Medicare and the Oregon Health Plan are often confused, but they answer different questions: Medicare is federal coverage you earn through age or disability, and the Oregon Health Plan (OHP) is Oregon’s Medicaid program, which you qualify for based on income. The practical difference between Medicaid and Medicare in Oregon shows up in three places: who can get it, what you pay, and what it covers when you need long-term care. Some Oregonians qualify for both at once and pay almost nothing out of pocket.
Who Qualifies for Each
Medicare eligibility has nothing to do with income. You qualify by turning 65, by receiving Social Security Disability Insurance for 24 months, or immediately if you have End-Stage Renal Disease or ALS.1Medicare. Which Path Is Right for Me? A retiree earning $200,000 a year has the same basic eligibility as one earning $20,000. Enrollment runs through the Social Security Administration, not the state. Your Initial Enrollment Period is a seven-month window around your 65th birthday month, and missing it without qualifying employer coverage triggers a permanent 10% Part B late penalty for every full year you could have signed up.2Medicare.gov. Avoid Late Enrollment Penalties That penalty never goes away.
OHP works the opposite way. Eligibility turns on income, not age or work history. For most adults, children, and pregnant Oregonians, the state uses the Modified Adjusted Gross Income standard, with an effective ceiling of about 138% of the Federal Poverty Level.3Oregon Secretary of State. Oregon Administrative Rules 410-200-0315 – Standards and Determining Income Eligibility Using the 2026 poverty guidelines, that works out to roughly:4U.S. Department of Health and Human Services. 2026 Poverty Guidelines
- Single adult: about $22,025 per year
- Family of two: about $29,863 per year
- Family of four: about $45,540 per year
Pregnant people and children under one qualify up to 185% FPL, and children qualify for Oregon’s CHIP up to 300% FPL. There is no open enrollment period for OHP. You can apply year-round through the ONE online portal, at a Department of Human Services office, or with a certified community partner.5Oregon Health Authority. Apply for the Oregon Health Plan (OHP)
Seniors 65 and older and people with disabilities take a different OHP path. This category uses an asset test — generally $2,000 in countable resources, excluding your home and one vehicle — and calculates income differently than the MAGI thresholds. For those who need nursing home care or home and community-based services, Oregon applies more generous limits: a gross monthly income cap of $5,320 (400% FPL) and a resource limit of $99,656 as of January 2026.6Oregon Department of Human Services. Medicaid (OPI-M) Income and Resource Standards If your income is above $5,320 but you need long-term care, Oregon allows an Income Cap Trust (sometimes called a Miller Trust) to redirect excess income so it doesn’t count against the limit.
What You Pay
This is where the two programs diverge most sharply. OHP has no premiums and little to no cost-sharing. Medicare involves real out-of-pocket spending at nearly every step.
About 99% of Medicare beneficiaries pay $0 for Part A because they or a spouse paid Medicare taxes for at least 10 years. If you don’t meet that threshold, Part A runs $311 per month with 30+ quarters of work history, or $565 per month without.7Centers for Medicare & Medicaid Services. 2026 Medicare Parts A and B Premiums and Deductibles The costs nearly everyone faces in 2026:8Medicare.gov. Costs
- Part A hospital deductible: $1,736 per benefit period. That’s not per year. If you’re hospitalized, discharged, and readmitted after 60 days, you pay it again.
- Part A hospital coinsurance: $0 for days 1–60, $434 per day for days 61–90, and $868 per day if you use your 60 lifetime reserve days.
- Part B monthly premium: $202.90 for most people, rising through income-related surcharges (IRMAA) to as much as $689.90 per month for individuals earning above $500,000.7Centers for Medicare & Medicaid Services. 2026 Medicare Parts A and B Premiums and Deductibles
- Part B annual deductible: $283, then you typically pay 20% coinsurance on covered services.
- Part D prescription drugs: national base premium of $38.99 per month, though actual plan premiums vary.9Centers for Medicare & Medicaid Services. 2026 Medicare Part D Bid Information and Part D Premium Stabilization Demonstration Parameters
What Each Program Covers
Medicare’s strength is acute care. Part A covers inpatient hospital stays, skilled nursing after a qualifying hospitalization, hospice, and some home health. Part B covers doctor visits, outpatient care, preventive services, and durable medical equipment. Part C (Medicare Advantage) bundles those through private plans, often adding vision or dental. Part D covers prescriptions.10Medicare.gov. Parts of Medicare
Original Medicare does not cover dental care, routine vision exams, or long-term custodial care. It covers mental health services with the standard 20% coinsurance. Medicare Advantage plans sometimes add dental and vision, but benefits and networks vary by plan.
OHP covers more. Medical, dental, behavioral health, prescription drugs, vision, and pregnancy-related care all come with no premium and little to no out-of-pocket cost.11Oregon Health Authority. Oregon Health Plan (OHP) Benefits OHP pays for non-emergency medical transportation to and from appointments. Behavioral health is especially broad: mental health therapy, substance use treatment including medication-assisted treatment with methadone and buprenorphine, residential treatment, and children’s behavioral services, with no primary care referral required.12Oregon Health Authority. Oregon Health Plan (OHP) Behavioral Health Coverage
The Long-Term Care Gap
If you’re planning for aging, this is the single most important difference. Medicare covers skilled nursing facility care for a limited window: the first 20 days at no cost after you meet the Part A deductible, then $217 per day for days 21 through 100. After day 100, Medicare pays nothing.13Medicare.gov. Skilled Nursing Facility Care The benefit also requires skilled care following a qualifying hospital stay. Medicare is not long-term care coverage.
OHP is. For Oregonians who qualify under the long-term care income and resource rules, OHP covers nursing facility stays without the 100-day cap, as well as home and community-based services that help people stay out of institutions.
Dual Eligibility and Medicare Savings Programs
If you qualify for both Medicare and OHP, you’re “dually eligible.” Medicare pays first for anything it covers, and OHP picks up the rest, including Medicare’s deductibles, coinsurance, and premiums.14Centers for Medicare & Medicaid Services. Dual Eligibility Categories For services Medicare doesn’t cover — dental, long-term custodial nursing facility care — OHP covers them directly.15Oregon Health Authority. Medicare and the Oregon Health Plan (OHP) A dually eligible Oregonian effectively has zero out-of-pocket cost for covered services.
If your income is too high for full OHP but still modest, Oregon offers four Medicare Savings Programs that pay some or all of your Medicare costs. Oregon does not impose an asset limit on these programs, which is more generous than many states.16Oregon Department of Human Services. Help Paying Medicare Costs
- Qualified Medicare Beneficiary (QMB) pays Part A and Part B premiums, deductibles, and coinsurance. Monthly income limit: $1,330 individual, $1,804 couple.
- Specified Low-Income Medicare Beneficiary (SLMB) pays the Part B premium. Monthly income limit: $1,596 individual, $2,164 couple.
- Qualifying Individual (QI) pays the Part B premium. Monthly income limit: $1,796 individual, $2,435 couple.
- Qualified Disabled Working Individual (QDWI) pays the Part A premium for disabled individuals who returned to work and lost premium-free Part A. Monthly income limit: $2,660 individual, $3,607 couple.
QMB offers the strongest protection. Medicare providers are legally prohibited from billing QMB enrollees for any Part A or Part B cost-sharing. If a provider sends a bill for those charges, it is not your responsibility.
A separate federal program called Extra Help reduces Part D prescription costs. In 2026, you may qualify with annual income below $23,940 (individual) or $32,460 (couple), and resources below $18,090 (individual) or $36,100 (couple).17Medicare. Help With Drug Costs Qualifying for any Oregon Medicare Savings Program makes you automatically eligible for Extra Help.
Estate Recovery: What Happens After Death
Most people don’t learn about this until it’s too late to plan around it. Federal law requires every state to seek repayment from the estates of deceased Medicaid recipients who were 55 or older when they received certain services, primarily nursing facility care, home and community-based services, and related hospital and prescription drug costs.18Medicaid.gov. Estate Recovery Oregon’s Department of Human Services handles this process after you pass away.
Oregon will not pursue a claim if you leave behind a spouse (recovery is deferred until the surviving spouse dies), a child under 21, or a blind or disabled child of any age.19Oregon Department of Human Services. Estate Recovery Up to $3,500 in burial-related expenses can be paid from the estate before any recovery claim, reduced by any prepaid burial funds or burial insurance.
Your home is usually the largest asset at risk. A surviving spouse is not required to sell the home while alive, but once the home becomes part of a probatable estate with no protected survivors, it can be subject to recovery. Oregon must offer a hardship waiver process, and heirs can apply. Estate planning with an elder law attorney before applying for long-term care Medicaid can meaningfully change what happens to your assets later.
One protection worth knowing: states cannot recover Medicare cost-sharing paid through Medicare Savings Programs. If OHP paid only your Medicare premiums and copays through QMB or SLMB, those payments are not subject to estate recovery. Estate recovery does not apply to Medicare at all — Medicare is insurance you earned, not a benefit the government reclaims from your estate.
Free Help Sorting This Out
Oregon runs the Senior Health Insurance Benefits Assistance program, known as SHIBA, which provides free, confidential one-on-one counseling from trained volunteers. SHIBA counselors help Oregonians compare Medicare Advantage and Part D plans, check whether they qualify for a Medicare Savings Program, and sort out billing problems. They don’t sell insurance. Reach SHIBA at 1-800-722-4134 or shiba.oregon.gov.20State of Oregon. Medicare Help For OHP questions, the Oregon Health Authority line is 1-800-699-9075.5Oregon Health Authority. Apply for the Oregon Health Plan (OHP)