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Medicare in North Carolina

North Carolina requires Medigap insurers to sell at least Plan A (and C/D and F/G if the insurer offers them) to Medicare beneficiaries under age 65

Key takeaways

Who is eligible for Medicare?

Medicare is a nationwide program created in 1965 to provide health insurance coverage for Americans aged 65 and older. Medicare is under the governance of the federal government, specifically the Centers for Medicare and Medicaid Services.

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

Medicare enrollment in North Carolina

As of July 2020, there were 2,025,301 residents with Medicare in North Carolina. For most of them, Medicare coverage enrollment was triggered by turning 65. But 17 percent of North Carolina Medicare beneficiaries — about 340,000 people — were under age 65 as of 2017.
Nationwide, there are nearly 10 million people under the age of 65 who are covered by Medicare, accounting for about 15 percent of all Medicare beneficiaries. This is because Medicare eligibility is also triggered once a person has been receiving disability benefits for 24 months, or has kidney failure or ALS.

In Alabama, Arkansas, Kentucky, and Mississippi, 22 percent of Medicare beneficiaries are disabled and under age 65. At the other end of the spectrum, just 9 percent of Hawaii’s Medicare beneficiaries are under 65.

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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 plans, where coverage is through private Medicare Advantage plans, and Original Medicare, where coverage is paid for directly by the federal government. Medicare beneficiaries also have options around Medigap policies and Medicare Part D (prescription drug) coverage.

Medicare Advantage in North Carolina

Medicare beneficiaries can use a private Medicare Advantage plan or Original Medicare. There are pros and cons to either option, and the right solution depends on each enrollee’s needs.

Since Medicare Advantage plans are offered by private insurers, plan availability varies from one area to another. There are Medicare Advantage plans for sale in all 100 counties in North Carolina in 2020, but plan availability ranges from just four plan options in Craven, Dare, Lenoir, and Onslow counties, to 38 plan options in Mecklenburg County.

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 percent of the state’s Medicare beneficiaries covered by Advantage plans. But as of mid-2020, total private Medicare enrollment in North Carolina (not counting people with private supplemental coverage like Part D and Medigap) had grown to nearly 41 percent of the state’s Medicare population, with 823,992 people enrolled in private plans. The other 1,201,309 Medicare beneficiaries had Original Medicare coverage as of mid-2020.

Medicare Advantage enrollment is an option when people are initially eligible for Medicare, and Medicare’s 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 plan). The Medicare Advantage open enrollment period, which runs from January 1 to March 31, gives people who are already use 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, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement 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.

As of 2018, according to an AHIP analysis, there were 505,388 North Carolina Medicare beneficiaries enrolled in Medigap plans as of 2018. That’s about 40 percent of the state’s Original Medicare beneficiaries (Medigap coverage cannot be used with 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 52 insurers that offer Medigap plans in North Carolina as of 2020. 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 base on age; some states require one of these approaches, but North Carolina does not. Only four Medigap insurers in North Carolina are using issue-age rating as of 2020, and just one — UnitedHealthcare-AARP — is using community rating.

Federal rules require Medigap insurers to offer plans on a guaranteed-issue basis during an enrollee’s open enrollment period, which begins when the person is at least 65 years old and enrolled in Medicare Part B (and Part A; you have to be enrolled in both to obtain Medigap). 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 MACRA, Medigap Plans C and F cannot be sold to people who become eligible for Medicare in 2020 or later).

North Carolina Medicare beneficiaries under age 65 are granted a one-time six-month 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.

But while state law in North Carolina guarantees access to Medigap plans for disabled beneficiaries under age 65, the insurers charge significantly higher premiums for these enrollees. Medigap Plan A rates in 2020 for a person age 55 range from $260 per month to $1,157 per month. In comparison, the same Plan A for a person age 65 ranges in price from $97 per month to $525 per month. And for Plan G, premiums for a 55-year-old range from $386 per month to $735 per month, whereas a 65-year-old would pay between $107 and $541 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, at the standard age-65 rates.

Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure (note that as of 2021, people with kidney failure will no longer be barred from joining Medicare Advantage plans). Medicare Advantage plans are otherwise available to anyone who is eligible for Medicare, and the premiums are not higher for those under 65. But Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care (increasing to $7,550 in 2021), plus the out-of-pocket cost of prescription drugs.

North Carolina Medicare Part D

Original Medicare does not provide coverage for outpatient prescription drugs. More than half of Original Medicare beneficiaries nationwide have supplemental coverage either through an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.

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

There are 28 stand-alone Medicare Part D plans for sale in North Carolina in 2020, with monthly premiums that range from about $13 to $121/.

781,274 North Carolina beneficiaries were enrolled in standalone Medicare Part D plans (which are called prescription drug plans or PDPs) as of July 2020. Another 772,179 beneficiaries had Medicare Advantage plans that included integrated Medicare Part D coverage. Together, that’s nearly three-quarters of the state’s Medicare beneficiaries with Part D coverage.

Medicare Part D enrollment is available when a person is first eligible for Medicare, and also during the annual open enrollment period that runs from October 15 to December 7.

Medicare spending in North Carolina

Average per-beneficiary spending for Medicare in North Carolina was about 5 percent lower than the national average in 2018, at $9,564 (nationwide, the average was $10,096). The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage.

Average per-beneficiary Original Medicare spending was highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.

How does Medicaid provide financial assistance to Medicare beneficiaries in North Carolina?

Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums and services Medicare doesn’t cover – such as long-term care.

Our guide to financial assistance for Medicare enrollees in North Carolina includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.

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.

  • Vou 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 theAffordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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