North Carolina is a state filled with mountains, beaches, universities, various industries (tobacco and furniture being a few staples), history and a relaxed atmosphere. With land woven throughout even its most urban settings, this state offers its residents access to both city and country elements in its landscape. North Carolinians have access to some of the best health insurers in the nation, including Aetna, Cigna, Celtic, Coventry, Humana and UnitedHealth Care. For a comparison of prices and availability between these companies in your area, enter your zip code in the quote engine below.
North Carolina residents as a total population do not have the best health in the nation. Despite the natural surroundings, parks, and opportunities to practice healthy living, many inhabitants are still unhealthy according to several factors collected by the UnitedHealth Foundation. These factors include a high percentage of impoverished children, a high infant mortality rate, and an average (yet still too prevalent) percentage of adults with obesity and diabetes. Positive points are the low percentage of binge drinking among adults in North Carolina (12%), as well as a high level of high school graduates.
While the cumulative levels of air pollution are moderate, some areas are extremely good, especially the Western part of the state. There is a slightly higher amount of individuals (17.4%) without health insurance in North Carolina than the U.S. average of 16%. If more North Carolinians use their health plans as well as getting active and eating well, the state could see an increase in overall health very soon.
For the uninsured, there are many plans available through insurance companies in the state, and it is now a legal requirement for all persons to have health insurance. There are also public programs that can be utilized, such as Medicaid for low-income residents (see Public Health Options below).
Health Insurance Plans
- Managed Choice Open Access PPO plans come in several types, which include Value and Individual, and are available with additional benefit options for dental and/or unlimited primary care visits. These plans give you the opportunity to choose an in-network provider for a discounted rate on covered services, including 100% coverage on all preventive care from the day your plan starts. Out-of-network care is also available if you prefer, for a higher percentage of coinsurance, though it is still partially covered. Value plans have a more limited selection of benefits for a lower monthly premium and higher cost sharing. Individual PPOs have more services available for a higher premium and lower coinsurance.
- Managed Choice Open AccessHigh Deductible plans are HSA compatible, which means you have the ability to open a health savings account for tax-advantaged funds for medical costs. You can use your HSA funds for deductibles, cost sharing, and withdraw without a tax. These plans are PPOs, allowing you the freedom to see in or out-of-network providers. Doctor’s office visits, prescription drugs, and hospital services are all available for no charge after meeting the deductible. Preventive care is available once your plan starts, covered at 100% for routine physicals, GYN exams, immunizations and more.
- CeltiCare Preferred plans are PPOs that come in several types: Select, Any Doc and Managed Indemnity. These plans have deductible options of $2,500, $5,000, or $10,000 for individuals, and have 80/20 coinsurance coverage after you meet the deductible. The services covered after deductible include emergency care and various hospital services. Before you meet your deductible, the first two doctor’s office visits have a $15 copay, and generic prescriptions have a $10 copay. Preferred plan members also qualify for value-added benefits for participating in healthy lifestyle programs, as well as quitting smoking.
- Celtic Basic plans also connect you to the Celtic Physician & Hospital PPO network with either 70/30 or 80/20 coinsurance. Basic plans have an optional prescription drug benefit, though the plan already makes generics available for a $15 copay with the deductible waived. Physician’s visits are $30 for the first two visits (before deductible) and subject to coinsurance afterwards. Preventive care is covered in full when using in-network providers as soon as your plan starts.
- CelticSaver HSA plans are available as either PPO or Managed Indemnity, with deductibles of $2,600 for individuals ($5,150 for families) and 80/20 coinsurance, or $5,000 for individuals ($10,000 for families) and 100% coverage after deductible. Both types offer doctor’s office visits, diagnostic services, prescriptions, and hospital care at the selected coinsurance level after deductible. These plans have the capacity to connect a health savings account to help pay for qualified medical costs and receive tax benefits.
- Open Access PPO plans from Cigna have a wide range of deductibles, coverage options, and several additional benefits such as dental and prescriptions. You can choose between Value or Individual PPO, depending on your price range and what services you expect to use. Preventive care is covered in full immediately when your plan starts, when using in-network services. Cigna has a great home delivery pharmacy option, or you can use a retail pharmacy. Either way you receive coverage on generic and brand name prescriptions.
- Health Savings plans give you the choice of opening a health savings account to help you meet your deductible, pay coinsurance or other qualified medical expenses. After you deductible, in-network care is covered at 100% (50% non-network) for doctor’s office visits, emergency room, urgent care, outpatient hospital services and more. Health Savings plans also cover mental health care, home health care, and skilled nursing facilities. Preventive care is available for no cost from your policy’s start date.
- QHDHP (WellPath Select) plans are qualified high deductible POS plans with the option of opening an HSA. There is no charge for preventive care in-network, which includes well-child care, routine physicals, GYN exams and more. After you meet your deductible, you won’t have to pay for doctor’s office visits, lab work, as well as inpatient and outpatient hospital care. These plans allow a comprehensive set of benefits paired with an effective way to manage your health care costs.
- Copay (WellPath Select) plans in North Carolina are available with a variety of deductibles and coinsurance options. Copay plans make it simple to receive and pay for care by issuing flat rates for many services, such as doctor’s office visits, prescriptions, vision exams, chiropractic, specialist visits, and more. The plan will pay your chosen amount of coinsurance after deductible for inpatient and outpatient hospital services. These are available in Traditional Copay (Plan 3A – 7A), Value Copay (Plan 9A – 16A), and Extra Value Copay (Plan 20A – 31A).
- Monogram plans are PPOs from HumanaOne offer 100% coverage on most medical care after deductible when you use an in-network provider, in addition to optional prescription and/or dental benefits. Out-of-network care is covered at 75% after you meet the deductible if you prefer. Preventive care is included in your plan from the day it starts, covered in full for physical exams, screenings for breast, cervical, ovarian, and colorectal cancer, newborn hearing exams, immunizations and more.
- Autograph plans are high deductible plans that have the option of being paired with a health savings account for optimum control over your health care. You also have the freedom of using Humana’s network, or non-network doctors and hospitals. These plans have a discount card for prescriptions, and preventive care covered at 100% immediately. Once you have met your deductible, physician visits (including specialists), emergency room, urgent care, outpatient and inpatient hospital services, and home health care are no cost when you choose an in-network provider.
- Portrait plans are PPOs, which allow you to see either in-network or out-of-network providers, depending on your preference. Based on the service, your coinsurance level will vary, but you will receive a comprehensive set of benefits covered by your plan after deductible. Most services are covered at 80%. These services include physician’s office visits, inpatient and outpatient care, surgery, emergency care, skilled nursing, as well as mental health care. There are additional prescription drug benefits available as well as a supplemental accident option.
- Copay plans have low out-of-pocket costs, with fixed rates for doctor’s office visits and prescriptions in exchange for a higher monthly premium. Once your deductible has been met, however, the plan will pay 100% of covered expenses. Various tiers of prescription drugs are available for different copays, with Tier 1 at $15, Tier 2 at $35 and Tier 3 at $65. Covered services after deductible include inpatient and outpatient hospital care, lab work, X-rays, emergency room, mental health, chemotherapy and more. Preventive care is available for no charge as soon as your plan starts.
- High Deductible plans come in three types: Plan 100, Plan 80 and Saver 80. Depending which one you choose, you will either be charged 20% coinsurance or no cost for most medical care after you meet your deductible. These services include but are not limited to emergency room care, X-ray and lab, surgery, and inpatient hospital stays. Preventive care is covered at 100% with each plan type, which includes vaccinations, screening for high blood pressure, cholesterol, diabetes, various types of cancer and routine physical exams.
- Health Savings Account plans have a high deductible and the ability to connect it to an HSA. In-network coverage on preventive care is available immediately for no cost. Most other medical services will be either no cost to you or 30% coinsurance after deductible. These services include office visits, prescription drugs, outpatient hospital care, inpatient stays, diagnostic services, lab work, spine and back disorders and more. There are a range of deductible to choose from, starting at $1,250 for individuals ($2,500 for families) with 70/30 coinsurance, and $2,500 for individuals ($5,000 for families) with 100% coverage.
Public Health Options
In North Carolina, there are a variety of services and programs, including Medicaid, that help residents with medical or financial needs receive access to health care. Medicaid has a variety of divisions for the various groups of people it assists (pregnant women, children, aged and disabled). There are also services for individuals with asthma, cancer, children with special diet needs, HIV/AIDS, and prevention programs for various illnesses. For a full list of all programs and services offered in the state and to locate them in your area, visit the North Carolina Department of Health & Human Services site. Below is a short list of important state-funded health programs to know about in North Carolina.
- Medicaid: health care coverage, also called Medical Assistance, for low-income families, children, pregnant women, and elderly, blind and disabled individuals.
- Health Choice for Children (NCHC): a free or low-cost health care program specifically for children, covering doctor’s office visits, dental and vision care, surgery, and other medical services
- Be Smart Family Planning: free, confidential family planning and birth control services
- Healthy Carolinians: a community-based healthy lifestyle promotion organization available throughout the state
Health Insurance Laws
North Carolina health insurance companies are required by HIPAA to offer to renew an individual’s health plan at the end of their term. This is called the guaranteed renewability provision, and it also protects the insured by giving them the right to keep their plan regardless of becoming ill after they have purchased insurance. As long as the policy-holder has not committed fraud, missed or neglected to pay medical costs, or violated their plan in any other way, their insurance company must follow this provision.
Pre-existing conditions are an important piece of health insurance legislation. Currently, insurers in North Carolina define a pre-existing condition by the objective standard, which means that the applicant has received treatment, diagnosis, or medical advice for a condition before enrolling in a health plan. Insurance companies are permitted to refuse an individual for a health plan based on the severity of their condition. They may also choose to sell a plan to someone with a pre-existing condition, though they can charge higher premiums. Exclusion periods are also allowed for a maximum of one year, where the insurance company will not pay for any care related to the pre-existing condition. A permanent exclusion period can also be issued, called an elimination rider.
Under health care reform, insurance laws have been changing (or preparing to change soon) in every state for the last two years. For individuals with pre-existing conditions, this is a positive. As of 2014, adults with pre-existing conditions will no longer be allowed to be rejected for a health insurance policy. The Affordable Care Act also makes it illegal for insurers to attach elimination riders and give exclusion periods. This will also apply to individuals who are high-risk for other reasons, based on medical history, tobacco use, high blood pressure, and other risk factors.
Until this law is in place, there is an alternative for those who have been denied health insurance, called the Pre-Existing Condition Insurance Plan. This offers medical coverage to adults with such conditions for a monthly premium, and functions similarly to a private insurance plan. In North Carolina, the PCIPs are run by the state, and are fairly well-funded. These plans offer a temporary solution, as they will expire in 2014. After the law is passed, those who receive PCIP benefits will have to apply with a private insurance company.