TABLE OF CONTENTS

For those approaching age 65, it’s time to start looking into Medicare options. Medicare is the federal health insurance program which covers all basic medical care and hospitalization for older Americans, as well as those who have certain disabilities or illnesses. New enrollees have the choice between Original Medicare and Medicare Advantage. While Original Medicare is administered by the government, Medicare Advantage (MA) plans are provided by private health insurance companies.

If you live in New Mexico, you have a wide array of Medicare Advantage plans available to you. Many people choose MA plans because they often provide additional coverage not offered by Original Medicare. To help you decide what’s best for you, this guide is a breakdown of how Medicare Advantage works.

Medicare Advantage Plans in New Mexico

Compare ratings of insurance companies offering Medicare Advantage Plans in New Mexico:

Insurance company Medicare rating A.M. Best rating BBB rating J.D. Power ranking
Aetna 4 stars A A+ 6th out of 9
Cigna 4 stars A- Not rated 8th out of 9
Humana 4 stars A- A+ 2nd out of 9

What You Should Know About Medicare Advantage Plans in New Mexico

  • In 2023, there are 72 Medicare Advantage plans available in New Mexico, compared to 69 plans in 2022.
  • 100% of Medicare beneficiaries have access to a zero premium Medicare Advantage plan in 2023.
  • The average Medicare Advantage monthly premium in 2023 is $11.98, a slight increase from 2022.
  • Through the CMS Innovation Center’s Value-Based Insurance Design (VBID) Model, 15plans will offer Medicare Advantage enrollees eliminated Part D cost-sharing; rewards and incentives programs related to healthy behaviors; and customized, innovative benefits that address social determinants of health, such as food insecurity and social isolation, for certain underserved and/or chronically ill enrollees.

Is Medicare Advantage Right for You?

You have choices in Medicare coverage. While you can opt to stick with Original Medicare, a Medicare Advantage Plan – also known as Part C – may be a better alternative for you.

Original Medicare Medicare Advantage Plans
Original Medicare covers your Part A hospital insurance and Part B medical insurance. Medicare Advantage Plans combine Part A, Part B, and additional benefits.
You can add Part D prescription drug coverage. Prescription drug coverage is usually included.
You’re able to use any medical provider in the U.S. that accepts Medicare. You’ll usually need to use doctors in your plan’s network.
You can buy supplemental coverage to manage out-of-pocket costs, including your coinsurance. Your Medicare Advantage Plan may have lower out-of-pocket costs than Original Medicare.
Vision, hearing, dental, and other benefits aren’t covered. Your plan may offer additional benefits, including vision, hearing, and dental.
  • Note:
  • You can’t have both a Medicare Advantage Plan and a Medicare Supplement Plan.
  • You must be enrolled in Medicare Parts A and B to join a Medicare Advantage Plan.

What’s covered with a Medicare Advantage Plan?

Medicare Advantage Plans cover benefits from Original Medicare Part A (hospital insurance), Part B (medical insurance), usually Part D (prescription drug coverage), and sometimes additional benefits that Original Medicare doesn’t cover. Each Medicare Advantage Plan insurer sets the rules about how you receive and pay for these benefits.

Hospital and skilled nursing facility inpatient care Home health care Prescription drug coverage (if included in your plan)
Medically necessary outpatient services, such as:

  • Doctor’s visits
  • Ambulance services
  • Emergency and urgent care
  • Durable medical equipment (DME)
  • Mental health care
  • Prescription drugs that you cannot self-administer
  • X-rays
  • Laboratory tests
 Preventive services, such as:

  • Vaccinations
  • Cancer screenings
  • Diabetes screenings
  • Depression screenings
 Additional benefits (depending on your plan), such as:

  • Routine vision exams with allowance for glasses
  • Routine dental exams
  • Hearing exams with allowance for hearing aids
  • Fitness and wellness programs and discounts
  • Transportation to medically necessary care
  • Over-the-counter (OTC) drugs

How to Compare Medicare Advantage Plans in New Mexico

With 72 Medicare Advantage Plans available in New Mexico, you likely have several options in your area. To help you choose the best plan for you, consider what is most important to you before selecting a plan. There are several factors to keep in mind:

  • Monthly premium: This is how much you pay for coverage monthly, regardless of the care you receive. You may need to pay your plan’s premium in addition to the Medicare Part B premium, although some plans have $0 premiums or help pay for your Part B premium.
  • Plan network: You may need to use doctors and providers who are within a plan’s network. Before choosing a Medicare Advantage Plan, think about the doctors and facilities (including pharmacies) you prefer to use, then check if the plan offers coverage at those locations. Some plans may provide out-of-network coverage, but this usually comes at a higher cost.
  • Deductible: Your deductible is the amount you must pay before your insurance plan starts helping cover the costs. Medicare Advantage Plans set their deductibles, and these may change only once per year on January 1.
  • Copayments and coinsurance: Copayments or coinsurance are how much you pay for each service or doctor’s visit, such as $20 per doctor visit. Each Medicare Advantage Plan sets its copayment or coinsurance amount that can differ from what you would pay through Original Medicare.
  • Out-of-pocket maximum: Each Medicare Advantage Plan sets a yearly limit on the maximum amount you’d be responsible for paying for services covered by Medicare. Once you reach this limit, you won’t have to pay anything for the services you receive covered by Part A and Part B in that year.
  • Additional coverage: Most Medicare Advantage Plans also provide prescription drug coverage and often include additional benefits that Original Medicare won’t cover, such as vision, dental, and hearing. Plans may provide even more benefits, like discounted gym membership or transportation to doctor’s visits. Medicare Advantage Plans can also tailor their benefits to the specific needs of particular chronically ill beneficiaries.

About Medicare Advantage Plans in New Mexico

With 39% of eligible New Mexico residents choosing a Medicare Advantage Plan, the state tracks with national enrollment levels. For those who choose an MA plan, you’ll have an average of 72 from which to choose. If you’re ready to enroll in Medicare, or you already have Medicare and want to switch plans, reviewing Medicare Advantage options each year is in your best interest.

Number of Medicare Advantage Plans available Medicare Advantage Plan types available Medicare Advantage Plans rated 3.5 or higher by NCQA
72
  • Local HMO
  • Local PPO
  • PFFS
  • Aetna Life Insurance Company
  • Presbyterian Health Plan, Inc.
  • Regence BlueShield
  • Sierra Health and Life Insurance Company, Inc.
  • UnitedHealthcare Insurance Company New Mexico

Types of Medicare Advantage Plans in New Mexico

In New Mexico, the most common Medicare Advantage plans available are HMOs or PPOs, although there are also a few SNPs and regional PFFS plans available. Seniors eligible for Medicare may choose from plans provided by multiple private insurers, although the choices available vary by county.

Types of Medicare Advantage Plans
HMOs HMOs typically require that you receive all services from in network providers:

  • You must have a primary care physician (PCP), referrals for specialists, and prior authorizations for treatments and some prescriptions.
  • Drug coverage usually is included. You aren’t able to purchase standalone drug coverage.
  • Lower costs if you stay in network.
PPOs PPOs include a preferred network of providers, but you have the option of choosing doctors or hospitals from outside of the network for a higher cost.

  • You don’t need to choose a primary care doctor or referrals for specialists.
  • Drug coverage is usually included.
  • You aren’t able to purchase stand-alone drug coverage.
  • Higher premium and out-of-network costs.
PFFS Plans PFFS plans don’t require a primary care physician or referrals for specialists:

  • You can go to any Medicare-approved health care provider or facility that accepts the plan’s payment terms and agrees to treat you.
  • May include drug coverage, or you can purchase a standalone drug plan.
  • Higher cost if you choose a provider that doesn’t agree to the plan’s terms.
SNPs SNPs are only for people with specific conditions and characteristics, and include care coordination and targeted benefits tailored to meet your specific needs:

  • You need a PCP and referrals to specialists.
  • Drug coverage is always included.
  • If you’re eligible, you can join an SNP at any time.

Enrollment and Eligibility for Medicare Advantage Plans in New Mexico

You’re eligible for Medicare when you turn 65 or if you’re younger and have a qualifying disability. A qualifying disability means at least one of the following applies:

  • You’ve received Social Security Disability Insurance or Railroad Board Disability Annuity for 24 months
  • You have Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease
  • You have End-Stage Renal Disease

When you become eligible for Medicare, you are also eligible for Medicare Advantage Plans. There are specific times of the year when you can enroll for the first time in a Medicare Advantage Plan: during your Initial Enrollment Period and the Open Enrollment Period.

  • Your IEP begins three months before the month you turn 65 and extends for three months after the month you turn 65. During this period, you can enroll in a Medicare Advantage Plan. If you join before the month you turn 65, your coverage will begin the first day of the month you turn 65. If you enroll in the three months after turning 65, your coverage will begin the first day of the month after you enroll.
  • If you miss your IEP, you can sign up for Medicare during the General Enrollment Period from January 1 to March 31.
  • After you enroll in Medicare, you can enroll in or make changes to your Medicare Advantage Plan coverage during the Medicare OEP from October 15 and December 7 of each year. During this time, you can change from Original Medicare to Medicare Advantage, switch to a different Medicare Advantage Plan, or change from Medicare Advantage back to Original Medicare.

Medicare Advantage Open Enrollment occurs between January 1 and March 31 of each year. This period is only for beneficiaries already in a Medicare Advantage Plan, and you can change plans or switch to Original Medicare. You cannot switch from Original Medicare to Medicare Advantage during Medicare Advantage Open Enrollment.

There are exceptions to these enrollment periods called Special Enrollment Periods. Certain events or circumstances may make you eligible to change your Medicare Advantage Plan outside of the open enrollment periods, such as if you move outside of your existing plan’s service area or to a location with new plan options you didn’t have before. If you think you may qualify for a Special Enrollment Period, call 1-800-MEDICARE and explain your situation.

Medicare Enrollment Periods
Enrollment period When it happens Medicare plans you can choose What you can do
Initial Enrollment Period Three months before you turn 65, the month you turn 65, and three months after Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Sign up for Medicare Part A and Part B. Complete your Part B enrollment to avoid a late enrollment penalty.
General Enrollment Period January 1 – March 31 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan. If you enroll in Medicare during this period, your MAP enrollment is April through June. Sign up for Medicare if you missed your IEP
Open Enrollment Period October 15 – December 7 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Join, switch, or drop a plan
Medicare Advantage Open Enrollment Period January 1 – March 31 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan If you’re enrolled in a Medicare Advantage Plan, you can change your plan or switch to Original Medicare
Special Enrollment Period When you have a qualifying event Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Make changes to your plan

New Mexico Medicare Advantage Plans With Prescription Drug Coverage

Most Medicare Advantage HMO and PPO plans and all SNP plans provide prescription drug coverage like you would get from Medicare Part D. Some PFFS plans may provide prescription drug coverage, but not all do. Evaluate a plan’s prescription drug coverage when deciding which New Mexico Medicare Advantage Plan to use.

Prescription drug coverage may vary by cost, coverage, and convenience among Medicare Advantage Plans. Your monthly premium may include a premium for the drug coverage in the plan. There is usually a copayment or coinsurance amount that you have to pay for each prescription after you reach your annual deductible.

Some plans use different cost tiers with different costs for different drugs. For instance, you may pay less for generic drugs than brand-name drugs or less for brand-name drugs within different tiers. If your plan uses tiers, the formulary will list all covered drugs and their tiers. Verify your preferred or local pharmacies are included in the plan’s network.

Getting Help with Medicare Advantage Plans

New Mexico-wide Medicare Advantage Resources
Resource Contact How they help
New Mexico Office of Superintendent of Insurance (855) 427-5674 The OSI enforces New Mexico law on insurance matters, including consumer protections, review of insurance forms and rates for accuracy and fairness. Residents can turn to the OSI for insurance concerns.
New Mexico Aging and Long-Term Services (800) 432-2080 New Mexico Aging and Long-Term Services supports aging in place-providing services in homes and communities, supports caregivers, combats senior hunger, encourages healthy and productive aging, and builds and sustains capabilities to meet emerging needs and challenges
Federal Medicare Advantage Resources
Resource Contact How they help
American Hospital Association – Medicare Advantage 1-800-424-4301 The AHA provides education for health care leaders and is a source of information on health care issues and trends.
CMS.gov – Medicare Advantage Applications (800) 633-4227 This page provides important information on the application process for Part C Medicare Advantage plans.
Medicare.gov – Medicare Advantage Plans (800) 633-4227 This government website provides information on the Medicare Advantage program.
author-img
Tammy Burns
Insurance and health care consultant

Tammy Burns is an experienced health insurance advisor. She earned her nursing degree in 1990 from Jacksonville State University, obtained her insurance billing and coding certification in 1995, and holds a health and life insurance license in Alabama, Georgia, Iowa, Mississippi, and Tennessee. Burns is Affordable Care Act (ACA)-certified for health insurance and other ancillary, life, and annuity products. She maintains an active nursing license and practices private-duty nursing.

Burns’ background as a nurse, insurance biller and coder, and insurance consultant includes infectious disease, oncology, gynecology, phlebotomy, post operative, family medicine, geriatrics, home health, hospice, human resources, management, billing, coding, claims, fixed annuities, group and individual health and life products, and Medicare. She’s always been driven by a desire to help people, spending more than 25 years as a practicing nurse in hospitals, private doctors’ offices, home health, and hospice. As a nurse, Burns supported patients filing insurance claims with Medicare, Medicaid, and private insurance companies as well as responding to billing questions from confused patients.

Seeing firsthand how unsuspecting patients are frequently confused by an overly complex system they don’t understand led Burns to become an insurance agent and health care consultant, now helping people understand the medical system. Since becoming an insurance agent in 2013, she has worked with some of the largest and most reputable insurance carriers and agencies in the nation, and she has built a large and loyal clientele by way of her commitment to transparency and personalized service.

author-img
Tammy Burns
Insurance and health care consultant

Tammy Burns is an experienced health insurance advisor. She earned her nursing degree in 1990 from Jacksonville State University, obtained her insurance billing and coding certification in 1995, and holds a health and life insurance license in Alabama, Georgia, Iowa, Mississippi, and Tennessee. Burns is Affordable Care Act (ACA)-certified for health insurance and other ancillary, life, and annuity products. She maintains an active nursing license and practices private-duty nursing.

Burns’ background as a nurse, insurance biller and coder, and insurance consultant includes infectious disease, oncology, gynecology, phlebotomy, post operative, family medicine, geriatrics, home health, hospice, human resources, management, billing, coding, claims, fixed annuities, group and individual health and life products, and Medicare. She’s always been driven by a desire to help people, spending more than 25 years as a practicing nurse in hospitals, private doctors’ offices, home health, and hospice. As a nurse, Burns supported patients filing insurance claims with Medicare, Medicaid, and private insurance companies as well as responding to billing questions from confused patients.

Seeing firsthand how unsuspecting patients are frequently confused by an overly complex system they don’t understand led Burns to become an insurance agent and health care consultant, now helping people understand the medical system. Since becoming an insurance agent in 2013, she has worked with some of the largest and most reputable insurance carriers and agencies in the nation, and she has built a large and loyal clientele by way of her commitment to transparency and personalized service.

Sources