Medicare Advantage

Medicare Advantage, also called Part C, is an alternative to Original Medicare that combines your hospital and medical coverage, often includes prescription drug benefits, and may offer additional perks like dental, vision, or fitness programs. Choosing the right plan requires careful review of your health needs, providers, and costs.

How to Choose the Right Plan

When evaluating Medicare Advantage plans in New Mexico, consider:

1. Doctors & Hospitals
   Ensure your primary care physician, specialists, and preferred hospitals are in-network.
2. Your Health Needs
   Factor in ongoing conditions, frequency of visits, and any specialized care.
3. Total Costs
   Look beyond the monthly premium. Check copays, deductibles, and the annual out-of-pocket maximum.
4. Extra Benefits
   Many plans offer additional benefits, like dental, vision, hearing, and wellness programs.
5. Plan TypeHMO: Lower cost, limited flexibility, network referrals required
   PPO: More flexibility, higher cost, less restrictive access
   Special Needs Plans: Tailored for specific medical conditions or dual-eligibility
   

Tip: Review your plan annually during Medicare Open Enrollment (October 15 – December 7) to make sure it still meets your needs.

Types of Medicare Advantage Plans

Health Maintenance Organizations (HMO)

• Requires a primary care doctor in-network
• Specialist referrals typically required
• Lower cost but must follow network rules

Preferred Provider Organizations (PPO)

• Greater flexibility to see out-of-network providers
• No referral needed for specialists
• May have higher costs than HMOs

Private Fee-for-Service (PFFS)

• Plan sets payment rates for providers and services
• No referral needed for specialists
• Some providers may not accept this plan

Special Needs Plans (SNPs)

• For individuals with chronic conditions, nursing home residents, or dual-eligible (Medicare and Medicaid)
• Offers tailored benefits to meet specific needs

Other Options: Provider-Sponsored Organizations (PSOs) and Medicare Medical Savings Accounts (MSAs)

Coverage and Costs

All Medicare Advantage plans cover Parts A and B services. Many include additional benefits, such as:

• Prescription drugs (Part D coverage)
• Dental, vision, and hearing
• Fitness and wellness programs

Costs:

• Plans may have $0 monthly premiums, but copays and deductibles apply
• Annual out-of-pocket maximums are required by law
• Some plans cover all or part of your Part B premium

Important: Plans use a network of providers. Out-of-network services may cost more. Always review network rules before enrolling.

Enrollment Periods

Initial Enrollment

• Best time to enroll is during your Medicare Initial Enrollment Period (3 months before your 65th birthday to 3 months after, or 25th month of disability for under 65).

Annual Enrollment (AEP)

• October 15 – December 7 each year
• Add, drop, or switch Part C plans
• Make changes to Part D plans
• Changes effective January 1

Open Enrollment

• January 1 – March 31
• Switch from one Part C plan to another, or return to Original Medicare

Special Enrollment

• For qualifying life events outside standard windows
• Coverage begins the first day of the month after disenrollment from a previous plan

Medicare Advantage vs. Medicare Supplement

• Medicare Advantage (Part C): Combines Parts A and B coverage, often includes prescription drugs, and may offer additional benefits like dental, vision, or fitness programs. Requires use of a network of providers.
• Medicare Supplement (Medigap): Helps pay costs not covered by Original Medicare, such as deductibles and copays. No network restrictions—see any provider that accepts Medicare. Does not include prescription coverage, so Part D is needed separately.

Choosing the right option depends on your health needs, budget, and preferred providers.

Review Your Plan Annually

Medicare Advantage plans change yearly. Review your Annual Notice of Change (ANOC) each fall for updates on:

• Premiums, copays, and deductibles
• Network providers and hospitals
• Prescription coverage and formulary updates

Making an informed review ensures your plan continues to meet your health needs and avoids unexpected out-of-pocket costs.

Next Steps
Medicare Advantage can simplify your coverage and provide extra benefits, but the right plan depends on your needs. Call (505) 417-6565 for a free consultation with Health Wealth Protect LLC. We’ll help you compare plans and choose the one that works best for you.