Health insurance north Carolina
Navigating the world of health insurance can be daunting, especially with the myriad of options available in North Carolina.
As an independent insurance agent with Blake Insurance Group, I understand potential clients’ unique challenges and concerns when seeking the right health coverage.
Whether you’re looking for individual plans, family coverage, or exploring the benefits of the Health Insurance Marketplace, our goal is to provide you with clear, comprehensive guidance tailored to your needs.
In this article, we will delve into the various health insurance options available in North Carolina, discuss the importance of affordability and subsidies, and explain key terms and enrollment periods to help you make an informed decision about your health insurance coverage.
Health Insurance Marketplace in North Carolina
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North Carolina uses the federally run exchange, HealthCare.gov, for individual market plans. This allows residents to enroll in health insurance plans that comply with the Affordable Care Act (ACA).
For 2024, nine insurers offer exchange plans in North Carolina, with coverage areas varying by insurer. Here are some detailed aspects of the Health Insurance Marketplace in North Carolina:
For the 2024 plan year, the following insurers are participating in North Carolina’s Marketplace, along with their approved rate changes:
Insurers and Rate Changes
Overall, the average approved rate change represents a 1.3% reduction in individual market premiums for 2024.
| Issuer | Percent Increase |
|---|---|
| Aetna Health Inc. | 2.44% |
| Ambetter/Centene | 0.96% |
| AmeriHealth Caritas | 0.00% |
| Blue Cross and Blue Shield of NC | -4.04% |
| Celtic/WellCare | 6.2% |
| Cigna | 7.23% |
| Oscar | 5.5% |
| UnitedHealthcare | -8.16% |
| CareSource | -3.39% |
Enrollment Periods
Open Enrollment: The annual open enrollment period runs from November 1 to January 15. Coverage starts January 1 if you enroll by December 15 or February 1 if you enroll between December 16 and January 15.
– **Special Enrollment Periods**: Outside open enrollment, you can enroll or make changes if you experience qualifying life events, such as marriage, birth of a child, or loss of other coverage.
Eligibility
To qualify for Marketplace coverage, you must:
– Reside in North Carolina
– Be lawfully present in the United States
– Not be incarcerated
– Not be enrolled in Medicare
Financial Assistance
Financial assistance is available to make health insurance more affordable:
– **Premium Subsidies**: Available based on income, these subsidies help reduce the monthly cost of premiums.
– **Cost-Sharing Reductions**: For those with incomes up to 250% of the federal poverty level, additional savings on out-of-pocket costs are available when purchasing a Silver plan.
How to Enroll
Residents can enroll in Marketplace plans through:
– **HealthCare.gov**: The official federal exchange website.
– **Phone**: By calling 1-800-318-2596.
– **Local Assistance**: Through agents, brokers, or navigators who can provide personalized help.
– **Enhanced Direct Enrollment**: Through approved entities that offer an alternative way to enroll.
Consumer Assistance
The North Carolina Department of Insurance offers several resources to help consumers:
**Health Insurance Smart provides regional walk-in locations to assist with health insurance questions, file complaints, and understand rights and responsibilities.
The North Carolina Department of Insurance Website offers information on rate filings, consumer alerts, and a checklist for buying health coverage.
Affordability and Subsidies
The Affordable Care Act (ACA) provides significant financial assistance to make health insurance more accessible and affordable for North Carolina residents. Here’s a detailed look at the subsidies available:
Premium Tax Credits
Premium tax credits are a key component of the ACA’s affordability measures:
Eligibility: These credits are available to households with incomes between 100% and 400% of the Federal Poverty Level (FPL).
– Expanded Eligibility: For 2021 and 2022, the American Rescue Plan Act temporarily eliminated the 400% FPL cap, allowing more people to qualify.
– Savings: More than 90% of eligible enrollees in North Carolina benefit from these credits, with an average monthly savings of $583.
Application: These credits can be applied to any metal-level plan (Bronze, Silver, Gold, or Platinum) but not to catastrophic coverage.
Cost-Sharing Reductions
Cost-sharing reductions offer additional savings on out-of-pocket expenses:
– Eligibility: Available to those with household incomes between 100% and 250% of the FPL.
– Benefits: Reduces deductibles, copayments, coinsurance, and other out-of-pocket costs.
– Plan Requirement: Must be applied to a Silver-level plan to receive these benefits.
Eligibility Requirements
To qualify for these subsidies, applicants must:
– Purchase insurance through the federal marketplace (HealthCare.gov).
– Not have access to affordable employer-sponsored coverage that provides minimum value.
– Not eligible for government programs like Medicaid, Medicare, CHIP, or TRICARE.
– File taxes jointly if married (except in cases of domestic abuse or spousal abandonment).
– Not be claimed as a dependent on someone else’s tax return.
Subsidy Calculator
To estimate potential subsidies:
– Use online calculators to consider estimated yearly income, age, and family size.
– These tools can estimate eligibility and potential savings on health insurance costs.
Impact on Affordability
The subsidies have significantly improved affordability in North Carolina:
– Premium Reduction: The average approved rate change for 2024 represents a 1.3% reduction in individual market premiums.
– Historical Context: This continues a trend of moderation in premium increases, with some years even seeing decreases.
Assistance in Navigating Subsidies
As an independent insurance agent, I can provide personalized assistance in:
– Determining eligibility for subsidies
– Estimating potential savings
– Choosing the right plan that maximizes subsidy benefits
These subsidies make health insurance more affordable for North Carolina residents. By understanding and utilizing these financial assistance options, many individuals and families can access quality health coverage at reduced costs.
Types of Health Insurance Plans
There are several types of health insurance plans available in North Carolina, each with its own features and benefits:
Health Maintenance Organizations (HMOs)
HMO plans typically offer:
– Lower premiums and out-of-pocket costs
– A primary care physician (PCP) who coordinates your care
– Referrals required to see specialists
– Limited coverage for out-of-network care, except in emergencies
Preferred Provider Organizations (PPOs)
PPO plans generally provide:
– More flexibility in choosing healthcare providers
– No requirement for a PCP or referrals
– Coverage for both in-network and out-of-network care, with higher costs for out-of-network services
– Higher premiums compared to HMOs
Exclusive Provider Organizations (EPOs)
EPO plans combine features of HMOs and PPOs:
– No coverage for out-of-network care, except in emergencies
– No requirement for a PCP or referrals
– Often lower premiums than PPOs but higher than HMOs
High Deductible Health Plans (HDHPs)
HDHPs are characterized by:
– Higher deductibles and lower monthly premiums
– Eligibility to open a Health Savings Account (HSA) for tax-advantaged savings
– Potential for significant out-of-pocket costs before insurance coverage kicks in
Point of Service (POS) Plans
POS plans blend HMO and PPO features:
– Require a PCP and referrals for specialists
– Offer some coverage for out-of-network care, but at higher costs
– More flexibility than HMOs but less than PPOs
Catastrophic Health Insurance
Available to those under 30 or with hardship exemptions:
– Very low premiums and very high deductibles
– Designed to protect against worst-case scenarios
– Covers three primary care visits per year before the deductible is met
Short-Term Health Insurance
Temporary coverage options in North Carolina:
– Available for up to 364 days with renewals up to 36 months
– Lower premiums but less comprehensive coverage
– Not required to cover essential health benefits or pre-existing conditions
When choosing a plan type, consider factors such as:
– Your budget for premiums and out-of-pocket costs
– Preferred healthcare providers and facilities
– Need for specialist care
– Desire for flexibility in choosing providers
– Willingness to coordinate care through a PCP
Key Terms to Understand
Navigating health insurance can be complex, and understanding key terms is crucial for making informed decisions. Here are some essential terms to know:
Deductible
The deductible is the amount of money you must pay out-of-pocket for covered healthcare services before your insurance plan starts to pay. For example, if your plan has a $1,000 deductible, you must pay the first $1,000 of covered services yourself.
Copayment (Copay)
A copayment is a fixed amount you pay for a specific healthcare service, such as $25 for a doctor’s visit. This payment is typically made during service and does not count toward your deductible.
Coinsurance
Coinsurance is the percentage of costs you pay for covered healthcare services after meeting your deductible. For instance, if your plan has 20% coinsurance, you pay 20% of the costs, and your insurance covers the remaining 80%.
Premium
The premium is the amount you pay for your health insurance coverage, typically monthly. This payment ensures that you remain covered under the policy.
Out-of-Pocket Maximum
The out-of-pocket maximum is the most you must pay for covered services in a plan year. After you reach this limit, your insurance plan pays 100% of the costs for covered benefits.
Health Maintenance Organization (HMO)
An HMO is a type of health insurance plan that requires members to use a network of doctors and hospitals. It would be best if you typically had a referral from your primary care physician (PCP) to see a specialist.
Preferred Provider Organization (PPO)
A PPO plan offers more flexibility in choosing healthcare providers and does not require referrals to see specialists. You can see both in-network and out-of-network providers but will pay less for in-network services.
Exclusive Provider Organization (EPO)
An EPO plan requires you to use the plan’s network of doctors and hospitals, except in emergencies. It does not require referrals to see specialists.
High Deductible Health Plan (HDHP)
An HDHP has higher deductibles and lower premiums. It is often paired with a Health Savings Account (HSA), which allows you to save pre-tax money to pay for medical expenses.
Health Savings Account (HSA)
An HSA is a personal savings account used in conjunction with an HDHP. It allows you to save pre-tax dollars to pay for qualified medical expenses, reducing your overall healthcare costs.
Cost-Sharing Reductions (CSR)
CSRs are subsidies that lower out-of-pocket costs (like deductibles, copayments, and coinsurance) for eligible individuals with household incomes up to 250% of the federal poverty level. These reductions are available only when purchasing a Silver plan through the Health Insurance Marketplace.
Premium Tax Credits
These subsidies help lower the cost of premiums for individuals and families with household incomes between 100% and 400% of the federal poverty level. These credits can be applied to any metal-level plan purchased through the Health Insurance Marketplace.
Explanation of Benefits (EOB)
An EOB is a statement from your insurance company detailing what costs it will cover for medical services you receive, what you owe, and any amounts paid by your insurance.
In-Network Provider
An in-network provider is a healthcare professional, hospital, or pharmacy that contracts with your health insurance plan to provide services at pre-negotiated rates. Using in-network providers usually results in lower out-of-pocket costs.
Out-of-Network Provider
An out-of-network provider does not have a contract with your health insurance plan. Using out-of-network providers typically results in higher out-of-pocket costs.
Metal Tiers on the Exchange
The Health Insurance Marketplace categorizes plans into four metal tiers: Bronze, Silver, Gold, and Platinum. These tiers help consumers understand the balance between premiums and out-of-pocket costs. Here’s a detailed explanation of each tier:
Bronze Plans
– **Premiums**: Lowest monthly premiums among the metal tiers.
– **Out-of-Pocket Costs**: These are the highest costs when you need care, including higher deductibles and copayments.
– **Coverage**: These plans cover approximately 60% of healthcare expenses, with the remaining 40% paid by the enrollee.
– **Ideal For**: Individuals who are generally healthy and do not expect to need frequent medical care prefer lower monthly premiums.
Silver Plans
– **Premiums**: Moderate monthly premiums.
Out-of-Pocket Costs**: These are moderate costs when you need care, with lower deductibles and copayments compared to Bronze plans.
– **Coverage**: These plans cover about 70% of healthcare expenses, with the enrollee paying the remaining 30%.
– **Additional Benefits**: Eligible for cost-sharing reductions (CSRs) that lower out-of-pocket costs for individuals with incomes up to 250% of the federal poverty level, but only if a Silver plan is chosen.
– **Ideal For**: Individuals who qualify for CSRs or those who want a balance between monthly premiums and out-of-pocket costs.
Gold Plans
– **Premiums**: Higher monthly premiums than Bronze and Silver plans.
– **Out-of-Pocket Costs**: Lower costs when you need care, with lower deductibles and copayments.
– **Coverage**: These plans cover approximately 80% of healthcare expenses, with the enrollee paying the remaining 20%.
– **Ideal For**: Individuals who expect to need frequent medical care and prefer to pay higher monthly premiums for lower out-of-pocket costs.
Platinum Plans
– **Premiums**: Highest monthly premiums among the metal tiers.
– **Out-of-Pocket Costs**: Lowest costs when you need care, including the lowest deductibles and copayments.
– **Coverage**: These plans cover about 90% of healthcare expenses, with the enrollee paying the remaining 10%.
– **Ideal For**: Individuals who require extensive medical care are willing to pay the highest premiums for the lowest out-of-pocket costs.
Choosing the Right Plan
When selecting a plan, consider your healthcare needs and financial situation:
**If you rarely visit the doctor**, a Bronze plan might be suitable due to its lower monthly premiums.
**If you qualify for cost-sharing reductions**, a Silver plan is ideal as it provides additional savings on out-of-pocket costs.
**If you expect frequent medical visits or have a chronic condition, a Gold or Platinum plan could be beneficial due to lower out-of-pocket expenses.
FAQs Related to Health Insurance in North Carolina
Who can buy Marketplace health insurance in North Carolina?
To qualify, you must:
- Live in North Carolina
- Be lawfully present in the United States
- Not be incarcerated
- Not be enrolled in Medicare
When is the open enrollment period for ACA-compliant plans in North Carolina?
The open enrollment period runs from November 1 to January 15. Coverage starts January 1 if you enroll by December 15, or February 1 if you enroll between December 16 and January 15.
How can I enroll in a North Carolina Marketplace plan?
- Online through HealthCare.gov
- By phone at 1-800-318-2596
- With local help from an agent, broker, or navigator
- Through an approved enhanced direct enrollment entity
What health insurance resources are available to North Carolina residents?
- HealthCare.gov
- Health Insurance Smart NC
- North Carolina Department of Insurance
- Community Care of North Carolina
- Legal Aid of North Carolina
Are subsidies available for health insurance in North Carolina?
Yes, individuals and families with household incomes from 100% to 400% of the federal poverty level may be eligible for premium tax credits and cost-sharing reductions on plans purchased through the Marketplace.
What types of health insurance plans are available in North Carolina?
Options include ACA Marketplace plans, short-term health insurance, TriTerm Medical Insurance, Medicare plans, and various supplemental plans like dental, vision, accident, and critical illness insurance.
How do the metal tiers work in the Health Insurance Marketplace?
Plans are categorized into Bronze, Silver, Gold, and Platinum tiers, representing different levels of cost-sharing between the insurer and the enrollee.
What happens if I miss the open enrollment period?
If you miss the open enrollment period, you may still be able to get coverage if you qualify for a Special Enrollment Period due to life events such as losing other coverage, getting married, or having a baby.
How do I apply for Medicaid in North Carolina?
You can apply for Medicaid online through the ePASS system, in person at your local Department of Social Services, by mail, or by phone.
Blake Nwosu
Owner & Principal Agent
Blake Insurance Group
Phone: (888) 387-3687
Email: info@blakeinsurancegroup.com
Hours: Mon-Fri 9:00 am to 5:00 pm
Sat-Sun: Closed