Providence are an insurance provider offering a range of Medicare Advantage plans to people living in parts of Oregon and Washington.
Providence offer Health Maintenance Organization (HMO) and Health Maintenance Organization Point of Service (HMO-POS) plans.
The company also have a Special Needs Plan (SNP) with additional benefits for those who qualify for Medicare and Medicaid.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
People who qualify for Medicare can join either original Medicare, comprising parts A and B, which the government administers, or a Medicare Advantage plan, consisting of Part C, which private insurance companies administer.
Medicare Advantage plans usually fall into different categories.
- HMO: These plans use a network of preferred providers that an individual must use for the plan to cover healthcare costs. A person must choose a primary care doctor to coordinate their care and any referrals to specialists.
- Preferred Provider Organization (PPO): PPO plans also use a healthcare provider network, but the plans do not require a person to select a primary care doctor. An individual may also visit a specialist directly without a doctor’s referral. PPO plans have a more extensive network of providers than HMO plans, but they are usually more expensive.
- Private Fee-For-Service (PFFS): Someone with a PFFS plan can visit healthcare providers and pay a fixed amount for their care, as agreed by the insurance company and Medicare.
- SNP: Medicare designs SNP to support people with disabilities or chronic health conditions, such as diabetes, end stage renal disease, and chronic heart failure. As these conditions require special care and medication, these plans may provide the best coverage for people living with complex health needs.
Medicare Advantage plans provide the same coverage as Medicare parts A and B. However, people may choose Medicare Advantage for additional benefits, which may include:
- annual physical examinations
- cover for alternative health services
- dental, hearing, and vision care
- fitness and wellness benefits
- prescription drug coverage under Part D
Plan details differ, and not all states have the full range of Medicare Advantage plans. For example, Alaska has no available programs.
Providence Health & Services began as the Sisters of Providence, a religious community of Catholic females, in 1843.
Providence offer commercial healthcare, Medicare, Medicaid, and individual and family plans to people in Oregon and Washington.
Although the company has origins in Canada, following mergers with other health plan providers, Providence now offer health coverage to over 650,000 people across the United States.
Providence administer a range of Medicare Advantage plans across Oregon and Washington.
Most of their plans offer:
- a 24-hour nurse advice line
- fitness center memberships
- optional supplemental dental plans
- preventive medical and dental care
- routine vision and hearing care
- telehealth services through Express Care Virtual
Plans usually include prescription drug coverage under Part D, and an individual must use an in-network pharmacy. A person may only use out-of-network pharmacies when traveling, in an emergency, or when an in-network pharmacy does not stock a particular drug.
HMO
Providence have eight HMO plans, with and without prescription drug coverage.
- Prime + Rx
- Extra 001 + Rx
- Timber + Rx
- Extra 002 + Rx
- Enrich + Rx
- Harbor + Rx
- Pine + Rx
- Focus Medical (no prescription drug coverage)
These plans offer the same benefits as original Medicare. They also include telehealth solutions, dental, vision, hearing care, plus alternative healthcare. The level of coverage depends on the plan and annual limits.
A person must choose a primary care physician and use healthcare providers from the plan’s network. These plans do not cover any medical services from out-of-network providers unless in an emergency.
HMO-POS
Providence’s nine HMO-POS plans include:
- Cottonwood + Rx
- Summit + Rx
- Compass + Rx
- Latitude + Rx
- Bridge 1 + Rx
- Choice 001 + Rx
- Bridge 2 + Rx
- Choice 002 + Rx
- Select Medical (no prescription drug coverage)
These plans allow the individual to use out-of-network providers. However, a person may have higher costs to pay, and the provider must agree in advance to accept the health insurance plan.
HMO Dual-Eligible Special Needs Plan
Providence provide one Medicare Advantage HMO Dual Eligible Special Needs Plan (D-SNPs) to people who qualify for both Medicare and Medicaid. The individual must also live in Clackamas, Multnomah, or Washington County in Oregon.
These plans have little to no out-of-pocket costs, such as premiums, deductibles, or copays. They also offer benefits, including prescription drugs, credit for over-the-counter medical supplies, and transport to healthcare services.
Providence offer Medicare Advantage plans in the following Oregon counties:
- Benton
- Clackamas
- Columbia
- Crook
- Deschutes
- Hood River
- Jefferson
- Lane
- Linn
- Marion
- Multnomah
- Polk
- Washington
- Wheeler
- Yamhill
The company also offer plans in these Washington counties:
- Clark
- Snohomish
- Spokane
When people join a Providence Medicare Advantage plan, they must pay the following costs:
- Plan premium: A person pays a monthly premium according to their location and plan. Some Providence plans do not have monthly premiums, but people must continue to pay the premiums for Medicare Parts A, if applicable, and Part B.
- Copayments and coinsurance: When a person receives healthcare, they may pay a copayment or coinsurance.
- Deductible: People must pay a certain amount before Providence cover the remaining costs.
- Out-of-pocket maximum: Unlike original Medicare, Medicare Advantage plans have an out-of-pocket maximum. The limit changes each year, but for 2021, a private insurer cannot charge more than $7,550 for in-network services or $11,300 for combined in-network and out-of-network services.
The table below shows example costs for some Providence Medicare Advantage plans in 2021:
| Location | Plan Name | Monthly Premium | Health / Drug deductible | Out-of-pocket Maximum | Doctor Copay | Specialist Copay |
|---|---|---|---|---|---|---|
| Clackamas, Oregon | Prime + Rx HMO | $0 | $0 / $150 (generics waived) | $5,900 | $0 | $40 |
| Benton, Oregon | Enrich + Rx HMO | $147 | $0, $325 (generics waived) | $5,000 | $15 | $40 |
| Snohomish, Washington | Summit + Rx HMO-POS | $59 | $0, $240 (genericswaived) | $5,500 / $10,000 out of network | $5 / $25 out of network | $40 / $50 out of network or no referral |
The government provide an online tool that allows people to compare Medicare Advantage plans.
A person can enter their ZIP code to determine which plans are available in the area along with expected costs.
Considerations
The table below looks at some of the key differences between original Medicare and Medicare Advantage, including 2021 costs.
| Original Medicare | Medicare Advantage | |
|---|---|---|
| Monthly premium | Part A: $0–$471 Part B: $148.50–$504.90 | $0–$100+ |
| Copayment | Yes | Variable by plan |
| Coinsurance | Yes | Variable by plan |
| Deductible | Part A: $1,484 per benefit period Part B: $203 each year | Variable by plan |
| Part D prescribed drugs | No | In 2021, 89% of plans include drug coverage |
| Out-of-pocket maximum | No | Yes |
| Healthcare Provider choice | Any provider that accepts Medicare | Usually, a person must choose an in-network provider |
A person should examine the different plans available and review their current and future health requirements to help them feel confident in their health plan selection.
The State Health Insurance Assistance Program (SHIP) are an impartial advice service. They provide individual counseling and help at no cost. Their mission is to help people navigate Medicare.
Trained volunteers work within SHIP centers, and they do not sell any form of health insurance. Individuals who need help can find their local SHIP office here or by calling 877-839-2675.
Providence provide Medicare Advantage plans to people living in some Oregon and Washington counties. Most plans include prescription drug coverage.
While they offer the flexibility of both HMO and HMO-POS plans, the latter involves higher associated costs.
Providence also offer a dual-eligible plan for those who qualify for Medicare and Medicaid, known as an HMO D-SNP program.
A person may use the Medicare plan finder to assess each plan’s costs and benefits and determine the most appropriate one for their needs.