OHP and Medicare at a glance
| Medicare | Oregon Health Plan (OHP) | |
|---|---|---|
| What it is | Federal health insurance | Oregon's Medicaid program, paid for by the state and federal government |
| Who runs it | CMS; Social Security handles sign-up | Oregon Health Authority (OHA); ODHS decides eligibility for older adults and people with disabilities |
| Who qualifies | People 65 and older, people under 65 after 24 months of Social Security disability benefits, and people with end-stage renal disease or ALS. Income doesn't matter. | People with low income who meet OHP rules. For people 65 and older or with Medicare, ODHS uses its rules for older adults and people with disabilities. |
| How you apply | Social Security: online, 1-800-772-1213 or a local office | one.oregon.gov, 1-800-699-9075 (TTY 711) or a local ODHS office |
| How you get care | Original Medicare (any provider who accepts Medicare) or a Medicare Advantage plan | Usually through a coordinated care organization (CCO) in your area, or open card (fee-for-service) |
| Premiums | Part B premium ($202.90 a month for most people in 2026); most people pay no Part A premium | None for members |
What does each cover?
| Service | Medicare | OHP |
|---|---|---|
| Hospital and doctor care | Part A and Part B, with deductibles and 20% coinsurance | Covered; for dual eligibles, OHP helps with Medicare's cost sharing |
| Prescription drugs | Part D plans, with a yearly out-of-pocket cap of $2,100 in 2026 | For people with Medicare, only certain drugs Part D excludes (OHP with Limited Drug) |
| Dental care | Not routine dental in Original Medicare | Listed among OHP benefits |
| Vision | Medical eye care, not routine glasses (except after cataract surgery) | Listed among OHP benefits |
| Behavioral health | Covered under Part A and Part B | Covered; OHP coordinates behavioral health care |
| Rides to appointments | Not covered except medically necessary ambulance | OHP lists travel help (rides) to covered care |
| Long-term care (nursing facility, in-home help) | Only short-term skilled care after a hospital stay, and home health | Medicaid long-term services through ODHS Aging and People with Disabilities, with separate eligibility rules |
For details on your own benefits, OHA says to check your OHP coverage letter. See the Oregon Health Plan and Medicare.
If you have both: how Medicare and OHP work together
- Medicare pays first. OHP pays after Medicare for covered services, and covers some services Medicare doesn't.
- Drugs move to Part D. Most OHP members with Medicare have "OHP with Limited Drug." You need a Part D plan or a Medicare Advantage plan with drug coverage; if you don't choose, Medicare enrolls you in a drug plan. You get Extra Help automatically.
- Your CCO doesn't change when you get Medicare, OHA says. You don't have to get your Medicare care through your CCO. OHA's CCO page shows which CCOs serve your area.
- Dual eligible special needs plans (D-SNPs) are Medicare Advantage plans for people with Medicare and OHP that work closely with OHP; OHA says they're available in many areas of Oregon. Your OHP benefits continue whichever Medicare plan you choose. See Medicare and OHP together.
- More chances to change plans. People with OHP or Extra Help can make certain Medicare plan changes once a month, not just during open enrollment.
Medicare Savings Programs: help even without full OHP
If your income is too high for full OHP, you may still qualify for a Medicare Savings Program through ODHS. Oregon has no asset limit for these programs. ODHS updates its income limits each March.
| Program (Oregon name) | Income limit | What it pays |
|---|---|---|
| QMB (Qualified Medicare Beneficiary) | Up to 100% of the federal poverty level | Part A and Part B premiums, deductibles and coinsurance. Providers can't bill you for Medicare cost sharing. |
| SMB (federally called SLMB) | Up to 120% | Part B premium |
| SMF (federally called QI) | 120% to 135% | Part B premium; limited yearly funding, and not for people eligible for other Oregon Medicaid |
| QDWI (Qualified Disabled Working Individual) | Up to 200% | Part A premium only |
Oregon doesn't recover correctly paid Medicare cost sharing (paid on or after January 1, 2010) from estates (OAR 461-135-0835). Apply at one.oregon.gov or call 1-800-699-9075; ODHS says it decides within 45 days. See Medicare Savings Programs in Oregon and Extra Help in Oregon.
Turning 65 or getting Medicare while on OHP
- Sign up for Medicare when you're eligible. Medicare becomes your primary coverage.
- Tell OHP. Send OHP your Medicare number. OHA says you keep your OHP until your next renewal; most people renew every two years.
- Choose drug coverage. Pick a Part D plan or a Medicare Advantage plan with drug coverage, or Medicare will assign a drug plan.
- Watch for your renewal. At renewal, ODHS reviews your eligibility under its rules for people with Medicare. If you no longer qualify for full OHP, ask about Medicare Savings Programs.
Questions about your OHP benefits or CCO go to OHP Client Services, 1-800-273-0557 (TTY 711), weekdays 8 a.m. to 5 p.m. Eligibility questions go to the ONE Customer Service Center, 1-800-699-9075. For Medicaid long-term care or in-home help, ODHS Aging and People with Disabilities, the state aging and disability agency, can help at 1-855-673-2372. To compare Medicare plans, including D-SNPs, from the companies they work with, you can request a call from a licensed insurance agent, or see plans for your ZIP code.
Sources
- Oregon Health Authority — OHP and Medicare (OHP with Limited Drug, CCOs, D-SNPs, Part D)
- Oregon Health Authority — OHP benefits
- Oregon Health Authority — Continuous eligibility (turning 65 or getting Medicare)
- Oregon Health Authority — OHP Client Services
- Oregon Department of Human Services — Medicare Savings Programs
- ODHS transmittal APD-PT-21-041 (MSP resource limits eliminated January 1, 2016)
- OAR 461-135-0835, limits on estate claims (ODHS)
- Oregon Department of Human Services — Aging and Disability Services
- Medicare.gov — Medicaid and Medicare
- Medicare.gov — Special Enrollment Periods (Medicaid and Extra Help)
Frequently asked questions
Can I have OHP and Medicare at the same time?
Yes. People with both are called dual eligibles. Medicare pays first, and OHP can help pay Medicare premiums, deductibles and coinsurance and covers some services Medicare doesn't. The Oregon Health Authority says most OHP members with Medicare have OHP with Limited Drug, which covers everything OHP Plus does except drugs Medicare Part D covers.
What happens to my OHP when I get Medicare?
Medicare becomes your primary coverage, and OHA says you keep your OHP until your next renewal, when your eligibility is reviewed. Send OHP your Medicare number. If your income is too high for OHP with Medicare, you may still qualify for a Medicare Savings Program.
Do I keep my CCO when I get Medicare?
OHA says that if you get Medicare while you have OHP, your CCO won't change. Medicare pays first for Medicare-covered care, and your CCO coordinates OHP benefits such as dental care, behavioral health and rides to appointments.
Does OHP pay my Medicare Part B premium?
If you qualify for a Medicare Savings Program, Oregon pays your Part B premium, and QMB also covers Medicare deductibles and coinsurance. Many people with full OHP and Medicare also have the premium paid by the state; ODHS can tell you if you qualify. Oregon has no asset limit for Medicare Savings Programs.
Does OHP pay for Part D drug plans?
No. OHA says OHP doesn't pay Part D premiums, deductibles or copays. Instead, people with OHP get Extra Help automatically, which lowers those costs, and OHP pays for only certain drugs Part D excludes.
Medicare in your Oregon county
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