Leaving Medicare Advantage in New Mexico: Switching to Original Medicare with QMB Protection

The Medicare Advantage Problem in New Mexico

Medicare Advantage plans can change their networks or stop serving an area. Presbyterian Health Plan has announced that its Senior Care HMO and HMO-POS Medicare Advantage plans will end on December 31, 2026; current coverage, provider networks, and prescription coverage remain unchanged through that date.

For low-income seniors in Albuquerque, Las Cruces, or Santa Fe, the immediate consequence is practical: the doctor they've been seeing for years suddenly isn't in-network, or the plan they enrolled in no longer serves their county.

The Original Medicare Alternative

When a Medicare Advantage plan exits or narrows its network, the typical fallback is Original Medicare (Parts A and B). Original Medicare has no plan network restrictions — your parent can use any provider that accepts Original Medicare.

The catch is cost-sharing. Under Original Medicare:

• Part A deductible: $1,736 per benefit period for hospital stays
• Part B deductible: $283 per year
• Part B coinsurance: 20% of the Medicare-approved amount for outpatient services

Without supplemental coverage, those costs add up fast. The standard solution is Medigap (Medicare Supplement Insurance), but Medigap premiums in New Mexico can run $150–$300/month depending on the plan and your parent's age.

Where QMB Changes the Equation

If your parent qualifies for QMB through New Mexico's Medicare Savings Programs, the state picks up all of those costs:

• Part A and Part B premiums
• The $1,736 hospital deductible
• The $283 annual Part B deductible
• All 20% coinsurance charges

QMB also makes it illegal for any Medicare provider to bill your parent for those amounts. The practical effect: Original Medicare with QMB coverage provides broader provider access than most Medicare Advantage plans, with zero out-of-pocket cost-sharing.

QMB eligibility requires countable monthly income at or below $1,330 for a single person ($1,804 for a couple), with a $20 unearned income disregard. New Mexico has no asset test.

QMB Works Inside Medicare Advantage Too

If your parent wants to stay in a Medicare Advantage plan — maybe they have a plan that still works for them — QMB protections apply equally. The MA plan's copayments and deductibles are covered. In-network providers cannot charge QMB enrollees any cost-sharing amounts.

But the combination of Original Medicare plus QMB often makes more sense for someone whose MA plan is deteriorating. They get unrestricted provider choice with zero cost-sharing instead of a shrinking network with zero cost-sharing.

How to Switch

During the Annual Enrollment Period (October 15 – December 7), your parent can disenroll from their Medicare Advantage plan and return to Original Medicare. They can also switch during the Medicare Advantage Open Enrollment Period (January 1 – March 31).

If their MA plan exits their service area, they qualify for a Special Enrollment Period to switch outside the regular windows.

Apply for the Medicare Savings Program through the YesNM portal or by calling 1-800-283-4465. The MSP application and the Medicare Advantage disenrollment are separate processes — one goes to the state, the other to Medicare.

Free, unbiased help comparing options is available through NM SHIP counselors at the Aging and Disability Resource Center (1-800-432-2080). SHIP counselors don't sell insurance and can walk through the numbers for your parent's specific situation.

The New Mexico Medicare Savings Programs & Extra Help Guide covers the full MSP application process, including how QMB interacts with both Original Medicare and Medicare Advantage plans.

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