What you are choosing between
Stay with the State Health Plan: once Medicare is primary, the Plan offers three options for 2027: the Base Plan and the Enhanced Plan (group Medicare Advantage PPOs with group Part D drug coverage) and the 70/30 Plan (the Plan's PPO that pays after Original Medicare). Your share of the premium (none, half or all) depends on your hire date and years of service. See State Health Plan retirees and Medicare.
Buy individual coverage: either an individual Medicare Advantage plan (most include drug coverage), or Original Medicare with a Medigap policy and a Part D plan. For 2027, CMS data show 106 Medicare Advantage plans open to everyone in North Carolina and 11 standalone Part D plans; the number in your county ranges from 11 in Carteret County to 57 in Guilford County.
Side by side
| Question | Plan Base or Enhanced Plan | Plan 70/30 Plan | Individual Medicare Advantage | Individual Medigap + Part D |
|---|---|---|---|---|
| Who pays first | The group Medicare Advantage plan, in place of Original Medicare | Original Medicare; the 70/30 Plan pays part of what's left | The plan, in place of Original Medicare | Original Medicare; Medigap pays part or all of what's left |
| Providers | National PPO: per the Plan, any provider who accepts Medicare and agrees to bill the plan | Any provider who accepts Medicare; for 2027 the 70/30 Plan's cost sharing depends on a three-tier network | The plan's network (HMO or PPO rules), sold by county | Any provider in the U.S. who accepts Medicare |
| Drug coverage | Included (group Part D) | Included; the Plan's drug list, not Part D but creditable | Usually included | Separate Part D plan; Medigap has no drug coverage |
| Parts A and B | Both required | Without Part B, you owe what Part B would have paid | Both required | Both required for Medigap |
| Part B premium | You pay it in every case, plus IRMAA if your income is higher. The Plan does not pay it. | |||
| Premium | Your share depends on contribution status and dependents; see the Plan's 2027 rate sheets | Set by each plan | Medigap and Part D premiums set by each company | |
| Part D protections | Group Part D: the $2,400 yearly cap for 2027 and Extra Help apply | Not Part D: the Plan's own drug rules; Extra Help does not apply | $2,400 cap in 2027; Extra Help applies | $2,400 cap in 2027 (Part D plan); Extra Help applies |
| When you can change | The Plan's Open Enrollment (Oct. 12 to 30, 2026 for 2027) or a qualifying life event | Medicare's enrollment periods, such as Oct. 15 to Dec. 7, or a Special Enrollment Period; Medigap any time, but health questions may apply | ||
| Spouse | Covered as a Plan dependent, with a dependent premium; a spouse not on Medicare stays on a non-Medicare Plan PPO | Each person buys his or her own plan or policy | ||
Medicare Advantage plans may offer extra benefits such as dental, vision, hearing or fitness. Extra benefits vary by plan and county, may have limits and costs, and not every plan offers them. Check a plan's Summary of Benefits or Evidence of Coverage.
What happens to your Plan coverage if you buy your own
- Individual Medicare Advantage or Part D plan: your Plan Medicare Advantage coverage is canceled and you are moved automatically to the 70/30 Plan. You remain a Plan member; the Plan warns this "may have a significant financial impact." You can choose a Plan Medicare Advantage option again at a later Plan Open Enrollment.
- Opting out of the Plan entirely: you can opt back in only at the Plan's Open Enrollment or after a qualifying life event.
- Medigap: it works only with Original Medicare, so it can't be paired with the Plan's Medicare Advantage options. With the 70/30 Plan, the Plan says a Medigap policy is generally not needed.
Medigap timing in North Carolina
North Carolina has no Medigap birthday or yearly switching rule (G.S. 58, Article 54). Outside your 6-month Medigap open enrollment, which starts the first month you're both 65 and enrolled in Part B, a company can ask health questions unless you have a federal guaranteed-issue right. One such right applies when retiree coverage that pays after Medicare is ending: you can apply within 63 days of the end date. Before canceling Plan coverage on purpose, get a written Medigap approval first. More: when can I buy Medigap in North Carolina?
How to compare
- Find your contribution status. Retirement Systems or the Plan's Eligibility and Enrollment Support Center (855-859-0966) can confirm whether you pay none, half or all of the premium.
- Add up the year. Plan premium for you and any dependents versus the individual plan's premium, plus likely copays, coinsurance and drug costs. Your Part B premium is the same either way.
- Check doctors and drugs. Look up your providers and prescriptions in the Plan's 2027 documents and in any individual plan you're considering.
- Think about your spouse. Plan dependent coverage moves with your choice; individual plans cover one person each.
- Time it. Don't drop the Plan until the new coverage is approved and has a start date.
To compare individual plans from the companies they work with, you can request a call from a licensed insurance agent. You can also see individual plans in your ZIP code.
Sources
- State Health Plan — 2027 Benefit Information: Medicare Members
- State Health Plan — 2027 Open Enrollment Medicare outreach presentation
- State Health Plan — 2027 Plan Comparison, Medicare-primary subscribers
- State Health Plan — Retiree Health Benefits Fact Sheet
- Medicare.gov — Compare Original Medicare and Medicare Advantage
- Medicare.gov — Choosing a Medigap Policy (guaranteed-issue rights)
- N.C. General Statutes Chapter 58, Article 54 (Medicare supplement insurance)
- CMS — Medicare Advantage and Part D contract and enrollment data
Frequently asked questions
State Health Plan or an individual Medicare plan: which is right for me?
It depends on what you pay for Plan coverage (set by your hire date and service), whether you cover a spouse, your doctors and your drugs. Retirees who pay half or all of the Plan premium, or who qualify for Extra Help, have the most reason to compare. Joining an individual Medicare Advantage or Part D plan moves you to the 70/30 Plan, so decide before you enroll.
Can I have the State Health Plan's 70/30 Plan and a Medigap policy?
You can, because both work with Original Medicare, but the Plan says a Medigap plan is generally not needed when you have secondary coverage to Medicare.
Does Extra Help work with the State Health Plan's 70/30 Plan?
No. The Plan says Extra Help works only with Medicare Part D coverage, and the 70/30 Plan's drug coverage is not Part D, though it is creditable. The Plan's Base and Enhanced Plans include group Part D coverage.
How many individual Medicare plans are there in North Carolina for 2027?
CMS data show 106 Medicare Advantage plans open to everyone from 16 companies across North Carolina, plus 11 standalone Part D plans. What's sold varies by county.
Medicare in your North Carolina county
Plans, local agents and help, county by county: Wake · Mecklenburg · Guilford · Forsyth · Durham · Cumberland · Buncombe · Union · Johnston · Cabarrus · New Hanover · Gaston · Onslow · Iredell · Alamance · Pitt · Davidson · Brunswick · Catawba · Rowan · All 100 counties →
