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Advantage Plans

Medicare Advantage (Part C) Plans in North Carolina

According to NC SHIIP:

Have you read or listened to advertisements (magazines, TV, radio, etc.), attended a presentation or spoken with an insurance agent about Medicare Advantage insurance plans? One type of Medicare Advantage insurance plan, Private-Fee-for-Service, is being heavily marketed to Medicare beneficiaries. If you are thinking about a change, we would like to provide you with answers to some important questions to consider before you make any changes in your Medicare health care coverage.

A Medicare Supplement/Medigap policy is a private insurance policy that will work only with Original Medicare and will help pay your share (coinsurance, copayments, or deductibles) of the costs of Medicare-covered services. On the other hand, a Medicare Advantage plan is coverage for Medicare Part A and Medicare Part B services but provided through a private insurance company under contract with the Medicare program. The Medicare Advantage plan, not Medicare, decides what you have to pay for copayments, coinsurance and deductibles.

These are the common types of Medicare Advantage plans available in North Carolina:

  • HMO (Health Maintenance Organization): Medical care and services given through a network of providers. In most cases includes Medicare Part D prescription drug benefits.
  • PPO (Preferred Provider Organization): Can receive medical care and services inside or outside of network provider. In most cases includes Medicare Part D prescription drug benefits.
  • PFFS (Private-Fee-For-Service): May require use of network providers, and provider must accept terms and conditions of the Plan’s payments. May or may not have Medicare Part D prescription drug benefits.
  • SNP (Special Needs Plan): Provides services through a network of providers to persons with certain chronic conditions, persons with full Medicaid and Medicare, or persons living in certain facilities. Always includes Medicare Part D prescription drug benefits.

As noted above, NC SHIIP focuses a lot of its attention on PFFS plans. If you select to join a Private-Fee-for-Service plan (or any other type of a Medicare Advantage plan), the Medicare Supplement/Medigap policy will not coordinate with these plans. Medicare Supplement/Medigap coverage only works with Original Medicare.

If you join a Medicare Advantage plan, you no longer have Original Medicare and will not use your red, white and blue card when you see a doctor or go to the hospital. You would need to use the card provided by the Medicare Advantage plan. The Medicare Advantage plan will pay (if the doctor or hospital accepts the plan) for your covered medical services. Medicare will not pay, because you have chosen a different plan.

It’s important to understand what your copayments or coinsurance will be under the Private-Fee-for-Service plan. Every plan is different. You need to look at and understand how much you will have to pay each time you go for a doctor visit, a hospital stay, outpatient hospital visit, etc.

Some Medicare Advantage plans include the Medicare prescription drug coverage, but many do not. If the plan does include the Medicare prescription drug coverage, you will need to make sure it covers your medications. If it doesn’t cover your prescriptions, it may not be the best choice for you.

There are limitations on when you can join or cancel a Medicare Advantage plan. For most beneficiaries you can only make a change during an Annual Election Period (October 15 through December 7, each year) or during a Medicare Advantage Open Enrollment Period (January 1 through February 14, each year). However, you may be entitled to a Special Election Period. For additional information, please contact the Medicare Advantage plan, 1-800-MEDICARE (1-800-633-4227) or NC SHIIP (1-800-443-9354).