Medicare Advantage Plans in North Carolina
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: October 12, 2020
Original Medicare Parts A and B offer coverage for hospitalization and general medicine, but extra services, such as vision and dental or prescription drug coverage, are left out. Medicare Advantage, or Part C, plans offer a more comprehensive coverage option that often bundles in these missing services. North Carolina seniors who enroll in Medicare Advantage get insurance through third-party insurers. While reimbursement levels for services are set through Medicare when enrolled in Parts A and B, private companies offering Medicare Advantage plans set their own rates, which can mean more affordable options that include extra coverage.
- 1 In 2019, there were 69 Medicare Advantage plans available in North Carolina.
- 2 33% of the total Medicare population in North Carolina is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $9,564 per beneficiary in North Carolina, which is 5% lower than the national average.
- 4 Available Medicare Advantage plans range from 4 to 38 across North Carolina’s 100 counties.
There are 69 Medicare Advantage plans available to North Carolina seniors, allowing you to compare policies to find the one that most closely matches your medical and financial needs. All Part C plans must meet policy minimums set by Medicare and provide coverage that is similar to Original Medicare. How seniors pay their share of the cost is one of the ways these plans may differ. Through the private market, the North Carolina Medicare Advantage program offers Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service plans, and Special Needs Plans. Not all Medicare Advantage plans are available in all areas.
Medicare Advantage Plans in North Carolina
Types of Medicare Advantage Plans
In North Carolina, the most commonly available Medicare Advantage plans are HMOs and PPOs. There’s a single PFFS plan option available in one area, while SNPs are offered throughout the state but have stringent eligibility requirements. The North Carolina Medicare Advantage program includes plans from several insurers, so you may have options when selecting a plan that meets your needs.
Health Maintenance Organizations (HMO)
An HMO plan works with a network of doctors, hospitals, and healthcare professionals to provide comprehensive care to policyholders. However, enrollees in an HMO must use in-network providers. Out-of-network care may not be covered, leaving seniors to pay the entire cost of any nonemergency services. (Out-of-network services include emergency, urgent care, and dialysis.)
Under an HMO, a primary care doctor acts as the coordinator for all health care. You will need to select a primary care doctor and get referrals for any specialist visits. While HMOs tend to be the most restrictive in terms of selecting doctors and other care providers, these plans also tend to be the most affordable and may have low or no premiums and deductibles.
Preferred Provider Organizations (PPO)
PPO plans offer a more flexible option than HMOs. These plans allow you to choose healthcare providers both in and out of network. Typically, care received from in-network doctors and hospitals is less expensive, but these plans will pay a share of the cost for any covered service at the location of your choice. PPO networks tend to be larger than with other plans, offering you more preferred providers with lower copays and coinsurance fees. When enrolled in a PPO, you won’t need to select a primary care doctor and may not need referrals to see a specialist.
It’s important to note that with PPO plans, while members can choose any provider, that doesn’t mean the provider has to accept the plan. Check with providers before scheduling services to make sure they’re covered.
Private Fee-For-Service Plans (PFFS)
With PFFS plans, you have the flexibility to go to any healthcare provider who accepts the payment terms offered by your insurance company. There’s no need to worry about in- or out-of-network providers, although most PFFS plans do have a network of guaranteed service providers that will always accept your insurance. A PFFS plan works on a fee-for-service model and lists payment amounts for covered services along with member cost shares. The insurance company always pays the same amount for each service, regardless of the provider. Premiums tend to be higher for this type of insurance, and it’s important to note that not all providers may accept the terms, and they may opt-out of your plan at any time.
Special Needs Plans (SNP)
Seniors with chronic illnesses may choose an SNP. These plans tailor benefits to meet the needs of individuals with a specific condition and offer drug formularies and specialist care targeted for those with preexisting conditions. Some examples of who might qualify for this type of plan include individuals in nursing homes, those eligible for both Medicare and Medicaid, and seniors diagnosed with a chronic, disabling disease. Like HMOs, SNPs require seniors to use in-network care for coverage, with certain exceptions, such as emergency services and dialysis treatments, when not available locally.
Enrollment & Eligibility for Medicare Advantage Plans in North Carolina
When seniors reach age 65, they become eligible for enrollment in Original Medicare Parts A and B. At the same time, they may opt to enroll in a Medicare Advantage plan instead. Individuals under the age of 65 who have been receiving disability benefits for at least 24 months are eligible for Medicare as well. Additional enrollment requirements include:
- Living in a Medicare Advantage service area with an acceptable plan option
- Not being enrolled in Medigap insurance
- U.S. citizenship or permanent resident status
- Those with end-stage renal disease may only be eligible for an SNP if one is available
In North Carolina, seniors who start receiving Social Security benefits are automatically enrolled in Medicare Parts A and B when they reach 65 years old. To opt for a Medicare Advantage plan, you must enroll before this enrollment occurs or change plans during certain periods.
Medicare Advantage enrollment time frames are different for each individual. Enrollment periods are available for both first-time members and existing enrollees.
- When Medicare first becomes available, seniors can select a plan up to three months before their birthday month, during their birthday month, and for three months after, creating a seven-month enrollment window the year they turn 65.
- The annual election period runs annually from October 15th to December 7th. During this time frame, current Medicare members can switch to an Advantage plan for the first time. Those currently enrolled in an Advantage plan can also use this period to switch plans.
- The open enrollment period is from January 1st to March 31st and allows Medicare Advantage members to switch back to Original Medicare or change plans.
- From April 1st and June 30th, general enrollment is available for those who had Medicare Part A, opted in to Part B during the prior open enrollment period for the first time, and are changing to an Advantage plan.
Prescription Drug Coverage
Most Medicare Advantage plans in North Carolina have prescription drug coverage. These plans have the designation MA-PD, and plan premiums may include drug coverage or have a separate premium to cover medications. If you enroll in an HMO or PPO that doesn’t include prescription drug coverage, you won’t be allowed to enroll in a separate Medicare Part D plan. Enrolling in Part D will automatically switch you back to Original Medicare. PFFS plans do allow you to enroll in a stand-alone Medicare Part D plan, but it’s a good idea to discuss your options with the plan administrator before making any changes. All SNPs bundle prescription coverage with their health insurance plans.
Medicare Advantage Resources in North Carolina
Aging seniors often need increasing levels of care, making Medicare a critical program to help maintain a high quality of life. Medicare Advantage plans often offer broader coverage than what’s available through Original Medicare, making these plans advantageous for those who need the extra benefits. Since there are dozens of Medicare Advantage programs available in North Carolina, choosing one can be an exhausting process for first-time enrollees and those dissatisfied with their current coverage. North Carolina has several resources available to help seniors navigate the complex information needed to make an informed decision about Medicare Advantage coverage.
Seniors’ Health Insurance Information Program
The North Carolina Department of Insurance operates a network of SHIP counselors and volunteers throughout the state. Seniors facing healthcare decisions can get more information about each of their coverage options from an unbiased source with no financial interest in the final option chosen. A quick locator tool helps seniors identify their local counselors and schedule appointments. For information about specific plans, seniors are encouraged to contact the provider. Counselors are not insurance agents or affiliated with insurance companies. SHIP operates Monday through Friday from 8 a.m. until 5 p.m.
Contact Information: Website | 855-408-1212
Area Agencies on Aging
Area Agencies on Aging provide a variety of senior services and act as a resource to connect seniors with available local providers. In addition to Medicare options counseling that helps new and current enrollees make informed health insurance decisions, this organization also provides information and access to home health services, financial assistance programs, and home-delivered meals. On the North Carolina Health and Human Services website, seniors can access a map and contact information for AAAs statewide to find the agency serving their local area.
Contact Information: Website | 800-662-7030
The Shepherd’s Center of Greater Winston-Salem
The Shepherd’s Center acts as the Forsyth County location delivering SHIP services and Medicare counseling to local residents in Winston Salem and the surrounding areas. It offers free assistance to Medicare-eligible seniors who have questions about healthcare coverage or need help changing their insurance plan. Counseling explains how Medicare works, what it covers, and what steps a senior needs to take to enroll. In a session, you get information about comparing plans in simple, easy-to-understand language and without any bias. Regular “Welcome to Medicare” workshops are held at the Center, providing a solid overview of the available programs and enrollment process.
Contact Information: Website | 336-748-0217
- Sources [-]
https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans Last accessed April 2021
https://www.cms.gov/Medicare/Health-Plans/PrivateFeeforServicePlans Last accessed April 2021
Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.