Seniors enrolled in Original Medicare Parts A and B can obtain most of the same benefits plus extras through Medicare Advantage, also referred to as Medicare Part C. While federally funded Original Medicare gives the same coverage to all beneficiaries, Medicare Advantage plans are run by private, Medicare-approved insurance companies and offer varying levels of coverage. Part C plans typically include benefits beyond Medicare Parts A and B, such as prescription drug coverage, vision and hearing care and wellness visits. Medicare Advantage enrollees cannot buy supplemental coverage, such as the Medigap policies available for Original Medicare enrollees.
Enrollment in Medicare Advantage has more than tripled since its introduction in 1999, according to research by the Kaiser Family Foundation. The KFF reports that 39% of all Medicare beneficiaries nationwide are enrolled in a Medicare Advantage plan. The share of these plans within each individual state varies considerably. However, New Mexico is right at the national average, and most of its neighbors including Texas, Colorado and Arizona have similar shares. However, Oklahoma to the northeast has a significantly lower Medicare Part C enrollment rate at only 24%.
Seniors in New Mexico can choose from hundreds of Medicare Advantage plans offered throughout the state. Not every plan is available everywhere, so it is important for seniors to learn what is offered in their area. Private health insurers offer a variety of HMO, PPO, PFFS, MSA and SNP plans. Many plans include prescription drug coverage. In this guide, we explain differences among these types of plans in addition to prescription coverage options for enrollees in New Mexico. We also explain when to enroll in Medicare Advantage. Finally, we list state and local resources for older New Mexicans who need guidance to help them choose the right Medicare Advantage Plan.
In New Mexico, seniors may select one of five Medicare Advantage plan types: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private-Fee-For-Service (PFFS) plans, Medical Savings Accounts (MSAs) and Special Needs Plans (SNPs).
Health Maintenance Organizations (HMOs)
HMOs typically charge lower premiums than other Part C plans. Enrollees must obtain medical services from doctors, hospitals and other health care providers in the plan’s network, except for emergency care and out-of-area urgent care or dialysis. In most cases, HMOs require that members choose a primary care doctor from within the network, and get a referral from them to see a specialist. Most HMO plans provide prescription drug coverage, and HMO Point-of-Service (HMO-POS) plans let enrollees get out-of-network care for a higher co-payment.
Preferred Provider Organizations (PPOs)
Preferred Provider Organizations (PPOs) offer members the option of getting health care services from its network of physicians, hospitals and other medical providers at a lower cost than from care providers outside the network. Enrollees always have coverage for emergency and urgent care, and many PPOs include Medicare drug coverage, but seniors must join a plan that specifically offers it. PPOs do not require designating a primary care doctor or obtaining a referral to see a specialist, but these plans typically have higher premiums than HMO plans.
Private Fee-For-Service (PFFS) Plans
Private Fee-For-Service (PFFS) plans allow members to see any Medicare-approved health care provider that agrees to accept the plan’s payment terms. Some plans have a network of providers who have agreed to always treat enrollees. Members can seek out-of-network medical care from providers who accept the plan’s terms, but that will likely cost more. PFFs plans do not require selecting a primary care physician or a referral to see a specialist, and some offer prescription drug coverage.
Medical Savings Accounts (MSAs)
Medical Savings Accounts (MSAs) are much like health savings accounts, combining high-deductible insurance with a savings account to cover fee-for-care medical costs. MSAs allow people to receive health care services anywhere in the US. All MSAs are zero-premium plans, and policyholders must pay for all medical expenses up to their deductible, at which point the plan covers all subsequent costs. These plans do not provide prescription drug coverage, so seniors with MSAs need to enroll in a separate Medicare Part D plan. They can, however, use their MSA funds to pay for prescriptions and certain other health care expenses not covered by Medicare Parts A and B.
Special Needs Plans (SNPs)
Special Needs Plans (SNPs) are customized benefits plans for people with limited incomes and certain diseases or health issues. These individuals might require institutional-level nursing care, be dually eligible for Medicare and Medicaid or have a debilitating chronic illness, such as end-stage renal disease, congestive heart failure or dementia. SNPs coordinate care services to meet the particular needs of the populations they serve. These plans normally use a network of health care providers, but some cover out-of-network services at a higher cost. By law, all SNP plans must provide Medicare prescription drug coverage. Usually, enrollees must choose an in-network primary care doctor and obtain a referral to see a specialist.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
In New Mexico, seniors enrolled in Medicare Advantage who want coverage for prescriptions must choose a type of plan called an MA-PD that includes this provision. MSA and certain PFFS plans do not offer drug coverage, so seniors with these plans can join a stand-alone Medicare prescription drug plan, also called a Part D plan. However, Medicare Advantage HMO and PPO plans cannot be combined with a Part D plan. Seniors who have Medicare Advantage and join a separate drug plan will be disenrolled from their Part C plan and returned to traditional Medicare. Some MA-PD plans charge two separate monthly premiums.
Medicare Advantage can simplify health care coverage for many seniors by providing a single insurer, additional coverage and lower costs. However, it can be difficult to sort through all the options and elements of the program to determine which plan best meets an individual’s needs. To help guide seniors on their Medicare Advantage search, we have assembled this list of state and community-based resources in New Mexico.
The New Mexico Aging and Long-Term Services Department is the headquarters for the state’s senior services, working with public and private agencies to inform, support and protect seniors and adults with disabilities in regards to aging-related resources, including various Medicare and Medicaid programs. The department collaborates with other programs and agencies, such as the Long-Term Care Ombudsman, Aging and Disability Resource Center and Area Agencies on Aging.
New Mexico’s Aging and Disability Resource Center (ADRC) is a centralized source for information and assistance with health care programs such as Medicare Advantage, long-term options counseling, prescription drug assistance and various local resources. Its Resource Directory provides the latest information about national, state and community programs.
New Mexico’s Long-Term Care Ombudsman Program advocates for residents of long-term care facilities. Volunteer ombudsmen work through grievances between residents, families and facilities to secure individual rights. They help clarify long-term care options and investigate Medicaid, Medicare and Social Security concerns. Ombudsmen also offer guidance on Medicaid and Medicare coverage stipulations, the application process and services covered.
Confidential help from an ombudsman can be arranged by calling 1-866-451-2091 toll free from anywhere in New Mexico.
New Mexico’s State Health Insurance Assistance Program (SHIP) program is available to address questions and concerns about Medicare and Medicaid. SHIP representatives provide seniors, family members and caregivers with up-to-date, unbiased information and do not promote or endorse any insurance plans.
To access free help with understanding or choosing a Medicare Advantage plan, call the ADRC at 1-800-432-2080 and ask for a SHIP representative.
New Mexico has four Area Agencies on Aging (AAAs) that plan, support and oversee community-based initiatives for people ages 60 and older, or aged 55 and older in tribal communities. Most of these services are available locally. Each AAA acts as an information and referral hub to help seniors and their families make the most of benefits at their disposal, including Medicare and Medicaid programs. These agencies place a priority on minorities with low incomes, seniors who reside in rural areas, those with limited English proficiency, older citizens with dementia and individuals at risk of being institutionalized in a nursing home or other facility. Each AAA assists older New Mexicans in one of the state’s six regional Planning and Service Areas (PSAs).
For more information about New Mexico’s Area Agencies on Aging and the PSAs each covers, call 1-800-432-2080. A list of the AAAs, their addresses and contact details is available on the New Mexico Aging & Long-Term Care Services website.Visit Website
The Senior Information and Assistance Program is a referral service for residents aged 50 and older in the city of Albuquerque and Bernalillo County. It connects seniors and their family members and caregivers with resources and programs regarding health insurance options and costs, including those of Medicare Advantage. The agency also publishes a free Quick Guide to Senior Services that offers information about key community-based services in the Albuquerque area.
The Deming Luna County Senior Citizens Center strives to be a one-stop information resource for seniors aged 60 and older living in Deming, Columbus and Luna County. The staff provides information and counseling about Medicare, Medicaid and other local, state and federal services and programs that benefit the senior population.