Sherwood Arts Center
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You can enroll in a FamilyCare Health Medicare Advantage plan if you:
Medicare is a federal health insurance program. It’s for people who are age 65 or older and for people younger than 65 who have certain disabilities, like permanent kidney failure. The program helps cover the cost of various healthcare services. Most people pay for at least some of their care.
It’s easy to start your Medicare coverage. Here are the first two steps:
1. Check your eligibility
You automatically qualify for Part A (hospital insurance) and Part B (medical insurance) if:
You can apply for Medicare if:
2. Choose your coverage
Once you know you are eligible for Medicare, it’s time to decide what kind of health insurance coverage you want and whether you want prescription drug coverage (Part D). Your choices are:
For more information about your Medicare options, visit Medicare.gov or call 800-MEDICARE (800-633-4227); TTY call 877-486-2048 toll-free.
Your initial enrollment period begins three months before you turn 65 and continues until four months after you turn 65. This is important. Mark it on your calendar. The enrollment period is officially 7 months long, but you avoid delays in coverage if you enroll in the three months before you turn 65. (For example: If you turn 65 on July 15th, you could sign up for Medicare beginning April 1. Your initial enrollment period would continue until October 31.)
It’s very important that you sign up for Medicare during this period. If you don't sign up for Part B when you're first eligible (or if you drop Part B), you may have to pay a significant enrollment penalty if you enroll in Part B later. This penalty could increase the cost of your premiums for as long as you have Medicare.
If you don't sign up for a Part D plan (or a Medicare Advantage plan that includes Part D coverage) when you are first eligible (or if you drop Part D coverage), you may have to pay a penalty if you enrolled in Part D later.
After your initial eligibility period, each year you have the opportunity to switch your coverage from October 15 to December 7. This is called the Annual Enrollment Period, and during this time you can switch from a Medicare Advantage Plan to Original Medicare (or vice-versa), switch from one Medicare Advantage Plan to another, or sign up for (or drop) prescription drug coverage.
During the Medicare Advantage Disenrollment Period, which lasts from January 1 to February 14, Medicare Advantage members can cancel their plans and get their coverage through Original Medicare. (They can also enroll in a stand-alone Part D plan during this period.)
You can add, drop, or switch Medicare Advantage plans if you qualify for a Special Enrollment Period (SEP). Usually, you qualify for a SEP if you move outside of the area covered by your old Medicare Advantage plan. You may also qualify for a SEP if you are a member of the Oregon Health Plan (Medicaid) or if you receive Extra Help from Social Security to pay your Part D prescription drug costs. To find out if you qualify for a SEP, visit Medicare.gov or call 800-MEDICARE (800-633-4227); TTY call 877-486-2048 toll-free.
FamilyCare Health offers HMO and PPO Medicare Advantage Plans. Our PPO plans aren't available in Clatsop County.
HMO means Health Maintenance Organization. In an HMO plan, you see doctors and other providers who are members of the plan's network. You will choose a Primary Care Provider (such as a doctor, nurse practitioner, or family nurse practitioner) who takes care of most of your routine medical needs. You get all of your care from network providers, including specialists and hospitals. In some cases, you may need a referral to see a specialist (for certain benefits). Except in an emergency or if you need urgent care, you need to get prior authorization from the HMO to see an out-of-network provider.
PPO means Preferred Provider Organization. With a PPO plan, you can see any healthcare provider in the health plan’s provider network. You do not need prior authorization to see an out-of-network provider, but may pay a higher amount for healthcare services.
It depends on whether you are a member of one of our HMO plans or one of our PPO plans. Our HMO plans are Community, Advantage Rx, Select, and Select Rx. Generally, if you are a member of one of these plans, you must get all of your care from providers in our network. If you need to see a provider outside of our network, ask your primary care provider (PCP) for a referral. Without a referral, neither FamilyCare Health Plans nor Medicare will pay for your care, except in the case of an emergency.
Our PPO plans are Choice and Choice Rx. Members of these plans do not need a referral to see out-of-network providers. Except in an emergency, you may pay a higher amount for services if you see a provider outside of our network
If you have a medical emergency, get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. As soon as possible, tell us about your emergency.
FamilyCare Health partners with hundreds of local primary care physicians and specialists, so many of our members are able to continue seeing their favorite medical providers once they join one of our plans. To see if your doctor is a part of our network, see Find a Provider. If your doctor is not a part of our network, you may ask your doctor to join our plan. Or you can look for a different doctor in our network.
Members of our Choice (PPO) and Choice Rx (PPO) plans can see any provider. However, they may pay more if they see an out-of-network provider.
Contact Navigation Services for help choosing a new Primary Care Provider (PCP) or specialist. Or search for providers based on location, medical specialty, language, and more using the Find a Provider tool on this website.
If you are a current FamilyCare Health member, check your Evidence of Coverage for your particular plan to see exactly what is and is not covered. (To find the Evidence of Coverage for your plan, go to the 2016 Medicare Advantage Plans page and click the link for your plan.)
Some of our Medicare Advantage plans include Medicare Part D coverage, which helps pay for prescription medicines. If you have Part D, it will be indicated on your member ID card.
To help you and your healthcare providers know which drugs we cover, we regularly update a drug list called a formulary. This is a large database of all drugs that we help you pay for. You should have received a copy of our formulary in the mail. You can also search for your medicine in our formulary, or with our comprehensive online prescription drug search tool. If a drug is not on the formulary, it is not covered.
If a drug you are prescribed is not covered, you can ask your doctor to prescribe a similar drug that is covered. If no other drugs are available, you or your doctor can contact us to request coverage for a temporary supply of the drug, or you can request an exception. To request an exception, your doctor will need to write a statement explaining that a drug is medically necessary, that no drugs in the formulary provide the same benefits, or that similar drugs in the formulary would have an adverse effect on you.
This provider’s statement for a medication exception can be mailed or faxed to:
825 NE Multnomah St., Suite 1400
Portland, OR 97232
Many, but not all, pharmacies accept FamilyCare Health Plan insurance. To find a pharmacy in our network, use the Find a Pharmacy app on this website.
Members with drug coverage can enroll in our mail-order pharmacy program. Many drugs can be delivered straight to your mailbox, saving you trips to the pharmacy. In many cases, if you order a 90-day supply through CVS Caremark, our network mail-order pharmacy, you only pay for a one-month supply. To learn more, see our Find a Medicare Drug page.
FamilyCare Health Plans covers the vaccines for flu, pneumonia, hepatitis B, shingles, and tetanus. The simplest way to get your immunization is to go to a network pharmacy and ask the pharmacist to give you the shot. If you get a vaccination from your doctor, you may have to pay for a doctor’s visit.
Supplies including syringes, needles, alcohol swabs, and gauze are covered by our plans. To purchase supplies for delivering insulin to the body, go to a network pharmacy or order from a durable medical equipment (DME) supplier in our network. We prefer that you also order lancets, glucose meters, test strips, and other supplies from one of the DME companies in our provider network.
The Medication Therapy Management (MTM) program is a free, voluntary program for members who take multiple medications for chronic conditions such as high blood pressure, high cholesterol, diabetes, and asthma. If you are in the MTM program, a pharmacist will look at all of your prescriptions to make sure you are not being over-medicated and that your drugs work properly with each other. To see if you qualify for MTM, call Navigation Services.
The costs you pay each year depend on the plan you enroll in and the services you use. If you are enrolled in a plan with a premium, you must pay the premium each month. You must also pay your Medicare Part B premium. (If you are a member of the Community (HMO SNP) plan, the Oregon Health Plan (Medicaid) pays your Medicare Part B premium for you.)
We pay the full cost of some benefits. For others, you will need to pay a co-pay (a fixed dollar amount) for co-insurance (a percentage of the cost). To find costs for your plan, see your Evidence of Coverage.
Medicare rules prevent recipients from enrolling in both a Part C Medicare Advantage Plan and a supplemental insurance plan (“Medigap”). If you currently pay for supplemental insurance and want to enroll with FamilyCare Health instead, you will have to cancel your supplemental insurance policy.
Occasionally, members pay for a service that we cover. If this happens to you, you can send us a request for payment along with your bill and proof of the payment you made. See your Evidence of Coverage for details on requesting a payment.
The amount that you pay depends on the plan you select, whether the doctor you see is in our network, and what tests or treatments you receive. Your plan's Evidence of Coverage shows you how much you will pay in co-pays, co-insurance, premiums, and deductibles. If you reach your out-of-pocket limit for the year, you will have fewer costs to pay for the rest of the year. For up-to-date information on costs, call Navigation Services.
The amount that you pay depends on several factors, including the plan you select, the medicine you are prescribed, and your deductible.
To find out which tier a drug is in, use our formulary or our comprehensive online prescription drug search tool. Check your plan’s Evidence of Coverage to see how much drugs in that tier cost. (To find the Evidence of Coverage for your plan, go to the 2016 Medicare Advantage Plans page and click the link for your plan.) With the exception of Tier 1 preferred generics, you must pay the full cost of your drugs until you meet your deductible (if your plan has a drug deductible). After that, you pay a co-pay or co-insurance based on the tier that your drug is in. For more information, see the Evidence of Coverage for your plan.
If you are enrolled in Advantage Rx, Select Rx, or Choice Rx and your total drug costs for the year (what you and the plan have paid) reach $3,310, you enter the Coverage Gap (also known as the "Donut Hole"). In the gap, you pay no more than 58% of the cost of generic drugs and the plan pays the rest. For brand drugs, the plan pays 42% of the cost. If your total out-of-pocket costs for the year reach $4,850, you pay no co-pay or co-insurance for your drugs the rest of the year.
If you need extra help paying for prescription drugs, you may qualify for assistance from Medicare. To see if you are eligible for getting this "Extra Help" (called a Low-Income Subsidy), call one of these three offices:
You can learn more about the Low-Income Subsidy here.
If you have HIV/AIDS, you may qualify for the AIDS Drug Assistance Program (ADAP). In Oregon, the ADAP program is called CAREAssist. For more information, call 800-805-2313 toll-free (TTY 711) or visit the CAREAssist website.
You may also be able to get help with drug costs from the Oregon Prescription Drug Program (OPDP). For more information, call 800-913-4284 or visit the OPDP website.
These are words and terms you might come across while you are learning about Medicare coverage and benefits.
Beneficiary: The person eligible to receive, or who is receiving, benefits from Medicare, an insurance policy, or a health plan.
Benefit Period: The way that the Original Medicare Plan and our plans measure a beneficiary’s use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day a beneficiary goes to a hospital or skilled nursing facility and ends when the beneficiary hasn’t received any inpatient hospital care (or skilled care in an SNF) for 60 days in a row. If a beneficiary goes into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. The beneficiary must pay the inpatient hospital costs for each benefit period. There is no limit to the number of benefit periods.
Benefits: The healthcare services and/or prescription drugs covered by a health insurance company, including wellness program offerings, incentives, and more. Benefits also include the cost savings that you gain, because a health insurance company is helping you pay the costs for healthcare.
Catastrophic Coverage: Once you've spent $4,850 out-of-pocket in 2016, you're out of the coverage gap. Once you get out of the coverage gap (Medicare prescription drug coverage), you automatically get "catastrophic coverage." It assures you only pay a small co-insurance amount or co-payment for covered drugs for the rest of the year.
Co-insurance: A percentage of the cost of covered service or drug that the beneficiary pays to the provider.
Co-payment, or “Co-pay”: A fixed dollar amount that the beneficiary pays to a provider for a covered service or drug.
Coverage: The healthcare services a health plan chooses to help you pay for, and how much money the plan pays for those services. This includes medical care, healthcare services, supplies, and equipment specified by the health plan.
Coverage Gap: Generally refers to a period of coverage in Medicare Part D that begins after you and the plan have spent $3,310 on covered drugs. Once you reach the coverage gap, you will pay no more than 42% of the plan’s cost for brand drugs or 58% of the plan’s cost for generic drugs. Once your total out-of-pocket costs for the year reach $4,850, you enter the catastrophic coverage stage.
Deductible: The amount you must pay out-of-pocket for healthcare or prescriptions before Original Medicare, a health plan or a prescription drug plan begins to pay for covered benefits.
Donut Hole: The coverage gap in Medicare Part D plans. (See “Coverage Gap.”)
Formulary: A list of prescription drugs covered by a prescription drug plan.
Health Maintenance Organization (HMO): A type of managed care plan. If you enroll in an HMO, you get health coverage if you go to doctors who are members of a provider network. You choose a Primary Care Provider (PCP) who will take care of most of your routine medical needs.
Managed Care Plan: The way a health plan helps you get healthcare services at reduced costs. The health plan contracts with certain doctors and facilities and negotiates what it will pay a doctor or facility for every type of healthcare service. The health plan shares those costs with you. In some cases, the plan covers the costs in full. Managed care plans that participate with Medicare and Medicaid must show how well they meet certain quality measures.
Medicare Advantage plan: A Medicare Part C health insurance plan offered by Medicare-approved private companies. People who have Medicare Parts A and B can choose Part C to replace and enhance Original Medicare coverage. Some Medicare Advantage plans include Part D coverage as well.
Medicare Supplements: Also known as “Medigap” policies, these are plans that help you pay your share of the cost of Medicare-covered services. Medicare supplements have federally standardized benefits, no network restrictions, do not include prescription drug coverage, and differ in monthly cost according to the plan.
Medigap: Health insurance plans sold by private insurance companies to fill gaps in Original Medicare coverage. They help you pay your share of the cost of Medicare-covered services. (See “Medicare Supplements.”)
Network: Providers, clinics, hospitals, pharmacies, and other healthcare facilities that have an agreement (contract) with a health plan to accept the health plan’s payment and your cost-sharing amount as payment in full. The providers in FamilyCare’s network bill us directly for our share of the costs for your treatment. You pay only your share of the cost (co-pay or co-insurance) for their services.
Original Medicare: For many years only Part A and Part B coverage were offered through Medicare. Part A and/or Part B coverage are often referred to as Original Medicare.
Out-of-Pocket Costs: The dollar amount that you pay for covered services out of your own pocket. This includes your deductible, co-insurance, and co-pays.
Out-of-Pocket Limits: The highest total amount you’ll have to pay for covered health services during a plan year. Each Medicare Advantage health plan will list its out-of-pocket limits in the detailed Summary of Benefits document and Evidence of Coverage document. This number is separate from any premium costs you may pay.
Premium: The periodic payment you make to Medicare, an insurance company, or a healthcare plan for medical or prescription drug coverage. Usually, you pay this on a monthly basis.
Preferred Provider Organization (PPO): A type of managed care plan. If you enroll in a PPO plan you can see any doctor you want, but you may pay more if you see a doctor who is not a member of the health plan’s preferred provider network.
Prior Authorization: A health plan’s requirement that it review a request for a medical service or drug before covering it.
Service Area: The area where a plan accepts members. For plans that require members to use their doctors and hospitals, it’s also the area where services are provided. The plan may disenroll a beneficiary who moves out of the plan’s service area.
Skilled Nursing Care: 24-hour-a-day supervision and medical treatment by a nurse, under the direction of a doctor.
Skilled Nursing Facility (SNF) Care: A level of care that requires the daily involvement of skilled nursing or rehabilitation staff. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (such as help with activities of daily living, like bathing and dressing) does not qualify for Medicare coverage in a skilled nursing facility if that is the only care needed.
Taken in part from Medicare & You 2013: Definition of Terms
FamilyCare Health Plans, Inc., is an HMO and PPO plan with contracts with Medicare and the Oregon Health Plan (Medicaid). Enrollment in FamilyCare Health depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information Limitations, co-payments, and restrictions may apply. Benefits, premiums, and or/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. To enroll in Community (HMO SNP), you must be eligible for Medicare Parts A and B and the Oregon Health Plan (Medicaid). If you qualify for Community (HMO SNP), the Oregon Health Plan will pay your Medicare Part B premium for you. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
If you have any questions about your coverage, please call Navigation Services at 503-345-5702 or 866-798-2273 toll-free (TTY/TDD 711).
From October 1 through February 14, you can reach Navigation Services by phone seven days a week from 8 a.m. to 8 p.m. (except Thanksgiving and Christmas). The rest of the year, phones are answered Monday through Friday from 8 a.m. to 8 p.m. and on weekends from 9 a.m. to 5 p.m. (except Memorial Day, Independence Day, and Labor Day). (On these holidays, you may leave a message and we will get back to you within one business day.)
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