This week’s newsletter is Sponsored By: 2026 Medicare Enrollment State Pages eBook
Medicare enrollment statistics for all 50 states → State Pages eBook
Here is what you’ll find in this week’s newsletter!
Important links 🔗 - the best articles we found this week about the Medicare Market along with links to Jared’s recent LinkedIn posts.
Deep Dive 📚 - Presbyterian Health Plan's MA Exit
Sponsor Snapshot 🚀 - brought to you by 2026 Medicare Enrollment State Pages eBook
It’s only a 5 minute read, but it will make you 10x smarter.
Here are IMPORTANT LINKS 🔗 for the week:
Alignment Health CEO 'very confident' in Q2 guidance as insurer eyes market expansion - (link)
Ocasio-Cortez Proposes Bill to Limit Compensation for Representatives of Medicare Advantage Organizations - (link)
How Medicare Advantage Rebates Disadvantage Medicare’s Stand-Alone Drug Plan Market - (link)
The Three Largest Medicare Advantage Organizations Denied Requests for Long-Term Acute Care and Inpatient Rehabilitation at Some of the Highest Rates - (link)
Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials - (link)
CMS proposes permanent framework for Medicare drug price negotiations - (link)
Jared’s recent LinkedIn posts:
DEEP DIVE 📚
Presbyterian Health Plan's MA Exit
Presbyterian Health Plan is exiting most of the Medicare Advantage market at the end of 2026, displacing ~30,500 members who will need new coverage heading into 2027.
The move isn't a surprise to anyone watching the MA financials closely. Presbyterian's MA plans generated more than $59 million in losses in 2025 alone (link), contributing to what Presbyterian reported as a broader operating loss of $568 million across the health system (link). Something had to give.
For the ~30,500 members now shopping for new coverage, and for the agents and carriers operating in New Mexico, this is one of the more significant market disruptions of the 2027 AEP cycle (so far).
Note: Presbyterian also has ~9,600 employer group MA members and ~13,500 D-SNP members. Reports are clear that D-SNP will continue, but not clear on whether or not employer group plans will continue.
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Who Is Presbyterian Health Plan?
Presbyterian Health Plan is the insurance arm of Presbyterian Healthcare Services, which is New Mexico's largest integrated health system. The broader organization runs hospitals across the state, an employed physician group, and dozens of clinics. The health plan serves members across commercial, Medicaid, Long-Term Care and Medicare lines. It is New Mexico's largest Medicaid managed care plan (~300,000 members).
Presbyterian's MA footprint is concentrated heavily in the Albuquerque metro. [MMI+ subscribers can drill into Presbyterian's county-level enrollment history in the MA Insights app.]
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Enrollment Breakdown
When focusing on Individual non-SNP enrollment, Presbyterian has the 3rd largest market share in New Mexico, making up ~30,500 of the ~150,600 members.
From MMI+ web application
Presbyterian’s membership is concentrated in the Albuquerque metro area.
From MMI+ web application
When only including the counties the 9 counties where Presbyterian has membership, they have the most market share (31%) followed by Humana (29%), HCSC (20%), and UnitedHealth (18%).
It’s also worth mentioning that 100% of membership is HMO plans.
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Who's Positioned to Absorb Members?
Currently, there are 8 other Carriers with membership in the state of New Mexico.
UnitedHealth, Humana, HCSC, Devoted, CHRISTUS Health, Molina, SCAN, and Total Community Options.
UnitedHealth and HCSC have grown the most in recent years while both Centene and CVS effectively exited the MA market in 2025.
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Loss Ratio / Financial Story
Using NAIC A&H Experience Exhibit information we can see why Presbyterian is exiting most of their MA business.
Their Medical Loss Ratio (Incurred Claims / Earned Premiums) has increased significantly during the last few years.
Year | Earned Premium | Incurred Claims | Loss Ratio |
|---|---|---|---|
2019 | $425,268,385 | $366,437,603 | 86.2% |
2020 | $476,801,092 | $401,590,163 | 84.2% |
2021 | $568,174,540 | $510,165,842 | 89.8% |
2022 | $602,562,236 | $572,622,810 | 95.0% |
2023 | $693,550,839 | $661,292,011 | 95.3% |
2024 | $754,248,755 | $751,741,398 | 99.7% |
2025 | $766,934,971 | $759,754,715 | 99.1% |
Source: NAIC A&H Experience Exhibit data; includes all individual and group lines
Running a loss ratio of 99.1%, means you only have 0.9% (~$7 million) to cover all of your other expenses (Admin, Sales, Quality Improvement, taxes, etc.).
The Company reported a $59 million loss on their MA business in 2025, which means their other expenses were ~$66 million (8.6% of earned premium) in 2025.
If their other expenses have been at a similar % of premium level over the past several years, it’s likely the case their MA business has been running a negative profit margin since 2022 and has continued to get worse with the high MLRs.
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Bottom Line
There are approximately 30,500 Individual MA members in New Mexico who will be shopping for new coverage this AEP. Nearly a third of the market in the counties where Presbyterian operated.
For agents, at the current CMS compensation rate of $363, that's approximately $11 million in annual commission revenue available to whoever shows up first.
For carriers, the 100% HMO membership and Albuquerque concentration means network adequacy will determine who wins the bulk of this population. Carriers with strong Presbyterian facility contracts have a head start.
But there may be another opportunity for Carriers. Every one of these members was on an Individual non-SNP plan, because Presbyterian never offered a C-SNP. Some portion of this population almost certainly has qualifying chronic conditions and was never presented that option. New Mexico has above-average prevalence rates for several C-SNP qualifying conditions, and carriers like UnitedHealth, Humana, Devoted and SCAN have active C-SNP products in these markets. So, there may be opportunities for Carriers to place some of these members on higher revenue SNP plans.
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Telos Actuarial → Medicare Enrollment State Pages
What MMI + Subscribers read this week…
Insurance Regulatory Insights June 2026 - Four new laws to take effect 👉 (link)
2026 Medicare Enrollment State Pages eBook - (link)
Non-Commissionable Plans - 2026 - Repository of 2026 Non-Commissionable Plans (link)
June ‘26 MA/MAPD and PDP enrollment data - June enrollment data has been loaded. Here are a few observations. (link)
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