Medicare in North Carolina

Medicare is a health insurance program funded by the federal government. Coverage extends to adults aged 65 and up, as well as younger adults with disabilities. As of 2021, over 2 million North Carolina residents were enrolled in Medicare. This includes those enrolled in Medicare Advantage, which currently has an enrollment rate of 53% in the state.

Medicare is available in several forms. Original Medicare covers a wide range of common health care services and consists of two parts — A and B. Part A includes inpatient medical care, along with nursing home and hospice expenses. Part B covers goods and services deemed medically necessary, including mental health treatment and medical equipment. Part C, also known as Medicare Advantage, consists of customized plans administered by private companies. These plans typically include additional coverage such as prescription fulfillment and dental care. Part D also enlists private insurance companies to provide coverage for prescription drugs. Seniors usually purchase these plans as an addition to their Original Medicare policy. 

From 2022 to 2023, the number of North Carolina Medicare enrollees grew by 12.07%. This is slightly higher than the nationwide growth of 9.75%. On average, the state’s spending per capita for each Medicare enrollee is $15,670. The cost remains slightly lower for Medicare Advantage enrollees, at $11,809. Within North Carolina, the highest-spending counties are largely concentrated in the state’s eastern half, with its western side spending slightly less per person. 

This guide is intended for seniors in North Carolina who are looking to find the Medicare plan that meets their health care needs. Following is a detailed exploration of parts A through D, along with a list of the state’s most popular plans. Seniors will also find a collection of resources designed to help them take advantage of the Medicare benefits they’re entitled to. 

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)

Because Medicare Original covers a wide range of the most common health care services, these policies work well for many seniors. But for those who have needs that fall outside of common coverage, Medicare Original may not be enough. In these cases, seniors often supplement their coverage with Medicare Advantage or other plans fulfilled by private insurance companies. This ensures they have access to the treatment, medications and services necessary for their health. 

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, or Part C, is an alternative to Medicare Original that is administered by a private insurance company. Laws mandate that Medicare Advantage Plans offer the most benefits available in Original Medicare except hospice, clinical research and some new treatments. Plans may include additional coverage for prescription drugs or other products and services, such as vision and dental. Additionally, they can be customized to meet each senior’s medical needs, making them suitable for those with chronic conditions such as diabetes and arthritis. 

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 August 2023. 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 2023 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.