844-259-6504

Wondering what Medicare Advantage options you have if you live in North Carolina? Read our guide to learn which plans best fit your needs.

By Jackie Trovato
Updated June 29, 2020

Key Takeaways:

  • There are pros and cons to both HMOs and PPO Medicare Advantage plans in North Carolina.

  • HMO drug costs and monthly premiums are typically lower than with other plans.

  • HMOs require you to stay within their network for care, or you'll have to pay more.

  • PPOs provide you the flexibility to go to doctors, specialists, or hospitals that aren't in the plan's list.

  • If you join a Medicare Advantage PPO plan that doesn't offer prescription drug coverage, you won't be allowed to join a Medicare Part D prescription drug plan.

Medicare Advantage plans in North Carolina cover everything included in both Medicare Part A and Part B, as well as other healthcare services like dental, vision, hearing, wellness programs (like gym memberships), and prescription drug coverage.

These plans can also cover extra benefits like transportation to doctor visits, over-the-counter drugs, adult day care services, and other health-related services to promote your health and wellness.

As of May 2020, 1,199,144 North Carolina residents were enrolled in Medicare. If you are one of them, you can sign up for a Medicare Advantage plan in North Carolina (called Part C and offered by private insurance companies).

What are the Pros and Cons of Medicare Advantage Plans In North Carolina?

Depending upon where you live, plans run the gamut from basic HMOs (Health Maintenance Organization plans) to those with drug plans. There is also a variety of PPOs (Preferred Provider Organization) plans.

So, what type of Medicare Advantage plan in North Carolina should you choose? There are pros and cons with each of the available Medicare Advantage plans in the Tar Heel State. We'll explain some of them here.

find a medicare plan that fits your lifestyle

The Advantages of Using an HMO Medicare Advantage Plan In North Carolina

In most cases, your prescription drugs will be covered in your Medicare Advantage HMO Plan. Medicare Advantage HMOs keep your drug costs lower by often prescribing only the generic form of a prescription medication.

Just be sure that you are joining an HMO Medicare Advantage plan that includes Medicare Part D (Medicare drug coverage).

Here are some real cost advantages to consider when using an HMO Medicare Advantage plan in North Carolina:

  • Your monthly premiums will be lower than when using another type of plan (like a PPO).

  • You won't have to file claims for reimbursements of medical costs.

  • You will generally be offered a lower out-of-pocket cost for your prescription medications.

The Disadvantages of Using an HMO Medicare Advantage Plan In North Carolina

With an HMO plan, you are typically required to receive healthcare services from the specific providers in their network. If you don't, you will pay more for your services. There are three exceptions — these include healthcare for:

  1. Medical emergencies

  2. Urgent care when you're out of the area.

  3. Dialysis when you're out of the area.

You will have one primary care provider in the HMO plan that you choose. This doctor coordinates all of your healthcare visits. To see a specialist, your primary care provider must authorize the appointment and provide a referral (unless it's for emergency care).

There may also be restrictions for the number of times you are allowed to receive services from a specialist without going back to your primary care doctor for a referral.

This can be a disadvantage for those who would rather see a healthcare provider who isn't in the HMO plan. With some HMO Medicare plans in North Carolina, you might be allowed to go out-of-network for certain healthcare services. This is called an HMO with a POS (point-of-service) option.

Remember, it will always cost more if you use a provider or service outside the HMO Medicare Advantage plan. In some cases, if you get healthcare outside the plan's network, you may have to pay the full cost of the service.

Also, HMOs keep drug costs down by usually prescribing only the generic form of a medication. If you prefer a particular brand-name medicine, it may not be covered, and you'll have to pay full price for it.

You will also need to get a referral to see a specialist with an HMO Medicare Advantage plan in North Carolina. This includes things like annual screening mammograms.

For some, this can be a nuisance because it requires an extra step to receive specialty care. And in some cases, if the primary care physician believes that he or she can render this service just as well, a specialty visit can be denied.

The Benefits of Using a PPO Medicare Advantage Plan In North Carolina

Each Medicare Advantage PPO plan provides you the flexibility to go to doctors, specialists, or hospitals that aren't in the Medicare plan's list (however, it will usually cost more). You'll pay less when you see doctors, hospitals, and healthcare providers in the Advantage PPO plan's network.

In most cases, no referrals are required. Just like an HMO, a Medicare Advantage PPO plan has its own network of doctors and hospitals. If you use the PPO's specialists, your covered services will usually cost less than if you use non-plan specialists.

With a Medicare Advantage PPO plan, you won't be tied to just one primary care doctor. You can visit any primary care doctor in the network without paying extra. You don't even need to choose a primary care doctor in a PPO plan. But you will pay more if you go outside the network.

With most PPO Medicare Advantage plans in North Carolina, prescription drugs are covered. Just be sure that you join a PPO plan that offers prescription drug coverage.

Plus, Medicare Advantage PPO plans in North Carolina typically offer extra benefits than what Original Medicare provides, but you may be required to pay extra for these benefits.

The Disadvantages of Using a PPO Medicare Advantage Plan In North Carolina

Just like a Medicare Advantage HMO, you'll pay more if you use doctors, hospitals, and providers outside of the PPO network.

If you join a Medicare Advantage PPO plan that doesn't offer prescription drug coverage, you won't be allowed to join a Medicare prescription drug plan (Part D). So, if you want drug coverage, be sure that your Advantage PPO plan in North Carolina provides it.

How Do Costs For Medicare Advantage In NC Compare to the Other States?

Each Medicare Advantage plan in North Carolina can charge different out-of-pocket costs. They also have differing rules regarding how you get services. These rules can change from year to year. The Medicare plan must notify you about any changes before the start of the next enrollment year.

If you're considering a Medicare Advantage Plan in North Carolina, there are quite a few you can choose from depending upon where you live in the state.

Visit this site and type in the requested information to find one. For example, if you live in Brunswick County, and you're a 68 year-old woman, your Medicare Advantage monthly premiums can range from $124.25 to $337.55, depending on the insurance company you choose.

The average monthly rated cost for a Medicare Advantage plan in North Carolina is $33. The highest monthly weighted cost is in Minnesota at $50, and the lowest are Florida, Louisiana, Nebraska, South Carolina, and Texas at an average monthly cost of $5.

When ranking all the states (except Alaska, which doesn't provide Medicare Advantage), North Carolina ranks 31st in cost, with one being the least expensive and 50 being the most costly.

Where Can You Go For More Information About Medicare Advantage Plans in North Carolina?

Take a look at all the Medicare Advantage plans for 2020 that are available in the various counties in North Carolina.

Medicare enrollees in North Carolina often have questions about benefits, claims, and Medicare Advantage plans. For more information regarding Medicare Advantage plans you can visit medicare.gov or you can call Medicare and Seniors' Health Insurance Information Program (SHIIP) toll-free at 1-855-408-1212 Monday through Friday from 8 a.m. to 5 p.m.