Medicare in North Carolina

Medicare is a federally funded health insurance program for older adults and individuals with certain disabilities in the United States. At the start of 2022, there were more than 2 million residents in North Carolina enrolled in Medicare. Adults aged 65 and older made up 84% of Medicare beneficiaries, which means that nearly all seniors in the state were enrolled. The average spending per capita for Medicare enrollees was $15,670 per year for fee-for-service coverage and $11,809 for Medicare Advantage. 

Medicare benefits are divided up into several parts. Part A, which is part of Original Medicare, covers some of the most common health services, such as inpatient hospital care, care in a skilled nursing facility, hospice care and some home health care services. Qualified seniors pay nothing out of pocket for these services. Part B is also an Original Medicare plan that covers clinical research, ambulance services, durable medical equipment, limited prescription drugs and mental health services.

Seniors in North Carolina who want customized coverage can enroll in private programs known as Medicare Advantage, which is also known as Medicare Part C. Advantage plans include the benefits available in Parts A and B and, in most cases, Part D as well. These plans may also cover some benefits not available in Original Medicare, such as dental, vision and hearing. 

With this guide, seniors in North Carolina can find out which Medicare plan is right for their health care needs. They can also discover community resources that make it easier to take advantage of Medicare benefits. 

Options for Medicare Coverage in North Carolina

Many seniors in North Carolina are happy with the benefits they receive from Original Medicare, but there are other options for older adults who have unique health needs that fall outside Parts A and B. By supplementing Original Medicare with Medicare Advantage and other private plans, seniors can ensure they get the treatments, prescriptions and other care services they need to stay healthy. 

Original Medicare (Parts A & B)

Original Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) and is open to seniors aged 65 and over, along with those under 65 years old, but with certain disabilities or end-stage kidney disease. It includes two parts. Part A covers inpatient hospital care, nursing home and skilled nursing care, hospice and home health care. Part B, or medical coverage, pays for medically necessary goods and services such as durable medical equipment, mental health services and emergency medical transportation. 

Unlike most private Medicare plans, Original Medicare’s provider network isn’t limited to the beneficiary’s geographic region, making it easier to obtain services while traveling within the country. In most cases, Medicare doesn’t pay for health services the individual receives outside the United States. 

Under this program, seniors pay for services as they receive them. They must pay an annual deductible, which is $1,556 for Part A and $233 for Part B in 2022. After they’ve paid this amount, Medicare covers all eligible services at 80%. Beneficiaries pay the remaining 20% out of pocket.

Who Should Consider Original Medicare

Original Medicare may be a good option for those who:

• Travel frequently within the United States
• Don’t need extra benefits such as home-delivered meals and coverage for over-the-counter medication
• Want to choose their own prescription drug coverage

Medicare Advantage (Part C)

Medicare Advantage plans, or Part C, are alternatives to Parts A and B and are administered by private companies rather than CMS. Laws mandate that Medicare Advantage plans offer most of the benefits available in Original Medicare except hospice, clinical research and some new treatments. They can also include additional coverage for things like prescription drugs or other health-related products and services, such as vision and dental. Plans can be customized to meet the medical needs of groups with certain chronic conditions, including illnesses like diabetes, arthritis and heart disease. 

Similar to private insurance available in the non-Medicare marketplace, Part C plans in North Carolina come in five types: Special Needs Plans, Private Fee for Service, Medicare Savings Account, Health Maintenance Organization and Preferred Provider Organization. While federal laws mandate the minimum amount of coverage these plans can provide, each option has unique costs and eligibility requirements. 

Who Should Consider Medicare Advantage

The following people may find that a Medicare Advantage plan is their best coverage option:

• Seniors with chronic conditions who require regular prescription medication
• Adults who prefer a managed care organization
• Healthy older adults who want lower insurance premiums
• Seniors with special care needs not covered by Original Medicare

The Top 10 Medicare Advantage Plans in North Carolina 

Seniors in North Carolina can choose between a variety of PPOs, HMOs, MSAs and SNPs from different companies. In some cases, enrollees will only be able to get care from a local or regional network of providers. Some SNPs specifically cater to seniors in long-term care, including assisted living facilities and nursing homes. Below are the 10 most popular Medicare Advantage plans in North Carolina, updated as of April 2022. Enrollment numbers reflect statewide totals, and prices are presented as a range from lowest to highest.

Medicare Prescription Drug Coverage (Part D)

Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later. Most Medicare Advantage Plans cover prescription drugs, and therefore seniors enrolled in this plan do not need to buy Plan D. 

Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.

Who Should Consider Medicare Prescription Drug Coverage

Seniors who may benefit from prescription drug coverage include those who:

• Currently take prescription medication or expect to in the future
• Want to avoid late enrollment penalties
• Want to reduce out-of-pocket prescription drug expenses

Medicare Supplement Insurance (Medigap)

While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.

In North Carolina, there are 10 types of Medigap plans, eight of which are available to new enrollees. Plans are standardized, meaning policyholders get the exact same coverage from a given plan regardless of the health insurance provider they buy it from. For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2022 page.

Who Should Consider Medicare Supplement Insurance

Good candidates for Medigap may be those who:

• Have ongoing health issues and expenses
• Travel overseas often
• Want to access an expanded network of health care providers
• Expect to need health services not covered by Original Medicare

Medicare Resources in North Carolina

Due to the wide range of coverage options, price differences and available providers, finding the right Medicare plan in North Carolina can be confusing for many seniors. The following resources may make this process easier by providing valuable information and guidance and, in some cases, direct one-on-one counseling. Help in North Carolina is available from both public and private organizations.