Benefit Navigation

Medicare is a federal health insurance program for people age 65 and older and fro people younger than 65 with SSDI and/or certain health conditions, which helps pay for a wide range of healthcare services.

Medicare Part A:

Federal health insurance covering the cost of inpatient hospital, skilled nursing care and Hospice care; accepted nationwide – sometimes no premium

Medicare Part B:

Federal health insurance covering 80% of the cost of outpatient care, medical, behavioral health care and physical therapy; accepted nationwide; usually does not have co-pays for services or require pre-authorization

Medicare Part D:

prescription drug plans, usually accepted nationwide

Medicare Advantage:

sometimes erroneously called Medicare Part C – is private insurance, networked based insurance that includes Part A, B, and D coverage plus some dental, vision and hearing payment assistance; usually has co-pays and for services that are not applied to the overall deductible and requires prior authorization.

Enrolling in Medicare:

To enroll in Medicare, you must apply through Social Security.

Exception: People who begin receiving social security benefit payments prior to turning 65 will be auto-enrolled in Medicare Parts A and B ONLY. Part D, the Medicare prescription drug plan, must be signed up for at Medicare.gov separately.  There are lifetime penalties for not signing up for Part D.

The fastest way to enroll in Medicare is online at ssa.gov/medicare. If the online process is not possible, the other options are to call a Social Security office set up a phone or an in-person appointment in Santa Fe.

Medicare Enrollment periods:

Unlike Medicaid, Medicare has restrictions as to when you can apply, if you have not been auto-enrolled. There are 4 enrollment periods.

Initial Enrollment Period:

For those turning 65 – 7 months – 3 months before your 65^th birthday, your birthday month and 3 months after

For those 18 and over who have received Social Security Disability Insurance (SSDI) or Railroad Disability payments* – initial enrollment is 24 months after SSDI payments begin

*unless they have been diagnosed with Amyotrophic Lateral Sclerosis (ALS) OR diagnosed with End Stage Renal Disease and have a qualifying Medicare work history – these individuals are eligible for enrollment as soon as SSDI payments begin

Medicare Open Enrollment – October 15 – December 7:

This enrollment period is for those who already have Traditional Medicare or a Medicare Advantage plan and want to change or add to their coverage.

Medicare Advantage/General Enrollment – January 1 – March 31:

This enrollment period is for those who have Medicare Advantage plans and want to change coverage and for people who did not sign up for Medicare their initial enrollment period. Unfortunately, for those who missed their initial enrollment, there can be financial penalties called late enrollment penalties.

Special Enrollment Period:

If still working full time when turning 65, and have employer-sponsored health insurance, signing up for Medicare B can be delayed.  Signing up for Medicare Part A is highly recommended because it will likely be free (due to meeting the work history requirements) and it may provide additional protections for unexpected serious illness requiring inpatient hospital care.

Reducing the cost of Medicare:

There are parts of Medicare that can be free for some people.

For Example: Medicare Part A – there is no premium for Part A for those who sign up during their initial enrollment who have a qualifying work history—working at jobs paying into social security for at least 10 years.

For those who did not work at all and those who worked at jobs that did not pay into social security or paid less than 10 years, Part A has a monthly premium, which can be as high as $515 in 2025.

Medicare Part B has a monthly premium in 2025 is $185 and the deductible is $257 per year. There is a life-time penalty of 10% of the standard premium for each year of delay assessed for late sign up for Part B.

Example: If Mrs. R was eligible in 2024 and didn’t apply for Part B until 2025 – she will have to pay an additional 10% of the $185 monthly premium of $18.50 more – totaling $203.50 a month for the rest of her life.

Medicare Part D in most cases does not have a monthly premium. There is a life-time penalty assessed for late sign up for Part D.  In 2025, it’s $.36 for every month after the initial enrollment period that Part D wasn’t applied for.

Example: Mr. G was eligible for Part D in January 2020 and did not apply until January 2025 – 5 years or 60 months later – his penalty will be $21.60 a month for the rest of his life. So, even if he signed up for a plan with a $0 monthly premium, he will have to pay $21.60 a month for his plan.

Late enrollment penalties can be avoided by keeping track of initial enrollment period start and end dates or qualifying for a Special Enrollment period.

The good news is that, for community members with limited income, there are assistance programs to help cover the cost of penalties and make Medicare more affordable.

Medicare Savings Plans:

Medicare Savings Plans or MSPs applied for through yes.nm.gov, cover the Part B premium for one year, when applicants are approved.

In 2025, a single applicant with income below $1,305.00 per month, will likely qualify for the Qualified Medicare Beneficiary (QMB) program, which will cover the cost of Medicare Part A, B and D, including premiums, deductibles, copays and late enrollment penalties.

QMB also covers the 20% that Medicare Part B does not cover and qualifies recipients for Extra Help. This provides those who qualify with virtually no cost, complete health coverage.

Extra Help:

This program helps people with slightly higher income and resources with the cost of prescription drugs, like deductibles and copays. You can apply for Extra Help any time before or after you enroll in Part D.  For more information or to apply: www.ssa.gov/medicare/part-d-extra-help

Medicare Supplement Plans aka Medigap Plans:

Developed by private insurance to help cover the costs of Medicare for those on traditional Medicare, who do not qualify for Medicare Savings plans, these plans cover Part A deductible, coinsurance and hospital costs and Hospice care; the 20% of Part B that Medicare doesn’t cover as well as Skilled nursing facility costs. They do not cover the Part B monthly premium or deductible.

They charge a monthly premium that increases with age. The best time to purchase one is during the initial enrollment period because seniors cannot be turned down and no medical questions are allowed, under guaranteed issue rights.

If purchase of a Medigap plan occurs after initial enrollment has ended, guaranteed issue rights are no longer in force, detailed questions about medical history will be asked, applicants can be turned down, and monthly premiums are often higher.

Medicare Supplement plans are not available to anyone who has a Medicare Advantage plan.

Health Exchange /Affordable Care Act:

In January 2014, the Affordable Care Act implemented Medicaid expansion in participating states, like New Mexico, to open up health insurance exchanges. Through these exchanges all Americans, who do not qualify for Medicaid or Medicare and are not provided health care by their employers, are eligible for qualified health insurance plans.

BeWell – New Mexico’s Health Insurance Marketplace

The Fall Open Enrollment Period for BeWell occurs every November 1 – January 15.

Coverage for approved applicants begins on January 1^st or February 1^st of the next year.

The Benefit Navigators of Holy Cross are certified each year by BeWell to provide free year-round benefit navigation and enrollment counseling services, because sometimes there are changes in people’s lives that qualify people for Special Enrollment periods with BeWell.

There are a few ways to apply for a BeWell plan:

1. Contact a Benefit Navigator to make an appointment. They will help you to complete the online application process.
   • Mary Walker, Benefit Navigation Coordinator: 575-751-8939; marywa@taoshospital.org
   • Megan Lopez, Benefit Navigation Specialist: 575-751-5848 – bilingual

Appointments can be in-person, virtual or over the phone. Walk-in hours on Mondays ONLY in Room 7 at Holy Cross Hospital from 9 AM to 3 PM are also offered.

2. Visit bewellnm.com and set up an online account and complete the application process
3. Call 1-833-862-3935 (TTY – 833-862-3935) and have a BeWell representative walk you through the application process.

Be prepared for your appointment:

• Know which insurance plans your doctors, specialists, therapists and counselors accept.
• Have an estimate of your income ready
• Have filed your taxes
• Know who is in your tax household, even if they are not applying

• • Dates of Birth
  • Social Security Number
  • Income

• Have a list of your current Medications and dosage prepared, so you can make the insurance plan you are considering will cover them.
• Read any notices you receive from BeWell, so if additional information is requested you can submit it before it effects your coverage.

Renewal of existing coverage with BeWell:

Auto-renewal is possible in 2025, if the plan member:

• Was covered last year and gave permission for BeWell to access income records from 2025
• Filed your 2024 taxes and reconciled your tax credits
• Is satisfied with your current plan, including the type of coverage and the amount of advanced premium tax credits
• Income and household information has not changed,

Tax credit eligibility will only be granted to BeWell members who continually file taxes and reconcile their tax credits.

Applying for BeWell outside of the Fall Enrollment period

Consumers who experience certain changes in circumstances outside of open enrollment may be eligible for a Special Enrollment Period (SEP) to enroll in or change marketplace health plans. Here are some examples:

• Loss of insurance coverage – not due to missing premium payments
• Loss of Medicaid coverage
• Change in employment
• Membership in a federally recognized American Indian or Alaska Native tribe
• Newly declared U.S. citizen, U.S. national or lawfully present individual
• Change in household and/or number of dependents (e.g. through marriage, birth, adoption, placement for adoption or in foster care, a child support order or other court order, divorce, out of state move, death)
• Termination of a non-calendar year plan (even if able to renew)
• Survivor of domestic violence or spousal abandonment
• New to New Mexico
• Newly released from incarceration
• Unintentionally, inadvertently, or erroneously being enrolled (or not enrolled)

If you believe you qualify for a SEP please contact our Benefit Navigators for assistance:

• Mary Walker, Benefit Navigation Coordinator: 575-751-8939; marywa@taoshospital.org
• Megan Lopez, Benefit Navigation Specialist: 575-751-5848 – for bilingual services

There are numerous categories of Medicaid, including SNAP and LIHEAP, each with specific eligibility requirements. These eligibility requirements are subject to state and federal laws and our navigators stay current with these changes.

Holy Cross Hospital’s Enrollment Team is happy to help you and your family enroll in Medicaid.

For assistance please contact:

• Mary Walker, Benefit Navigation Coordinator: 575-751-8939; marywa@taoshospital.org
• Megan Lopez, Benefit Navigation Specialist: 575-751-5848 – for bilingual services

Support with Medicaid Enrollment

If you’d like help applying for Medicaid, please call us and we can help. We can also talk through your situation to see if there might be other programs for which you might qualify. When applying for Medicaid benefits for any member of your household you may be asked to bring in the following documents to your appointment:

Proof of Income

• Pay stubs of last 30 days
• Documents showing any unearned income – such as child support, Social Security benefits, unemployment benefits
• Proof of New Mexico Residency – This can be a utility bill or mail addressed to the applicant at a New Mexico address
• Social Security Numbers of individuals needing Medicaid (S.S. Card not needed)
• Proof of Citizenship or Legal Immigration Status AND Identity:

Citizenship or Legal Immigration Status

• S. Birth Certificate
• An American Indian Card issued by the Dept. of Homeland Security
• Passport (can be expired)
• Legal Immigration Status (applicants who are eligible must have resided in the US for five years)
• Permanent Resident Card (also known as a “green card”)

Identity

• A current State Driver’s License with a picture
• A current State ID card with a picture
• A school ID card with a picture of the individual
• Documents proving childcare expenses, if applicable
• Medical Insurance Card if applicable
• Proof of Pregnancy if applicable
• Proof of New Mexico Residency – This can be a utility bill or mail addressed to the applicant at a New Mexico address
• Social Security Numbers of individuals needing Medicaid (S.S. Card not needed)

We can help with:

Medicaid Health Insurance – Application – available on-site, over the phone or via video call

Medicaid Applications

Submitted online through yes.nm.gov for ongoing (as opposed to short-term) Medicaid for low-income individuals and families, children under 19 with a parent or guardian present, and pregnant women. The review and approval process can take up to 45 days.

Presumptive Eligibility

This short-term Medicaid (up to 45 days) is a determination for immediate coverage granted at the discretion of our Benefit Navigators, for those without current coverage, while the ongoing application is being reviewed. There is a “presumption” that the client’s statement regarding citizenship, household and income is true and correct.

Re-Certification

We also assist clients with renewing Medicaid applications. It is important renewals are submitted annually before the deadline so there is no lapse in Medicaid coverage.  Our Benefit Navigators can help keep you on track.

Other types of Medicaid:

QMB/SLIMB/QI-1

Our Benefit Navigators can help with filling out a Medicaid Application to help pay for Medicare and qualify for lower cost prescription drugs:

• Qualified Medicare Beneficiaries (QMB), and
• Specified Low Income Medicare Beneficiaries (SLIMB)
• Qualified Individual (QI-1)

QMB:

available to the lowest income group, you must have or be eligible for Medicare part A (Hospital Insurance) or have Medicare parts A & B. Medicaid will pay your Medicare A & B premiums, deductibles, and co-insurance charges on Medicare covered services only. Medicaid will not cover dental, vision or Part D prescription drugs.

SLIMB:

available to those with slightly higher income than QMB recipients, you must have or be eligible for Medicare part A (Hospital Insurance) or have Medicare parts A & B. Medicaid will pay your Medicare Part B (Medical Insurance) premium only.

QI-1:

available to those with slightly higher income than QMB or SLMB recipients, you must have or be eligible for Medicare part A (Hospital Insurance) or have Medicare parts A & B. Medicaid will pay your Medicare Part B (Medical Insurance) premium only.

SNAP – Supplemental Nutrition Assistance Program – provides temporary and ongoing food assistance

1. Application
   Submitted online – review and approval for this program–including required in-person or phone interview–can be completed within a manner of days
2. Usage
   EBT card is issued to pay for groceries at super markets and some farmer’s markets. The minimum monthly amount for an individual is $23 and the maximum is $292
3. Recertification
   Renewal is on an annual basis, with a required 6-month interim report – please note if the interim report is not completed in a timely manner benefits will be ended. Our Benefit Navigators can help keep you on track.

LIHEAP – The Low-Income Home Energy Assistance Program

This program provides assistance with winter heating bills for income-qualifying New Mexico residents. It is available once a year and the amount requested is paid directly to the energy supplier

1. Applications
   Submitted online – review and approval for this program–including required in-person or phone interview–can be completed within a manner of days

2. Usage
   Types of assistance available: bill payment assistance, energy crisis assistance, weatherization or energy-related home repairs.
   Holy Cross Hospital’s Benefit Navigators are happy to help you and your family get enrolled in any of these Medicaid programs.

For assistance please contact:

• Mary Walker, Benefit Navigation Coordinator: 575-751-8939; marywa@taoshospital.org
• Megan Lopez, Benefit Navigation Specialist: 575-751-5848 – for bilingual services