Basically, a Medicare Advantage Plan takes over for Medicare and is sold by private insurance companies who must follow Medicare’s guidelines and cover the same items as Original Medicare. Medicare Advantage Plans frequently include prescription drug coverage, all in one package deal. If you join a Medicare Advantage Plan in New Mexico you must continue paying your Medicare Part B premium, but you will get your Medicare-qualified health care through the Medicare Advantage Plan—not through Medicare.
New Mexico Medicare Advantage Plans are primarily
managed care plans—meaning insurance companies
may require referrals and pre-authorize what services
are covered. It also means coverage is generally
limited to providers in their network. There are two
types of networks: a PPO (Preferred Provider
Organization) or an HMO (Health Maintenance
In this type of network, you’ll get the best benefits when
you go to a network provider. If you go to a non-network
provider, you’ll still be covered, but will incur higher
out-of-pocket expenses. Still, it’s nice to have the option
of being able to go out of network.
HMO networks are, usually, smaller than PPO networks.
Also, in most cases you have to get a referral from your
primary doctor to see a specialist. Be aware that there
is no coverageif you go to an out of network physician
or hospital. An exception to this rule exists if you have
a bona fide medical crisis and go to the emergency
room. In this instance youwould still be covered.
The Advantages of a Medicare Advantage Plan
Lower price tag: Low premiums are the biggest attraction. Premiums in New Mexico can range from about $65 per month for a PPO plan to as low as $0 for an HMO plan. Yep, zero as in zip, zilch, nada.
Changes: How long such $0 premium plans will last is a big question mark, but at least in 2018 they are available from several carriers. Most plans automatically include prescription drugs at no additional cost. Some plans include dental and vision, and even free health club memberships.
The Disadvantages of a Medicare Advantage Plan
Out of Pocket Costs: You will incur costs
for virtually every single doctor visit
and medical procedure, both in and out of the hospital (except for preventive services which are free). Your costs can include deductibles, copayments and coinsurances which will continue until you reach your maximum out of pocket (MOOP). The Max Out of Pocket amount differs between insurance plan.
Network Restrictions: You must see an in-network providers. This mean if you want to see someone out of the network you could pay the entire amount. Some health plans will allow you to go out of network a limited number of times.