself,
qualify you for Guaranteed Issue to
purchase a Medigap supplement.
Note: If you did not have prior creditable
drug coverage, you may incur a late-enroll
-
ment penalty.
● This period allows one election only:
– May enroll into a stand-alone
prescription drug plan (PDP), which
automatically disenrolls member from
MA/MAPD –or –
– May disenroll in writing from MA/
MAPD or by calling 1-800-MEDICARE
(1-800-633-4227, toll-free)
● You may not use this period to enroll in
or switch Medicare Advantage plans.
● You may not use this period to enroll in
a Part D plan if you enter the period in
Original Medicare only.
About Medicare Advantage
dental coverage
Original Medicare does not cover
routine dental care. There are limited
dental services you may get when you are
in the hospital, but these are rare.
Some Medicare Advantage (MA) plans
have dental coverage included in the plan
or as an additional rider.
Other MA plans choose to cover preventive
care, such as cleanings and X-rays, up to a
capped limit.
For more information, contact the plan.
Contact SHIBA for a list of stand-alone
dental plans or for other community
resources go to oregondental.org.
Treat your Medicare, Medicaid, and Social Security numbers like a
credit card number. Never give these numbers to a stranger, and do
not carry your cards in your purse or wallet.
52
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
Medicare Special Needs Plans (SNPs)
These are specially designed MA plans with membership limited to certain groups of people; those who
have both Medicare and Medicaid (dual eligibles), those who reside in institutions such as nursing homes
or have chronic and disabling conditions (cardiovascular disorders, chronic heart failure, and diabetes).
Dual eligible (Medicaid*)
Company/plan Contact Available counties
ATRIO Health Plans H3814-007
ATRIO Special Needs Plan (HMO SNP)
atriohp.com
Non-member and member
877-672-8620; TTY 800-735-
2900
Douglas, Klamath
ATRIO Health Plans H3814-029
ATRIO Special Needs Plan (Rogue)
(HMO SNP)
atriohp.com
Non-member and member
877-672-8620; TTY 800-735-
2900
Jackson, Josephine
ATRIO Health Plans H5995-001
ATRIO Special Needs Plan (Willamette)
(HMO SNP)
atriohp.com
Non-member and member
877-672-8620; TTY 800-735-
2900
Marion, Polk
CareOregon Advantage H5859-001
CareOregon Advantage Plus
(HMO-POS SNP)
careoregonadvantage.org
Non-member and member
888-712-3258; TTY 800-735-
2900
Clackamas, Clatsop,
Columbia, Jackson,
Josephine, Multnomah,
Tillamook, Washington,
Yamhill
FamilyCare Health Plans, Inc. H3818-
002
FamilyCare Community (HMO SNP)
familycarehealthplans.org
Non-member 866-225-2273;
Member 866-798-2273; TTY
711
Clackamas, Clatsop,
Multnomah, Washington
Providence Health Assurance H9047-
043
Providence Medicare Dual Plus (HMO
SNP)
ProvidenceHealthAssurance.com
Non-member and member
800-603-2340; TTY 711
Clackamas, Multnomah,
Washington
Samaritan Advantage Health Plan
H3811- 003
Samaritan Advantage Special Needs Plan
(HMO SNP)
samhealth.org/medicare
Non-member and member
800-832-4580; TTY 800-735-
2900
Benton, Lincoln, Linn
Trillium Advantage H2174-001
Trillium Advantage Dual (HMO SNP)
trilliumadvantage.com
Non-member 877-826-5519,
member 844-867-1156; TTY
711
Lane
53
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
Institutional (Nursing homes or skilled nursing facilities)
AgeRight Advantage Health Plan
H1372-001
AgeRight Advantage Health Plan (HMO
SNP) (HMO SNP)
agerightadvantage.com
Non-member and member 844-
854-6885; TTY 711
Clackamas, Klamath,
Multnomah, Washington,
Yamhill
Trillium Advantage H2174-005
Trillium Advantage TLC Community
ISNP (HMO SNP)
trilliumadvantage.com
Non-member 877-826-5519,
member 844-867-1156; TTY 711
Lane
Trillium Advantage H2174-003
Trillium Advantage TLC ISNP
(HMO SNP) trilliumadvantage.com
Non-member 877-826-5519,
member 844-867-1156; TTY 711
Lane
UnitedHealthcare H3113-008
UnitedHealthcare Assisted Living Plan
uhcmedicaresolutions.com
Non-member 888-834-3721,
member 800-393-0993, TTY 711
Lane
UnitedHealthcare H2228-016
UnitedHealthcare Nursing Home Pla
(HMO SNP) H3113-008
uhcmedicaresolutions.com
Non-member 888-834-3721,
member 800-393-0993, TTY 711
Benton, Clackamas, Lane,
Linn, Marion, Multnomah,
Washington, Yamhill
UnitedHealthcare H2228-016
UnitedHealthcare Assisted Living Plan
uhcmedicaresolutions.com
Non-member 888-834-3721,
member 800-393-0993, TTY 711
Benton, Clackamas,
Linn, Marion, Multnomah,
Washington, Yamhill
Chronic or Disabling Condition
(Cardiovascular disorders, chronic heart failure, and diabetes)
Health Net Health Plan of Oregon, Inc.
Health Net Jade (HMO SNP)
H6815-004
healthnet.com/medicare
Non-member 800-949-6192,
member 888-445-8913, TTY 711
Benton, Clackamas,
Lane, Linn, Multnomah,
Washington, Yamhill
New enrollees to SNPs have a once-only special enrollment period (SEP) at any time during the year. After the
once-only special enrollment, changes must be done during an annual enrollment period (AEP).
PACE (Program of All Inclusive Care for the Elderly)
Providence Health Plans
Providence ElderPlace providence.org/
elderplace
503-215-6556 Clatsop, Multnomah,
Tillamook, and parts
of Clackamas and
Washington.
Beneciary must meet eligibility requirements. Monthly premium is $3,500 unless the beneciary qualies
for Medicaid and then the premium is paid by the state. Costs do not change if medical/social care needs
increase. There are no out-of-pocket costs or deductibles. All necessary medical and social services are
covered. Chiropractic, podiatry, prosthetic devices, and acupuncture are covered only if identied as benecial/
necessary.
54
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Medicare Advantage plan contact information
Insurer
Nonmember
number
Member number TTY Website
AllCare Advantage
888-460-0185 888-460-0185 800-735-2900
allcarehealth.com/advantage
ATRIO Health Plans
877-672-8620 877-672-8620 800-735-2900
atriohp.com
CareOregon Advantage
888-712-3258 888-712-3258 711
careoregonadvantage.org
F
amilyCare Health Plans, Inc.
866-225-2273 866-798-2273 711 familycareinc.org
Health Net
800-949-6192 888-445-8913 711
healthnet.com/medicare
Humana
800-833-2364 800-457-4708 711
humana-medicare.com
Kaiser Permanente
877-408-3496 877-221-8221 711
kp.org/medicare
Moda Health Plan, Inc.
888-217-2375 877-299-9062 711
modahealth.com/medicare
PacicSource Medicare
888-863-3637 888-863-3637 800-735-2900
medicare.pacicsource.com
Providence Health Assurance
800-457-6064 800-603-2340 711
providencehealthassurance.
com
Regence BlueCross BlueSheild of
Oregon
844-734-3623
PPO 800-541-8981
HMO 855-522-8896
711
regence.com/medicare
Samaritan Advantage Health Plan
800-832-4580 800-832-4580 800-735-2900
medicare.samhealthplans.org
Trillium Advantage
877-826-5519 84 4 - 867-1156 711
triliumadvantage.com
UnitedHealthcare
800-555-5757
PPO 800-643-4845
HMO 800-950-9355
711
aarpmedicareplans.com
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Medicare Advantage plans by county
Baker, Page 56
Moda
Benton, Page 56
Health Net
Humana
Kaiser
Moda
Regence
Samaritan
UnitedHealthcare
Clackamas, Page 57
CareOregon
FamilyCare
Health Net
Humana
Kaiser
Moda
PacicSource
Providence
Regence
UnitedHealthcare
Clatsop, Page 58
CareOregon
FamilyCare
Moda
Columbia, Page 59
CareOregon
Humana
Kaiser
Moda
Providence
Regence
Coos, Page 60
Moda
PacicSource
Regence
Crook, Page 60
Humana
Moda
PacicSource
Providence
Curry, Page 60
Moda
PacicSource
Regence
Deschutes, Page 61
Humana
Moda
PacicSource
Providence
Douglas, Page 61
AllCare
ATRIO Health Plans
Health Net
Moda
Regence
Gilliam, Page 56
Moda
Grant, Page 62
Moda
PacicSource
Harney, Page 56
Moda
Hood River, Page 63
Humana
Moda
PacicSource
Providence
Jackson, Page 63
AllCare
ATRIO Health Plans
Health Net
Moda
Regence
Jefferson, Page 61
Humana
Moda
PacicSource
Providence
Josephine, Page 64
AllCare
ATRIO Health Plans
Health Net
Moda
Regence
Klamath, Page 65
ATRIO Health Plans
Moda
PacicSource
Lake, Page 62
Moda
PacicSource
Lane, Page 66
Health Net
Moda
PacicSource
Providence
Regence
Trillium
UnitedHealthcare
Lincoln, Page 67
Humana
Moda
Samaritan
Linn, Page 56
Health Net
Humana
Kaiser
Moda
Regence
Samaritan
UnitedHealthcare
Malheur, Page 67
Humana
Moda
Marion, Page 67
ATRIO Health Plans
Health Net
Kaiser
Moda
Providence
Regence
UnitedHealthcare
Morrow, Page 56
Moda
Multnomah, Page 69
CareOregon
FamilyCare
Health Net
Humana
Kaiser
Moda
PacicSource
Providence
Regence
UnitedHealthcare
Polk, Page 70
ATRIO Health Plans
Health Net
Kaiser
Moda
Providence
Regence
UnitedHealthcare
Sherman, Page 62
Moda
PacicSource
Tillamook, Page 71
CareOregon
Moda
Umatilla, Page 56
Moda
Union, Page 56
Moda
Wallowa, Page 56
Moda
Wasco, Page 72
Moda
PacicSource
Washington, Page 69
CareOregon
FamilyCare
Health Net
Humana
Kaiser
Moda
PacicSource
Providence
Regence
UnitedHealthcare
Wheeler, Page 72
Moda
PacicSource
Providence
Yamhill, Page 73
CareOregon
Health Net
Kaiser
Moda
Providence
Regence
UnitedHealthcare
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Baker, Gilliam, Harney, Morrow, Umatilla, Union and Wallowa counties
Moda Health HMO (HMO-POS) H8506-001 HMO $63 NA $3,400 $110 $120 $28.20
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Benton and Linn counties
*Available only in the following ZIP codes: Benton - 97330, 97331, 97333, 97339, 97370;
Linn - 97321, 97322, 97335, 97355, 97358, 97360, 97374, 97389
AARP MedicareComplete Plan 1 (HMO) H3805-007 HMO $46 NA $2,900 $0 $180 $24.80
AARP MedicareComplete Plan 2 (HMO) H3805-013 HMO $0 NA $3,400 $0 $220 $0
Health Net Aqua (PPO) H5520-001 PPO NA $45 $2,500/$5,100 $125 NA NA
Health Net Jade (HMO SNP) H6815-004-2 SNP $0 NA $4,200 $0 $0 $0
Health Net Ruby (HMO) H6815-003-2 HMO $0 NA $4,200 $0 $125 $0
Health Net Violet Option 1 (PPO) H5520-002 PPO $116 NA $2,900/$4,000 $220 $95 $81.20
Health Net Violet Option 2 (PPO) H5520-012-2 PPO $24 NA $5,100/$6,600 $245 $120 $0
HumanaChoice H6609-012 (PPO) H6609-012 PPO NA $0 $3,600/$4,500 $0 NA NA
HumanaChoice H6609-073 (PPO) H6609-073 PPO $201 NA $6,700/$10,000 $0 $300 $168.90
Kaiser Permanente Senior Advantage (HMO)* H9003-001 HMO $127 NA $2,500 $0 $0 $92.20
Kaiser Permanente Senior Advantage Basic (HMO)* H9003-006 HMO $44 NA $4,900 $0 $0 $14.70
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Regence MedAdvantage Basic (PPO) H3817-007-2 PPO NA $40 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-2 PPO $101 NA $6,700/$10,000 $0 $240 $66.20
Medicare Advantage plans
57
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Benton and Linn counties, continued
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-2 PPO $238 NA $5,000/$8,300 $0 $0 $203.20
Samaritan Advantage Conventional Plan (HMO) H3811- 0 01 HMO NA $72 $3,750 $0 NA NA
Samaritan Advantage Premier Plan (HMO) H3811- 002 HMO $110 NA $3,750 $0 $0 $75.20
Samaritan Advantage Premier Plan Plus (HMO) H3811- 0 09 HMO $140 NA $3,750 $0 $0 $105.20
Clackamas County
AARP MedicareComplete Choice (PPO) H2228-029 PPO $32 NA $4,900/$10,000 $0 $200 $2.50
AARP MedicareComplete Plan 1 (HMO) H3805-001 HMO $67 NA $3,500 $0 $180 $40.50
AARP MedicareComplete Plan 2 (HMO) H3805-012 HMO $0 NA $5,900 $250 $250 $0
CareOregon Advantage Star (HMO-POS) H5859-003 HMO $34.80 NA $6,700 $150 $400 $0
FamilyCare Advantage Rx (HMO) H3818-003 HMO $0 NA $6,700 $0 $200 $0
Health Net Aqua (PPO) H5520-001 PPO NA $45 $2,500/$5,100 $125 NA NA
Health Net Jade (HMO SNP) H6815-004-1 SNP $0 $0.00 $3,950 $0 $0 $0
Health Net Ruby (HMO) H6815-003-1 HMO $0 $0.00 $3,950 $0 $125 $0
Health Net Violet Option 1 (PPO) H5520-002 PPO $116 NA $2,900/$4,000 $220 $95 $81.20
Health Net Violet Option 2 (PPO) H5520-012-1 PPO $19 NA $5,550/$6,600 $245 $120 $0
Humana Gold Choice H8145-093 (PFFS) H8145-093 PFFS $87 NA $5,000 $0 $320 $52.20
HumanaChoice H6609-012 (PPO) H6609-012 PPO NA $0 $3,600/$4,500 $0 NA NA
Humana Gold Plus H1036-153 (HMO) H1036-153 HMO $0 NA $5,700 $0 $260 $0
Kaiser Permanente Senior Advantage (HMO) H9003-001 HMO $127 NA $2,500 $0 $0 $92.20
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Clackamas County, continued
Kaiser Permanente Senior Advantage Basic (HMO) H9003-006 HMO $44 NA $4,900 $0 $0 $14.70
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare MyCare Rx 22 (HMO) H3864-022 HMO $78 NA $3,400 $0 $150 $48.80
Providence Medicare Choice (HMO-POS) H9047-035 HMO NA $45.00 $3,400/$6,700 $0 NA NA
Providence Medicare Choice + RX (HMO-POS) H9047-024 HMO $88 NA $3,400/$6,700 $0 $100 $53.20
Providence Medicare Extra (HMO) H9047-033 HMO NA $109.00 $3,000 $0 NA NA
Providence Medicare Extra + RX (HMO) H9047-001 HMO $162 NA $3,000 $0 $0 $127. 2 0
Providence Medicare Prime + RX (HMO-POS) H9047-037 HMO $0 NA $5,500 $0 $200 $0
Regence BlueAdvantage HMO (HMO) H6237- 003-2 HMO $0 NA $6,700 $0 $0 $0
Regence MedAdvantage Basic (PPO) H3817-007-1 PPO NA $28 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-1 PPO $43 NA $6,700/$10,000 $0 $240 $8.20
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-1 PPO $197 NA $5,000/$8,300 $0 $0 $162.20
Clatsop County
CareOregon Advantage Star (HMO-POS) H5859-003 HMO $34.80 NA $6,700 $150 $400 $0
FamilyCare Advantage Rx (HMO) H3818-003 HMO $0 NA $6,700 $0 $200 $0
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Columbia County
CareOregon Advantage Star (HMO-POS) H5859-003 HMO $34.80 NA $6,700 $150 $400 $0
HumanaChoice H6609-012 (PPO) H6609-012 PPO NA $0 $3,600/$4,500 $0 NA NA
HumanaChoice H6609-073 (PPO) H6609-073 PPO $201 NA $6,700/$10,000 $0 $300 $168.90
Kaiser Permanente Senior Advantage (HMO) H9003-001 HMO $127 NA $2,500 $0 $0 $92.20
Kaiser Permanente Senior Advantage Basic (HMO) H9003-006 HMO $44 NA $4,900 $0 $0 $14.70
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Providence Medicare Choice (HMO-POS) H9047-035 HMO NA $45.00 $3,400/$6,700 $0 NA NA
Providence Medicare Choice + RX (HMO-POS) H9047-024 HMO $88 NA $3,400/$6,700 $0 $100 $53.20
Providence Medicare Extra (HMO) H9047-033 HMO NA $109.00 $3,000 $0 NA NA
Providence Medicare Extra + RX (HMO) H9047-001 HMO $162 NA $3,000 $0 $0 $127. 2 0
Regence MedAdvantage Basic (PPO) H3817-007-2 PPO NA $40 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO)
H3817-008-2 PPO $101 NA $6,700/$10,000 $0 $240 $66.20
Regence MedAdvantage + Rx Enhanced (PPO)
H3817-009-2 PPO $238 NA $5,000/$8,300 $0 $0 $203.20
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Coos and Curry counties
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare Essentials Rx 26 (HMO) H3864-026-1 HMO $86 NA $5,000 $0 $150 $55.00
PacicSource Medicare Explorer 8 (PPO) H4754-008 PPO NA $42.00 $4,500/$6,000
1
$0 NA NA
PacicSource Medicare Explorer Rx 7 (PPO) H4754-007 PPO $120 NA $4,500/$5500 $0 $150 $90.40
Regence MedAdvantage Basic (PPO) H3817-007-2 PPO NA $40 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-2 PPO $101 NA $6,700/$10,000 $0 $240 $66.20
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-2 PPO $238 NA $5,000/$8,300 $0 $0 $203.20
Crook County
HumanaChoice H6609-012 (PPO) H6609-012 PPO NA $0 $3,600/$4,500 $0 NA NA
HumanaChoice H6609-013 (PPO) H6609-013 PPO $102 NA $6,700/$10,000 $0 $320 $70.50
HumanaChoice H6609-073 (PPO) H6609-073 PPO $201 NA $6,700/$10,000 $0 $300 $168.90
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare Essentials 2 (HMO) H3864-002 HMO NA $42.00 $5,500 $0 NA NA
PacicSource Medicare Essentials Choice Rx 14
(HMO-POS)
H3864-014 HMO $127 NA $5,500 $0 $150 $93.00
PacicSource Medicare Essentials Rx 6 (HMO) H3864-006 HMO $205 NA $5,000 $0 $150 $170.20
PacicSource Medicare Essentials Rx 27 (HMO) H3864-027 HMO $122 NA $6,700 TBA $400 $87. 20
Providence Medicare Compass + RX (HMO-POS) H9047-039 HMO $99 NA $5,000/$6,700 $0 $100 $64.20
Providence Medicare Latitude + RX (HMO-POS)
H9047-038 HMO $169 NA $3,400/$5,500 $0 $0 $134.20
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Deschutes and Jefferson counties
HumanaChoice H6609-012 (PPO) H6609-012 PPO NA $0 $3,600/$4,500 $0 NA NA
HumanaChoice H6609-013 (PPO) H6609-013 PPO $102 NA $6,700/$10,000 $0 $320 $70.50
HumanaChoice H6609-073 (PPO) H6609-073 PPO $201 NA $6,700/$10,000 $0 $300 $168.90
Humana Gold Plus H1036-219 (HMO) H1036-219 HMO $71 NA $5,700 $0 $320 $54.90
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare Essentials 2 (HMO) H3864-002 HMO NA $42.00 $5,500 $0 NA NA
PacicSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864-014 HMO $127 NA $5,500 $0 $150 $93.00
PacicSource Medicare Essentials Rx 6 (HMO) H3864-006 HMO $205 NA $5,000 $0 $150 $170.20
PacicSource Medicare Essentials Rx 27 (HMO) H3864-027 HMO $122 NA $6,700 TBA $400 $87. 20
Providence Medicare Compass + RX (HMO-POS) H9047-039 HMO $99 NA $5,000/$6,700 $0 $100 $64.20
Providence Medicare Latitude + RX (HMO-POS) H9047-038 HMO $169 NA $3,400/$5,500 $0 $0 $134.20
Douglas County
*Available only in Glendale and Azalea
AllCare Advantage Gold (HMO)* H3810-001 HMO NA $81.00 $3,000 $0 NA NA
AllCare Advantage Gold Plus Rx (HMO)* H3810-003 HMO $141.50 NA $3,000 $0 $295 $106.70
ATRIO Bronze (PPO) H6743-006 PPO NA $0.00 $3,400/$5,100 $110 NA NA
ATRIO Bronze Rx (Umpqua) (PPO) H6743-007 PPO $0 NA $3,400/$5,100 $230 $0 $0
ATRIO Gold Rx (PPO) H6743-004 PPO $180 NA $2,500/$3,500 $0 $0 $147.40
ATRIO Silver (PPO) H6743-002 PPO NA $59.00 $3,200/$4,700 $50 NA NA
62
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CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Douglas County, continued
ATRIO Silver Rx (PPO) H6743-003 PPO $113 NA $3,200/$4,700 $50 $0 $80.40
Health Net Aqua (PPO) H5520-003 PPO NA $49.00 $2,500/$5,100 $150 NA NA
Health Net Violet Option 1 (PPO) H5520-004 PPO $105 NA $2,900/$4,700 $180 $95 $71.10
Health Net Violet Option 2 (PPO) H5520-015-2 PPO $25 NA $3,400/$4,500 $300 $130 $0
Health Net Violet Option 3 (PPO) H5520-014 PPO $0 NA $6,700/$8,700 $220 $200 $0
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Regence MedAdvantage Basic (PPO) H3817-007-2 PPO NA $40 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-2 PPO $101 NA $6,700/$10,000 $0 $240 $66.20
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-2 PPO $238 NA $5,000/$8,300 $0 $0 $203.20
Grant, Lake, and Sherman counties
*Available only in the following ZIP codes in Lake County: 97638, 97641, 97735, and 97739
Moda Health HMO (HMO-POS) H8506-001 HMO $63 NA $3,400 $110 $120 $28.20
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare Essentials 2 (HMO)* H3864-002 HMO NA $42.00 $5,500 $0 NA NA
PacicSource Medicare Essentials Choice Rx 14 (HMO-POS)*
H3864-014 HMO $127 NA $5,500 $0 $150 $93.00
PacicSource Medicare Essentials Rx 6 (HMO)* H3864-006 HMO $205 NA $5,000 $0 $150 $170.20
PacicSource Medicare Essentials Rx 27 (HMO)* H3864-027 HMO $122 NA $6,700 TBA $400 $87. 20
63
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Hood River County
HumanaChoice H6609-012 (PPO) H6609-012 PPO NA $0 $3,600/$4,500 $0 NA NA
HumanaChoice H6609-073 (PPO) H6609-073 PPO $201 NA $6,700/$10,000 $0 $300 $168.90
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare Essentials 2 (HMO) H3864-002 HMO NA $42.00 $5,500 $0 NA NA
PacicSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864-014 HMO $127 NA $5,500 $0 $150 $93.00
PacicSource Medicare Essentials Rx 6 (HMO) H3864-006 HMO $205 NA $5,000 $0 $150 $170.20
PacicSource Medicare Essentials Rx 27 (HMO) H3864-027 HMO $122 NA $6,700 TBA $400 $87. 20
Providence Medicare Compass + RX (HMO-POS) H9047-039 HMO $99 NA $5,500/$6,700 $0 $100 $64.20
Providence Medicare Latitude + RX (HMO-POS) H9047-038 HMO $169 NA $3,400/$5,500 $0 $0 $134.20
Jackson County
AllCare Advantage Gold (HMO) H3810-001 HMO NA $81.00 $3,000 $0 NA NA
AllCare Advantage Gold Plus Rx (HMO) H3810-003 HMO $141.50 NA $3,000 $0 $295 $106.70
ATRIO Bronze (Rogue) (PPO) H6743 - 013 PPO NA $0.00 $3,400/$5,100 $185 NA NA
ATRIO Bronze Rx (Rogue) (PPO) H6743-014 PPO $0 NA $3,400/$5,100 $185 $150 $0
ATRIO Gold Rx (Rogue) (PPO) H6743-017 PPO $165 NA $2,500/$3,500 $0 $0 $136.00
ATRIO Silver (Rogue) (PPO) H6743-015 PPO $0 $54.00 $3,200/$4,700 $50 NA NA
ATRIO Silver Rx (Rogue) (PPO) H6743 -016 PPO $103 NA $3,200/$4,700 $50 $0 $89.50
Health Net Aqua (PPO) H5520-003 PPO NA $49.00 $2,500/$5,100 $150 NA NA
64
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Jackson County, continued
Health Net Violet Option 1 (PPO) H5520-004 PPO $105 NA $2,900/$4,700 $180 $95 $71.10
Health Net Violet Option 2 (PPO) H5520-015-1 PPO $25 NA $5,200/$6,700 $185 $130 $0
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Regence MedAdvantage Basic (PPO) H3817-007-2 PPO NA $40 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-2 PPO $101 NA $6,700/$10,000 $0 $240 $66.20
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-2 PPO $238 NA $5,000/$8,300 $0 $0 $203.20
Josephine County
AllCare Advantage Gold (HMO) H3810-001 HMO NA $81.00 $3,000 $0 NA NA
AllCare Advantage Gold Plus Rx (HMO) H3810-003 HMO $141.50 NA $3,000 $0 $295 $106.70
ATRIO Bronze (Rogue) (PPO) H6743 - 013 PPO NA $0.00 $3,400/$5,100 $185 NA NA
ATRIO Bronze Rx (Rogue) (PPO) H6743-014 PPO $0 NA $3,400/$5,100 $185 $150 $0
ATRIO Gold Rx (Rogue) (PPO) H6743-017 PPO $165 NA $2,500/$3,500 $0 $0 $136.00
ATRIO Silver (Rogue) (PPO) H6743-015 PPO $0 $54.00 $3,200/$4,700 $50 NA NA
ATRIO Silver Rx (Rogue) (PPO) H6743 -016 PPO $103 NA $3,200/$4,700 $50 $0 $89.50
Health Net Aqua (PPO) H5520-003 PPO NA $49.00 $2,500/$5,100 $150 NA NA
Health Net Violet Option 1 (PPO) H5520-004 PPO $105 NA $2,900/$4,700 $180 $95 $71.10
Health Net Violet Option 2 (PPO) H5520-015-2 PPO $25 NA $3,400/$4,500 $300 $130 $0
Health Net Violet Option 3 (PPO) H5520-014 PPO $0 NA $6,700/$8,700 $220 $200 $0
65
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Josephine County, continued
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Regence MedAdvantage Basic (PPO) H3817-007-2 PPO NA $40 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-2 PPO $101 NA $6,700/$10,000 $0 $240 $66.20
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-2 PPO $238 NA $5,000/$8,300 $0 $0 $203.20
Klamath County *Available only in the following ZIP codes in Klamath County: 97731, 97733, 97737, and 97739
ATRIO Bronze (PPO) H6743-006 PPO NA $0.00 $3,400/$5,100 $110 NA NA
ATRIO Bronze Rx (Basin) (PPO) H6743 - 001 PPO $21 NA $3,400/$5,100 $185 $0 $0
ATRIO Gold Rx (PPO) H6743-004 PPO $180 NA $2,500/$3,500 $0 $0 $147.40
ATRIO Silver (PPO) H6743-002 PPO NA $59.00 $3,200/$4,700 $50 NA NA
ATRIO Silver Rx (PPO) H6743-003 PPO $113 NA $3,200/$4,700 $50 $0 $80.40
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare Essentials 2 (HMO)* H3864-002 HMO NA $42.00 $5,500 $0 NA NA
PacicSource Medicare Essentials Choice Rx 14 (HMO-POS)*
H3864-014 HMO $127 NA $5,500 $0 $150 $93.00
PacicSource Medicare Essentials Rx 6 (HMO)* H3864-006 HMO $205 NA $5,000 $0 $150 $170.20
PacicSource Medicare Essentials Rx 27 (HMO)* H3864-027 HMO $122 NA $6,700 TBA $400 $87. 20
66
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Lane County
AARP MedicareComplete Choice (PPO) H2228-029 PPO $32 NA $4,900/$10,000 $0 $200 $2.50
AARP MedicareComplete Plan 1 (HMO) H3805-007 HMO $46 NA $2,900 $0 $180 $24.80
AARP MedicareComplete Plan 2 (HMO) H3805-013 HMO $0 NA $3,400 $0 $220 $0
Health Net Aqua (PPO) H5520-001 PPO NA $45 $2,500/$5,100 $125 NA NA
Health Net Ruby (HMO) H6815-003-1 HMO $0 $0.00 $3,950 $0 $125 $0
Health Net Jade (HMO SNP) H6815-004-1 SNP $0 $0.00 $3,950 $0 $0 $0
Health Net Violet Option 1 (PPO) H5520-002 PPO $116 NA $2,900/$4,000 $220 $95 $81.20
Health Net Violet Option 2 (PPO) H5520-012-1 PPO $19 NA $5,550/$6,600 $245 $120 $0
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare Essentials Rx 26 (HMO) H3864-26-2 HMO $69 NA $5,000 $0 $150 $38.00
PacicSource Medicare Explorer 8 (PPO) H4754-008 PPO NA $42.00 $4,500/$6,000
1
$0 NA NA
PacicSource Medicare Explorer Rx 4 (PPO) H4754-004 PPO $162 NA $4,500/$5,500
1
$0 $150 $127. 20
Providence Medicare Choice (HMO-POS) H9047-035 HMO NA $45.00 $3,400/$6,700 $0 NA NA
Providence Medicare Choice + RX (HMO-POS) H9047-024 HMO $88 NA $3,400/$6,700 $0 $100 $53.20
Providence Medicare Extra (HMO) H9047-033 HMO NA $109.00 $3,000 $0 NA NA
Providence Medicare Extra + RX (HMO) H9047-001 HMO $162 NA $3,000 $0 $0 $127. 2 0
Regence MedAdvantage Basic (PPO) H3817-007-1 PPO NA $28 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-1 PPO $43 NA $6,700/$10,000 $0 $240 $8.20
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-1 PPO $197 NA $5,000/$8,300 $0 $0 $162.20
Trillium Advantage Pioneer Rx (PPO) H6951-002 PPO $90 NA $3,400/$5,100 $0 $125 $55.20
67
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Lincoln County
HumanaChoice H6609-012 (PPO) H6609-012 PPO NA $0 $3,600/$4,500 $0 NA NA
HumanaChoice H6609-073 (PPO) H6609-073 PPO $201 NA $6,700/$10,000 $0 $300 $168.90
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Samaritan Advantage Conventional Plan (HMO) H3811- 0 01 HMO NA $72 $3,750 $0 NA NA
Samaritan Advantage Premier Plan (HMO) H3811- 002 HMO $110 NA $3,750 $0 $0 $75.20
Samaritan Advantage Premier Plan Plus (HMO) H3811- 009 HMO $140 NA $3,750 $0 $0 $105.20
Malheur County
HumanaChoice H6609-009 (PPO) H6609-009 PPO $56 NA $6,000/$9,000 $0 $320 $40.90
HumanaChoice H6609-012 (PPO) H6609-012 PPO NA $0 $3,600/$4,500 $0 NA NA
HumanaChoice H6609-073 (PPO) H6609-073 PPO $201 NA $6,700/$10,000 $0 $300 $168.90
Moda Health HMO (HMO-POS) H8506-001 HMO $63 NA $3,400 $110 $120 $28.20
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Marion County
AARP MedicareComplete Choice (PPO) H2228-029 PPO $32 NA $4,900/$10,000 $0 $200 $2.50
AARP MedicareComplete Plan 1 (HMO) H3805-001 HMO $67 NA $3,500 $0 $180 $40.50
AARP MedicareComplete Plan 2 (HMO) H3805-012 HMO $0 NA $5,900 $0 $250 $0
ATRIO Gold Rx (Willamette) (PPO) H7006-001 PPO $185 NA $2,500/$5,100 $0 $0 $150.20
ATRIO Silver Rx (Willamette) (PPO) H7006-003 PPO $67 NA $3,400/$5,100 $50 $0 $54.10
Health Net Aqua (PPO) H5520-001 PPO NA $45 $2,500/$5,100 $125 NA NA
68
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Marion County, continued
Health Net Ruby (HMO) H6815-003-2 HMO $0 NA $4,200 $0 $125 $0
Health Net Violet Option 1 (PPO) H5520-002 PPO $116 NA $2,900/$4,000 $220 $95 $81.20
Health Net Violet Option 2 (PPO) H5520-012-3 PPO $32 NA $6,700/$8,700 $245 $120 $0
Kaiser Permanente Senior Advantage (HMO) H9003-001 HMO $127 NA $2,500 $0 $0 $92.20
Kaiser Permanente Senior Advantage Basic (HMO) H9003-006 HMO $44 NA $4,900 $0 $0 $14.70
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Providence Medicare Choice (HMO-POS) H9047-035 HMO NA $45.00 $3,400/$6,700 $0 NA NA
Providence Medicare Choice + RX (HMO-POS) H9047-024 HMO $88 NA $3,400/$6,700 $0 $100 $53.20
Providence Medicare Extra (HMO) H9047-033 HMO NA $109.00 $3,000 $0 NA NA
Providence Medicare Extra + RX (HMO) H9047-001 HMO $162 NA $3,000 $0 $0 $127. 2 0
Regence BlueAdvantage HMO (HMO) H6237- 003-2 HMO $0 NA $6,700 $0 $0 $0
Regence MedAdvantage Basic (PPO) H3817-007-2 PPO NA $40 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-2 PPO $101 NA $6,700/$10,000 $0 $240 $66.20
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-2 PPO $238 NA $5,000/$8,300 $0 $0 $203.20
69
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Multnomah and Washington counties
AARP MedicareComplete Choice (PPO) H2228-029 PPO $32 NA $4,900/$10,000 $0 $200 $2.50
AARP MedicareComplete Plan 1 (HMO) H3805-001 HMO $67 NA $3,500 $0 $180 $40.50
AARP MedicareComplete Plan 2 (HMO) H3805-012 HMO $0 NA $5,900 $0 $250 $0
CareOregon Advantage Star (HMO-POS) H5859-003 HMO $34.80 NA $6,700 $150 $400 $0
FamilyCare Advantage Rx (HMO) H3818-003 HMO $0 NA $6,700 $0 $200 $0
Health Net Aqua (PPO) H5520-001 PPO NA $45 $2,500/$5,100 $125 NA NA
Health Net Ruby (HMO) H6815-003-1 HMO $0 $0.00 $3,950 $0 $125 $0
Health Net Jade (HMO SNP) H6815-004-1 SNP $0 $0.00 $3,950 $0 $0 $0
Health Net Violet Option 1 (PPO) H5520-002 PPO $116 NA $2,900/$4,000 $220 $95 $81.20
Health Net Violet Option 2 (PPO) H5520-012-1 PPO $19 NA $5,550/$6,600 $245 $120 $0
Humana Gold Choice H8145-093 (PFFS) H8145-093 PFFS $87 NA $5,000 $0 $320 $52.20
HumanaChoice H6609-012 (PPO) H6609-012 PPO NA $0 $3,600/$4,500 $0 NA NA
Humana Gold Plus H1036-153 (HMO) H1036-153 HMO $0 NA $5,700 $0 $260 $0
Kaiser Permanente Senior Advantage (HMO) H9003-001 HMO $127 NA $2,500 $0 $0 $92.20
Kaiser Permanente Senior Advantage Basic (HMO) H9003-006 HMO $44 NA $4,900 $0 $0 $14.70
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare MyCare Rx 22 (HMO) H3864-022 HMO $78 NA $3,400 $0 $150 $48.80
Providence Medicare Choice (HMO-POS) H9047-035 HMO NA $45.00 $3,400/$6,700 $0 NA NA
70
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Multnomah and Washington counties, continued
Providence Medicare Choice + RX (HMO-POS) H9047-024 HMO $88 NA $3,400/$6,700 $0 $100 $53.20
Providence Medicare Extra (HMO) H9047-033 HMO NA $109.00 $3,000 $0 NA NA
Providence Medicare Extra + RX (HMO) H9047-001 HMO $162 NA $3,000 $0 $0 $127. 2 0
Providence Medicare Prime + RX (HMO-POS) H9047-037 HMO $0 NA $5,500 $0 $200 $0
Regence BlueAdvantage HMO (HMO) H6237-003-1 HMO $0 NA $3,400 $0 $0 $0
Regence MedAdvantage Basic (PPO) H3817-007-1 PPO NA $28 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-1 PPO $43 NA $6,700/$10,000 $0 $240 $8.20
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-1 PPO $197 NA $5,000/$8,300 $0 $0 $162.20
Polk County
AARP MedicareComplete Plan 1 (HMO) H3805-001 HMO $67 NA $3,500 $0 $180 $40.50
AARP MedicareComplete Plan 2 (HMO) H3805-012 HMO $0 NA $5,900 $0 $250 $0
ATRIO Gold Rx (Willamette) (PPO) H7006-001 PPO $185 NA $2,500/$5,100 $0 $0 $150.20
ATRIO Silver Rx (Willamette) (PPO) H7006-003 PPO $67 NA $3,400/$5,100 $50 $0 $54.10
Health Net Aqua (PPO) H5520-001 PPO NA $45 $2,500/$5,100 $125 NA NA
Health Net Ruby (HMO) H6815-003-2 HMO $0 NA $4,200 $0 $125 $0
Health Net Violet Option 1 (PPO) H5520-002 PPO $116 NA $2,900/$4,000 $220 $95 $81.20
Health Net Violet Option 2 (PPO) H5520-012-3 PPO $32 NA $6,700/$8,700 $245 $120 $0
Kaiser Permanente Senior Advantage (HMO) H9003-001 HMO $127 NA $2,500 $0 $0 $92.20
71
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Polk County, continued
Kaiser Permanente Senior Advantage Basic (HMO) H9003-006 HMO $44 NA $4,900 $0 $0 $14.70
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Providence Medicare Choice (HMO-POS) H9047-035 HMO NA $45.00 $3,400/$6,700 $0 NA NA
Providence Medicare Choice + RX (HMO-POS) H9047-024 HMO $88 NA $3,400/$6,700 $0 $100 $53.20
Providence Medicare Extra (HMO) H9047-033 HMO NA $109.00 $3,000 $0 NA NA
Providence Medicare Extra + RX (HMO) H9047-001 HMO $162 NA $3,000 $0 $0 $127. 2 0
Regence BlueAdvantage HMO (HMO) H6237- 003-2 HMO $0 NA $6,700 $0 $0 $0
Regence MedAdvantage Basic (PPO) H3817-007-2 PPO NA $40 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-2 PPO $101 NA $6,700/$10,000 $0 $240 $66.20
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-2 PPO $238 NA $5,000/$8,300 $0 $0 $203.20
Tillamook County
CareOregon Advantage Star (HMO-POS) H5859-003 HMO $34.80 NA $6,700 $150 $400 $0
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
72
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Wasco County
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare Essentials 2 (HMO) H3864-002 HMO NA $42.00 $5,500 $0 NA NA
PacicSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864-014 HMO $127 NA $5,500 $0 $150 $93.00
PacicSource Medicare Essentials Rx 6 (HMO) H3864-006 HMO $205 NA $5,000 $0 $150 $170.20
PacicSource Medicare Essentials Rx 27 (HMO) H3864-027 HMO $122 NA $6,700 TBA $400 $87. 20
Wheeler County
Moda Health HMO (HMO-POS) H8506-001 HMO $63 NA $3,400 $110 $120 $28.20
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
PacicSource Medicare Essentials 2 (HMO) H3864-002 HMO NA $42.00 $5,500 $0 NA NA
PacicSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864-014 HMO $127 NA $5,500 $0 $150 $93.00
PacicSource Medicare Essentials Rx 6 (HMO) H3864-006 HMO $205 NA $5,000 $0 $150 $170.20
PacicSource Medicare Essentials Rx 27 (HMO) H3864-027 HMO $122 NA $6,700 TBA $400 $87. 20
Providence Medicare Compass + RX (HMO-POS) H9047-039 HMO $99 NA $5,000/$6,700 $0 $100 $64.20
Providence Medicare Latitude + RX (HMO-POS) H9047-038 HMO $169 NA $3,400/$5,500 $0 $0 $134.20
73
Medicare Advantage plans, continued
1
Combined in- and out-of-network MOOP
CONTENTS
Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
Plan Name
Plan & Contract
number
Plan
Type
Premium
with Rx
Premium
without
Rx
In-net./In-and out-
of-net. MOOP
(maximum out-of-
pocket)
Plan
deduc-
tible
Part D
(drug plan)
deductible
Premium
with 100%
Extra Help
Yamhill County
AARP MedicareComplete Choice (PPO) H2228-029 PPO $32 NA $4,900/$10,000 $0 $200 $2.50
AARP MedicareComplete Plan 1 (HMO) H3805-001 HMO $67 NA $3,500 $0 $180 $40.50
AARP MedicareComplete Plan 2 (HMO) H3805-012 HMO $0 NA $5,900 $0 $250 $0
CareOregon Advantage Star (HMO-POS) H5859-003 HMO $34.80 NA $6,700 $150 $400 $0
Health Net Aqua (PPO) H5520-001 PPO NA $45 $2,500/$5,100 $125 NA NA
Health Net Ruby (HMO) H6815-003-2 HMO $0 NA $4,200 $0 $125 $0
Health Net Jade (HMO SNP) H6815-004-2 SNP $0 NA $4,200 $0 $0 $0
Health Net Violet Option 1 (PPO) H5520-002 PPO $116 NA $2,900/$4,000 $220 $95 $81.20
Health Net Violet Option 2 (PPO) H5520-012-2 PPO $24 NA $5,100/$6,600 $245 $120 $0
Kaiser Permanente Senior Advantage (HMO) H9003-001 HMO $127 NA $2,500 $0 $0 $92.20
Kaiser Permanente Senior Advantage Basic (HMO) H9003-006 HMO $44 NA $4,900 $0 $0 $14.70
Moda Health PPO (PPO) H3813-001 PPO NA $16 $3,400 $0 NA NA
Moda Health PPORX (PPO) H3813-006 PPO $98 NA $3,400 $125 $120 $63.20
Providence Medicare Choice (HMO-POS) H9047-035 HMO NA $45.00 $3,400/$6,700 $0 NA NA
Providence Medicare Choice + RX (HMO-POS) H9047-024 HMO $88 NA $3,400/$6,700 $0 $100 $53.20
Providence Medicare Extra (HMO) H9047-033 HMO NA $109.00 $3,000 $0 NA NA
Providence Medicare Extra + RX (HMO) H9047-001 HMO $162 NA $3,000 $0 $0 $127. 2 0
Regence MedAdvantage Basic (PPO) H3817-007-2 PPO NA
$40 $6,700/$10,000 $0 NA NA
Regence MedAdvantage + Rx Classic (PPO) H3817-008-2 PPO $101
NA $6,700/$10,000 $0 $240 $66.20
Regence MedAdvantage + Rx Enhanced (PPO) H3817-009-2 PPO $238
NA $5,000/$8,300 $0 $0 $203.20
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Original Medicare
1. Redetermination
▪ Performed by Medicare carrier, s-
cal intermediary, or Medicare Admin-
istrative Contractor, depending on
the issue.
– Appeal information is found on
the Medicare Summary Notice.
▪ 120 days to le with a 60-day time
limit for processing.
▪ Expedited process:
– Performed by Quality Improve-
ment Organization.
– File by noon the next calendar
day with a 72-hour time limit.
2. Reconsideration
▪ Performed by Qualied Independent
Contractor.
▪ 180 days to le with a 60-day time
limit for processing.
▪ Expedited process:
– Performed by Qualied Indepen-
dent Contractor.
– File by noon the next calendar
day with a 72-hour time limit.
3. Administrative law judge
▪ Performed by Ofce of Medicare
Hearings and Appeals.
– Minimum amount in question
must be more than $150 in 2016.
▪ 60-days to le with a 90-day time
limit.
4. Medicare Appeals Council
▪ 60 days to le with a 90-day time
limit for processing.
5. Judicial review
▪ Performed in a federal district court.
– Amount in question must be more
than $1,500 in 2016 (may com-
bine claims to meet this dollar
amount).
▪ 60 days to le.
Appeal
Level
Medicare Part A & B Medicare Advantage Part D
1 Medicare Contractor Medicare Advantage plan Medicare prescription drug plan
2 Qualied Independent
Contractor
Independent Review Entity
3 Ofce of Medicare Hearings and Appeals
4 Medicare Appeals Council
5 Judicial review
Appeals
Original Medicare, Medicare Advantage, and Part D plans have ve levels of appeals. The
differences usually are in the time frames involved. There may be an expedited process
available. For details, see
medicare.gov/claims-and-appeals/le-an-appeal/appeals.html
.
Appeals can be initiated by the beneciary, provider, or representative. Include copies of
any information relative to your case. Always appeal denials.
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Medicare Advantage
1. Reconsideration
▪ Performed by the Medicare Advan-
tage plan.
▪ 60 days to le, pre-service 30-day
time limit, payment 60-day time limit.
▪ Expedited process:
– 60 days to le, 72-hour time limit.
– Payment requests cannot be ex-
pedited.
2. Independent Review Entity
reconsideration
▪ Performed by an Independent
Review Entity.
▪ Automatic if plan upholds denial,
pre-service 30-day time limit, pay-
ment 60-day time limit
▪ Expedited process:
– 60 days to le, 72-hour time limit.
– Payment requests cannot be
expedited.
3. Administrative law judge
▪ Performed by Ofce of Medicare
Hearings and Appeals.
– Minimum amount in question
must be more than $150 in 2016.
▪ 60 days to le, no statutory time limit
for processing.
4. Medicare Appeals Council
▪ 60 days to le, no statutory time limit
for processing.
5. Judicial review
▪ Performed in a federal district court.
– Amount in question must be more
than $1,500 in 2016 (may com-
bine claims to meet this dollar
amount).
▪ 60 days to le.
Part D
1. Redetermination
▪ Performed by the prescription drug
plan.
▪ 60 days to le, seven-day time limit
▪ Expedited process:
– 60 days to le, 72-hour time limit.
2. Independent Review Entity
reconsideration
▪ Performed by an Independent
Review Entity.
▪ 60 days to le, seven-day time limit.
▪ Expedited process:
– 60 days to le, 72-hour time limit.
3. Administrative law judge
▪ Performed by Ofce of Medicare
Hearings and Appeals.
– Minimum amount in question
must be more than $150 in 2016.
▪ 60 days to le, 90-day time limit.
▪ Expedited process:
– 60 days to le, 10-day time limit
4. Medicare Appeals Council
▪ 60 days to le, 90-day time limit.
▪ Expedited process:
– 60 days to le, 10-day time limit
5. Judicial review
▪ Performed in a federal district court.
– Amount in question must be more
than $1,500 in 2016 (may com-
bine claims to meet this dollar
amount).
▪ 60 days to le.
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
Resources and publications
You can request a free copy of these and
other publications or view them on one of the
websites listed. CMS publication numbers are
in parentheses.
SHIBA’s ve favorite CMS publications
1. Who Pays First (02179)
2. Medicare Basics: A Guide for
Families and Friends of People With
Medicare (11034)
3. Choosing a Medigap Policy: A Guide for
People with Medicare (02110)
4. Medicare Coverage of Kidney
Dialysis and Transplant Services (10128)
5. Medicare Coverage of Diabetes and
Supplies (11022)
To order Medicare publications:
● Call 800-MEDICARE
(800-633-4227)
● Website:
medicare.gov/publications
Website resources
● Aging and Disability Resource Connection
of Oregon (ADRC):
adrcoforegon.org
● Medicare Rights Center:
medicarerights.org
● Benets Checkup:
benetscheckup.org
● Health Insurance Marketplace
healthcare.gov
● dfr.oregon.gov
About SHIBA
The Senior Health Insurance Benets
Assistance (SHIBA) program is part of
the Oregon Department of Consumer and
Business Services (DCBS). SHIBA is part of
the Administration for Community Living (ACL)
State Health Insurance Assistance Program
(SHIP) network; a statewide network of cer
-
tied counselors who provide one-on-one
assistance to people with Medicare. SHIBA’s
goal is to help people make better decisions
about health insurance by providing conden
-
tial and objective counseling.
Contact the SHIBA program:
● To order free brochures
• Free Help with Medicare Information and
Prescription Drug Plans
● To get free help ling claims, comparing
Medicare Advantage plans, Medigap poli
-
cies, and Prescription Drug Plans, or under-
standing long-term care insurance
● To become a SHIBA volunteer
Contact information:
● Toll-free: 800-722-4134
● Email: shiba.oregon@oregon.gov
● Website: oregonshiba.org
For help with Part D Extra Help
applications, contact Oregon Medicare
Savings Connect at 855-447-0155 (toll-free)
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Glossary
ABN (Advance Beneciary Notice) – A notice
given to Medicare beneciaries indicating the cost
of an item or service that Medicare may not cover.
AEP (annual enrollment period) – A period of time
from Oct. 15 to Dec. 7 in which Medicare benecia
-
ries may join or disenroll from Part D prescription
drug coverage or a Medicare Advantage plan.
Changes usually become effective Jan. 1. Also
known as Fall Open Enrollment.
Alternative care – A variety of therapeutic or pre
-
ventive health care practices, such as homeopathy,
naturopathy, chiropractic, and herbal medicine, that
may not follow generally accepted medical methods
and may not have a scientic explanation for their
effectiveness.
Annual physical exam – Not a Medicare-covered
expense. A yearly examination by your physician
to check your overall health status. The exam may
include tests to monitor vitals such as weight, blood
pressure, and cholesterol.
Areas – Also called “area factors.” This is how a
Medigap insurance company determines the pre
-
mium rates throughout the state. Some divide the
state into multiple areas (by ZIP code) and each
area has a specic premium rate.
Assignment – A method of payment under
Medicare Part B. The doctor agrees to accept the
amount of the Medicare-approved charge as full
payment.
Attained age – Insurance policies in which premi
-
ums increase based on the age of the insured.
Beneciary – A person who is receiving payments
for medical services through an insurance company.
Benet period – The period for which benets are
payable. In Original Medicare Part A, for example,
the benet period begins on the rst day of hospital
-
ization and ends when the beneciary has been out
of the hospital or associated skilled nursing facility
for 60 consecutive days.
Benets – Covered items under an insurance plan,
also referred to as coverage.
Catastrophic coverage – The highest amount of
money paid out of pocket before a health plan pays
the majority of or all co-payment amounts.
Chronic – Long-lasting and recurrent condition
or characterized by long suffering. A chronically ill
person is not expected to recover or get much better.
Claim – A request for payment of medical services
under the terms of an insurance policy, usually
made by either a provider or an insured person.
CMS (Centers for Medicare and Medicaid
Services) – The division of the Department of
Health and Human Services that administers the
Medicare and Medicaid programs.
COBRA (Consolidated Omnibus Budget
Reconciliation Act) – A law that mandates an
insurance program provide employees the ability to
continue health insurance coverage after employ
-
ment ends.
Co-insurance – A xed percentage paid per
service received or prescription lled.
Community rating – A Medigap policy rating
method that assigns a single rate to all ages and
classes of individuals in the group, regardless of
risk factors such as age or health.
Co-payment or co-pay – A xed dollar amount
paid per service received or prescription lled.
Coverage gap – The stage in Medicare prescrip
-
tion drug coverage when a higher portion of drug
costs are paid by the beneciary. Also known as the
donut hole.
Creditable coverage – Prescription drug insurance
that is determined to be as good as or better than
coverage through a Medicare plan.
Deductible – A dollar amount determined by an
individual’s insurance policy (including Medicare)
that must be paid by the insured individual for
covered services before Medicare or the insurance
policy begins paying.
DHS (Oregon Department of Human Services)
– The state agency that houses Aging and People
with Disabilities and other assistance programs.
Diagnostic tests – Tests ordered by a physician to
provide information that assists in making a diagno
-
sis when symptoms are present.
Direct bill – Method of paying your insurance plan
premium directly to the plan. The insurer sends
either a bill or coupon book to collect payment.
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Disenrollment – Cancellation of an individual’s
enrollment in a health plan.
Donut hole – See coverage gap.
DME (durable medical equipment) – Equipment
that is medically necessary and prescribed by a
doctor for use in the home, such as oxygen equip
-
ment, wheelchairs, and other medically necessary
equipment.
DMEPOS (durable medical equipment prosthet
-
ics orthotics and supplies) – See DME.
Effective date – The date upon which an insurance
policy is in effect and coverage begins.
EFT (electronic funds transfer) – The transfer of
funds from one account to another by computer.
Also known as AFT (automatic funds transfer).
EGHP (Employer Group Health Plan) – Health
insurance or benet plan offered through an
employer.
Election period – The period during which an
eligible person may join or leave Original Medicare,
a Medicare Advantage plan, or a prescription drug
plan.
Equitable relief – Federal employees must give
adequate and accurate information. If the inad
-
equate or inaccurate information received caused
harm (benets delayed or penalty incurred), and the
client has documented the contact, then the agency
must make the client whole under the equitable
relief provision.
Enrollee – A person eligible and receiving benets
from an insurance plan or managed care orga
-
nization. Also called member when referring to
Medicare Advantage plans.
EOC (evidence of coverage) – The insurance plan
document that gives details about what the plan
covers, how much you pay, and more. Also known
as a Certicate of Benets.
ESRD (end-stage renal disease) – A medical
condition in which a person’s kidneys no longer
function, requiring dialysis or a kidney transplant to
maintain life.
Excess charge – The difference between the
Medicare-approved amount and the limiting charge,
which cannot exceed 15 percent more than the
Medicare-approved amount. Also known as a limit
-
ing charge.
Extra Help – A Medicare program to help people
with limited income and resources pay Medicare
prescription drug program costs, such as premiums,
deductibles, and co-insurance.
Also known as LIS.
Fall open enrollment period – Another name for
annual enrollment period (Oct. 15 to Dec. 7).
See AEP.
Fee for service – Original Medicare is a fee-
for-service system of payment for health care
providers. An amount is billed for each medical
service provided (ofce visits, tests, or procedures)
as the provider deems is medically necessary for
the beneciary.
Formulary – A list of prescription drugs covered by
an insurance plan.
GEP (general enrollment period) – The period
from Jan. 1 through March 31 of each year during
which people can enroll in Medicare Part A or Part
B, if they did not do so when they were rst eligible.
They can also re-enroll if they suspended their Part
A or Part B benets. Coverage takes effect July 1.
GI (guaranteed issue) – Rights you have in situa
-
tions when the law requires insurance companies
to sell you a Medigap policy. In these situations,
an insurance company cannot deny you a policy
for pre-existing conditions, and cannot charge you
more for a policy because of past or present health
conditions.
HMO (health maintenance organization) –
A Medicare Advantage plan in which a member
must receive care provided through the plan’s
network of providers. The member may have to
get referrals for specialists through a primary care
physician.
IEP (initial enrollment period) – A seven-month
period of time that surrounds a Medicare benecia
-
ry’s 65th birthday (qualifying month); three months
before, the month of, and three months after.
Inpatient care – Care given an admitted patient
while in a hospital, nursing home, or other medical
or post acute institution.
Institutional care – Care provided in a hospital,
skilled or intermediate nursing home, or other state
facility certied or licensed by the state primarily
affording diagnostic, preventive, therapeutic, reha
-
bilitative, maintenance, or personal care services.
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Issue age – Insurance policies whose premiums
are based on your age when purchased. Premiums
will not increase due to an increase in age; how
-
ever, premiums may increase for other reasons.
Late enrollment penalty – An amount added to
your monthly premium for Medicare Part B or Part
D if beneciaries do not join when they are rst
eligible. The penalty remains in place as long as the
beneciary has Medicare, with a few exceptions.
Lifetime reserve days – The beneciary is entitled
to 60 additional reserve days after Medicare pro
-
vides 90 days of benets for hospitalization. These
days are not renewable.
Limiting charge – See excess charge.
LIS (Low or Limited Income Subsidy) – The
LIS program is operated by the Social Security
Administration and provides Extra Help with pre
-
scription drug costs for individuals who meet the
income and asset requirements. See Extra Help.
Lookback – See waiting period.
LTC (long-term care) – A general term that includes
a wide range of services that address the health,
medical, personal, and social needs of people with
chronic or prolonged illnesses, disabilities, and cog
-
nitive disorders (such as Alzheimer’s). The delivery
of LTC services can include skilled nursing care in
a nursing home, in-home health and personal care,
assisted living, adult day care facilities, and other
options. Medicare does not cover LTC.
MA (Medicare Advantage) – Medicare Advantage
plans offer your Medicare benets through private
companies that manage your care. Medicare pays
the companies a set amount per person, plus you
pay a share of the costs through co-pays, co-insur
-
ance, deductibles, and premiums. Also known as
managed care, Part C or Medicare+Choice.
MADP (Medicare Advantage Disenrollment
Period) – The period from Jan. 1 to Feb. 14 when
you have one action to cancel your Medicare
Advantage enrollment. If you want prescription
drug coverage, that one action would be to enroll
in a prescription drug plan (PDP), which would
automatically disenroll you from your Medicare
Advantage plan and switch you to Original Medicare
(Parts A and B only).
MAPD (Medicare Advantage with Prescription
Drug coverage) – Medicare Advantage plan that
includes a Part D plan.
MSA (Medicare savings account) – Similar to an
HSA (health savings account), combines a high-
deductible plan with a savings account to be used
for medical costs. Not available in Oregon at this
time.
Medicaid – A federal-state partnership designed
to ensure that America’s aged, sick, and impover
-
ished are cared for. This program is a safety net
that provides aid in the form of medical services
to low-income people who fall below the state-
established poverty line. There are strict income
and asset guidelines used to qualify people for
Medicaid. Administered in Oregon by DHS. Also
known as Medicare Savings Program, MA (Medical
Assistance), or Title 19 (XIX).
Medically necessary – Services or supplies
needed for the diagnosis or treatment of a medi
-
cal condition and that meet accepted standards of
medical practice. Also known as reasonable and
necessary.
Medigap – An insurance policy sold by private com
-
panies that can help pay some of the health care
costs after Original Medicare pays its portion, such
as co-payments, co-insurance, and deductibles.
Benet packages are standardized and plans are
named by alphabet letters A-N. Plans with a given
letter (for example, F) offer identical coverage,
although companies’ premiums may differ.
MOOP (maximum out of pocket) – The maximum
amount of money for medical cost share of deduct
-
ible, co-pay, and co-insurance the MA plan member
would have to pay in a calendar year.
MSP (Medicare Savings Program) – A federal-
state partnership program that provides nancial
assistance to Medicare beneciaries with the out-of-
pocket costs associated with Medicare.
Original Medicare (OM) – Part A and Part B of
Medicare.
PAC (preauthorized check) – Checks that are
authorized by a payer in advance.
PDP (Prescription Drug Plan) – Prescription drug
coverage that adds to Original Medicare. It can be a
stand-alone plan or a part of a Medicare Advantage
plan. Also known as Part D.
PFFS (private fee for service) – A type of
Medicare health plan in which you may go to any
Medicare-approved doctor or hospital that accepts
the plan’s payment. The insurance plan, rather than
the Medicare program, decides how much it will pay
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
CONTENTS
and what you will pay for the services you receive.
You may pay more or less for Medicare-covered
benets. You may have extra benets Original
Medicare does not cover.
POS (point of service) – An option that is available
with some HMO plans that allows the beneciary
to use doctors and hospitals outside the plan for an
additional cost.
PPO (preferred provider organization) – A type of
Medicare Advantage Plan in which the beneciaries
pay less if they use doctors, hospitals, and providers
that belong to the network. If they use doctors, hos
-
pitals, and providers outside of the network, there
could be higher cost to the beneciary.
Pre-existing condition – A medical condition diag
-
nosed, treated, or needing treatment before the
purchase of an insurance policy.
Preferred drug list – See formulary.
Preferred pharmacy – A pharmacy that has negoti-
ated with a specic insurance plan to provide lower
cost-sharing on covered prescription drugs. Certain
out-of-pocket costs may be lower for covered drugs.
Premium – The monthly charge for insurance plans.
Prescription drug – A drug that must have a
health care provider’s written order (prescription) in
order to be dispensed.
Preventive (preventative) care – Health care that
is intended to keep people from becoming ill (e.g.,
checkups, mammograms, immunizations, and
screening tests).
Prior authorization – Prior approval is required
from the insurance plan before the prescription
can be lled. If a drug has a prior authorization,
you need to work with the plan and the prescribing
doctor to obtain approval before the pharmacy can
dispense that medication under your plan’s cover
-
age benet. Go to the plan’s website to identify the
specic requirements and forms needed.
Provider – The doctor, hospital, home health
agency, hospice, nursing facility, or therapist that
delivers health services.
QMB (Qualied Medicare Beneciary) – A fed
-
eral-state partnership Medicare Savings Program
(MSP) that provides nancial help with paying the
Medicare Part B premium as well as Medicare Parts
A and B deductibles and co-insurances. Eligibility
is determined by local Aging and People with
Disabilities ofces based on income and assets.
Quantity limits – For safety and cost reasons,
plans may limit the quantity of covered drugs
over a certain period of time. If the drug has a
quantity limit restriction, contact the plan for more
details. If you take one pill per day and the drug
has a 30-day/month quantity limit, the impact will
be minimal (i.e., you may not be able to rell the
prescription until a few days before running out
of pills). If you currently take two pills per day and
the quantity limit is 30 pills per month, you need
to work with the plan to get authorization for the
higher quantity.
Referral – A written order from your primary care
doctor to see a specialist or get certain medical
services. In many HMOs, the beneciary needs to
get a referral before he or she can get medical care
from anyone except the primary care physician. If
a referral is not obtained before the visit, the claim
may not be paid for the services.
Reserve days – See lifetime reserve days.
Restrictions – Limitations placed on access to
drugs on Medicare Part D plans. The three restric
-
tions are prior authorization, step therapy, and
quantity limits.
Rx – An abbreviation for prescription.
Screening tests – Tests used to try to detect a
disease when there is little or no evidence of a
suspected disease.
SEP (special enrollment period) – A period of
time that provides an opportunity to join or leave a
plan outside regular enrollment periods.
Service area – The specied geographic area that
an insurance plan has agreed to cover.
SHIBA (Senior Health Insurance Benets
Assistance) – A program that uses a statewide
network of certied counselors who educate, assist,
and advocate for Medicare beneciaries about their
rights and options regarding health insurance so
they can make informed choices.
SHIP (State Health Insurance Assistance
Program) – A nationwide state-based program
that offers local one-on-one counseling and assis
-
tance to people with Medicare and their families.
Through ACL (Association for Community Living)-
funded grants directed to states, SHIPs provide
free counseling and assistance via telephone and
face-to-face interactive sessions, public education
presentations and programs, and media activities.
SHIBA is Oregon’s SHIP.
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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Skilled care – Care for an illness or injury that
requires the training and skills of a licensed profes
-
sional, by physician prescription, and is medically
necessary for the condition or illness of the patient.
SMB/SMF (Specied Low-Income Beneciary)
– A federal-state partnership Medicare Savings
Program (MSP) that provides nancial assis
-
tance with paying the Medicare Part B premium.
Eligibility is determined by local Aging and People
with Disabilities ofces based on income and
assets.
SMP (Senior Medicare Patrol) – A national volun
-
teer network dedicated to informing seniors about
health care fraud, error and abuse, and resolving
complaints.
SNF (skilled nursing facility) – A facility at which
medically necessary (prescribed) care is provided
by licensed health care professionals.
SNP (special needs plan) – Private insurance
plans that provide Medicare benets, including
drug coverage, to people eligible for Medicare and
Medicaid, those living in certain long-term care
facilities, and those with severe chronic or dis
-
abling conditions who may qualify to join.
Specialist – The physician who provides expertise
and care in a particular area (e.g., surgeon, oncol
-
ogist, dermatologist, and allergist).
SSI (Supplemental Security Income) – Monthly
amount paid by Social Security to people with lim
-
ited income and resources who have disabilities,
are blind, or age 65 or older with little or no income
to meet basic needs for food, clothing, and shelter.
SSA (Social Security Administration) – A gov
-
ernment agency responsible for the Social Security
system.
SSDI (Social Security Disability Insurance) –
Determined by Social Security, a monthly benet
for eligible people who are unable to work for a
year or more due to a disability.
Stand-alone drug plan – See PDP.
Supplement insurance – Private health insurance
designed to pay secondary after Medicare. Also
known as Medigap.
Suppressed – Medicare Advantage and stand-
alone prescription drug plans that do not appear
on the Medicare Plan Finder until issues or correc
-
tions are reviewed by Medicare.
Step therapy – In some cases, plans require you
to rst try one drug to treat your medical condition
before they will cover a more expensive drug for
that condition. For example, if Drug A and Drug
B both treat your medical condition, a plan may
require your doctor to prescribe Drug A rst.
If Drug A does not work for you, then the plan will
cover Drug B. If a drug has step therapy restric
-
tions, you need to work with the plan and your
doctor to obtain an exception.
Tier – Pricing levels associated with prescrip
-
tion drug plans. Each drug is assigned a tier level
depending on the type and cost of the drug. The
lowest co-payment is for generics, followed by
formulary brands.
Total drug costs – The total retail value for
prescription medicines. It includes what the bene
-
ciary pays and also what the drug plan pays.
TROOP (true out-of-pocket) costs – The total
amount a beneciary pays out-of-pocket plus 50
percent of brand-name drugs in a Part D plan.
TRICARE – A health insurance program offered by
the Department of Defense to active duty military
personnel.
TRICARE For Life – A health insurance program
offered by the Department of Defense to retired
military personnel.
TTY (Teletypewriter) – Telecommunications relay
service that provides voice telephone access to
people who use TTYs. Specially trained relay
agents complete calls and stay online to relay
messages by TTY and verbally to hearing parties.
This service is available 24 hours a day with no
restrictions to the length or number of calls placed.
Also known as TDD (telecommunications for the
deaf).
Underwriting – The process by which an insurer
determines whether or not, and on what basis, it
will accept an application for insurance.
Waiting period – The amount of time that must
pass before benets are paid or before pre-existing
conditions or specic illnesses are covered by a
health insurance policy.
82
Note: Rates vary per
individual factors.
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CONTENTS
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Basics Drug Coverage Medigap Medicare Advantage Resources Glossary
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