Although IMCNC does not participate in the Medicare program for office visits, patients can use their Medicare or Medicare Advantage benefits for many lab tests and for imaging tests such as x-rays. IMCNC has a special designation that allows our providers to order tests, prescribe medications and refer patients to other care providers. If you have questions about IMC’s relationship with Medicare, feel free to contact our Practice Director, Mary Pat Whaley by calling or texting (984) 248-0529 or emailing her at marypat.whaley@imcnorthcarolina.com.
Medicare can be confusing—especially during enrollment periods! Each year, between October 15th and December 7th (for general Medicare Open Enrollment) and January 1st to March 31st (for Medicare Advantage Open Enrollment), beneficiaries across the U.S. consider their options, often feeling overwhelmed.
If you’re in North Carolina and impacted by Hurricane Helene, a special extended enrollment period allows you to make changes to your plan in the 25 counties affected by the disaster for two months after the declared end of the emergency.
Your Coverage Notice
By now, you should have received an Annual Change of Notice from your Medicare Advantage, Medigap, and Part D drug coverage providers detailing plan updates for the upcoming year. If you didn’t receive this letter, reach out to Member Services (using the contact number on the back of your insurance card). Additionally, Medicare sends a booklet annually with information about changes in benefits.
Original Medicare vs. Medicare Advantage
Medicare coverage starts with an Original Medicare card (the red, white, and blue card). Later, if you opt for a Medicare Advantage plan, you’ll receive a replacement card specific to your Advantage plan.
Original Medicare is government-sponsored, covering hospital (Part A) and medical (Part B) expenses. You can add a separate Part D drug coverage plan. In contrast, Medicare Advantage (MA) is a private, government-funded plan that bundles hospital and physician coverage and often includes extras like dental, vision, hearing, and drug coverage. Medicare Advantage plans vary by county, so it’s essential to explore the options in your area.
Types of Medicare Advantage Plans
- Health Maintenance Organization (HMO): Requires in-network providers and often a referral to see a specialist.
- Preferred Provider Organization (PPO): Offers in- and out-of-network options without referrals, but in-network care costs less.
- Private Fee-for-Service (PFFS): Sets service rates for providers and typically doesn’t require referrals; in-network providers are less costly.
- Special Needs (SN) Plans: Designed for individuals with specific conditions, providing tailored services, providers, and drug coverage.
Original Medicare with Medigap Supplement Insurance
With Original Medicare, 80% of services are covered, but beneficiaries often add a secondary insurance policy, Medigap, to help pay the remaining 20%. Offered by companies like Blue Cross Blue Shield, Humana, Aetna, Cigna, and UnitedHealthcare, Medigap is distinct from Medicare Advantage. It only works with Original Medicare, not Medicare Advantage plans.
Medigap plans are standardized and range from Plan A to Plan N, each offering different cost coverage levels. Plan G is among the most popular. Explore available Medigap options through the Medicare website or learn more about different Medigap policies from sources like NerdWallet.
Drug Coverage: Part D Plans for Original Medicare
Original Medicare doesn’t cover medications, so many beneficiaries choose a Part D drug plan. In 2025, there will be key changes: the donut hole (coverage gap) is gone, and a $2,000 out-of-pocket cap will apply to drug costs. For costs above $2,000, Medicare will cover drugs entirely under “catastrophic coverage.”
From October 15th to December 7th, beneficiaries can switch Part D plans. For North Carolina residents, 14 statewide plans will be available for 2025.
New in 2025, the Prescription Payment Plan allows beneficiaries to spread out their out-of-pocket costs monthly, making medication costs more predictable throughout the year.
How to Decide: Original Medicare vs. Medicare Advantage
When choosing between Original Medicare and Medicare Advantage, consider the following factors:
- Provider Access: Check with each provider to verify which plans they accept.
- Benefits: Does the Medicare Advantage plan cover extras like drug, dental, or vision benefits?
- Medications: Confirm that your prescriptions are covered, as some plans may drop or substitute drugs.
- Health Conditions: Medicare Advantage plans with limited networks and prior authorizations might complicate care for chronic conditions.
- Costs: Medicare Advantage plans often have a $0 premium but can have higher out-of-pocket costs, capped at $8,850 in 2024.
- Relocation Plans: Medicare Advantage is location-specific. If you move, check whether your plan covers your new area.
Key Medicare Terms
- Premium: Monthly payment for coverage.
- Deductible: Amount paid before coverage begins.
- Coinsurance: Cost-sharing percentage between you and your insurer.
- Co-pay: Flat fee paid for specific services or prescriptions.
Get Help Making Medicare Decisions
In North Carolina, the Seniors’ Health Insurance Information Program (SHIIP) provides free, unbiased Medicare guidance. SHIIP counselors are available statewide for one-on-one assistance at 1-855-408-1212 or visit SHIIP online.
Preparing for Medicare Before Age 65
If you’re nearing 65, your Initial Enrollment Period lasts for 7 months around your birthday month. Delaying enrollment could result in penalties, so it’s important to act promptly. If you enroll in a Medicare Advantage plan but later want to switch to Original Medicare with Medigap, you may have up to 12 months to do so under certain circumstances.
For more details, visit the North Carolina Department of Insurance Medicare Guide.
Whether you’re new to Medicare or reviewing your options, take time to understand the plans that best suit your healthcare needs and budget. And remember, resources like SHIIP are here to help!
Recap on Medicare Parts A, B, C & D
Part A provides inpatient and hospital coverage.
Part B provides outpatient/medical coverage such as physician, emergency room and observation
Part C offers an alternate way to receive your Medicare benefits
Part D provides prescription drug coverage.
