Medicare in North Carolina

Who is eligible for Medicare?

Medicare is a nationwide program created in 1965 to provide health insurance coverage for individuals aged 65 and older.⁶ Recipients must be a U.S citizen or a permanent legal resident who has lived in the United States for at least five years.⁷ Medicare is run by the federal government, specifically the Centers for Medicare & Medicaid Services.

Medicare was later expanded to include and now also covers people younger than 65 who have permanent disabilities, as well as those diagnosed with end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS). Learn more about Medicare.⁷

Medicare enrollment in North Carolina

As of March 2023, there were 2,146,428 residents with Medicare in North Carolina. For most of them, Medicare coverage enrollment was triggered by turning 65. But more than 13% of North Carolina Medicare beneficiaries — about 284,000 people — were under age 65 as of March 2023.¹

Nationwide, there are nearly eight million people under the age of 65 who are covered by Medicare, accounting for almost 12% of all Medicare beneficiaries.⁸ This is because Medicare eligibility is also triggered once a person has been receiving disability benefits for 24 months, or has kidney failure or amyotrophic lateral sclerosis (ALS).

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Medicare health insurance options

Medicare beneficiaries can choose among a number of coverage options. The first choice is between Medicare Advantage, with coverage provided by private insurance companies that contract with Medicare, and Original Medicare, with coverage provided directly by the federal government. There are pros and cons to either option, and the right solution depends on each enrollee’s needs.

Medicare beneficiaries also have options around Medigap policies and Medicare Part D (prescription drug) coverage.

Medicare Advantage in North Carolina

Since Medicare Advantage plans are offered by private insurers, plan availability varies from one area to another. There are Medicare Advantage plans in all 100 counties in North Carolina for 2023, but plan availability ranges from 13 plans in Onslow County, to 51 plans in Guilford County.²

As of 2018, a little more than a third of all Medicare beneficiaries nationwide were enrolled in Medicare Advantage plans, and North Carolina’s Medicare Advantage enrollment was very much in line with the national average, with 33% of the state’s Medicare beneficiaries covered by Advantage plans.

By Apirl 2023, total Medicare enrollment in North Carolina (not counting people with supplemental coverage like Medicare Part D prescription drug coverage and Medigap) had grown to over 50% percent of the state’s Medicare population¹  (slightly higher than the national average at that point),⁸ with 1,126,179 people enrolled in Medicare Advantage plans. The other 1,022,236 Medicare beneficiaries had Original Medicare coverage as of April 2023.⁹

Medicare Advantage plan enrollment is an option when people are initially eligible for Medicare, and during the Medicare Annual Election Period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to change between Medicare Advantage and Original Medicare (and add, drop, or switch to a different Medicare Part D prescription drug plan). The Medicare Advantage open enrollment period, which runs from January 1 to March 31, gives people who already have a Medicare Advantage plan an opportunity to change to a different one or switch to Original Medicare.

Medigap in North Carolina

Original Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage. Nationwide, over 80% of Original Medicare beneficiaries get their supplemental coverage.¹⁰ But for those who don’t, Medigap plans (also known as Medicare supplement insurance plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have to pay if they had Original Medicare on its own.

According to a 2022 American Health Plans (AHIP) analysis, there were 494,578 North Carolina Medicare beneficiaries enrolled in Medigap plans as of 2020.⁴ This was down slightly from 2019, when there were 510,098 Medigap enrollees in the state. As Medicare Advantage plan enrollment growth outpaces overall Medicare enrollment growth, Medigap enrollment tends to decrease. This is because people do not need (and cannot use) Medigap coverage if they have Medicare Advantage plans.

Medigap plans are sold by private insurers, but they’re standardized under federal rules and regulated by state laws and insurance commissioners. There are 42 insurers that offer Medigap plans in North Carolina.¹¹ The state’s plan comparison tool displays the plans based on how much they cost, to make it easy to compare the various options. Since the plan benefits are standardized (ie, Plan G has the same benefits regardless of which insurer sells it), consumers can make their plan selection based on premiums and less tangible factors like customer service. North Carolina’s Medigap shopping guide is a useful resource for consumers.

North Carolina allows Medigap insurers to pick their own rating approach, so nearly all of the plans for sale in the state use attained-age rating, which means that an enrollee’s premiums will increase as they get older, regardless of how old they were when they first enrolled. The other two approaches to Medigap premiums are issue-age rating, in which premiums are based on the age the person was when they enrolled, and community rating (sometimes called “no age” rating), which means premiums don’t vary based on age; some states require one of these approaches, but North Carolina does not.

Federal rules require Medigap insurers to offer plans on a guaranteed-issue basis during an enrollee’s Medigap Open Enrollment Period, which begins when the person is at least 65 years old and enrolled in Medicare Part B (and Medicare Part A; you have to be enrolled in both to obtain Medigap).¹² But federal rules do not guarantee access to Medigap plans for people under age 65. But North Carolina is among the majority of the states that have enacted rules to ensure access to Medigap plans for disabled enrollees under age 65.

North Carolina law (see North Carolina statute § 58-54-45) requires all Medigap insurers in the state to offer at least Plan A to people under age 65 who are enrolled in Medicare due to a disability. And if the insurer also offers either Plan C or Plan F to people who are 65+, they must also make that plan available to beneficiaries under age 65 who were eligible for Medicare prior to 2020. If the insurer offers either Plan D or Plan G to people who are 65+, they must also offer that plan to people who are under 65 and eligible for Medicare (under federal rules, as a result of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medigap Plans C and F cannot be sold to people who become eligible for Medicare in 2020 or later).¹²

North Carolina Medicare beneficiaries under age 65 are granted a one-time six-month Medigap Open Enrollment Period that begins when they’re enrolled in Medicare Part B (or when they find out they’ve been retroactively enrolled in Part B). So they essentially have the same enrollment period as people who are turning 65, but it applies regardless of age, and it only guarantees access to Plan A and, in some cases, Plan C and Plan F or Plan D and Plan G.

But while state law in North Carolina guarantees access to Medigap plans for disabled beneficiaries under age 65, the insurers may charge significantly higher premiums for these enrollees.¹³ Medigap Plan A rates in 2023 for a person aged 55 range from $260 per month to $1,387 per month. In comparison, the same Plan A for a person aged 65 ranges in price from $98 per month to $338 per month. And for Plan G, premiums for a 55-year-old range from $230 per month to $1,485 per month, whereas a 65-year-old would pay between $108 and $256 per month for the same plans.

Disabled Medicare beneficiaries have access to the Medigap open enrollment period when they turn 65. At that point, they have access to any of the available Medigap plans in their state, at the standard age-65 rates.

Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare. Medicare Advantage plan monthly premiums are not higher for those under 65.¹⁴ But Medicare Advantage plans may have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $8,300 in 2023 for in-network care,¹⁵ plus the out-of-pocket cost of prescription drugs. New in 2025, a Medicare Part D prescription drug plan will feature a $2,000 out-of-pocket spending cap.¹⁶

North Carolina Medicare Part D

Original Medicare does not provide coverage for outpatient prescription drugs. Nationwide, over 80% of Original Medicare beneficiaries nationwide have some type of supplemental coverage.¹⁰

But Medicare Part D, created under the Medicare Modernization Act of 2003, provides prescription drug coverage for Medicare beneficiaries who do not have another source of coverage for prescription costs. Medicare beneficiaries can enroll in Medicare Part D prescription drug plans on a stand-alone basis, or obtain Part D coverage integrated with a Medicare Advantage plan (not all Medicare Advantage plans include Part D coverage, but most do).

There are 24 stand-alone Medicare Part D plans in North Carolina for 2023, with monthly premiums starting at $4.20 per month.⁵

644,401 North Carolina beneficiaries were enrolled in stand-alone Medicare Part D prescription drug plans (which are called prescription drug plans or PDPs) as of early 2023.⁹ Another 1,051,534 beneficiaries had Medicare Advantage plans that included integrated Medicare Part D coverage. Together, that’s more than three-quarters of the state’s Medicare beneficiaries with Part D coverage.

Medicare Part D prescription drug plan enrollment is available when a person is first eligible for Medicare, and also during the Medicare Annual Enrollment Period that runs from October 15 to December 7.

Helpful resources for North Carolina Medicare beneficiaries and their caregivers

Do you have questions about Medicare eligibility in North Carolina or need help selecting the best options for your specific situation? These resources provide free assistance and information.

• You can contact North Carolina’s Seniors’ Health Insurance Information Program (SHIIP) with questions related to Medicare enrollment in North Carolina. Visit the website or call 855-408-1212.
• North Carolina’s Senior Medicare Patrol Program (NCSMP) strives to “reduce Medicare error, fraud, and abuse” by educating Medicare beneficiaries and their caregivers about Medicare benefits, statements, explanations of benefits, etc.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

Footnotes

1. “Medicare Monthly Enrollment – North Carolina.” Centers for Medicare & Medicaid Services Data, March 2023. ⤶ ⤶ ⤶ ⤶ ⤶
2. Jeannie Fuglesten-Biniek and Meredith Freed. “Medicare Advantage 2023 Spotlight: First Look.” Kaiser Family Foundation, November 10, 2022. ⤶ ⤶
3. “Supplement Insurance (Medigap) Plans – North Carolina.” Medicare.gov. Accessed July 24, 2023. ⤶ ⤶
4. “The State of Medicare Supplement Coverage.” AHIP.org, March 2022. ⤶ ⤶
5. Fact Sheet – Centers for Medicare & Medicaid Services. Page 101. CMS, September 29, 2022. ⤶ ⤶
6. “Medicare History.” CMS.gov. Accessed July 24, 2023. ⤶
7. “Original Medicare (Part A and B) Eligibility and Enrollment.” CMS.gov. Accessed July 24, 2023. ⤶ ⤶
8. Medicare Monthly Enrollment – US.” Centers for Medicare & Medicaid Services Data, March 2023. ⤶ ⤶
9. Medicare Monthly Enrollment – North Carolina.” Centers for Medicare & Medicaid Services Data, March 2023. ⤶ ⤶
10. Ochieng, Nancy, and Jeannie Fuglesten Biniek. “Cost-Related Problems Are Less Common among Beneficiaries in Traditional Medicare than in Medicare Advantage, Mainly Due to Supplemental Coverage.” Kaiser Family Foundation, July 7, 2021. ⤶ ⤶
11. “Medigap Plans Company Names in North Carolina.” NC Department of Insurance, April 3, 2023. ⤶
12. “2023 Choosing a Medigap Policy.” Medicare.gov. Accessed July 29, 2023. ⤶ ⤶
13. Supplement Insurance (Medigap) Plans – North Carolina.” Medicare.gov. Accessed July 24, 2023. ⤶
14. “Can I Be Charged a Higher Premium for Medicare Advantage Plans?” Kaiser Family Foundation. Accessed August 4, 2023. ⤶
15. “Medicare Advantage/Medicare Part C Costs.” The National Council on Aging, October 20, 2022. ⤶
16. Cubanski, Juliette. “Changes to Medicare Part D in 2024 and 2025 under the Inflation Reduction Act and How Enrollees Will Benefit.” Kaiser Family Foundation, April 20, 2023. ⤶