Medicare Advantage Plans in North Carolina

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans include Part A (hospital insurance) and Part B (medical insurance), and most also include Part D (prescription drug coverage). Many plans offer added benefits such as dental, vision, hearing, fitness programs, and telehealth services.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first sign up for Original Medicare (Parts A and B). Most people become eligible for Medicare enrollment at age 65, although some qualify earlier due to disability or conditions such as ALS or ESRD.

Key enrollment periods include:

• Initial Enrollment Period (IEP)
• General Enrollment Period (GEP)
• Special Enrollment Periods (SEP)

Failure to enroll during these periods may result in late penalties or limited plan choices.

What Types of Medicare Advantage Plans Are Available in North Carolina?

North Carolina offers the following MA plan types:

• Health Maintenance Organizations (HMOs): Require in-network care and referrals for specialists. Most MA plans fall under this category.
• Preferred Provider Organizations (PPOs): Offer flexibility to visit out-of-network providers at higher costs, with no referral required.
• Private Fee-for-Service (PFFS) Plans: Allow care from any provider who accepts the plan terms. Some plans have networks but don’t require referrals or a PCP.
• Special Needs Plans (SNPs):
  • C-SNPs: Designed for individuals with chronic conditions such as diabetes, dementia, or heart failure.
  • I-SNPs: For people receiving care in a nursing facility or at home.
  • Dual Eligible Special Needs Plans (D-SNPs): Available to people eligible for both Medicare and Medicaid. These plans include care coordination and extra benefits with minimal out-of-pocket costs.
• Medical Savings Accounts (MSAs): Combine a high-deductible plan with a medical savings account funded by your insurer to help pay healthcare expenses.

What Are Your Prescription Drug Options with Medicare Advantage?

Most Medicare Advantage plans in North Carolina include Part D drug coverage. However, MSAs and some PFFS plans do not.

If your plan doesn’t include drug coverage:

• You may enroll in a standalone Part D plan—only for certain plan types.
• You may face a late enrollment penalty if you delay enrollment and do not have creditable prescription coverage.

How Do You Choose a Medicare Advantage Plan?

Before selecting a plan, it’s important to understand Medicare Advantage costs:

• Premiums: Many plans have $0 premiums, but you must continue to pay the Medicare Part B premium.
• Deductibles, Copays & Coinsurance: Review how much you’ll pay for routine and emergency services.
• Out-of-Pocket Maximums: This cap limits how much you’ll spend annually on covered services. Once reached, the plan pays 100%.
• Extra Benefits: Look for plans offering additional perks such as dental, vision, hearing, fitness memberships, transportation, or telehealth.

When and How Do You Enroll in a Medicare Advantage Plan?

You can enroll in Medicare during several specific enrollment periods:

• Initial Enrollment: Begins 3 months before and ends 3 months after your 65th birthday month.
• Annual Open Enrollment (Oct 15–Dec 7): Join, drop, or switch MA plans. Coverage starts January 1.
• General Enrollment (Jan 1–Mar 31): For those enrolling in Part B during this window. MA coverage begins July 1.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch to a different MA plan or return to Original Medicare.
• Special Enrollment Periods: Apply if you:
  • Move out of your plan’s service area
  • Lose Medicaid or employer coverage
  • Gain Medicaid eligibility
  • Experience plan termination
  • Are diagnosed with a qualifying chronic condition

What If You Want to Change Your Medicare Advantage Plan?

You can change your MA plan during:

• Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

Enrolling in a new plan automatically cancels your previous coverage when the new plan takes effect.

Understanding Medicare Advantage Star Ratings

The CMS star ratings system is how the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) plans using a 5-star quality scale. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

CMS Star Ratings Overview

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

What Are Medicare Resources in North Carolina?

North Carolina offers helpful resources for Medicare guidance:

• North Carolina SHIIP (Seniors’ Health Insurance Information Program): Provides free Medicare counseling. Call 1-855-408-1212 or email ncdoi.ncshiip@ncdoi.gov.
• North Carolina SMP (Senior Medicare Patrol): Educates beneficiaries on detecting and reporting Medicare fraud.
• North Carolina Department of Insurance: Handles Medicare-related complaints.
• North Carolina Medicaid: Assists eligible residents with healthcare costs. Call 1-800-662-7030.

Learn more about the differences between Medicare and Medicaid.

Other Medicare Plan Options to Help with Out-of-Pocket Costs

Medicare Supplement Plans, also known as Medigap, help cover costs that Original Medicare doesn’t—like copayments, coinsurance, and deductibles.

• You must be enrolled in Medicare Parts A and B to qualify.
• The best time to buy a Medigap policy is during your six-month Medigap Open Enrollment Period after enrolling in Part B. During this time, you can’t be denied coverage due to health.
• After this period, you may face medical underwriting requirements.
• Medigap plans don’t include prescription drug coverage. You’ll need a separate Part D plan.

Medicare Supplement Plan G had the highest enrollment in 2023. Plans G and N are growing rapidly. Plan F is no longer available to newly eligible individuals as of 2020.

Learn more about Medicare Supplement plans in North Carolina.

Next Steps

If a Medicare Advantage plan in North Carolina fits your healthcare needs and budget, compare options in your area. Review plan premiums, out-of-pocket costs, provider networks, drug formularies, and added benefits—then enroll during your eligible enrollment window.