Medicare Advantage Plans in New Mexico

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans include Part A (hospital) and Part B (medical) coverage, and most also include prescription drug coverage through Part D. Many Medicare Advantage (MA) plans offer additional benefits, such as routine dental, vision, hearing, fitness memberships, and more.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first be enrolled in Original Medicare (Parts A and B). Most people qualify for Medicare enrollment when they turn 65. However, individuals under 65 may also qualify if they have certain disabilities, ALS (Lou Gehrig’s disease), or end-stage renal disease (ESRD).

Enrollment is limited to specific periods:

• Initial Enrollment (3 months before and after your 65th birthday month)
• General Enrollment
• Special Enrollment Periods for qualifying life events

What Types of Medicare Advantage Plans Are Available in New Mexico?

New Mexico offers a variety of MA plan types, including:

• Health Maintenance Organizations (HMOs): Require in-network care and referrals for specialists.
• Preferred Provider Organizations (PPOs): Allow out-of-network care at a higher cost, typically no referrals needed.
• Private Fee-for-Service (PFFS) Plans: May or may not include provider networks; providers must accept the plan’s terms.
• Special Needs Plans (SNPs):
  • C-SNPs: For chronic conditions such as diabetes, HIV/AIDS, or heart disease.
  • I-SNPs: For individuals in institutional settings or who need nursing care.
  • Dual Eligible Special Needs Plans (D-SNPs): For people who qualify for both Medicare and Medicaid, offering added benefits like care coordination, drug coverage, and dental services.
• Medical Savings Accounts (MSAs): Combine a high-deductible plan with a medical savings account funded by the insurer to help pay for qualified healthcare expenses.

What Are Your Prescription Drug Options with Medicare Advantage?

Most Medicare Advantage plans include Part D drug coverage. However, exceptions include MSAs and some PFFS plans. If your plan does not include prescription drug benefits, you may:

• Enroll in a separate Part D plan (only allowed with certain MA plans)
• Face a late enrollment penalty if you delay enrolling without other creditable coverage

How Do You Choose a Medicare Advantage Plan?

Before enrolling, it’s important to understand Medicare Advantage costs:

• Premiums: Some MA plans in New Mexico have $0 premiums; others may charge a monthly fee.
• Deductibles, Coinsurance & Copays: Know what you’ll pay out of pocket for healthcare services.
• Out-of-Pocket Maximums: This annual cap limits your total spending on covered services.
• Extra Benefits: Look for plans that include dental, vision, hearing, telehealth, gym memberships, and over-the-counter allowances.

When and How Do You Enroll in a Medicare Advantage Plan?

You can enroll in Medicare during specific enrollment periods:

• Initial Enrollment: 3 months before and after your 65th birthday month
• Annual Open Enrollment (Oct 15–Dec 7): Join, switch, or drop MA plans
• General Enrollment (Jan 1–Mar 31): For people signing up for Part B
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch MA plans or revert to Original Medicare
• Special Enrollment Periods: Triggered by life events such as:
  • Moving outside your plan’s service area
  • Losing job-based coverage
  • Plan termination
  • New chronic or dual-eligible status

What If You Want to Change Your Medicare Advantage Plan?

You can switch MA plans during:

• Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

Understanding Medicare Advantage Star Ratings

The CMS star ratings system is how the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) plans using a 5-star quality scale. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

CMS Star Ratings Overview

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

What Are Medicare Resources in New Mexico?

New Mexico residents have access to helpful programs:

• State Health Insurance Assistance Program (SHIP): Offers free Medicare counseling
• Senior Medicare Patrol (SMP): Educates beneficiaries on avoiding healthcare fraud
• New Mexico Office of Superintendent of Insurance: Handles insurance complaints
• New Mexico Medicaid: May help low-income residents with healthcare costs

Learn more about the differences between Medicare and Medicaid.

Other Medicare Plan Options to Help with Out-of-Pocket Costs

Medicare Supplement Plans (Medigap) are policies sold by private insurers to cover deductibles, copayments, and coinsurance from Original Medicare.

• You must be enrolled in Parts A and B.
• The best time to enroll is during the six-month Medigap Open Enrollment Period.
• Plans do not include drug coverage—you’ll need a separate Part D plan.
• There are 10 standardized Medigap plans. Medicare Supplement Plan G is currently the most popular.
• Plan F is no longer available to those newly eligible for Medicare after 2020.
• All Medigap plans offer predictable costs, nationwide coverage, and no referrals.

Learn more about Medicare Supplement plans in New Mexico.

Next Steps

If a Medicare Advantage plan in New Mexico fits your healthcare needs, compare plans available in your area. Check provider networks, prescription coverage, out-of-pocket costs, and additional benefits—then be ready to enroll during your next eligibility window.