Presbyterian Medicare Plans: Eligibility, Benefits, and Costs Explained

Important Update — June 2026#

On June 2, 2026, Presbyterian Healthcare Services announced that most of its Medicare Advantage plans will be discontinued in 2027 due to financial losses. Approximately 30,000 members are affected. Presbyterian will continue to offer its Medicare Advantage Dual Plus Special Needs Plan (D-SNP). Current 2026 coverage is not affected. Members with questions can call Presbyterian at (505) 923-2000 (TTY 711). During the Annual Enrollment Period (October 15 – December 7, 2026), affected members should review alternative plans through Medicare.gov, the State Health Insurance Assistance Program, or a licensed insurance broker.

Table of Contents#

1. What Are Presbyterian Medicare Plans?
2. Eligibility Requirements for Presbyterian Medicare Plans 2.1 Basic Medicare Eligibility 2.2 Plan-Specific Eligibility Rules
3. Types of Presbyterian Medicare Plans & Their Core Benefits 3.1 Medicare Advantage (Part C) Plans 3.2 Prescription Drug (Part D) Plans
4. Costs Associated with Presbyterian Medicare Plans 4.1 Monthly Premiums 4.2 Deductibles, Copayments, and Coinsurance 4.3 Out-of-Pocket Maximums
5. How to Enroll in Presbyterian Medicare Plans
6. Final Thoughts: Is a Presbyterian Medicare Plan Right for You?
7. What the 2027 Changes Mean for Current Members
8. References

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1. What Are Presbyterian Medicare Plans?#

Presbyterian Healthcare Services is a non-profit health system serving patients in New Mexico. Their Medicare plans are designed to fill gaps in original Medicare (Parts A and B) or provide an all-in-one alternative, offering flexible coverage options for seniors and individuals with disabilities.

Presbyterian's Medicare portfolio currently includes two primary plan types: Medicare Advantage (Part C) and Prescription Drug (Part D) plans. Medicare Advantage plans are offered as HMO (Health Maintenance Organization) plans, which require the use of in-network providers for non-emergency care. Each plan type is tailored to different needs, whether you want comprehensive all-in-one coverage or standalone prescription drug protection.

Note: As of June 2026, Presbyterian has announced that most Medicare Advantage plans will be discontinued in 2027. Only the Dual Plus Special Needs Plan (D-SNP) will continue beyond 2026.

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2. Eligibility Requirements for Presbyterian Medicare Plans#

To enroll in any Presbyterian Medicare Plan, you must first meet basic Medicare eligibility criteria, plus additional plan-specific rules.

2.1 Basic Medicare Eligibility#

You qualify for original Medicare (and thus can enroll in Presbyterian's plans) if you:

• Are 65 years of age or older;
• Are under 65 and have received Social Security Disability Insurance (SSDI) for 24 consecutive months;
• Have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease).

2.2 Plan-Specific Eligibility Rules#

Beyond basic Medicare eligibility, you must meet these requirements for Presbyterian's plans:

• Geographic residency: Presbyterian Medicare Plans are only available in New Mexico. You must live within the service area of the plan you want to enroll in.
• Medicare Part enrollment:
  • For Medicare Advantage (Part C): You must have active Medicare Parts A and B.
  • For Part D: You must have active Medicare Part A or B.
• Special Needs Plan (SNP) eligibility: If enrolling in a Presbyterian SNP (a type of Medicare Advantage Plan), you must meet specific criteria. Currently, Presbyterian offers a Dual-Eligible SNP (D-SNP) for individuals who qualify for both Medicare and Medicaid, or who are Qualified Medicare Beneficiaries (QMB).

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3. Types of Presbyterian Medicare Plans & Their Core Benefits#

Presbyterian offers two main plan categories, each with distinct benefits to suit different health and financial needs.

3.1 Medicare Advantage (Part C) Plans#

Presbyterian Medicare Advantage Plans replace original Medicare by combining Parts A (hospital coverage) and B (medical coverage) into one plan. Most also include Part D (prescription drug coverage) and extra benefits not covered by original Medicare.

Key benefits vary by plan type:

• HMO Plans: Require you to use in-network providers (except for emergencies) and obtain referrals for specialist visits. Benefits include:
  • Coverage for hospital stays, doctor visits, and preventive care (e.g., annual wellness exams, cancer screenings).
  • Extra perks like dental, vision, and hearing coverage, fitness memberships (SilverSneakers), telehealth services, and an over-the-counter benefits card.
  • No-cost primary care appointments and $0 virtual care for in-network providers.
• Special Needs Plans (SNPs): Tailored to specific groups:
  • Dual-Eligible SNPs (D-SNPs): For individuals on both Medicare and Medicaid, covering most or all out-of-pocket costs and coordinating benefits between programs. Presbyterian's Dual Plus (HMO D-SNP) plans include additional benefits such as no-cost transportation to appointments and quarterly over-the-counter allowances.

Note: Presbyterian currently offers only HMO-based Medicare Advantage plans. PPO plans are not available through Presbyterian as of 2026. Additionally, most Presbyterian Medicare Advantage plans (except the D-SNP) will be discontinued in 2027.

3.2 Prescription Drug (Part D) Plans#

Presbyterian Part D plans offer standalone prescription drug coverage for individuals with original Medicare. Core benefits include:

• Coverage for brand-name and generic prescription drugs, organized into tiered formularies (lower tiers have lower costs).
• A streamlined three-stage coverage structure: deductible (if applicable), initial coverage, and catastrophic coverage. Thanks to the Inflation Reduction Act, the Medicare Part D coverage gap ("donut hole") was eliminated as of 2025. Once your out-of-pocket spending on covered drugs reaches $2,100 in 2026, you automatically enter catastrophic coverage and pay nothing for covered drugs for the rest of the year.
• Insulin copays are capped at $35 per month, and recommended vaccines are available at no cost.
• Mail-order pharmacy options for convenient delivery of long-term medications.

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4. Costs Associated with Presbyterian Medicare Plans#

Costs vary widely depending on the plan type, your location, and your health needs. Here's a breakdown of key cost components:

4.1 Monthly Premiums#

• Medicare Advantage: Many Presbyterian MA plans have $0 monthly premiums (funded by Medicare), though you'll still need to pay your standard Medicare Part B premium ($202.90 in 2026). Some specialized plans (like SNPs) may have small premiums.
• Part D: The national average Part D premium is approximately $34.50 per month in 2026, though some low-income individuals may qualify for Extra Help to reduce or eliminate premiums.

4.2 Deductibles, Copayments, and Coinsurance#

• Medicare Advantage: Deductibles vary by plan—some have $0 deductibles for medical services, while others may have annual deductibles for prescription drugs. Copays for doctor visits range from$10 to $30, and hospital stays may have a daily copay after the deductible is met.
• Part D: Annual deductibles can be up to $615 in 2026, though many plans waive or reduce this. Copays range from$1 to $50+ depending on the drug tier. After your deductible, you pay 25$2,100 out-of-pocket cap.

4.3 Out-of-Pocket Maximums#

• Medicare Advantage: CMS sets an annual out-of-pocket maximum (OOPM) for MA plans ($9,250 in 2026 for in-network services; higher for out-of-network). Once you reach this limit, the plan covers 100% of covered services for the rest of the year.
• Part D: The annual out-of-pocket cap is $2,100 in 2026 (up from$2,000 in 2025), established by the Inflation Reduction Act. Once you reach this amount, you pay nothing for covered Part D drugs for the remainder of the year.

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5. How to Enroll in Presbyterian Medicare Plans#

Enrolling in a Presbyterian Medicare Plan is straightforward if you follow these steps:

1. Check eligibility: Confirm you meet basic Medicare and plan-specific residency/enrollment criteria.
2. Compare plans: Use the official Medicare Plan Finder (medicare.gov) or Presbyterian's website to compare plans based on benefits, costs, provider networks, and prescription drug coverage.
3. Choose your enrollment period:
   • Initial Enrollment Period (IEP): 3 months before your 65th birthday, the month of your birthday, and 3 months after.
   • Annual Enrollment Period (AEP): October 15 to December 7, when you can switch or enroll in plans for the next year. This is especially important in 2026 for members whose plans will be discontinued in 2027.
   • Special Enrollment Period (SEP): For life changes like moving to a new service area, losing employer coverage, or qualifying for Medicaid.
4. Enroll: You can enroll online via Presbyterian's website, by phone at 1-800-347-4766, or in person with a licensed Medicare representative.

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6. Final Thoughts: Is a Presbyterian Medicare Plan Right for You?#

A Presbyterian Medicare Plan may be a good fit if:

• You live in their service area (New Mexico).
• You want extra benefits (dental, vision, fitness) not covered by original Medicare.
• You prefer an all-in-one plan (Medicare Advantage).
• You qualify for dual Medicare-Medicaid coverage (D-SNP plans, which will continue in 2027).

Before enrolling, take time to compare plan costs, provider networks, and prescription drug formularies to ensure the plan aligns with your health needs and budget. Given the upcoming 2027 changes, it is especially important to review your options during the Annual Enrollment Period (October 15 – December 7, 2026) and consider alternative plans if your current Presbyterian MA plan will be discontinued.

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7. What the 2027 Changes Mean for Current Members#

In June 2026, Presbyterian Healthcare Services announced that it will discontinue most of its Medicare Advantage plans effective 2027, citing $59 million in financial losses. Approximately 30,000 members will be affected. Key points:

• Current 2026 coverage is not affected. Members retain all benefits through December 31, 2026.
• The Dual Plus (HMO D-SNP) plan will continue for members who qualify for both Medicare and Medicaid.
• During the 2026 AEP (October 15 – December 7), affected members should explore alternative Medicare Advantage plans or return to Original Medicare with a standalone Part D plan and optional Medigap coverage.
• Resources for help: Medicare.gov Plan Finder, the State Health Insurance Assistance Program (SHIP), local Area Agency on Aging, or a licensed insurance broker. Members can also call Presbyterian at (505) 923-2000 (TTY 711).
• Presbyterian Medical Group will continue to accept Original Medicare and other Medicare Advantage plans in 2027, so existing patients can see their Presbyterian providers regardless of plan changes.

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8. References#

1. Presbyterian Healthcare Services. (2026). Medicare Plans. Retrieved from https://www.phs.org/medicare
2. Centers for Medicare & Medicaid Services (CMS). (2025). 2026 Medicare Parts A & B Premiums and Deductibles. Retrieved from https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles
3. Medicare.gov. (2026). How much does Medicare drug coverage cost? Retrieved from https://www.medicare.gov/health-drug-plans/part-d/basics/costs
4. Medicare.gov. (2026). Medicare Plan Finder. Retrieved from https://www.medicare.gov/find-a-plan
5. CMS. (2025). Final CY 2026 Part D Redesign Program Instructions. Retrieved from https://www.cms.gov/newsroom/fact-sheets/final-cy-2026-part-d-redesign-program-instructions
6. KOAT. (2026). Medicare Advantage Plan cuts to affect roughly 30,000 patients in New Mexico. Retrieved from https://www.koat.com/article/presbyterian-medicaid-jobs-cuts-new-mexico/71498820