North Carolina Medicare Advantage Plans | A Must-Read Guide

What Are Medicare Advantage Plans in North Carolina?

Medicare Advantage (MA) plans are a bundled alternative to Original Medicare for North Carolina residents. Original Medicare includes Part A, which is hospital insurance, and Part B, which is medical insurance. MA plans cover these services, and most cover Part D as well, which is Medicare’s prescription drug coverage. MA plans may offer additional benefits like hearing, vision, and dental care and fitness club memberships.¹ 

What You Need to Know 

Medicare Advantage plans are an alternative to Original Medicare. 

North Carolina residents can choose among many plans. About half have a $0 premium. 

Most Medicare Advantage plans cover prescription drugs and offer additional benefits like vision and dental care. 

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

There are several types of Medicare Advantage plans for you to choose from. A Medicare Advantage plan can be a/an:

• HMO (health maintenance organizations): HMOs have a network of healthcare providers from whom you must get your care unless it’s an emergency. You typically need a referral to see a specialist. 
• PPO (preferred provider organization): PPO plans also have a provider network. You can see out-of-network providers, but you typically pay more if you do. You typically don’t need a referral to see a specialist. 
• SNP (special needs plan): This type of plan is designed for Medicare members with specific health needs. 
  • C-SNP (chronic condition special needs plan): This type of SNP serves people with ongoing health conditions like diabetes, heart failure and dementia. 
  • D-SNP (dual eligible special needs plan): A kind of plan that serves people who have both Medicare and Medicaid. 
  • I-SNP (institutional special needs plan): This plan serves people who need long-term care in a facility or at home. 
• PFFS (private fee-for-service): With a PFFS plan, you can see any Medicare-approved healthcare provider who accepts your plan. Some PFFS plans have a network, but you can typically see out-of-network providers as well. You may pay more if you do. 
• MSA (Medicare savings account): This kind of plan combines a medical savings account with a high-deductible insurance plan. Medicare and your plan deposit money into your savings account. You use those funds to pay for healthcare costs. Once you meet your deductible, the plan starts paying for your healthcare. You may need to pay for healthcare if you use all the funds in your savings account before you meet your deductible.² 

Most Medicare Advantage plans are HMOs.³

What Are Prescription Drug Options with Medicare Advantage in North Carolina?

Most Medicare Advantage plans include Part D, which is Medicare’s drug coverage. MSA plans don’t cover prescription drugs, and some PFFS plans don’t either. If you have one of those plans, you can purchase a separate Part D plan. If you enroll in an HMO or PPO without prescription coverage, you can’t join a separate drug plan. 

Keep in mind that if you enroll in a plan that has no prescription coverage and you don’t or can’t enroll in a separate drug plan, you may be required to pay a late enrollment penalty if you choose to join a plan at a later date.⁴

How Do You Choose a Medicare Advantage Plan in North Carolina?

You should consider several factors when it comes to choosing an Medicare Advantage plan. First, look at the plan premiums. This is the amount you pay each month. Some plans have a $0 premium, while other plans have a cost. You also have to continue to pay your Medicare Part B premium.⁵ 

Next, look at the other costs associated with the plan. These include:

• Coinsurance: This is a percentage you pay for a covered service. For example, you might pay 20% of the cost of a hospital stay. 
• Copayments: This is a set fee you pay for a covered service. You might pay $20 for a visit to your primary care doctor. 
• Deductibles: This is the amount you pay for covered services before your plan starts paying. If you have a $1,000 deductible and a $2,000 hospital bill, you’ll pay the first $1,000. Your Medicare Advantage plan will help cover your stay after you pay your deductible, but you may have additional out-of-pocket costs depending on your coinsurance.⁶ 
• Maximum out-of-pocket costs: This number is critical. It is the most you will pay out of pocket for covered benefits, including your deductibles, copays and coinsurance. Once you meet the limit, the plan will pay for your Part A and B covered services.⁷ 

Finally, look at the plan benefits—in particular, the “extras” that aren’t covered by Medicare, such as vision, dental and hearing care. Find out whether the plan offers telehealth and other perks you’re interested in, such as membership in a fitness program.⁸ 

When and How to Enroll in Medicare Advantage in North Carolina?

Enrolling in an Medicare Advantage plan might seem complicated. The good news is that you have plenty of opportunities to change plans or disenroll from a plan if you’re not happy with it. Here’s when you can enroll, change plans or disenroll. 

• Initial Enrollment Period: This is a seven-month period when you’re first eligible for Medicare. For most people, eligibility begins at age 65. The period starts three months before the month you turn 65 and ends three months after that month. 
• Open Enrollment Period: Also known as your Annual Election Period, this is from October 15 – December 7 each year. You can join an Medicare Advantage plan, change it or drop it during this period, and the changes take effect on January 1. 
• Medicare Advantage Open Enrollment Period: From January 1 – March 31 each year you can switch to another Medicare Advantage plan or drop it plan and return to Original Medicare. 
• General Enrollment Period: This period also goes from January 1 – March 31. If you start Part B during this time, you can also join a Medicare Advantage plan. Your plan will start on July 1.⁹  
• Special Enrollment Period: You may also make changes to your plan under certain circumstances, such as:
  • Moving to a new service area.
  • Losing coverage, such as losing Medicaid benefits. 
  • Gaining coverage, such as qualifying for Medicaid benefits.
  • Plan changes, such as Medicare terminating your plan. 
  • Special circumstances, such as a chronic condition that would be better served by a C-SNP. 

How Much Do Medicare Advantage Plans Cost in North Carolina?

Medicare Advantage plan costs vary depending on plan benefits and where you live. The average monthly cost for an Medicare Advantage plan in North Carolina is $13.49.¹⁰ In Mecklenburg County, home to Charlotte, you have access to 29 plans offered by six different health insurance carriers. About half the plans have a $0 premium. The remainder range from $20 to $86, with one plan costing significantly more at $199 per month.¹¹

In Wake County, home to Raleigh, you have access to 23 plans offered by eight different health insurance carriers. About three-quarters of the plans have a $0 premium. The rest have premiums that range from $13.90 to $84 per month.¹²

What If You Want to Change Your Medicare Advantage Plan in North Carolina?

If you want to change your Medicare Advantage plan, you can do so during open enrollment from October 15 – December 7 each year. You can also change your plan during Medicare Advantage Open Enrollment from January 1- March 31. 

What Are Medicare Resources in North Carolina?

The Seniors’ Health Insurance Information Program (SHIIP) is an excellent resource for information on Medicare or Medicare plans. There are SHIIP counselors in every county in North Carolina. You can also call SHIIP at 1-855-408-1212, Monday – Friday, from 8AM – 5PM or email SHIIP at ncdoi.ncshiip@ncdoi.gov. 

If you have a complaint about an Medicare Advantage plan, contact the North Carolina Department of Insurance. If your income is limited, consider applying for Medicaid, which is a health insurance program for those with low incomes.

State Medicare Advantage Data in North Carolina

Next Steps

The Medicare plan finder is an excellent tool for connecting you to Medicare Advantage plans in your area. You can compare plans and find ones that cover your prescriptions. Choose an affordable plan that covers the benefits that matter to you.