Area health care providers offer Medicare, ACA enrollment tips

Open enrollment can strike fear and confusion in the hearts of consumers entering or returning to the Medicare market or buying insurance through the Affordable Care Act.

And rightfully so.

“It’s complex, and it is not easy,” said Ronda Hefton, who must juggle insurance needs for her son who has a chronic heath condition and for her aging parents. “I would give anything if it were more simple.”

But Hefton has an edge.

As the chief administrative officer for Christus Health Plan, Hefton is schooled in buying insurance, unlike the thousands of consumers who will take to a plethora of webpages during open enrollment to navigate their way through complex plans with varying premiums, copays, in-network and out-of-network providers.

Open enrollment for Medicare and Medicare Advantage has already begun and will run through Dec. 7. Open enrollment for Affordable Care Act plans, which New Mexicans can buy under the state’s BeWellnm.com marketplace, is now active and will run through Jan. 15. For those who need coverage by Jan. 1, plans would need to be purchased by Dec. 15.

The biggest mistake consumers make when buying medical insurance is not taking a hard enough look at the year ahead, said Brian Brown, vice president of sales and marketing with Presbyterian Health Plan.

“Health insurance is a very personalized experience,” Brown said. “Most people don’t buy a house without expert guidance, which is what I would encourage any member to do — seek expert guidance. There are a lot of plans and a lot of nuances and misinformation out there, especially with national television ads, so go to a seminar hosted by a carrier and speak with them privately afterward.”

More than 41,000 New Mexicans signed up for ACA

marketplace coverage in 2023, and over 293,000 New Mexicans are enrolled in Medicaid expansion coverage, according to federal data. About 38% of BeWellnm enrollees qualify for state-supported premiums of $10 per month or less, while all those earning under 400% of the federal poverty line qualify for some sort of subsidy.

As many as 24% of Santa Fe residents are 65 and older and eligible for Medicare benefits, said Arturo Delgado, a spokesman for Christus St. Vincent Regional Medical Center.

Traditional Medicare Part A is provided with no monthly premiums to people who are 65 and older, Hefton said. It covers hospitalization, but not the outpatient provider services covered by Part B.

But not necessarily. According to medicare.gov, “most” people are eligible for Medicare if they paid Medicare taxes while working, usually for 10 years. If they did not make those contributions, they “might” be able to buy Medicare insurance at premiums of $278 or $506 each month, depending on their contributions.

“You also have to sign up for Part B to buy Part A,” the website advises, and consumers not buying Part A when they turn 65 could face a 10% penalty on future premiums.

Because Medicare does not cover vision, dental or drug prescription costs, consumers can elect to purchase Parts C and D for a monthly premium, or they can select a Medicare Advantage plan that offers a varying degree of coverages for those services and goods.

Medicare Advantage premiums vary based on the insurer and the level of coverage. Some, like the Presbyterian Health Plan, come at no additional cost. Others could be as much as $200 per month.

Both Hefton and Brown offered their best tips for purchasing health care insurance for 2024:

◆ While no one has a crystal ball, consumers often make health insurance choices based solely on what they can pay rather than finding a plan that matches what they may need. That is a big mistake, Brown said, since costs of unforeseen health events can add up quickly. Brown advises shopping for a livable premium with enough coverage should things go wrong.

◆ Consumers don’t always examine their health circumstances closely enough. Brown says consumers should take a hard look at their health conditions and what they might need in the coming year. Is the patient aging or in need of maintenance medication, a hearing aid or a hip replacement? If so, examine policies and even supplemental insurance to meet those needs.

◆ Are providers in or out of network? Consumers need to know beforehand if the provider they’ve been working with for years will suddenly no longer be available to them. Brown suggests looking for plans that offer flexibility of services like Presbyterian Health Plan’s UltraFlex, which he said is more suited to healthy adults who want to travel since it pays for both in-network and out-of-network providers.

◆ Consumers need to think about what’s convenient. Are in-network providers hours away? Will care have to be scheduled for aging parents or transportation secured so a doctor’s appointment can be made?

◆ Even healthy people can experience unforeseen events. Ask employers if they offer supplemental insurance plans or consider buying a single supplemental major medical plan so an unexpected major event doesn’t break the bank.

◆ For seniors on fixed incomes, look for Medicare Advantage plans that come with no additional cost after buying Medicare Parts A and B. “That plan sits on top of your traditional Medicare plan and provides a lot of benefits and cost savings for members because of the way the co-pays are set up,” Brown said.

◆ Look for a plan with extra advantages like the Silver Sneakers perk, which offers discounts on gym memberships.

◆ Employees who pay more than 9.5% of their gross salaries for health insurance are eligible for ACA subsidies. Visit BeWellnm.com to enroll.

If all else fails, consumers facing enormous medical bills should talk with insurance payers, hospitals and providers.

“Talk to them about a payment plan. Ask for help with guidance,” Brown said. “There are resources available, and they can put some really reasonable programs in place or provide an opportunity to get some assistance somewhere. Don’t delay that talk.”