Medicare FAQ

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.

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.

You can find your Evidence of Coverage on the My plan documents page.

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.

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:

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 

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:

If you have questions about the authorized representative procedure, call 503-416-4279, toll-free at 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.

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. 

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 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 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. 

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 at 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. You can find your Evidence of Coverage on the My plan documents page.

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, which can be found on the My plan documents page.

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

• Call: 503-416-4279, toll-free at 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

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 EthicsPoint at 888-331-6524. You also can file a report online at EthicsPoint.

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).

You can find your Evidence of Coverage on the My plan documents page.