Curious about health care in the Tar Heel State? North Carolina holds the 37th best health care ranking in the nation. The US News study looked at health care access, quality, and good public health for the rankings.
Health insurance options in North Carolina
According to the North Carolina Department of Insurance, there are a number of ways residents can get health insurance:
Employer-provided
- From your employer
- Through your spouse's employer
Individual or family plans
- Through HealthCare.gov
- Directly from a health insurance company
Government-assisted
- Medicare
- Medicaid
Where do most North Carolina residents get their health insurance coverage?
| Sources | Percent | ||
|---|---|---|---|
| Employer-Provided | 47% | ||
| Individual or family | 6% | ||
| Medicaid | 18% | ||
| Medicare | 15% | ||
| Military | 3% | ||
| Uninsured | 11% | ||
| Source: Kaiser Family Foundation, Health Insurance Coverage of the Total Population | |||
Eleven percent of NC residents are uninsured, a few percent above the national average. This is bad news for policyholders, as the higher the rate of uninsured people, the more prices rise for insured people.
North Carolina health insurance companies
There are only two insurers that offer coverage for 2018 in the North Carolina insurance marketplace exchange:
Ambetter
Ambetter of North Carolina Inc. is Centene Corporation‘s Health Insurance Marketplace product. Ambetter exists to improve the health of its beneficiaries through focused, compassionate and coordinated care. Their approach is centered around delivering localized, individual care that focuses on the individual's needs. Ambetter offers tiered coverage from Bronze to Gold. The bronze tier covers all essential care needs, while the gold or "secure" tier offers more comprehensive coverage.
Centene Corporation, Ambetter's parent company, is a multinational Fortune 500 company with over 30 years of experience in the Managed Care industry and a robust portfolio of specialty health solutions.
BlueCross BlueShield of North Carolina
BlueCross BlueShield of North Carolina offers individual and family plans for NC residents. Plans include benefits like health and wellness programs, fully covered preventive care, fitness discounts, a 24/7 nurse line, and more. Plans levels are organized into metal tiers. The metal tiers include bronze, silver, and gold. Bronze covers 60 percent of medical costs, silver covers 70 percent of costs, and gold covers 80 percent. You may also qualify for a catastrophic health plan If you are under 30 or qualify for a hardship.
Blue Cross NC was founded in 1933. The company has more than 4,700 employees and serves more than 3.89 million members.
Bright Health
Bright Health is a consumer focused health insurance and technology company that offers both individual and family plans in NC. Bright Health providers focus on 24/7 nurse lines, same-day appointments, after-hours appointments, Care Navigator support, seamless care and predictable costs. Expect great extras like: online bill pay, online scheduling, wait-time notifications, text reminders, health coaching, in-home care and medication adherence programs.
Bright Health has several partners in North Carolina, including Novant Health in Charlotte and the Winston-Salem area if you live in the big city.
Cigna
Cigna has several individual and family plan options. Plan options vary based on the NC county you live in, the size of your household, income, and more. Plan levels include bronze, silver, and gold. The company also offers several health and wellness resources for members. These include tips on nutrition, healthy aging, exercise, family care, and more.
Cigna has over 40,000 employees and 95 million customers around the world. Founded in 1982, their mission is “to improve our customers’ health, well-being, and sense of security with the power of preventive care.”
Oscar
Oscar's team is comprised of more than 1,400 individuals. They serve more than 420,000 members ranging from small businesses to individuals and families. The company has been growing and gaining more recognition in the insurance marketplace. They expect to offer coverage in 19 states and 47 markets by 2021.
Oscar’s Net Promoter Score is 33, compared to an industry average of -12 across the ACA. Members gave them a 4.5 out of 5 average customer service satisfaction rating in 2019. Oscar aims to make healthcare more streamlined by connecting it's customers with their Care Team, who then route the customer to the proper healthcare provider. Oscar has seen excellent adoption of it's app, with 52% of it's customers downloading the app (5x the industry average).
Sentara/Optima
Optima Health is a potential new provider in the state of North Carolina in 2021. They provide health plan coverage to approximately 551,000 members.
They offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual and Family health plans, employee assistance plans and plans serving Medicare and Medicaid enrollees. Optima's network consists of more than 33,000 providers including specialists, primary care physicians and hospitals.
They offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help their members improve their health.
United Healthcare
If you’re self-employed or without insurance from your employer – in other words, you’re looking for individual or family health insurance in North Carolina – you might be looking for Affordable Care Act insurance, what's often called Obamacare. However, we want to make you aware of the whole range of individual and family insurance products we have available in your state.
United Healthcare is offering ACA health insurance in North Carolina beginning in 2021, a market they exited after 2016. They have numerous options for both short term and long-term health insurance in the state.
These providers offer both family and individual health care plans. Your policy could depend on which county you live in, so check insurer websites to see what policies your zip code qualifies for.
North Carolina health insurance costs and rate factors
North Carolina residents spend an average of $7,264 on health care expenditures per year, less than the national average. Health care costs are largely determined by the risk level of each person. Here are the factors insurance companies will look at to price your policy:
Plan type
Your costs also depend on the level of coverage you want. You'll pay more for a higher level of coverage. Marketplace plans come in metal tiers: bronze, silver, gold, and platinum.
How do these metal categories affect your costs? These are the average costs for a 40-year-old North Carolina resident in 2020:
| Bronze | Silver | Gold | |
|---|---|---|---|
| $365 | $518 | $553 | |
| Source: Kaiser Family Foundation, Change in Average Marketplace Premiums by Metal Tier | |||
A gold plan costs about 41 percent more than a bronze plan. This steep price jump is because gold plans cover 80 percent of health care costs, and bronze plans cover 60 percent of costs.
You may qualify for a catastrophic health plan, which is the lowest level of coverage. Monthly premiums for this type of plan are low, but it also comes with a $8,150 yearly deductible. A bronze or silver plan may save you money when you need to use your insurance.
Body mass index
According to the CDC, a high BMI can lead to several health conditions. Because of this, insurance companies look at your BMI to determine your risk level. A high BMI means high insurance costs.
In 2018, North Carolina had a 33 percent obesity rate, the 19th highest in the country. An average of 34 percent of North Carolina residents who use QuoteWizard to compare health insurance plans have a BMI in the obese range.
Tobacco use
Due to the harmful effects of smoking, insurance companies will charge you more if you're a tobacco user. About 17.2 percent of North Carolina residents are smokers, ranking 26th in the nation.
Age
You'll also be paying more as you age. According to HealthCare.gov, older people pay three times more in premiums than younger people. On average, North Carolina residents who shop for health insurance on QuoteWizard are 41 years old.
Location
Where you live plays a major role in how much you'll be paying for health care. Every state has different rules, regulations, and providers surrounding the health insurance marketplace.
According to the North Carolina Department of Insurance, health insurance costs are also community rated. Rates are based on the combined claims people around you are filing. So, if a neighbor files an abnormally high number of claims, your premium prices could soar.
Living in a more health-conscious state could keep your costs low. According to America's Health Rankings, North Carolina is the 33rd healthiest state in the country.
North Carolina health insurance laws
The Affordable Care Act made it so that insurance companies can't use certain factors when pricing your policy. Here's what they can't use:
- Pre-existing conditions: Before the ACA, people with pre-existing conditions were often charged more for health care coverage. Now, insurers can't analyze pre-existing conditions while pricing your policy.
- Gender: According to a study that looked at lifetime health care costs, women historically pay more for health insurance than men. But the ACA doesn't allow insurance companies to charge women and men different prices for the same policy.
- Insurance and medical history: Insurance companies used to analyze your medical history and your past insurance coverage. Providers would charge steep premiums to people with previous medical problems or lapses in insurance.
There's a limit to how much you'll be paying out-of-pocket for a marketplace plan. The out-of-pocket maximum limit for 2018 is $8,150 for an individual plan and $16,300 for a family plan.
NC law requires insurance providers to offer at least some coverage for the following services:
- Emergency care
- Certain clinical trials
- Anesthesia for dental procedures
- Treatment of diabetes
- Newborn hearing screening
- Cancer screening
- Hearing aids
There are more requirements for providers in North Carolina. Check the full list of required benefits here.
Medicare and Medicaid in North Carolina
Medicare and Medicaid are both government-funded health care programs. Medicare helps people over 65 pay for health care. Similarly, Medicaid offers financial assistance to low income families and children.
Medicare
In North Carolina, Medicare is called SHIIP and is available for people over 65. There are several options within the program, including parts A, B, C, D, and supplemental coverage plans. There are three levels of Medicare-Aid that you may qualify for as a resident of North Carolina. These are the requirements for the state's Medicare Savings Program:
- Individual monthly income limit: $1,456
- Married couple monthly income limit: $1,960
Medicaid
North Carolina offers Medicaid to low income families. These are the state's Medicaid financial requirements:
| Household Size | Maximum Yearly Income |
|---|---|
| 1 | $16,971 |
| 2 | $22,930 |
| 3 | $28,888 |
| 4 | $34,846 |
| 5 | $40,805 |
| 6 | $46,763 |
| 7 | $52,722 |
| 8 | $58,680 |
North Carolina Office of the Insurance Commissioner
- Website:
- Homepage
- Insurance Commissioner:
- Mike Causey
- Insurance Hotline:
- (855) 408 – 1212
- Office Hours:
- Monday - Friday
8:00 am to 5:00 pm
- File a Consumer Insurance Complaint
- Complaint Page
Sources:
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