Page Reviewed / Updated - May 11, 2020
Medicare Advantage, also known as Medicare Part C or MA, is an all-in-one private alternative to Original Medicare Parts A (hospital insurance) and B (medical insurance). While Medicare Parts A and B are federally funded provisions offering the same coverage to all beneficiaries, Medicare Advantage is only available through private insurance companies and has varying levels and costs of coverage. Unlike Original Medicare, Medicare Advantage can also cover vision, hearing, prescription drugs and wellness programs. Another distinction is that Original Medicare offers Medigap, a supplemental policy that is neither needed nor provided with a Medicare Advantage Plan.
About 22 million people — 34% of Medicare beneficiaries — participate in Medicare Advantage plans nationwide. However, the share of beneficiaries varies by state. In 2019, about 35% of Medicare participants in North Carolina were enrolled in a Medicare Part C plan. At least 25 states, including western neighbor Tennessee, have the same or a close percentage. Others, such as southern neighbor South Carolina at 27% and northern neighbor Virginia at 20%, have much lower shares.
Seniors looking for Medicare Advantage in North Carolina can select from a vast array of plans. Multiple insurers offer HMO, PPO, SNP, PFFS and MSA plans; however, all options are not available in every county. This guide covers the five plan types, prescription drug coverage for North Carolina enrollees and enrollment time frames for Medicare Advantage. We also share additional Medicare resources to help seniors in North Carolina choose the Medicare Advantage plan that best fits their needs.
In North Carolina, seniors may participate in one of five plan types: Health Maintenance Organizations, Preferred Provider Organizations, Special Needs Plans, Private-Fee-for-Service plans and Medical Savings Accounts.
Health Maintenance Organizations
HMOs typically offer lower premiums than other Medicare Advantage plans, but care options are limited in comparison. These plans only cover the cost of care received within its network of medical professionals. If a member receives services from an out-of-network provider, they may be liable for the entire bill. Under most HMOs, patients must choose a primary care doctor and obtain a referral to see a specialist. Some HMOs may allow members to receive certain out-of-network services for a higher co-payment or coinsurance. These are called HMO Point-of-Service (HMO-POS) plans.
Preferred Provider Organizations
PPOs decide how much a member pays for services, detailing the cost-sharing in the Annual Notice of Change and Evidence of Coverage documents sent out each year. PPOs require members to use in-network providers, but these plans also offer limited coverage for out-of-network care. Staying in the PPO’s network avails members of the lowest co-pays and coinsurance. Members do not need a referral to see a specialist. PPOs usually have higher premiums than HMOs.
Special Needs Plans
SNPs offer coordinated medical services to members with certain chronic illnesses, disabilities or limited income. To be eligible for enrollment, an individual must have the condition that the SNP is designed for. Some SNPs cover out-of-network services, while others do not. Typically, members must choose a primary care physician and get referrals through the doctor. These plans must provide prescription drug coverage, while HMOs and PPOs are not required to do so. Different types of SNPs are available in different parts of the state each year.
PFFS plans allow members to see any Medicare-approved health care provider who accepts the plan’s terms and agrees to treat the patient. However, in-network care usually costs less. PFFS plans do not require a primary care doctor or referrals to see specialists, and a few plans cover prescription drugs.
Medical Savings Accounts
Medicare MSAs are similar to Health Savings Account plans in that members can select their health care providers and services. MSAs combine a high-deductible insurance plan and a medical savings account to use for paying medical expenses before the plan member meets the deductible. These plans do not offer Medicare drug coverage.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
Many Medicare Advantage plans offer prescription drug coverage; such plans are known as MA-PDs. PFFS and MSA plans do not typically provide this benefit, so seniors with those plans can enroll in a stand-alone Medicare Prescription Drug plan. However, if an individual in a Medicare Advantage HMO, HMO-POS or PPO joins a separate Medicare Prescription Drug plan, they will be unenrolled from their Medicare Advantage plan and placed back into Original Medicare. Seniors must reside in the service area of the Medicare drug plan they wish to join.
For Medicare Advantage plans that include Medicare prescription drug coverage, the monthly premium could include an amount for this benefit. Members who want their premiums deducted from their Social Security or Railroad Retirement Board (RRB) payment must contact the drug plan.
Understanding Medicare Advantage enrollment and coverage options can feel like a formidable task. Many seniors face confusion when trying to figure out which plan best suits their situation. We've made a list of state and local resources in North Carolina to help guide seniors through the Medicare Advantage process, so they can gain the most benefits from their coverage.
SHIIP provides free, unbiased guidance to help Medicare beneficiaries and caregivers understand Medicare health care products. Counselors in every county meet with seniors by appointment only. Through the NC Senior Medicare Patrol Program, counselors help seniors recognize and avoid Medicare billing errors, fraud and abuse. SHIIP also offers information on its website, including this fact sheet, which discusses Medicare Advantage terms, enrollment periods and questions to ask when comparing plans. This program is available for current Medicare clients, people looking to enroll soon and their caregivers.
SHIIP can be contacted by phone at 1-855-408-1212 or by email at [email protected]. Seniors can consult this list of contacts for local counseling by county. They can also reach counselors through local Area Agencies of Aging.
Options Counseling helps seniors make informed decisions regarding long-term services and supports. This free service guides seniors through assessing the benefits and drawbacks of different options in light of their situation, values, preferences and resources. The program can benefit those who do not know how to take advantage of long-term services and supports, such as Medicare Advantage, or are unaware of existing local supports and resources. Options Counselors can also assist seniors with planning for future needs and help them formulate an individualized Action Plan.
Options Counseling is expanding throughout the state, so it may not be available in all areas yet. To see if there is an Options Counselor in their county, seniors can contact the program manager by email at [email protected].
The Long-Term Care Ombudsman Program (Advocacy for Residents in Long- Term Care Facilities) is made up of the State Long-Term Care Ombudsman and 16 Regional Long-Term Care Ombudsmen. These officials help long-term care facility residents secure their rights and work through grievances between residents, families and facilities. They explain long-term care options and investigate financial concerns, including Medicaid, Medicare and Social Security. Guidance is offered for Medicaid and Medicare, particularly on coverage conditions, the application process and the services covered. The ombudsmen also educate long-term care providers and community groups on residents’ rights, care planning and new legislation.
Established through the Older Americans Act, North Carolina’s Area Agencies on Aging (AAAs) are local programs that connect seniors and their caregivers with a wide range of local services and resources. These agencies develop, enhance and support systems designed to preserve dignity and promote independence for seniors. North Carolina has 16 AAAs located within regional Councils of Government. These agencies are direct providers of information and referral or assistance, educating seniors about available services in their community and helping them gain access to those benefits. AAAs advocate for seniors on local and state concerns beyond the services and programs they render or fund. Available services include case management, meals, in-home services, transportation and counseling on health insurance and benefits.
AAAs are dispersed throughout the state of North Carolina. A list of locations and contact information can be found on their website.
Community and Senior Services of Johnston County (CSS) is a private senior support organization in Smithfield. It provides home-delivered meals, in-home aides, housing assistance and transportation accommodations throughout the county. The nonprofit also has centers in Benson, Clayton, Harrison, Kenly and Princeton. CSS is a certified official counseling site for SHIIP and has an Options Counselor available to discuss long-term options, based on needs and preferences. The counselor acts as a liaison between seniors and services, following up with each person with status check-ins. Seniors who need help paying for Medicare coverage can ask the Options Counselor about the Extra Help Program. CSS holds SHIIP workshops at some of its senior centers, by appointment only, for seniors and caregivers looking for information about Medicare. Seniors can consult the bi-monthly newsletter on the CCS home page to find events near their location.
CSS is located at 1363 West Market Street in Smithfield. To make an appointment with an Options Counselor, seniors can call 1-919-934-6066.
Resources for Seniors provides information and support for seniors and adults with disabilities in Wake County. This private organization coordinates direct services, including adult day care, home care and senior centers to foster independence, security and comfort. It publishes a free annual directory of resources for the Triangle area, available in print or by PDF download.
Information Services at Resources for Seniors is available weekdays by phone, email and fax. Seniors can call 1-919-872-7933 to reach an Information and Referral Specialist who can assess their situation, help them identify the services they need and point them to the appropriate programs and resources.