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How do I join?

If you have Medicare and Medicaid coverage and live in our service area, you are eligible to join CareOregon Advantage Plus HMO-POS SNP any time during the year.

The service area for CareOregon Advantage Plus includes Clackamas, Columbia, Jackson, Multnomah, Tillamook and Washington counties in Oregon.

Please see the Enroll page for more information on how to apply for Medicare coverage.

Can I change health plans if I want to?

Yes, you can change health plans. Your ending date will likely be the first of the month following the date we receive your letter requesting to leave CareOregon Advantage. You won't lose your Medicare benefits, and you may choose another Medicare Advantage plan (if available in your area). Or you can access benefits through the traditional Medicare program.

What if I have other health insurance?

If you are covered under another health insurance plan through your spouse’s employer, workers compensation or a Medicaid (OHP) plan that is not affiliated with CareOregon, please call Customer Service and let us know.

Doctors, hospitals, pharmacists and other providers in the CareOregon Advantage network will need to have the correct information about you in order to process your claims correctly. Because of this, it is very important that you help us keep your information up to date.

How much do I pay?

CareOregon Advantage Plus has no plan premium for medical coverage for Part A and B services. You must continue to pay your Medicare Part B premium unless it's paid for you through your Medicaid coverage. Most medical services have no copayment as long as you have Medicaid coverage through CareOregon.

For Part D services in 2021, CareOregon Advantage Plus has a premium of $0 per month for prescription drugs (the $36 premium is covered through Low-Income Subsidy).

For Part D services in 2022, CareOregon Advantage Plus has a premium of $0 per month for prescription drugs (the $40.50 premium is covered through Low-Income Subsidy). 
 
If you qualify for Extra Help with your Medicare prescription drug plan costs, your premium will be lower. When you join CareOregon Advantage, Medicare will tell us how much Extra Help you are getting. Then, we will let you know the amount you will pay. If you aren't getting any Extra Help, you can see if you qualify by calling:

  • 800-MEDICARE (800-633-4227).
    TTY users should call 877-486-2048
  • Health Systems Division  (8 a.m. to 5 p.m.)
    Phone: 503-945-5772
    Phone: 800-527-5772
    TTY: 800-375-2863 
  • The Social Security Administration at 800-772-1213 (7 a.m. to 7 p.m. Monday through Friday). TTY users should call 800-325-0778

An online application for Extra Help is also available.

What should I do if I get a bill?

As a member of CareOregon Advantage, most medical services and office visits do not have copays. If you receive a bill, do not pay it. Please call Customer Service, who can work with you and your provider to resolve the balance.

What services are covered/not covered under CareOregon Advantage?

The best way to find out what’s covered is to look at Chapter 4 of your Evidence of Coverage. It lists all covered and non-covered services and any limits or restrictions.

For 2021 benefits, see your 2021 Evidence of Coverage

For 2022 benefits,
see your 2022 Evidence of Coverage

My doctor made a request for services or referred me to another provider. What’s the status of this request/referral?

To check the status of prior authorization requests, contact your provider first before calling Customer Service. If you are wondering about the status of a referral request, check with your primary care provider.

Which doctors can I see?

CareOregon Advantage assigns a primary care provider (PCP) to each member. You can change your PCP by calling Customer Service at 503-416-4279, toll-free at 888-712-3258 or TTY 711. Our hours are 8 a.m. to 8 p.m. seven days a week, October 1 to March 31, and 8 a.m. to 8 p.m. Monday through Friday, April 1 to September 30. Except for women's health and emergency care, your PCP will coordinate your care. See our Provider Directory or Provider Search to find a specific doctor. If you already have a primary care provider, check to be sure they accept CareOregon Advantage. Generally, you must use providers who are in our network to receive benefits. There are exceptions, though.

CareOregon Advantage Plus HMO-POS SNP has a Point-of-Service (POS) option that allows you to get care from out of network PCPs and specialists under certain conditions. There are annual limits to this benefit. For more information, see “POS benefit” Chapter 4, section 2.1 of your Evidence of Coverage.

I’m sick. Should I go to my primary care provider, urgent care or the emergency room?

  • If your symptoms feel life threatening — e.g., chest pain, head trauma, breathing problems or mental distress — go to the emergency room or call 911. You do not need to call your provider or health plan first.
  • If your symptoms are not life threatening and you do not have a primary care provider (PCP), go to your nearest urgent care facility. You’ll probably be seen faster here than at the ER.
  • If your symptoms are not life threatening and you have a PCP, schedule an appointment for routine care. Problems like common colds, constipation and back pain are best cared for by your PCP. If they say you need care before they are able to see you, go to urgent care.


After-hours care for evenings, weekends and holidays

If you’re sick or injured and need help, call your PCP’s regular phone number any time of day or night. The person who answers your call will either contact your doctor or a different doctor at the clinic or advise you on what to do.

Virtual visits         

In 2022, you’ll pay $0 copay per visit for virtual visits with Doctor on Demand. You’ll be able to visit with board-certified doctors 24/7 through video chat or phone for prescriptions, treatment of non-emergency health issues and more.

 

Can’t decide where to get help? Call the FREE Nurse Advice Line

If you have questions about a specific health problem, need health care advice or are unsure if you need to see a doctor, CareOregon Advantage can help. Call our free 24-hour Nurse Advice Line toll-free at 866-209-0905. 

Which cards should I take to my appointments?

Please bring both your CareOregon Advantage and Medicaid Member ID cards and a photo ID to all appointments. This lets the provider know you’re our member. You don’t need to take your red, white and blue Medicare card to appointments.

Are vaccines covered?

It is always best to call us before you get a vaccine. You can check on coverage, any restrictions that may apply and explore whether you want to get it at your pharmacy or your health care provider’s office.

You will never pay more than your copay for vaccines you get at a network pharmacy. In 2022, Part D vaccines have a $0 copayment. Note: If you are given a Part D vaccine at your health care provider’s office, the office may bill you for the entire cost of your vaccine; most will not bill us directly. If you receive a Part D vaccine at your provider’s office and have paid for it, you can ask us to reimburse you up to our allowable cost by submitting a Direct Member Reimbursement form.

Vaccines at the pharmacy

We cover most vaccines given by a pharmacist at a network pharmacy. These include some Part B vaccines, like flu and pneumonia vaccines, and some Part D vaccines, like the shingles vaccine. Some vaccines have coverage limits. Please see our pharmacy formulary to check if a vaccine is covered and if any limits apply.

Vaccines given by your health care provider’s office

We cover vaccines given by your health care provider. These include Part B vaccines, such as flu and pneumonia. Your health care provider may provide you with Part D vaccines as well. It is likely that the provider’s office will bill you for the entire cost of Part D vaccines. You may ask us to reimburse you for Part D vaccines given by your provider by submitting a Direct Member Reimbursement form.

 

What are the rules for out-of-network coverage?

With limited exceptions, while you are a member of CareOregon Advantage you must use network providers to get your medical care and services. The only exceptions are:

  • Emergencies.
  • Urgently needed care when the network is not available (generally, when you are out of the area).
  • Out-of-area kidney dialysis services.
  • Cases in which CareOregon Advantage authorizes use of out-of-network providers.
  • When you use your Point-of-Service (POS) benefit.

For more specific information about emergency, out-of-network and out-of-area coverage, please refer to Chapter 3 of your Evidence of Coverage. For more specific information about your POS benefit, see “POS benefit” in Chapter 4 of your Evidence of Coverage.

If our network cannot provide a service or treatment that Medicare requires our plan to cover, you can get this care from an out-of-network provider. Out-of-network providers must obtain authorization from the plan prior to any treatment. In this situation, we will cover these services as if you got the care from a network provider.

What if I have a problem or concern?

You have the right to make a complaint if you are unhappy with the benefits or services you receive from a CareOregon Advantage provider. You can file a complaint or grievance directly to Medicare by filling out the Medicare Complaint form found on the Medicare website. Members can also contact CareOregon Advantage in writing, by phone or by fax to make a complaint. Members can also obtain a summary of the total number of grievances, appeals and exceptions filed with the Plan.

To contact us by telephone, call Customer Service at 503-416-4279, toll free at 888-712-3258 or TTY 711. Our hours are 8 a.m. to 8 p.m. seven days a week, October 1 to March 31, and 8 a.m. to 8 p.m. Monday through Friday, April 1 to September 30. Our fax number is 503-416-8118.

To send your complaint by mail, our address is:

CareOregon Advantage
315 SW Fifth Ave
Portland, OR  97204

How do I give permission to release my personal health information?

Information about you and your health, called protected health information (PHI), is sensitive. Health plans, such as CareOregon Advantage, may not use this PHI or disclose it to anyone unless you say it’s OK in writing. To give us your consent to use and disclose your PHI, please fill out the Authorization to Release Health Information form

En español: Mi autorización para divulgar información de salud protegida 

How do I appoint an authorized representative to help me make medical decisions?

You can choose a friend, family member or other person to be your authorized representative. As your authorized representative, this person can help you make decisions about your Medicare coverage, such as joining or leaving a plan and filing appeals and grievances. If you would like to appoint an authorized representative, fill out an Appointment of Representative form and mail it to the address below.

An authorized representative cannot make decisions about your medical care. You may complete an Advance Directive form to tell your doctor what kind of care you want if you cannot make medical decisions.

Mail completed forms to:

CareOregon Advantage
Attn: Customer Service
315 SW Fifth Ave
Portland, OR, 97204

If you have questions about the authorized representative procedure, call 503-416-4279, toll-free 888-712-3258 or TTY 711. You can also send us a secure message through our member portal.

Note: CareOregon Advantage's Medicare contract with the federal government is renewed annually. Coverage beyond the end of the current year is not guaranteed. If the contract is not renewed or the service area is reduced, CareOregon Advantage must provide affected members with 90-day notice and a written description of members' rights and responsibilities, including alternatives for obtaining Medicare services.

What forms of evidence or best available evidence (BAE) can I provide to my plan or pharmacist if my copayments are not correct?

Certain members receive extra help with paying for their prescription drugs. This is usually referred to as Low Income Copayment level or LIC level. View materials related to the CMS BAE policy

What are my Rights and Responsibilities on disenrollment?

Ending your membership in CareOregon Advantage may be voluntary (your choice) or involuntary (not your choice):

  • You might leave our plan because you have decided that you want to leave. There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. Your Evidence of Coverage (EOC) document tells you when you can end your membership in the plan. The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. See your Evidence of Coverage (EOC) document for additional details.
  • There are also limited situations in which you do not choose to leave, but we are required to end your membership. Your Evidence of Coverage document describes situations in which we must end your membership.
  • If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends. If you leave CareOregon Advantage, it may take time before your membership ends and your new Medicare coverage goes into effect. (See your Evidence of Coverage document for information on when your new coverage begins.) During this time, you must continue to get your medical care through our plan.
  • If we end your membership in our plan, we must tell you our reasons for ending your membership in writing. We must also explain how you can make a complaint about our decision to end your membership. See your Evidence of Coverage for information about how to make a complaint. 

How do I request an organization determination (prior authorization) for medical services?

An organization determination is the first decision we make about your benefits and coverage or about the amount we will pay for your medical services.

There are several ways you, your representative, or your doctor can request an organization determination:

  • Call: 503-416-4279, toll free 888-712-3258 or TTY 711
  • Fax: 503-416-3671
  • Write: CareOregon Advantage
    315 SW Fifth Ave
    Portland, OR 97204

For more information on asking for coverage decisions about your medical care, see Chapter 9 in your Evidence of Coverage.

 

How do I appeal a decision not to cover a medical service my provider or I requested?

If we make a coverage decision and you are not satisfied with it, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. Except when you request a filing time extension, the request must be filed within 60 calendar days from the date of the notice of the coverage determination denial.

You will find information about your appeal rights in Chapter 9 of your Evidence of Coverage.

There are several ways you, your representative or your doctor can request an appeal:

  • Call:503-416-4279, toll-free 888-712-3258 or TTY 711
  • You can write out your request and fax or mail it to us:
    Fax: 503-416-8118
    Write: CareOregon Advantage
    315 SW Fifth Ave
    Portland, OR 97204

How do I report suspected fraud, waste and abuse?

CareOregon Advantage and CMS take fraud, waste and abuse very seriously. If you suspect that your benefits aren't being used correctly or want to report a case of fraud, waste or abuse, please contact Ethics Point at 888-331-6524. You also can file a report online at ethicspoint.com.

How do I get reimbursed for a covered service that my provider made me pay?

You can ask us to reimburse you up to our allowable cost by filling out and submitting the Direct Member Reimbursement form.

If you send us paperwork asking for reimbursement for medical services, you are asking us to make a coverage decision (for more information about coverage decisions, see Chapter 9, Section 4.1 of your Evidence of Coverage). To make this coverage decision, we will check to see if the medical care you paid for is a covered service — see Chapter 4: Benefits Chart (what is covered and what you pay).

We will also check to see if you followed all the rules for using your coverage for medical care (these rules are given in Chapter 3 of your Evidence of Coverage: Using the plan's coverage for your medical services).

For questions on getting started with Medicare, or other questions you may have not answered here, please check our Medicare Basics page.

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   Page last updated: October 1, 2021
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