Medicare Health Plans

Q:  Can I stay on OHP when I turn 65?

A:  Probably not.  OHP and QHPs are generally available to those under age 65 and not eligible for Medicare.

Q: What is Medicare?

A: Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant.

Q:  What is a Medicare Advantage Plan?

A: Medicare Advantage Plans (sometimes called Part C or “MA Plans) are Medicare approved plans offered by private insurance companies. Medicare provides funding to these companies to cover your Medicare benefits. If you join a Medicare Advantage Plan, the plan will provide your Medicare Part A (hospital stays) Medicare Part B (doctor and outpatient visits) coverage.  Many Advantage plans include Medicare Part D (prescription drug) coverage.

Q:  What is a Medicare Supplement Insurance?

A:   Medicare Supplement Insurance Plans (sometimes referred to as Medigap plans) are sold by private insurance companies to pay for some of the out of pocket health care costs not covered by Original Medicare. Medicare supplement plans will pay up to 100% of your Medicare copayments, coinsurance, and deductibles.  Many people opt for Plan F, Plan G, or Plan N.  For Medicare covered expenses, these plans pay much of what Medicare does not pay such as deductibles and co-payments.

Individual Health Insurance

Q: Can I get help paying the premiums for my individual health insurance?

A:  Tax credits are available to help pay premiums when you enroll for your coverage through the Federally Facilitated Marketplace – often referred to as healthcare.gov or the health insurance marketplace.  Since help is available based on income, the more you make, the less help you get.

Q:  What is a Qualified Health Plan or QHP?

A:  A QHP is health insurance you buy that meets specific criteria from the Affordable Care Act.   In addition to covering hospital stays, doctor visits and prescriptions, a QHP includes things like wellness exams, flu shots and colonoscopies at no cost to the insured.

Q:  What is the Oregon Health Plan or OHP?

A:  OHP is Medicaid and is primarily for people under age 65 (not eligible for Medicare).  If you qualify to be on OHP, generally, you will have access to medical care at no cost to you.  You are eligible for OHP if your income is below 138% of the Federal poverty level, you live in Oregon and are a US citizen.  Many non-citizens who meet the income requirements, live in Oregon and are lawfully in the US are also eligible for OHP.

Q:  What is a tax credit?

A:  A premium tax credit (PTC) can be used to off-set your monthly premium.  You establish your tax credit amount by providing a estimate of your income.  You want to be careful when using your PTC.  If you underestimate your income, you’ll need to repay some or all of your PTC when you file your Federal tax return.

Q:  What is a tax subsidy:

A:  For people with incomes below certain levels, assistance is provided to off-set the cost of some services.  This is accomplished though lower co-pays, deductibles and out-of-pocket maximums.

Q:  How do I qualify for premium tax credits or tax subsidies?

A:  The help you get paying for your medical costs or premiums is determined by your income, your family size and your age.

Q:  What is ObamaCare?

A:  ObamaCare is a term that is used to describe the Affordable Care Act.  It is often misused and misunderstood.  When talking about your health insurance, it’s best to use the terms qualified health plans to talk about insurance you buy.  Oregon Health Plan (OHP) or Medicaid are good terms to use when referring to no-cost insurance.

Agents

Q: What does it cost to have an agent help me?

A:  There is no cost for you to receive help enrolling in a plan from an agent.  Agents are paid commissions from the insurance companies if they help you enroll you in a plan.  If you use an agent to help you, you’ll want to have the agent enroll you so they can be paid for their time and expertise.

Q:  What is the difference between an agent and a broker:

A:  A broker is an agent that represents multiple companies. An agent usually represents one insurance company.

Q:  What is the benefit to having a broker help me choose a plan and enroll in coverage.

A:   A broker represents most of the individual health and Medicare Advantage plans in your area.  A broker is normally concerned about enrolling you in the most appropriate plan for your health needs,

Supplemental Health Insurance

Q:  Is dental insurance a worth the cost?

A:  If you go to the dentist twice a year, it’s likely that you will save money with dental insurance.  Also, if you need significant dental work, you may be able to save money, however, many dental plans have waiting periods for up to a year for major services like crowns and root canals.

Q:  Is it advisable to have vision insurance?

A:  Vision insurance generally covers your annual exam and either contacts or glasses only.  You should determine what the services will cost without insurance and compare that to what those services will cost with insurance.  Generally, people who wear contacts see some savings with vision insurance.  Medical services for your eyes are usually covered by your health insurance plan.

Networks

Q:  Why is it important to find an in-network provider?

A:  Many plans do not cover services that are performed by out-of-network providers (doctors, hospitals, labs, etc.).  If your plan provides for out-of-network coverage, it will be more expensive than services provided by in-network providers.

Q:  What is the difference between an HMO and a PPO?

A:  An HMO or health maintenance organization generally requires that you see in-network providers and that you have a referral to see a specialist.  A PPO or preferred provider organization provides for out-of-network coverage and generally, you can see a specialist without a referral.  Typically, a PPO provides greater flexibility while an HMO is a lower cost plan.