Medicare Advantage Plans in New Mexico

checkmark Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Updated: Jun 02, 2021

 

Medicare Advantage lets seniors in New Mexico opt to receive general healthcare and hospitalization coverage through private Medicare-approved insurers in place of Original Medicare Parts A and B. Medicare Advantage plans are sometimes referred to as Medicare Part C and have similar benefits to traditional federally managed Medicare plans, but typically offer additional coverage, such as prescription medications, vision, dental, and hearing services. Coverage specifics, premiums, and out-of-pocket costs for services may vary by individual plan.

Key Points

  • 1 In 2019, there were 25 Medicare Advantage plans available in New Mexico.
  • 2 33% of the total Medicare population in New Mexico is enrolled in Medicare Advantage plans as of 2018.
  • 3 In 2018, Original Medicare spent an average of $8,112 per beneficiary in New Mexico, which is 20% lower than the national average.
  • 4 Available Medicare Advantage plans range from three to 27 across New Mexico’s 33 counties.

When New Mexico seniors enroll in a Medicare Part C plan, they can reduce unexpected healthcare expenses by limiting their out-of-pocket costs for covered services, such as physician visits and hospital stays. Although coverage is provided by private companies, insurers must abide by rules set by Medicare, and enrollees are afforded the rights and protections that come with Original Medicare. Plans may vary in price, coverage, and availability, depending on the participant’s county of residence. Enrollees should compare each plan’s specifications to determine which option best suits their individual needs.  

Medicare Advantage Plans in New Mexico

Types of Medicare Advantage Plans

New Mexico’s Medicare Advantage program includes several common types of plans, including HMOs, PPOs, and PFFS plans. These options are available at various price points through several prominent private insurers and may resemble traditional employer-sponsored health insurance. In some geographic areas, seniors can also find SNPs, which offer benefits tailored to their unique medical or situational needs. Plan specifics may vary depending on the individual insurer and the area of coverage. 

Health Maintenance Organizations (HMO)

Seniors who opt for an HMO receive care and services through a network of plan-approved medical professionals and hospitals. Enrollees choose a primary care physician who is typically the patient’s first point of contact for health care and who may provide specialist referrals, as needed. Out-of-network services generally are only covered in emergencies, such as out-of-area urgent care. Otherwise, out-of-network care may result in the patient incurring the full cost of services. Some Medicare Advantage HMOs also offer prescription healthcare coverage. Although care options through HMOs may be restrictive, they’re usually the most affordable type of plan, often carrying low or no deductibles.

Preferred Provider Organizations (PPO)

PPO plans are more flexible than HMOs but tend to have higher premiums and come with deductibles. Members aren’t generally required to select a primary care physician or to get referrals for seeing specialists. Still, PPOs do provide an extensive list of preferred providers for enrollees who want to incur the lowest co-pay and coinsurance rates. PPO members may seek services from out-of-network doctors and hospitals at a higher out-of-pocket cost. Prescription drug coverage may be available through some PPO plans.

Private Fee-For-Service Plans (PFFS)

PFFS plans typically have higher premiums than HMOs or PPOs but offer plan members the greatest flexibility when it comes to choosing providers. Although some PFFS plans have a network of practitioners, enrollees may choose to receive care from any Medicare-approved provider who agrees to the plan’s terms and still be covered. PFFS plans don’t require referrals for specialist visits, and members don’t need to select a PCP. Out-of-network providers may elect not to treat a plan participant, even if they’re an established patient of the practice.

Special Needs Plans (SNP)

SNPs are limited-membership plans. Dual Medicare/Medicaid-eligible seniors, individuals with chronic or disabling conditions, such as dementia, cancer, and alcohol or drug dependence, or those who require long-term care may be eligible for an SNP designed for their specific circumstances. Although premiums are generally high, SNPs tailor benefits to the needs of their enrollees through targeted provider networks and special drug formularies. Plan participants must receive care from within the approved network of providers, except during emergencies or for out-of-area dialysis in the case of End-Stage Renal Disease. Enrollees may be required to select a primary care physician and have a care coordinator for treatments. SNPs may be limited to specific geographic areas, which can vary year to year.

Enrollment & Eligibility for Medicare Advantage Plans in New Mexico

Eligibility

To qualify for New Mexico’s Medicare Advantage program, seniors must meet the eligibility requirements for Medicare Parts A and B.  Applicants must also meet the following criteria:

  • Be at least 65 years old or have a qualifying disability
  • Be a U.S. citizen or permanent resident
  • Reside in an area where Medicare Advantage plans are offered
  • Not be enrolled in Medigap insurance

New Mexico seniors with End Stage Renal Disease aren’t eligible for Medicare Advantage plans, with the exception of relevant SNPs. Seniors who receive benefits through Social Security or the Railroad Retirement Board at least four months prior to turning age 65 are automatically enrolled in Original Medicare but may opt for an Advantage plan. The start date of coverage may vary depending on when sign up occurred.

Enrollment Periods

Enrollment in a Medicare Advantage plan must occur during predetermined enrollment periods, although special registration times may open up for unique situations. During these time frames, seniors who are new to the program may complete initial sign-ups, and existing members may change plans. Annual enrollment periods may also be open to applicants who delayed their initial coverage. These enrollment periods are broken down as follows:

  • Initial coverage election periods run for seven months, spanning the three months before, during and after an enrollee’s 65th birthday month. During this time, seniors aging into the program may sign up for coverage.
  • Annual election periods run from October 15th to December 7th. Current Medicare recipients may switch to a Medicare Advantage plan for the first time, and Medicare Advantage participants may switch plans or join a prescription drug plan.
  • The open enrollment period runs from January 1st to March 31st and is for current Medicare Advantage recipients only. During this period, participants may change plans or revert back to Original Medicare.
  • The general enrollment period runs from April 1st to June 30th and is intended for seniors who had Medicare Part A and signed up for Part B during open enrollment. At this time, members may switch to Medicare Advantage.

Prescription Drug Coverage

New Mexico seniors may receive prescription drug coverage through certain Medicare Advantage plans, known as Medicare Advantage Prescription Drug plans or MA-PDs, and coverage varies by plan. To receive benefits, members opting for an HMO or PPO must choose a plan that bundles in prescription drug coverage. They may not obtain separate Medicare Part D prescription drug plans, and forfeit Medicare Advantage if they do, reverting to Original Medicare. Members of PFFS plans can opt for a plan that includes prescription drug coverage or choose to enroll in a separate Medicare Part D plan. By law, SNPs must include prescription drug coverage. Plans may vary in cost and in medications covered.

Medicare Advantage Resources in New Mexico

Medicare Advantage provides valuable health insurance coverage to New Mexico seniors, but with so many options available, choosing a plan can be confusing. First-time enrollees and individuals considering changes in coverage may need help finding plans that suit their unique healthcare needs. New Mexico provides state and local resources to help qualified seniors understand the choices available and assist with completing the enrollment process.

Aging & Disability Resource Center (ADRC)

Operating through the New Mexico Aging & Long-Term Services Department, the Aging & Disability Resource Center (ADRC) is designed to connect seniors and disabled individuals with resources that support their health and can help them maintain an independent lifestyle. The ADRC’s trained counselors provide unbiased, accurate, current information about Medicare, helping New Mexico seniors explore available options and obtain affordable healthcare coverage that’s right for their needs. The organization also sponsors a Senior Medicare Patrol, which helps beneficiaries detect and avoid falling victim to Medicare fraud.

Contact Information: Website | 1-800-432-2080

Sponsored by the State Bar of New Mexico, the LREP provides free legal advice and services to state residents aged 55 and older. Callers go through a thorough intake process and are then connected with qualified attorneys who specialize in legal issues affecting seniors, including those related to Medicare, Medicaid, and long-term care. The organization also runs statewide workshops and legal clinics on senior-related topics. There are no income restrictions for receiving LREP services, and counseling is available in English and Spanish.

Contact Information: Website | 1-800-876-6657

HMS Family Services

Serving Hidalgo and Grant counties, HMS is a nonprofit organization that offers healthcare-related support services to the area’s senior population. Through HMS Family Services, New Mexico seniors can get help with Medicare enrollment and receive referrals to other community resources. HMS is dedicated to addressing social factors that may affect patients’ health outcomes, and the organization regularly sponsors health-related community outreach events.

Contact Information: Website | 1-888-271-3596

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Contributing Expert:

Roseann Birch, Medicare Consultant

With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.

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Reviewed by:

Leron Moore, Medicare Consultant

With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.