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Health Insurance Advisor

A subject matter expert in insurance since 2008, Gabriel Segrera specializes in health, life, property and casualty insurance. Gabriel’s practice services self-employed, small businesses, individuals, and families across the United States to access innovative and affordable coverage solutions that meet their specific needs.

There are several ways to obtain health insurance coverage in North Carolina. You can enroll in your employer’s health insurance plan, purchase private insurance, or if you’re eligible, you can enroll in Medicare or Medicaid. This guide provides detailed information about your North Carolina health insurance options.

What to know about insurance in North Carolina

  • Marketplace plans: In North Carolina, if you choose not to enroll in your employer’s health care insurance (or you’re not happy with the coverage offered by your employer), you can purchase a health insurance plan from the Health Insurance Marketplace or from a private insurer.
  • Open Enrollment: Typically, the Open Enrollment period for North Carolina’s Health Insurance Marketplace runs from November 1 to December 15. In most cases, you’ll need a qualifying event to enroll outside of these dates. Otherwise, you’ll need to wait until the following year. In 2021, Open Enrollment is until August 15 due to the COVID-19 pandemic.
  • Special Enrollment: Qualifying events enable you to use a Special Enrollment Period. These occur when you lose qualifying coverage or need to change your current plan due to getting married, losing your job, having a baby, or getting divorced.
  • Premium tax credit: If you’re interested in applying for health care tax credits, North Carolina uses the Federal Health Insurance Exchange. You can purchase health coverage directly from one of North Carolina’s health insurance companies. Many of the plans on the exchange offer a tax credit to help with costs.
  • Coverage types: Just over 46% of North Carolina residents get health coverage through an Another 17.9% are enrolled in Medicaid, 15.3% are enrolled in Medicare, 6.7% are enrolled in non-group private individual or family coverage, and 2.4% are enrolled in military coverage. Currently, 11.4% of North Carolina residents are uninsured.

How do I enroll in North Carolina’s health insurance marketplace?

Like many other states, North Carolina does not have a separate website to purchase health insurance. To enroll in North Carolina’s health insurance marketplace, you’ll need to visit Healthcare.gov and create an account to see available plans and compare prices. Creating an account is fairly straightforward. You’ll provide your name and personal contact information, create a password, and set up several security questions.

Once you’re up and running, Healthcare.gov checks to see if you’re eligible for Medicare and whether you qualify for any tax credits, such as the Advance Premium Tax Credit. Whether you’re applying for yourself or your family, you’ll need every person’s name, birth date, and Social Security number included in your application.

The application includes several questions related to your income and family, including the following:

  • Are you single or married?
  • How many tax dependents will you claim on your current return?
  • How much income will your household make this year?
  • Do you want to see if you can get help paying for coverage?

At this point, you’ll be able to see a list of available Healthcare.gov coverage plans for North Carolina. The website also has a tool that allows you to review up to three different plans side-by-side so that you can compare costs for different levels of coverage. You can then pick a plan and complete the application process.

The companies that provide individual health insurance plans in North Carolina are:

  • Ambetter of North Carolina
  • Blue Cross and Blue Shield of NC
  • Bright Health
  • Cigna Healthcare
  • Oscar Health Plan of North Carolina, Inc
  • UnitedHealthcare

How do I enroll in North Carolina’s individual and family insurance?

There are some important considerations when shopping for individual coverage, whether for yourself or multiple people. These considerations include:

  • Medical needs
  • Preferred plan type
  • Premium affordability
  • Individual vs. family deductibles

Insurance for individuals in North Carolina

You have several health plan options when you’re only looking for insurance for yourself, including low deductibles with higher premium costs and high deductibles with lower monthly premiums. Some plans can offer coverage at a lower price if you qualify medically. A low deductible means a higher upfront premium cost, but you’ll pay less when you need coverage. A higher deductible results in lower monthly premiums, but you’ll pay more when you’re sick or injured.

There are several different types of health insurance plans.

  • Health Maintenance Organization (HMO) plans have lower costs but stricter rules about how you receive care. You’ll need to find a doctor in-network, name a primary care physician, and obtain a referral to see a specialist. The plans mainly offer local coverage.
  • Preferred Provider Organizations (PPO) plans have a higher upfront premium cost, but you’ll be able to use out-of-network health care providers nationwide if necessary. You won’t need to name a primary care physician or obtain a referral to see a specialist.
  • Point-of-Service (POS) plans combine the benefits of HMO and PPO plans. You’ll still need a referral to see a specialist, but you’ll be able to use out-of-network providers if you’re willing to accept a higher fee.

Insurance for families in North Carolina

Your considerations change when you’re thinking about health care for your family. You might be in good health, but perhaps your spouse has diabetes, or you have a child who requires mental health care. You’ll need to balance your family’s needs with your ability to pay out-of-pocket costs.

These concerns will affect the type of plan you select. If your family is healthy overall, an HMO plan might be the best option. However, if you, your spouse, or one of your children requires ongoing health care, you may prefer a PPO plan, which gives you more flexibility to see specialists without referrals. Always check the health care company’s network of providers to ensure it covers a range of specialties that can meet your family’s needs.

How much does health insurance cost in North Carolina?

Healthcare.gov offers four plan levels or tiers, including bronze, silver, gold, and platinum. Each level offers different premiums, deductibles, and coinsurance payments. Within each level, you’ll find a variety of plans.

Average premiums in North Carolina 2018 2019 2020 2021
Most affordable bronze plan $464 $417 $365 $350
Most affordable silver plan $609 $570 $518 $503
Most affordable gold plan $656 $605 $553 $518

  • Bronze plans have a low monthly premium and a high deductible. You’ll also have to pay a 40% coinsurance payment when you receive medical services. These plans are best if you’re healthy but want to have some coverage. The most affordable bronze plan in North Carolina has an average monthly premium of $350.
  • Silver plans have higher premiums than bronze plans but also have lower deductibles and a 30% coinsurance requirement. Silver plans can be less expensive than bronze plans if you have a lower income and qualify for extra savings and cost-sharing programs. Silver plans are ideal for younger people with chronic conditions who are starting their first jobs. The lowest-priced silver plan in North Carolina costs $503 per month.
  • Gold and platinum plans have lower deductibles and coinsurance payments (only 20% for gold and 10% for platinum), but you’ll pay a much higher monthly premium. A gold or platinum plan would be ideal if you require regular medical care for a chronic condition, such as a heart problem or arthritis. The most current affordable gold plan in North Carolina costs $518 per month.

What kind of low-income health insurance is available in North Carolina?

Medicaid and the North Carolina Health Choice Health Insurance Program for Children provide health insurance coverage for low-income North Carolina residents. If you’re 65 or older (or younger and disabled) and meet the income and asset requirements, you might qualify for Medicaid.

The North Carolina Health Choice Health Insurance Program for Children is a comprehensive health plan for low-income children. In many other states, the program is called CHIP — Child Health Insurance Program.

Medicaid in North Carolina

Medicaid in North Carolina is available to those who are low income and as qualify as one of the following:

  • At least 65 years old
  • Blind
  • Pregnant
  • Responsible for a child under the age of 18
  • Disabled
  • Care for a disabled family member

To qualify for Medicaid, you must have a low income. You can’t earn more than the maximum annual income, which is based on your household size. For example, an individual can’t earn more than $17,131 annually, while a family of four can’t have an annual income of more than $35,245 per year.

Asset limits are $2,000 for an individual and $3,000 for a couple. The limit is based on income and property but doesn’t include your primary home, furnishings, appliances, and one vehicle. You can apply for Medicaid at the ePass website.

NC Health Choice Health Insurance Program for Children in North Carolina

North Carolina Health Choice is for children in families with low income between 6 and 18. Family income must be between 133% and 211% of the Federal Poverty Guidelines. For example, a single mother in North Carolina with one child cannot earn more than $1,931 per month or $36,768 per year. If your family income is above 159% of Federal Poverty Guidelines, an enrollment fee of $50 per child applies. To find out more about the program, visit the North Carolina Health Choice site.

What are North Carolina’s Medicare options for seniors and people with disabilities?

Medicare is the federal health program open to seniors 65 and older and those who are younger with qualifying disabilities. You can select from several different forms of Medicare.

  • The most basic form is Original Medicare. It includes Part A (hospitalizations, hospice, skilled nursing facilities, and home care) and Part B (doctor’s visits, mental health care, ambulance services, and durable medical equipment). Medicare Part D provides prescription drug coverage. Original Medicare doesn’t cover prescription drugs, so you’ll need to purchase a Part D plan if you want coverage.
  • Another option is a Medicare Advantage Plan. There are four different types of Medicare Advantage plans, including Health Management Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-For-Service (PFFS) plans, and Special Needs Plans (SNPs). Medicare Advantage Plans offer vision, dental and hearing coverage, and they sometimes cover fitness programs. Many MA plans also offer prescription drug coverage.

Medicare Supplement Insurance, also known as Medigap, is designed to plug holes in your Original Medicare coverage by covering deductibles, copays, and coinsurance. These plans can also provide coverage if you travel overseas.

Eligibility and Enrollment
Eligibility
  • You need to meet several criteria to qualify for Original Medicare or North Carolina’s Medicare Advantage program. You must be a U.S. citizen or a permanent resident, and you must be 65 or older or younger with a qualifying disability.
Enrollment
  • Your first opportunity to enroll in Medicare is during your initial enrollment period. This period runs for the seven months surrounding your 65th birthday, including the three months before your birthday, the month you turn 65, and the three months following your birthday.
  • Every year, Medicare has an open enrollment period that runs from October 15 and December 7. You can move from Original Medicare to a Medicare Advantage Plan, return to Original Medicare, or switch between Medicare Advantage Plans during this period.
  • Certain circumstances may qualify you for a Special Enrollment Period.

Medicare Resources

The North Carolina State Health Insurance Assistance Program (SHIP) provides free, unbiased, and confidential counseling to all Medicare-eligible residents. The trained volunteer counselors aren’t licensed insurance agents, and they will never endorse any company or try to sell you a plan. Their primary purpose is to advise North Carolina seniors about their health care options.

Are there short-term health insurance plan options in North Carolina?

Short-term health insurance in North Carolina is available through off-exchange health insurance companies. These plans are thin and don’t provide the same essential benefits as Healthcare.gov marketplace plans. The plans are designed to be temporary, primarily to cover gaps in coverage. For example, if you know you’ll be switching jobs, and your new coverage won’t kick in for a few months, a short-term health insurance plan might make sense.

Although North Carolina doesn’t have state rules about short-term policies, it follows federal government guidelines. Plans can provide coverage for up to one year and are renewable for up to 36 months. Short-term policies don’t cover preexisting conditions or mental health care. Conditions that could result in denied or non-renewal of coverage include:

  • Asthma
  • Cancer
  • COPD
  • Diabetes
  • Epilepsy
  • Sleep apnea

As soon as you know you might have a gap in your health care coverage, consider applying for short-term health insurance. Short-term insurance can also help if you miss the Affordable Care Act (ACA) enrollment period and need health care coverage until you’re able to apply the following year.

North Carolina Insurance FAQs

Does North Carolina require health insurance?

Technically, the ACA requires all Americans to have health insurance. While a few states have passed laws requiring citizens to have health care insurance, North Carolina is not one of them. Congress removed the tax penalty for Americans failing to maintain a minimum level of coverage, and North Carolina doesn’t enforce the mandate.

Do I have to use the Health Insurance Marketplace in North Carolina?

No one will force you to use the Health Insurance Marketplace. However, some incentives make using it attractive (such as the Advance Premium Tax Credit) if you’re trying to reduce your out-of-pocket costs.

What types of alternative health insurance plans (like cost-sharing plans) are available in North Carolina?

Health care sharing and faith-based health plans are usually based on religious beliefs, but you don’t need to be associated with any religious group to purchase a plan. Since they’re not considered insurance, the North Carolina Department of Insurance doesn’t regulate them. You should carefully check the plan before you purchase one. Under the ACA, some benefits are mandated, and faith-based plans may not offer the critical coverage you need.

Do I need health insurance if I have an FSA/HSA?

Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA) are good ideas, but they don’t replace health insurance coverage. While these accounts allow you to save money on your health care costs or put money aside to deal with medical expenses, it’s unlikely an FSA or HSA will provide enough money to cover all your out-of-pocket expenses.

Do I need short-term disability coverage in North Carolina if I have health insurance?

Short-term disability coverage is typically used to cover household expenses when you’re injured. You’ll still need regular health insurance to cover your medical expenses. Short-term disability payments won’t help you if you’re hospitalized for an extended period.

Do I need long-term disability coverage in North Carolina if I have health insurance?

Like short-term disability payments, long-term disability payments are used to pay for household expenses. It’s not a substitute for health insurance. Even if you have long-term disability coverage, you should also have health care insurance.

What does North Carolina Health Choice cover?

North Carolina Health Choice is a comprehensive health insurance program that provides coverage for low-income children between 6 and 18. It provides support for immunizations, regular checkups, and treatment for injuries or illnesses. Your children may qualify for North Carolina Health Choice if your income is between 133% and 211% of the Federal Poverty Guidelines.

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