Medicare Advantage Plans in North Carolina

Fact Checked
Published: 2/5/2021

Medicare Part A and Medicare Part B make up Original Medicare, the federal government's health care program for seniors and eligible disabled adults. Medicare Part A covers your hospital expenses, while Part B takes care of various outpatient medical costs. Another option is Medicare Advantage or Medicare Part C, which consists of health care plans managed by Medicare-approved private companies. Medicare Advantage Plans are legally required to provide the same benefits as Original Medicare. They may include extra services, too, like routine dental and hearing care, prescription drug coverage, and wellness programs.



  • In 2019, there were 69 Medicare Advantage Plans available in North Carolina.
  • 33% of the total Medicare population in North Carolina is enrolled in Medicare Advantage Plans as of 2018.
  • In 2018, Original Medicare spent an average of $9,564 per beneficiary in North Carolina, which is 5% lower than the national average.
  • Available Medicare Advantage Plans range from four to 38 across North Carolina’s 100 counties.

If you decide to enroll in a Medicare Advantage Plan in North Carolina, you can choose from four main plan types to get the coverage you need. The plans available to you are limited by where you live and the health insurance provider. Plans differ in whether they have a provider network, if you need to choose a primary care doctor, and the amount you spend each year on premiums, copays, and deductibles.

Medicare Advantage Plans in North Carolina

Types of Medicare Advantage Plans

If you’re eligible to apply for North Carolina’s Medicare Advantage program, you can choose between Health Maintenance Organization Plans, Preferred Provider Organization Plans, Private Fee-For-Service Plans, and Special Needs Plans. HMOs and PPOs are the most common, while PFFS plans and SNP options may be more limited. When comparing plans, carefully consider which benefits serve your needs best.

Health Maintenance Organizations (HMO)

Medicare Advantage HMO plans give you coverage through a network of service providers. For an annual or monthly fee, you receive access to health care from select physicians and specialists who are part of that organization’s contract. HMOs typically have lower premiums than other types of MA plans. The trade-off is that you’re limited on where you can seek medical care. You’ll need to select an in-network primary care provider and get referrals to see specialists.

Preferred Provider Organizations (PPO)

Medicare Advantage PPO plans are more flexible than an HMO, allowing you to seek health care from any provider within the network. You don’t need to select a primary care doctor or get referrals to see specialists with a PPO plan, and you can seek care outside the plan’s provider network, but you can expect to pay more for out-of-network services. The benefit of PPOs is the increased flexibility, but you’ll pay higher premiums than you would with an HMO plan.

Private Fee-For-Service Plans (PFFS)

PFFS plans allow you to enroll in Medicare Part D for drug coverage if it’s not included in your Medicare Advantage plan. With PFFS plans, the insurance company determines how much they pay providers for various services, and in turn, how much you must pay them. You don’t need to choose a primary care physician or obtain referrals to see specialists, and you can seek health care from any provider who agrees to the plan’s terms. If your plan has a provider network and you stay within it when receiving care, you’ll enjoy lower costs.

Special Needs Plans (SNP)

Special Needs Plans are only available to people with certain conditions or diseases and those in certain circumstances. Each SNP offers specific benefits to meet the needs of qualifying individuals, and it must provide prescription drug coverage. Once enrolled, you may only see providers within your plan’s network, except for emergency services and out-of-area dialysis for End-Stage Renal Disease (ESRD).

Enrollment & Eligibility for Medicare Advantage Plans in North Carolina

Eligibility

To be eligible for enrollment in a Medicare Advantage or Medicare Part C plan in North Carolina, you must be a U.S. citizen or permanent resident for five years or more and meet one of the following criteria:

  • You’re enrolled in Original Medicare Part A and Part B and not enrolled in Medigap insurance
  • You’re aged 65 or older
  • You have ESRD or ALS
  • You’ve been on Social Security Disability Insurance (SSDI) for two years or more

Enrollment Periods

There are multiple periods throughout each year that the federal government has designated for seniors to enroll in Medicare Advantage Plans. Some of these periods can be used for new enrollees, and others are meant for current enrollees to switch plans. These are the only times you can join a Medicare Advantage Plan.

  • The initial election period is a seven-month span that starts three months before your 65th birthday month and ends three months later.
  • The annual election period lasts from October 15th to December 7th each year. During this period, you can enroll in a Medicare Advantage Plan for the first time or switch to a new plan.
  • The open enrollment period takes place from January 1st to March 31st annually. If you’re already enrolled in Medicare Advantage, you can switch plans or return to Original Medicare during this period.
  • The general enrollment period runs from April 1st to June 30th each year. You can sign up for a Medicare Advantage plan between these dates if you enrolled in Medicare Part B for the first time during that year’s open enrollment period.
  • You may qualify for a special enrollment period due to certain events, such as relocating outside your current plan’s service area, losing eligibility for your SNP, becoming eligible for an SNP, or losing your health insurance coverage.

Prescription Drug Coverage

Medicare Part D offers prescription drug coverage for a wide variety of drugs, including those in protected classes like drugs for treating HIV or cancer. You’ll be able to review a full list of available drugs under the plan formulary. Part D coverage is available as an add-on to Original Medicare.

The only type of Medicare Advantage Plans that must include Medicare Part D drug coverage are SNPs. Many HMOs and PPOs offer prescription coverage as a benefit, and PFFS plans allow you to sign up for a separate Medicare Part D drug plan. If you’re enrolled in an HMO or PPO plan that doesn’t include prescription drug coverage and sign up for a separate Medicare Part D plan, you’ll be dropped from your MA plan and switched back to Original Medicare.

Medicare Advantage Resources in North Carolina

Selecting a Medicare Advantage Plan requires quite a bit of research, and there are many factors to consider. To ensure you understand your options, you can make use of community resources available to help seniors in North Carolina make decisions regarding their health care coverage.

North Carolina Department of Insurance  (SHIIP)

The Seniors Health Insurance Information Program is offered through the North Carolina Department of Insurance and counsels beneficiaries and caregivers about Medicare health plans and recognizing billing mistakes. The program’s trained volunteers aren’t insurance agents, and they don’t attempt to sell you anything or steer you in a specific direction. You can count on unbiased opinions.

Contact Information: www.ncdoi.gov | 855-408-1212

North Carolina Senior Medicare Patrol (SMP)

SMP is a North Carolina Department of Insurance program and has volunteers on hand to answer your questions about Medicare billing errors and potential instances of fraud. SMP volunteers advise you about Medicare Part D drug coverage and can help you understand summary notices, statements, and explanations of benefits to protect you against fraud.

Contact Information: www.ncdoi.gov| 855-408-1212

New Hanover County Senior Resource Center

The New Hanover County Senior Resource Center is available to guide seniors living in and around Wilmington who are preparing for their first Medicare Advantage enrollment period. The Center’s staff can provide additional resources in North Carolina to ensure you understand your coverage options, including prescription drug plans.

Contact Information: src.nhcgov.com|910-798-6400

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