Although Original Medicare was introduced in 1965, Medicare Part D in North Carolina has only been around since 2006. It is the result of the Medicare Modernization Act of 2003 (MMA). Congress passed the MMA to help seniors get lower prescription drug costs and more Medicare coverage options. On this page, we explain your Medicare prescription drug plan options in North Carolina.
How Does Medicare Work in North Carolina?
Original Medicare includes Part A, hospital insurance, and Part B, medical insurance. It does not include prescription drug coverage. For that, you need Medicare Part D.
You have two options for Medicare Part D in North Carolina.
A standalone Part D plan works with either Original Medicare or a Medicare Advantage (MA) plan that does not include prescription drug coverage.
Medicare Advantage plans offer at least the same coverage you get with Original Medicare, with most (over 90 percent) providing additional benefits as well. The most common add-ons are:
- Prescription drug coverage
- Routine vision and dental care
- Fitness programs
Your second Part D option is a Medicare Advantage Prescription Drug plan (MA-PD). Also known as an all-in-one plan, this option gives you the same benefits as Original Medicare with a standalone Part D plan. If you want a Medicare Prescription drug plan, look for the MA-PD designation when comparing Part D options in North Carolina.
You cannot have both an MA-PD plan and a standalone Part D plan. If you sign up for a standalone plan after joining an MA-PD plan, you will be unenrolled from your MA-PD plan and placed back in Original Medicare.
Who Can Join a Medicare Prescription Drug Plan in North Carolina?
To qualify for Medicare Part D in North Carolina, you need to first sign up for Part A and/or Part B. You must also live in the plan's service area.
Most people become eligible for Medicare when they turn 65. If you begin collecting Social Security benefits at least 4 months before your 65th birthday, enrollment in Medicare Parts A and B is automatic. Everyone else has to apply through Social Security.
Around 15 percent of beneficiaries qualify for Medicare due to a disability. In this case, you will be automatically enrolled in Original Medicare during your 25th month of collecting Social Security disability benefits.
When it comes to Medicare Part D, you are never automatically enrolled. Even if you're already collecting Social Security, you will always have to choose to sign up for a prescription drug plan.
Medicare Part D Enrollment Periods in North Carolina
In every state, Medicare restricts Part D enrollment to specific times, starting with your Initial Enrollment Period (IEP).
Your IEP begins 3 months before the month you become eligible for Medicare and ends 7 months later. If you become eligible for Medicare due to a disability, your IEP surrounds your 25th month collecting disability. If you "age in" to the program, your IEP revolves around the month you turn 65. So, if your eligibility month falls in May, your Initial Enrollment Period begins on February 1 and ends on August 31. Once you enroll in Medicare Part A and/or Part B, you may then sign up for Part D.
If you miss your Initial Enrollment Period AND you don't qualify for a Special Enrollment Period (SEP), you have to wait for General Enrollment, which occurs every year from January 1 through March 31. You can apply for Medicare Parts A and B during General Enrollment, but not Part D. That window opens on April 1 and closes on June 30.
Next is the Medicare Annual Enrollment Period (AEP). Available to all current Medicare beneficiaries, Annual Enrollment runs from October 15 through December 7. During these 8 weeks, you may make a variety of changes to your Medicare coverage, including signing up for a new Part D or MA-PD plan.
If you belong to an Advantage plan, the Medicare Advantage Open Enrollment Period lets you either change to a new MA plan or return to Original Medicare. If making this change results in you losing your prescription drug coverage, you may also enroll in a standalone Part D plan at this time. MA Open Enrollment lasts from January 1 through March 31.
Special Enrollment Periods are available to Medicare beneficiaries who experience certain life changes. Common examples are losing your current coverage through no fault of your own and moving to a new address. There are numerous ways to qualify for a Part D SEP. Find the full list on Medicare.gov here.
How to Compare Medicare Part D Plans in North Carolina
Since private insurance companies provide Medicare Part D and MA-PD plans in North Carolina, coverage and costs can vary widely. It's a good idea to compare your options carefully to ensure you get the right Part D plan for your needs and budget.
Although most people focus on cost (understandably), it's actually more important to look at coverage first. This is because a plan that doesn't cover your prescriptions isn't worth much, no matter how cheap it is.
The plan's drug formulary lists all of the medications it covers. Always look at the formulary first. While comparing your medications to the formulary, you should also look at the plan's drug tiers. Where your prescriptions fall on the drug tiers indicates how much you'll pay out-of-pocket. Drugs on the lower tiers cost less than ones you find on the upper tiers.
Your Part D out-of-pocket costs include:
- Annual deductible
- Monthly premium
- Copays and/or coinsurance
Please note that a rock-bottom monthly premium often hides higher out-of-pocket costs elsewhere, so review all of your costs. Remember, you can guesstimate copayments by looking at the drug tiers.
If income and resources are limited, you may qualify for Extra Help. This Medicare program covers a variety of prescription drug costs. Medicare or Social Security should notify you if you qualify for Extra Help. However, if they don't and you believe you could or should qualify, call your plan.
Please note that all communications from both Medicare and Social Security are via United States mail. Unless you specifically request a call, nobody from either program will ever call you. If someone does call claiming to be with Medicare or Social Security, hang up and call the appropriate entity (1-800-MEDICARE or 1-800-772-1213).
Do You Have to Sign Up for Medicare Part D in North Carolina?
No, you don't have to sign up for any part of Medicare, including Parts A, B, and D. However, failure to join a Part D plan may land you with lifelong late enrollment penalties. You earn the Part D late enrollment penalty any time you go 63 days or more without creditable drug coverage. To be creditable, your plan must be comparable to Medicare in terms of both cost and coverage.
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