Have you heard about Medicare coverage gaps? These are the potentially expensive gaps in the hospital and outpatient services which Medicare Parts A and B are designed to provide for. Although Medicare aims to be comprehensive, these gaps in your coverage benefits need to be covered with some type of supplemental insurance – or you could end up paying thousands out of pocket. There are many different forms of Medicare supplemental insurance which are designed to address the concern of Medicare coverage gaps. Medicare Part C, a.k.a. Medicare Advantage, is one such supplement. It will be the main focus of this article.

Federal Regulations for Medicare Advantage

Medicare Advantage is separate from your federal Medicare benefits in that, once you sign up for an Advantage plan, the government is no longer responsible for your health care. Your benefits are replaced by a health insurance plan provided by a private company. However, in order to protect you from inferior coverage, Medicare Advantage plans are regulated by the federal government. It is illegal for any company to sell you an advantage plan unless the promised benefits are equal to or greater than what Medicare offers. Indeed, most providers will offer you many more coverage and benefits options than Medicare alone. But those additional benefits may come with a higher price tag.

Medicare Advantage Enrollment In North Carolina

More than a quarter of North Carolina seniors (32% of them to be exact) have decided to switch to a Medicare Advantage policy. Those aren’t the highest rates nationwide, but the number isn’t nothing to sneeze at either. Below, you can get a snapshot of which types of Advantage plans are more popular than others:

Plan Type Enrollment Percentage
HMO Plans 59%
Local PPO Plans 13%
Special Needs Plans 11%
Regional PPO Plans 9%
Private Fee-For-Service Plans 5%
Other (Cost Plans, MSA’s, etc.) 3%

Plan Coverage & Cost

The state you live in, your age, and your current health status may all play a role in determining how much you’ll pay for an Advantage plan. Even very specific information, such as your zip code, could make a significant difference in your quoted rate. Below this paragraph, you can take a look at a chart with a list of estimated rates which seniors near you are being quoted right now:

Most Popular Medicare Advantage Plans in North Carolina

Finding the most popular Medicare Advantage plan in North Carolina, could be as simple as checking a single report. The Medicare Overall Star Rating is an annual report published by Medicare that provides a “star grade” for all companies that provide Medicare products and services. The more stars the better. The report is a compilation and evaluation of data collected by Medicare on each company. For companies providing healthcare services, like those providing Medicare Advantage plans, the report grades how well the company uses preventive techniques like vaccinations and screenings, how well chronic disease is managed, member experiences and changes in performance levels, complaints, and customer service. This report can be helpful in evaluating a plan you are interested in.

Helpful Medicare Advantage Tips & Tricks

Doctor/Provider Network Restrictions

As mentioned earlier, your provider network is a significant factor in your Medicare Advantage plan. Unlike some other Medicare supplement plans, Advantage plans are not as universally accepted as Medicare itself. Medicare Advantage plans are limited to a select network of doctors and facilities which have agreed to provide medical care to seniors who subscribe to specific Advantage plans. Check with your current doctor to see what, if any, Medicare Advantage provider networks they are a member of before you start shopping for a policy.

Where you generally need to get your care and services from for:

  • HMO Plans – If you opt for a Medicare Advantage plan that is set up as a Health Maintenance Organization (HMO), the doctors and facilities you can use, including your primary care physician, specialists, hospital, surgery center, labs, etc., will be limited to those providers and facilities within the HMO network. Emergency or urgent care and out-of-state dialysis are exceptions. Some plans will offer a Point of Service (POS) plan with their HMO which allows you to use a provider outside the network for a fee.
  • PPO Plans – PPOs also operate networks – however, unlike HMOs, you can use any provider you like providing they accept Medicare and the insurance company’s terms. It is always less expensive to use healthcare providers that are in-network, but if you have a specialist that you’ve been seeing for years that is out-of-network, you can use him or her and pay a higher copay.
  • PFFS Plans – There are no restrictions on your choice of providers when you have a Private Fee For Services Medicare Advantage plan. If a provider will accept Medicare and your insurance, your plan will cover you. However, many providers will not accept PFFS patients even if they accept Medicare patients. Some PFFS plans have networks of doctors who will accept the coverage. But even if you use one of these, it is a good practice to confirm acceptance when making an appointment.
  • Special Needs Plans – Special Needs Plans work much the same way as HMOs except membership is limited to people with chronic diseases, live in a nursing home, or qualify for both Medicare and Medicaid. Like an HMO, the SNP has a comprehensive network of physicians and facilities and members are restricted to using those network resources.

Doctor/Providers List

Finding a doctor who accepts your Medicare Advantage plan:

  • HMO Plans – If you are a member of an HMO, finding a doctor that takes the plan isn’t an issue. You can only use providers and facilities that are part of the HMO. Your primary care physician will select and refer you to network providers and resources when appropriate.
  • PPO Plans – PPOs don’t have any restrictions on who you use so long as they accept Medicare and the terms of the insurance. PPOs do have networks and it is significantly more cost effective to use member resources rather than out-of-network providers. Most PPOs have an online directory that works similar to Medicare’s. You’ll find specialties, bios, locations and contact information making finding a doctor a snap.
  • PFFS Plans – PFFS plans present the biggest problem in finding a doctor that will accept your plan. PFFS payment plans for providers, are often not competitive for all treatments and procedures. A doctor may accept the plan for a certain procedure but decline it for another. Always confirm coverage when you make an appointment even if the doctor has accepted the plan in the past.
  • Special Needs Plans – In a sense, SNPs are like HMOs when it comes to finding doctors that accept the plan. As a member of a SNP, you are limited to using the Medicare SNP Network providers and facilities that serve the group.

Medicare makes finding a physician who accepts Original Medicare pretty easy thanks to their Medicare’s physician search tool. Finding doctors who take your Medicare Advantage plan, with one exception, is equally easy. Just keep in mind there may be some conditions.

Drug, Vision and Dental Coverage

Eye care is another service offered by many Medicare Advantage plans that is not available from Original Medicare. Benefits can vary plan to plan but typically include an annual eye exam, lenses, and contacts. Check your plan’s directory to find participating vendors. Many will offer discounts to plan members on frames and other services.

Often Medicare Advantage plans will offer benefits not provided by Medicare. Dental care is an example of those kind of services. Many Medicare Advantage plans have participating dentists who will provide routine dental exams including x-rays, and even cleaning. Some plans provide more comprehensive benefits including fillings, periodontal care, and dentures.

Enrollment Options & Best Time To Enroll

As soon as you turn 65, you should begin the enrollment process for Medicare (and also for Medicare Advantage). The sooner you enroll, the easier it is to get approved for coverage by the plan of your choice. If you try to enroll outside of your IEP (see below) and do not qualify for a Special Enrollment Period, it becomes significantly harder to qualify for coverage. And even if you enroll on time, serious medical conditions (such as End Stage Renal Disease) can significantly complicate your search for affordable coverage. For more information, you can take a look at our Medicare Advantage Enrollment Options page, consult your state department of insurance, or talk to a local insurance agent near you.

  • Initial Enrollment Period: 6-month timeframe when you first enroll in Medicare to purchase a Medicare Advantage plan.
  • Annual Enrollment Period (AEP): This timeframe runs from October 15th through December 7th every year, and during this time you can change or cancel your Medicare Advantage and part D drug plan.
  • Special Enrollment Period (SEP): During special circumstances, you may be eligible to purchase/change a plan outside of the Annual Enrollment Period. Things such as moving out of the plans’ service area, losing group health or employer coverage, a company no longer offering plans in the area, etc. are all events that could trigger a SEP.

What Medicare Advantage Plan Is Best For Me?

We think the best North Carolina Medicare Advantage plan for you is one that you fully understand, has the healthcare providers that best serve your specific needs, and is affordably priced. Be sure to check out the plan’s directory to ensure there are providers you have confidence in as members and that other facilities are conveniently located for you. If the plan offers Part D drug coverage, check the formulary to ensure the medicines you need are carried. Not all plans carry all drugs.

Premiums are important but with Medicare Advantage plans there are many zero-premium programs. Check copays for in and out of network services and deductibles, Also consider the company’s reputation and financial stability. But understand that your time is limited within your Enrollment Period. If you delay, you might miss out.

by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.