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Medicare Advantage in North Carolina

October 6, 2016

Medicare Advantage, also known as Medicare Part C, provides an alternative way for Medicare beneficiaries to receive their Original Medicare Part A (hospital insurance) and Part B (medical insurance) benefits.  Medicare Advantage plans are offered by private insurance companies that contract with Medicare to provide Original Medicare, Part A and Part B benefits to those who decide to enroll.

Enrolling in a Medicare Advantage plan doesn’t mean that you no longer have Medicare Part A and Part B. It means you decided to receive your Medicare benefits from a private health insurer contracted with Medicare in North Carolina rather than directly from the federal government-administered program. In fact, you must continue paying your Part B premium if you enroll in a Medicare Advantage plan.

How Medicare Advantage works in North Carolina

Medicare Advantage plans are required to provide the same coverage that Original Medicare Part A and Part B provides, with the exception of hospice care which remains covered by Medicare Part A. While this is the minimum coverage Medicare Advantage plans must provide, these plans commonly offer additional benefits, such as routine vision, dental, hearing, and wellness programs. Many Medicare Advantage plans, known as Medicare Advantage Prescription Drug plans (MA-PDs), also include prescription drug coverage. You may have a Medicare Advantage plan premium, as well as the Medicare Part B premium, to pay monthly.  Medicare Advantage plan premiums vary and some plans may offer insurance premiums as low as $0.

There are several times throughout the year when you generally can enroll in a Medicare Advantage plan in North Carolina, as in other states.

Initial Coverage Election Period (ICEP) is the time period for enrolling in a Medicare Advantage plan when you are first eligible to do so.

  • If you enroll in Original Medicare, Part A and Part B, when you’re first eligible for coverage, then you’re typically eligible to enroll in a Medicare Advantage plan during the same time period. For most people, the Initial Coverage Election Period is a seven-month period that starts three months before the month you turn age 65. The period continues through your birth month, and for the three months following your birthday month. In addition people who are younger than age 65 may be able to enroll in a Medicare Advantage plan when they become eligible for Original Medicare because of certain health conditions or disabilities. To learn more about Medicare eligibility, click here.
  • If you delay enrolling in Original Medicare (for example, some people delay Part B enrollment if they’re covered through an employer’s group health plan or a union’s health & welfare trust fund), your Initial Coverage Election Period is the three-month period before your effective date for Part B coverage. For example, if you enrolled in Part B during the General Enrollment Period (January 1 to March 31), your Part B effective start date is July 1, so your Initial Coverage Election Period for enrolling in a Medicare Advantage plan, with or without prescription drug coverage, would be April 1 to June 30. Note:  you may also enroll in a stand-alone Medicare Part D Prescription Drug Plan during this period if the Medicare Advantage plan you choose does not provide prescription drug coverage.

The Annual Election Period (AEP) takes place every year from October 15 through December 7. This is for Medicare beneficiaries who would like to go from Original Medicare to a Medicare Advantage plan, from one Medicare Advantage plan to another, or from a Medicare Advantage plan back to Original Medicare.

The Medicare Advantage Disenrollment Period goes from January 1 to February 14 of each year. During this period, the only changes a Medicare beneficiary can make are to leave Medicare Advantage in favor of going back to Original Medicare (Part A and Part B), and then enroll in a stand-alone Medicare Part D Prescription Drug Plan to go alongside their Original Medicare coverage. You cannot go from one Medicare Advantage plan to another during this time.

A Special Enrollment Period (SEP) provides an opportunity to enroll in a Medicare Advantage plan outside the normal enrollment periods in some cases. For example, if you move to or from a skilled nursing facility (or if you’re living in one), or if you had Medicaid but are no longer eligible for it, you might qualify for a Special Enrollment Period (SEP). For other examples and for more information, see Medicare Special Enrollment Periods.

Types of Medicare Advantage plans in North Carolina

There are varying types of Medicare Advantage plans. Some of the types are determined by the arrangements the Medicare Advantage plans have with health-care providers participating in their networks and the corresponding benefits that are available when plan members use network participating health-care providers.  It’s important to understand the differences so that you can find one that works best for you.

  • Health Maintenance Organization (HMO): To receive coverage, an HMO plan usually requires you to visit doctors, health-care providers, and hospitals in your plan’s network, except in emergency situations or when approved by the plan. You select a primary care physician from the plan’s network who coordinates your care.
  • HMO Point-of-Service: An HMO-POS plan is a slightly more flexible option than an HMO, allowing you to go out of network and still have your services covered, but generally at a higher out-of-pocket cost than if you received care from a provider participating in the plan’s network.
  • Preferred Provider Organization (PPO)*: A PPO plan offers flexibility, allowing you to choose doctors, health care providers, and hospitals outside of your plan’s network, but usually at a higher out-of-pocket cost for covered services than you would pay if you used a provider in the plan’s network. .
  • Private Fee-for-Service (PFFS): A Private Fee-for-Service plan may or may not offer a partial or full network of providers. This type of plan decides how much it will pay for covered services provided by your doctor, health-care provider, or hospital visits and how much you will pay. Keep in mind that not all providers accept this type of plan.  Make sure you check with the provider before receiving services
  • Medical Savings Account (MSA): A Medical Savings Account plan combines a high deductible with a savings account that you can use to pay for your health care expenses.
  • Medicare Special Needs Plan (SNP): Designed for Medicare beneficiaries with certain health conditions, a Medicare Special Needs plan offers coverage tailored to suit those specific situations. There are Medicare SNPs for people with specific chronic health conditions such as HIV/AIDS, those who are eligible for both Medicare and Medicaid, and for people who are living in an institution, such as a nursing home.
  • Many Medicare Advantage plans include prescription drug coverage. Called a Medicare Advantage Prescription Drug (MAPD) plan, this kind of plan combines health and prescription drug coverage into a single insurance plan.

Remember that if you decide to sign up for a Medicare Advantage plan, you continue paying your Medicare Part B premium in addition to any premium the plan may charge.

Comparing Medicare Advantage plans available in North Carolina

As a Medicare beneficiary in North Carolina, you may find it useful to compare all the Medicare Advantage plans available in your area.

The availability and costs of Medicare Advantage plans generally depend on your county of residence, the insurance company offering the Medicare Advantage plan, and the plan’s specific benefit details. You may find that some Medicare Advantage plans in North Carolina offer premiums as low as $0, but you might want to also consider the plan’s other costs such as copayments and deductibles. (Keep in mind that you continue to pay your monthly Medicare Part B premium, no matter which Medicare Advantage plan you choose.)  Some further considerations to keep in mind when selecting a Medicare Advantage plan:

  • Do you need prescription drug coverage? If so, make sure the plan you choose is a Medicare Advantage Prescription Drug plan.  Also, check the plan’s formulary, or list of covered prescription drugs, to see if your medications are included in the formulary. Note that a plan’s formulary may change at any time. You will receive notice from your plan when necessary.
  • Does the Medicare Advantage plan have a network of participating providers?  If so, check to see if your doctors, your other health-care professionals, and your preferred hospitals participate.  Your out-of-pocket expenses for care may be higher if your providers do not participate in the plan’s network.
  • What kinds of extra benefits are you interested in? Some Medicare Advantage plans may offer additional coverage beyond what is included in Original Medicare, Part A and Part B, such as routine dental care – so you might want to compare the plans available in your area to see which ones may include benefits that would be valuable to you.

You can see why it’s important to compare Medicare Advantage plans to find one that offers benefits and costs suited to your personal health and budget requirements.

To start comparing Medicare Advantage plans in North Carolina right away, enter your zip code above for a list of plans available in your area. You can also enter the names of your prescription drugs to further customize your search and cost estimates.

To learn more about Medicare in North Carolina, you are invited to review the following resources:

* Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.