Haris Ashley
The North Carolina (NC) state insurance program offers a range of health plans for its residents, with options available for both individuals and employees. The NC State Health Plan provides online resources to help residents understand their plan options and how to enroll in benefits. The state's official website provides information on insurance premiums, with the lowest SHOP premiums available for employers with between 1 and 50 full-time employees. NC State University also offers health insurance to its students and employees, including custom dental insurance. NC Medicaid was expanded in December 2023 to cover more individuals, and the state's Department of Insurance (DOI) actively works to educate North Carolinians about insurance-related matters.
NC State Insurance Coverage on Medications
| Characteristics | Values |
|---|---|
| Dental Insurance Coverage | Up to $2,000 for over 200+ dental procedures with $0 out-of-pocket expenses at the Campus Smiles dental clinic |
| Pharmacy Benefits | Not specified; members can refer to the monthly e-newsletter for updates |
| Medicare-Eligible Members | Designed for retired members turning 65 in the next 2 years and for members over 65 who are still actively working |
| Medicaid Expansion | Expanded in December 2023 to cover more people |
| Cost of Premiums | Not specified; may be shared between employers and employees |
| Claims | Processed by Blue Cross NC |
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What You'll Learn
Dental insurance
In North Carolina, there are several options for dental insurance. If you are enrolled in Medicaid, you are eligible for dental services with no limits on annual spending. Medicaid is designed to cover individuals with low income levels and provides more services for children than adults. All children covered by Medicaid must have access to dental health, relieve pain or infections, and restore damaged teeth. North Carolina is one of 17 states that offers "extensive" dental benefits, which includes routine examinations, preventative services, and basic and advanced tooth restoration procedures. Full x-rays are covered once every five years, complete denture replacement is covered every 10 years, and partial denture replacement is covered every 8 years.
If you are not enrolled in Medicaid, you can purchase dental insurance through the Health Insurance Marketplace, HealthCare.gov. Stand-alone dental plans are available for purchase that covers both adults and children. In 2025, premiums for stand-alone dental coverage in North Carolina range from about $8 to $46 per month. If you have a family health plan with pediatric dental coverage, the dental costs can count towards your overall deductible and may be affected by premium tax credits.
Additionally, if you are employed by the state of North Carolina, you may be eligible for the NCFlex Dental Plan, administered by the Metropolitan Life Insurance Company (MetLife). This plan allows you to visit any licensed dentist, in or out of the MetLife Preferred Dental Provider (PDP) Plus Network, and still receive benefits. The NCFlex Dental Plan offers three options: Low, Classic, and High. The amount you pay per pay period and at the time of service differs based on the plan option you choose.
Finally, if you are a student or employee at NC State University, you have access to custom dental insurance. Once enrolled, you are covered up to $2,000 for over 200+ dental procedures and pay $0 out of pocket at the Campus Smiles dental clinic on campus.
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Pharmacy and health benefits
The NC State Health Plan offers a range of benefits to its members, including pharmacy and health advantages. The plan provides resources and support to help members understand their options and make informed decisions about their health care.
For instance, the State Health Plan website offers online tools to assist members in navigating their benefits. Members can log in to eBenefits to manage their State Health Plan benefits, access important forms, and find information about providers, including Clear Pricing Project providers. Additionally, the monthly e-newsletter, Member Focus, keeps members informed about pharmacy and health benefits, offering tips on staying healthy and saving money.
In terms of specific coverage, the NC State Health Plan provides custom dental insurance to its students and employees, covering up to $2,000 for over 200+ dental procedures with $0 out-of-pocket expenses at the Campus Smiles dental clinic. For prescriptions, individuals must provide their insurance information to the pharmacy. While the exact details of medication coverage are not explicitly stated, the plan emphasizes assisting members with their health care costs.
For retired members or those over 65, the NC State Health Plan offers resources to understand medical plan options when becoming Medicare-eligible. Furthermore, NC Medicaid expansion in December 2023 increased access to healthcare for more residents, providing additional options for those seeking health coverage.
It is important to note that NC State University also provides health services to its students through Campus Health. While there may be charges for these services, students have the option to pay on the day of their appointment or have the charges billed to their student account. Campus Health also accepts most insurance plans and offers courtesy filing.
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Medicare-eligible
If you are Medicare-eligible in North Carolina, you can enrol in the federal Medicare health insurance programme. This is available to all US citizens aged 65 or older who live in North Carolina. Some people under 65 may also qualify for Medicare in North Carolina, including residents who have received 24 months of Social Security Disability Insurance payments or Railroad Board benefit payments.
Medicare Part A (Hospital Insurance) is available for free to those who are 65 or older and who paid into the Social Security System for 10 or more years. If you have paid into the Social Security System for fewer than 10 years, you can buy Medicare Part A coverage. Part B is medical insurance and has a standard monthly premium of $185 for 2025. There are scenarios where you may pay less or more for Medicare in North Carolina based on your income.
Medicare Part D is the drug coverage provided by private insurance companies aligned with federal guidelines for Original Medicare beneficiaries. To get Medicare drug coverage, you must join a Medicare prescription drug plan. These plans typically cover insulin, anti-diabetic drugs, and certain diabetes supplies such as syringes and needles. The Part D Low-Income Subsidy (LIS), or Extra Help, is a federal program that helps pay for some to most of the costs of Medicare Part D prescription drug coverage. You may be eligible for Extra Help if you meet the income and asset limits.
Medicare Advantage plans, also known as Part C, are offered by private insurance companies that replace Original Medicare, bundling drug and supplemental coverage and offering additional coverage like dental and vision. These plans can often be more beneficial than Original Medicare, with more benefits and more affordable premiums. Medicare Supplement Insurance plans are also available and can help fill gaps in your coverage.
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Medicaid
NC Medicaid expanded to more people in December 2023, and now provides health care coverage to people aged 19-64. To qualify for NC Medicaid, individuals must meet income requirements, be a legal North Carolina resident, and have a Social Security number. There are no monthly premiums for this insurance, and the highest copay is $4, which is only needed for some services. A copay is a fee paid when one receives certain health care services or prescriptions.
NC Medicaid covers vision exams and glasses for those under the age of 20. For those above the age of 20, coverage is provided for eye-related diseases like glaucoma, cataracts, macular degeneration, eye strain, and related headaches. The programme also includes a comprehensive prescription drug benefit plan, with a "preferred drug list" that pharmacists and doctors are encouraged to use when awarding prescriptions to Medicaid beneficiaries. To get a prescription that is not included in the list, prior approval from NC Medicaid is required.
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Insurance claims
For instance, the NC State Health Plan offers online resources to help members understand their plan options and benefits. They provide a monthly e-newsletter, Member Focus, which keeps members informed about pharmacy and health benefits and offers tips on staying healthy and saving money. This can be a great way to stay up-to-date on the latest information and make informed decisions about your insurance claims.
Additionally, the NC State University's Campus Health Center provides comprehensive dentistry services to students and employees. They offer custom dental insurance, covering up to $2,000 for over 200+ dental procedures with $0 out-of-pocket expenses at the Campus Smiles dental clinic. To facilitate insurance claims, individuals are responsible for providing their current health insurance card to the Insurance Department, ensuring smooth processing for any charges incurred.
For those with NC State insurance, it's important to note that you can decide at each appointment whether to use your insurance. While privacy is protected, an itemized statement can be provided upon request. After a visit, the policyholder may receive an Explanation of Benefits (EOB) from the insurance company, detailing the services received, the amount paid by insurance, and any remaining responsibility.
In terms of small businesses and employers, North Carolina's official website, HealthCare.gov, offers insights into insurance premiums. Employers with 1-50 full-time equivalent employees can offer insurance through the Small Business Health Options Program (SHOP). They can choose to share the cost of premiums with their employees or explore tax credits if they meet certain criteria, such as having fewer than 25 employees with an average annual income of less than $50,000.
Overall, understanding insurance claims and coverage in North Carolina involves utilizing available resources, staying informed through newsletters and websites, and making informed decisions about healthcare and insurance usage.
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Frequently asked questions
The NC State Health Plan is a health insurance plan for state employees and retirees. It offers a range of benefits, including medical, dental, and pharmacy services.
The NC State Health Plan covers a wide range of medications. For specific information about medication coverage, you will need to refer to your plan's benefits or contact the insurance company directly.
The amount covered for prescriptions varies depending on the medication and the specifics of your plan. You will need to provide your insurance information to the pharmacy to determine the coverage for each prescription.
Yes, there may be out-of-pocket costs for medications depending on your specific plan. You can refer to the Explanation of Benefits (EOB) provided by the insurance company, which details the services received, the amount covered by insurance, and any remaining responsibility.
