Medicare Advantage Plans in New Mexico

What do Medicare Advantage plans in New Mexico cover?

As a starting point, they must provide at least the same amount of coverage as Original Medicare Parts A and B. Medicare Part A provides the hospital coverage portion of Medicare by helping cover inpatient services. Part B, known as medical insurance, helps pay for medically necessary services — doctor’s visits, lab work, durable medical equipment and more.

But in order to get all the coverage you need, Original Medicare may not be enough; Parts A and B leave out some key coverages, forcing many beneficiaries to enroll in separate policies that cover services like dental, hearing, vision and prescription drugs.

Medicare Advantage (Part C) replaces Original Medicare, but offers the same Part A and B benefits and coverages as Original Medicare. What’s different? Along with receiving Part A and B benefits, Medicare Part C often bundles additional services like dental, hearing, vision and prescription drug coverage — all under one plan.

Medicare Advantage coverage areas

If you’re enrolled in a Medicare Advantage plan, you’ll probably need to see doctors in a specific provider network. These are groups of doctors and providers in your area that have agreed to treat your health insurer’s customers. How strictly you need to stick to this group of doctors depends on the type of Medicare Advantage plan you have.

• Of the Medicare Advantage plans in New Mexico, Health Maintenance Organizations (HMO) are among the most popular. HMOs are managed-care plans that use a primary care physician to direct your care and refer you to other in-network doctors. Outside of emergencies, you must usually see in-network providers for your Medicare Advantage plans to cover the costs.
• Among the other popular Medicare Advantage plans in New Mexico are Preferred Provider Organizations (PPO). PPOs differ slightly from HMOs in that most PPO plans do offer some flexibility to see out-of-network providers.
• Private Fee-for-Service (PFFS) pays your provider for each service you receive. While you may have a provider network of doctors that have agreed to these terms, some PFFS beneficiaries can see any doctor who accepts their plan.
• Special Needs Plans (SNP) are designed specifically for people living with certain diseases or conditions. D-SNP assists dual-eligible individuals, and C-SNP is for people with chronic diseases.

When you enroll in Medicare Advantage plans in New Mexico, you may pay a monthly premium, typically in addition to the Part B premium you pay to Medicare. The average Medicare Advantage premium in New Mexico in 2023 was $11.98 monthly.

However, some people do not pay a monthly premium for their Medicare Advantage plan; in 2023, all New Mexicans had access to a $0 monthly premium Medicare Advantage plan.

Even with a premium-free option, you will have costs related to your Medicare Advantage plan, just as you would with Original Medicare. Examples of these costs can include copayments, coinsurance and a deductible. Unlike Original Medicare, Medicare Advantage plans feature an out-of-pocket maximum. This means there is a limit to what you would pay out-of-pocket. Once you hit this threshold, your insurance company will pay the rest of your costs (excluding your monthly premiums) for the rest of your plan year. Some Medicare Advantage beneficiaries prefer the assurance that their healthcare spending won’t exceed this amount.

Most New Mexico residents are eligible for Medicare Advantage when they turn 65. The first step is to enroll in Medicare Parts A and B. The first time to do so is during your Initial Enrollment Period (IEP). This is the time three months before you turn 65, the month of your birthday, and the three months after. For example — if you were born in June, you can enroll in Medicare starting in March. Your IEP closes at the end of September. You can enroll in Medicare later, but missing your Initial Enrollment Period may mean you’ll be stuck paying long-lasting enrollment penalties each month.

Once you’re enrolled in Original Medicare (Parts A and B), you can make the switch to a Medicare Advantage plan.

If you are already receiving Social Security benefits, you will automatically be enrolled in Medicare Parts A and B. If you aren’t, you can enroll in Medicare online, by phone, or in-person at your local Social Security office.

Enrolling in a Medicare Advantage plan doesn’t mean you have to stay with that plan forever. Instead, you can shop around and change your Medicare Advantage plan if you find one that would potentially better serve your healthcare needs.

Enrollment in a new plan most often takes place during the Medicare Open Enrollment Period. Held from October 15 through December 7 each year and also known as the Annual Enrollment Period, this is the time to enroll in a new Medicare Advantage plan for the upcoming year. If you’re already enrolled in Medicare Advantage, you can also switch your plan once each year from January 1 to March 31 during the Medicare Advantage Open Enrollment Period.

What is the Medicare Advantage ratings system?

One way that Medicare Advantage plans help you compare their benefits is by the star ratings system. Each year, Medicare assigns a star rating of up to 5 (excellent) to its members. A number of factors go into the star ratings system, from plan participant satisfaction to how well the plan engages in preventive care for its members. The ratings system allows you to compare plans more easily. Note that some newer plans may not yet have ratings.

Yes, there are Medicare Advantage plans in New Mexico that include prescription drug coverage. For many, an advantage of having a Part C plan with drug coverage is that many are available at low premiums. Others enjoy having just one insurance provider for all of their medical benefits.

In 2021, Medicare launched their Senior Savings Model. This model allows a person to select a participating plan that offers lower-cost insulin. Plans that participate in this model cannot charge more than $35 a month for a variety of insulin options. In 2023, 21 Medicare Advantage plans in New Mexico with prescription drug coverage participated in this model.

What are “tiers” on a Part D plan?

Part D plans arrange their medications on a list called a formulary. Tier I medications are usually generic and therefore low-cost medications. Tier V medications are usually specialty medications that carry the highest costs. The remaining tiers vary based on coverage and your plan. It is important to read a plan’s formulary carefully to ensure your medications are covered. Otherwise, you may have to pay more for your prescription drugs.