Over 2.2 million North Carolinians are enrolled in Medicare. Whether you're newly eligible or looking to review your coverage, these frequently asked questions cover what you need to know about Medicare costs, enrollment, and coverage options in 2025-2026.
The best Medicare coverage depends on your individual health needs, including your medications, preferred doctors, and budget. When evaluating your options, consider:
Your prescription drugs: Make sure your medications are covered and check the plan's drug costs. If you take regular prescriptions, you'll need Part D coverage—either a standalone plan or through Medicare Advantage.
Your doctors and hospitals: Original Medicare lets you see any provider that accepts Medicare. Medicare Advantage plans typically use networks, so verify your preferred providers are in-network before enrolling.
Additional benefits: Do you need dental, vision, or hearing coverage? Original Medicare doesn't cover these, but many Medicare Advantage plans include them.
Your budget: Compare monthly premiums, deductibles, and out-of-pocket costs. Lower premiums don't always mean lower overall costs.
Our North Carolina-based agents at Health Plans of NC can review your needs and help find the right fit. There's no cost for our service, and we can compare options from multiple carriers.
If you plan to work beyond 65 and have creditable employer group health coverage (from an employer with 20 or more employees), you can delay enrolling in Medicare Part B and Part D without penalties. Here's what to know:
Part A: You may still enroll in premium-free Part A while working. However, if you have a Health Savings Account (HSA), enrolling in Part A could prevent further HSA contributions. Consult a tax advisor before making this decision.
Part B: You can delay enrollment as long as you have creditable employer coverage. When your employment or coverage ends, you'll have an 8-month Special Enrollment Period to sign up without penalties.
Part D: Similar rules apply—you can delay as long as you have creditable prescription drug coverage through your employer.
Important: If your employer has fewer than 20 employees, different rules apply, and Medicare generally becomes your primary insurance at 65. Contact a local NC Medicare agent to evaluate your specific situation and avoid costly penalties.
Medicare coverage automatically renews each year unless you make changes. However, your plan's benefits, costs, and provider networks may change from year to year, so it's important to review your coverage annually.
Annual Enrollment Period (AEP): From October 15 to December 7 each year, you can switch Medicare Advantage plans, change Part D plans, or switch between Original Medicare and Medicare Advantage. Changes take effect January 1.
Medicare Advantage Open Enrollment Period: From January 1 to March 31, if you're already in a Medicare Advantage plan, you can switch to a different Medicare Advantage plan or return to Original Medicare (and add a Part D plan).
Each fall, you'll receive an Annual Notice of Change (ANOC) from your plan detailing any changes for the upcoming year. Our NC agents can assist with annual reviews and answer questions about whether your current plan still meets your needs.
If you're disabled, you're typically eligible for Medicare after receiving Social Security Disability Insurance (SSDI) benefits for 24 months. Here's how it works:
You'll be automatically enrolled in Medicare Parts A and B in your 25th month of receiving SSDI benefits
You'll receive your Medicare card in the mail about three months before your coverage begins
Part B premiums will be deducted from your disability check unless you opt out
Exceptions to the 24-month wait: People with ALS (amyotrophic lateral sclerosis) qualify for Medicare as soon as they start receiving SSDI—no 24-month wait required. People with End-Stage Renal Disease (ESRD) requiring dialysis or a kidney transplant may also qualify for Medicare sooner. Contact Social Security for details about your specific situation.
Medicare costs are set at the federal level and are the same nationwide, but our local NC agents specialize in helping North Carolina residents understand their costs and options.
2025 Medicare Costs:
Part A premium: $0 for most people (if you or your spouse paid Medicare taxes for 40+ quarters). Those with fewer work credits pay up to $518/month.
Part B premium: $185/month (standard premium, deducted from Social Security or billed quarterly)
Part B deductible: $257/year
Part A hospital deductible: $1,676 per benefit period
Part D out-of-pocket cap: $2,000 annually (new in 2025—once you reach this limit, you pay $0 for covered drugs the rest of the year)
2026 Medicare Costs (announced November 2025):
Part B premium: $202.90/month (increase of $17.90)
Part B deductible: $283/year (increase of $26)
Part A hospital deductible: $1,736 per benefit period (increase of $60)
Part D out-of-pocket cap: $2,100 annually
Part D maximum deductible: $615 (some plans have lower or no deductible)
IRMAA surcharges: Higher-income individuals pay more for Parts B and D based on income from the two years prior. For 2026, the IRMAA threshold is $109,000 (individual) or $218,000 (joint filers), based on 2024 tax returns.
Original Medicare (Parts A & B) does not cover routine dental care, vision exams, eyeglasses, or hearing aids. If you need these benefits, you have several options:
Medicare Advantage (Part C): Many Medicare Advantage plans in North Carolina include dental, vision, and hearing benefits. Some plans also offer fitness programs, over-the-counter allowances, and transportation to medical appointments. There are 175 Medicare Advantage plans available in NC for 2026.
Standalone dental and vision plans: If you have Original Medicare and a Medigap policy, you can purchase separate dental and vision insurance plans.
Discount programs: Some organizations offer dental and vision discount programs for Medicare beneficiaries.
Benefit levels vary significantly by plan, so check the specifics before enrolling. Our NC agents can compare options and help find coverage that fits your needs and budget.
No, Medicare is not mandatory. However, delaying enrollment beyond your Initial Enrollment Period may result in lifetime late enrollment penalties—unless you have qualifying creditable coverage.
Late enrollment penalties:
Part B: 10% added to your monthly premium for each full 12-month period you could have had Part B but didn't enroll (and didn't have creditable coverage)
Part D: 1% of the national base beneficiary premium ($38.99 in 2026) for each month you delayed enrollment without creditable drug coverage
These penalties are added to your monthly premium for as long as you have Medicare. Special Enrollment Periods are available for people with employer coverage. Our local NC agents can guide you through enrollment decisions to help you avoid penalties.
Medicare is a federal health insurance program primarily for people 65 and older, regardless of income. It also covers certain younger people with disabilities and people with End-Stage Renal Disease. Payroll taxes, premiums, and general federal revenues fund Medicare.
Medicaid is a joint federal-state program that provides health coverage to low-income individuals. In North Carolina, Medicaid expanded in December 2023, and over 450,000 newly eligible residents had enrolled by May 2024. The state determines eligibility and benefits within federal guidelines.
Medicare in North Carolina: As of September 2024, there were over 2.2 million Medicare beneficiaries in North Carolina. More than 56% are enrolled in Medicare Advantage plans, which is higher than the national average. About 12% of NC Medicare beneficiaries (nearly 268,000 people) are under age 65 due to disability.
Dual eligibility: Some individuals qualify for both Medicare and Medicaid. These "dual-eligible" beneficiaries may access special programs that help coordinate their benefits and reduce out-of-pocket costs.
Several programs help low-income Medicare beneficiaries with their costs:
Extra Help (Low-Income Subsidy): Helps pay Part D premiums, deductibles, and copays. Eligibility is based on income and resources. Those who qualify may pay little to nothing for prescriptions.
Medicare Savings Programs (MSPs): Help pay Part B premiums and may also cover deductibles and coinsurance. Programs include QMB, SLMB, and QI, with varying eligibility levels.
Medicaid: Low-income beneficiaries may qualify for Medicaid in addition to Medicare, which can help cover costs Medicare doesn't pay.
State Pharmaceutical Assistance Programs: Some states offer additional help with drug costs.
Our NC agents can help determine which programs you may qualify for and assist with the application process.
Yes—Medicare covers FDA-approved COVID-19 vaccines at no cost to beneficiaries. This includes:
Updated 2024-2025 formula vaccines from Moderna, Pfizer-BioNTech, and Novavax
Boosters for eligible beneficiaries
Administration fees at participating pharmacies and healthcare providers
Coverage is provided under Medicare Part B with no deductible, copay, or coinsurance. Medicare also covers other vaccines recommended by the CDC's Advisory Committee on Immunization Practices (including flu, pneumonia, shingles, and RSV) at no cost under Part D as of 2023.
Check with your provider or plan for specific details about vaccination availability and scheduling.
Major changes to Medicare Part D went into effect in 2025, with additional updates for 2026:
Out-of-pocket cap: Part D now has a $2,000 annual cap on out-of-pocket drug costs (increasing to $2,100 in 2026). Once you reach this limit, you pay $0 for covered prescriptions the rest of the year. Previously, there was no cap, and beneficiaries could face unlimited out-of-pocket costs.
Elimination of the "donut hole": The coverage gap that previously left beneficiaries paying more for drugs has been eliminated. Part D now has just three phases: deductible, initial coverage, and catastrophic coverage.
Medicare Prescription Payment Plan: You can now opt to spread your out-of-pocket drug costs into monthly payments instead of paying everything at the pharmacy. This can help if you have high costs early in the year.
Negotiated drug prices: Starting in 2026, Medicare-negotiated prices apply to the first 10 drugs selected for negotiation, including medications for diabetes, heart disease, and cancer. This is expected to save an estimated $1.5 billion in out-of-pocket costs for millions of beneficiaries.
Insulin cap: Insulin costs are capped at $35 per month for Part D enrollees.
These changes result from the Inflation Reduction Act of 2022 and represent the most significant updates to Part D since the program began.
Contact our North Carolina-based Medicare experts at Health Plans of NC today. We'll guide you through your options and help you find the best coverage for your health needs and budget—at no cost to you.
Call 1-800-797-0327 to speak with a local Medicare agent who understands the options available to North Carolina residents.
