Medicare is a government health insurance program for people aged 65 and older, those with disabilities who receive Social Security, and all individuals with end-stage renal disease. Medicare Part A and B cover your hospital insurance and medical insurance, but leaves some gaps in coverage.

Medicare Advantage Plans offer comprehensive health insurance, which may include vision, hearing, dental, fitness programs, over-the-counter drugs, or transportation to medical appointments. You can choose a Medicare Advantage Plan from an insurance company as an alternative to regular Medicare.

As you determine the best Medicare coverage for your situation, consider this guide as insight for comparing plans and understanding your benefits as a North Carolina resident.

What You Should Know About Medicare Advantage Plans in North Carolina

  • Determine eligibility: North Carolina residents should explore Medicare Advantage plans for several months before turning 65. If you have an employer group health plan, you could keep it as a secondary plan to Medicare.
  • Coverage by county: Medicare Advantage coverage can vary by provider and county. When selecting a plan through the North Carolina Department of Insurance, review the Medicare Advantage Landscapes by County.
  • Get help: The North Carolina Department of Insurance Seniors’ Health Insurance Information Program (SHIIP) offers counselors who can answer your Medicare questions.

Is Medicare Advantage Right for You?

You have choices in Medicare coverage. While you can opt to stick with Original Medicare, a Medicare Advantage Plan – also known as Part C – may be a better alternative for you.

Original Medicare Medicare Advantage Plans
Original Medicare covers your Part A hospital insurance and Part B medical insurance. Medicare Advantage Plans combine Part A, Part B, and additional benefits.
You can add Part D prescription drug coverage. Prescription drug coverage is usually included.
You’re able to use any medical provider in the U.S. that accepts Medicare. You’ll usually need to use doctors in your plan’s network.
You can buy supplemental coverage to manage out-of-pocket costs, including your coinsurance. Your Medicare Advantage Plan may have lower out-of-pocket costs than Original Medicare.
Vision, hearing, dental, and other benefits aren’t covered. Your plan may offer additional benefits, including vision, hearing, and dental.
Note:

  • You can’t have both a Medicare Advantage Plan and a Medicare Supplement Plan.
  • You must be enrolled in Medicare Parts A and B to join a Medicare Advantage Plan.

How to Compare Medicare Advantage Plans in North Carolina

With 104 Medicare Advantage Plans available in North Carolina, you likely have several options in your area. To help you choose the best plan for you, consider what is most important to you before selecting a plan. There are several factors to keep in mind:

  • Monthly premium: This is how much you pay for coverage monthly, regardless of the care you receive. You may need to pay your plan’s premium in addition to the Medicare Part B premium, although some plans have $0 premiums or help pay for your Part B premium.
  • Plan network: You may need to use doctors and providers who are within a plan’s network. Before choosing a Medicare Advantage Plan, think about the doctors and facilities (including pharmacies) you prefer to use, then check if the plan offers coverage at those locations. Some plans may provide out-of-network coverage, but this usually comes at a higher cost.
  • Deductible: Your deductible is the amount you must pay before your insurance plan starts helping cover the costs. Medicare Advantage Plans set their deductibles, and these may change only once per year on January 1.
  • Copayments and coinsurance: Copayments or coinsurance are how much you pay for each service or doctor’s visit, such as $20 per doctor visit. Each Medicare Advantage Plan sets its copayment or coinsurance amount that can differ from what you would pay through Original Medicare.
  • Out-of-pocket maximum: Each Medicare Advantage Plan sets a yearly limit on the maximum amount you’d be responsible for paying for services covered by Medicare. Once you reach this limit, you won’t have to pay anything for the services you receive covered by Part A and Part B in that year.
  • Additional coverage: Most Medicare Advantage Plans also provide prescription drug coverage and often include additional benefits that Original Medicare won’t cover, such as vision, dental, and hearing. Plans may provide even more benefits, like discounted gym membership or transportation to doctor’s visits. Medicare Advantage Plans can also tailor their benefits to the specific needs of particular chronically ill beneficiaries.

About Medicare Advantage Plans in North Carolina

There are several types of Medicare Advantage plans in North Carolina, including: Health Maintenance Organization (HMO) plans, Preferred Provider Organization (PPO) plans, Private Fee-for-Service (PFFS) plans, and Special Needs Plans (SNPs).

There are 104 different Medicare Advantage plans available in North Carolina, with one rated 3.5 or higher by the National Committee for Quality Assurance (NCQA).

Number of Medicare Advantage Plans available Medicare Advantage Plan types available Medicare Advantage Plans rated 3.5 or higher by NCQA
104
  • Local HMO (37)
  • Local PPO (26)
  • MSA (3)
  • PFFS (1)
  • Regional PPO (2)
  • Sierra Health and Life Insurance

Understanding Medicare Advantage Plan Types:

  • HMO: Health Maintenance Organization plans generally provide coverage only at in-network providers except in medical emergencies. You usually need to have a primary care physician who can give you a referral to see specialists. Most HMO plans include prescription drug coverage.
  • HMO-POS: HMO-POS plans are HMO plans with a Point of Service benefit for out-of-network providers. In these plans, you may be able to use out-of-network providers for certain services but may pay more for your care if you do.
  • PPO: Preferred Provider Organization plans have a network of healthcare providers and facilities where your care will cost less. You can use out-of-network providers as well, but your care will cost more. You usually do not need a primary care doctor to get referrals to see specialists or receive treatment. Most PPO plans include prescription drug coverage.
  • PFFS: Private Fee-for-Service plans allow you to use any Medicare-approved provider. Some PFFS plans have networks of providers where you can receive lower-cost care. You don’t need referrals to see specialists in PFFS plans, but prescription drugs are not always covered.
  • SNPs: Special Needs Plans are for beneficiaries with specific diseases or characteristics. These plans tailor benefits and providers to the special needs of the group they serve. You are generally limited to the network of providers the plan offers and need a primary care doctor and get referrals to specialists. All SNP plans include prescription drug coverage.

Enrollment and Eligibility for Medicare Advantage Plans in North Carolina

You’re eligible for Medicare when you turn 65 or if you’re younger and have a qualifying disability. A qualifying disability means at least one of the following applies:

  • You’ve received Social Security Disability Insurance or Railroad Board Disability Annuity for 24 months
  • You have Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease
  • You have End-Stage Renal Disease

When you become eligible for Medicare, you are also eligible for Medicare Advantage Plans. There are specific times of the year when you can enroll for the first time in a Medicare Advantage Plan: during your Initial Enrollment Period and the Open Enrollment Period.

  • Your IEP begins three months before the month you turn 65 and extends for three months after the month you turn 65. During this period, you can enroll in a Medicare Advantage Plan. If you join before the month you turn 65, your coverage will begin the first day of the month you turn 65. If you enroll in the three months after turning 65, your coverage will begin the first day of the month after you enroll.
  • If you miss your IEP, you can sign up for Medicare during the General Enrollment Period from January 1 to March 31.
  • After you enroll in Medicare, you can enroll in or make changes to your Medicare Advantage Plan coverage during the Medicare OEP from October 15 and December 7 of each year. During this time, you can change from Original Medicare to Medicare Advantage, switch to a different Medicare Advantage Plan, or change from Medicare Advantage back to Original Medicare.

Medicare Advantage Open Enrollment occurs between January 1 and March 31 of each year. This period is only for beneficiaries already in a Medicare Advantage Plan, and you can change plans or switch to Original Medicare. You cannot switch from Original Medicare to Medicare Advantage during Medicare Advantage Open Enrollment.

There are exceptions to these enrollment periods called Special Enrollment Periods. Certain events or circumstances may make you eligible to change your Medicare Advantage Plan outside of the open enrollment periods, such as if you move outside of your existing plan’s service area or to a location with new plan options you didn’t have before. If you think you may qualify for a Special Enrollment Period, call 1-800-MEDICARE and explain your situation.

Medicare Enrollment Periods

Enrollment period When it happens Medicare plans you can choose What you can do
Initial Enrollment Period Three months before you turn 65, the month you turn 65, and three months after Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Sign up for Medicare Part A and Part B. Complete your Part B enrollment to avoid a late enrollment penalty.
General Enrollment Period January 1 – March 31 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan. If you enroll in Medicare during this period, your MAP enrollment is April through June. Sign up for Medicare if you missed your IEP
Open Enrollment Period October 15 – December 7 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Join, switch, or drop a plan
Medicare Advantage Open Enrollment Period January 1 – March 31 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan If you’re enrolled in a Medicare Advantage Plan, you can change your plan or switch to Original Medicare
Special Enrollment Period When you have a qualifying event Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Make changes to your plan

North Carolina Medicare Advantage Plans With Prescription Drug Coverage

Most Medicare Advantage HMO and PPO plans and all SNP plans provide prescription drug coverage like you would get from Medicare Part D. Some PFFS plans may provide prescription drug coverage, but not all do. Evaluate a plan’s prescription drug coverage when deciding which North Carolina Medicare Advantage Plan to use.

Prescription drug coverage may vary by cost, coverage, and convenience among Medicare Advantage Plans. Your monthly premium may include a premium for the drug coverage in the plan. There is usually a copayment or coinsurance amount that you have to pay for each prescription after you reach your annual deductible.

Some plans use different cost tiers with different costs for different drugs. For instance, you may pay less for generic drugs than brand-name drugs or less for brand-name drugs within different tiers. If your plan uses tiers, the formulary will list all covered drugs and their tiers. Verify your preferred or local pharmacies are included in the plan’s network.

Getting Help with Medicare Advantage Plans

North Carolina-wide Medicare Advantage Resources

Resource Contact How they help
North Carolina Department of Insurance  Phone: 855-408-1212 Trained experts can answer questions about insurance including Medicare and Medicare Advantage plans
Seniors’ Health Insurance Information Program (SHIIP) Phone: 855-408-1212 Medicare Advantage support with counselors who can answer questions

Local Medicare Advantage Resources

Resource Contact How they help
North Carolina Local Department of Social Services Phone: 800-662-7030 DHHS provides essential services to improve the health, safety and well-being of all North Carolinians

Federal Medicare Advantage Resources

Resource Contact How they help
Benefits Checkup by the National Council on Aging  Phone: 800-794-6559 The National Council on Aging (NCOA) is a respected national leader and trusted partner helping older adults meet the challenges of aging
Centers for Medicare & Medicaid Services N/A A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services as a guide to navigating your Health Care options
Medicare & You Guide by Centers for Medicare & Medicaid Services N/A A PDF guide comparing and contrasting Original Medicaid with Medicaid Advantage
Medicare.gov Phone: 800-633-4227 The main government website for signing up for (or making changes to) your Medicare coverage
Understanding Medicare Advantage Plans N/A A PDF primer on the Medicaid Advantage program
author-img
Insurance and healthcare consultant

Tammy Burns is an experienced health insurance advisor. She is ACA-certified for health insurance and other ancillary, life, and annuity products.

She’s always been driven by a desire to help people, spending more than 25 years as a practicing nurse in hospitals, private doctors’ offices, home health, and hospice. As a nurse, Burns supported patients filing insurance claims with Medicare, Medicaid, and private insurance companies, as well as responding to billing questions from confused patients.

Seeing firsthand how unsuspecting patients are frequently confused by an overly complex system they don’t understand led Burns to become an insurance agent and healthcare consultant, now helping people understand the medical system. Since becoming an agent, she has worked with some of the largest and most reputable insurance carriers and agencies in the nation, and she has built a large and loyal clientele by way of her commitment to transparency and personalized service.

Sources