What Is the Best Health Insurance in North Carolina?

Finding the “best” health insurance in North Carolina is subjective, depending on individual needs, financial capacity, and preferences. Understanding the various options and evaluating their components is fundamental to making an informed decision. This guide clarifies the health insurance landscape within North Carolina to assist residents in navigating their choices effectively.

Available Health Insurance Options in North Carolina

North Carolina residents have several avenues through which they can obtain health insurance coverage. The primary sources include the Affordable Care Act (ACA) Marketplace, employer-sponsored plans, and government-funded programs.

The ACA Marketplace, accessed through HealthCare.gov, serves as a platform for individuals and families to purchase health insurance plans. North Carolina uses the federally facilitated exchange, allowing residents to compare and enroll in plans from multiple private insurers. For 2025, nine insurance companies are offering individual and family health plans through North Carolina’s Marketplace.

Many individuals also receive health coverage through their employment. Employer-sponsored plans typically involve contributions from both the employer and the employee towards premiums. Some employers may require a waiting period before new employees can enroll.

Government programs provide coverage for specific populations based on age, income, or disability. Medicare is a federal program primarily for individuals aged 65 or older, as well as some younger individuals with qualifying disabilities or medical conditions. North Carolina residents enrolled in Medicare can choose between Original Medicare (Parts A and B) or Medicare Advantage plans offered by private companies.

Medicaid, a joint federal and state program, assists individuals and families with lower incomes and limited resources. North Carolina expanded its Medicaid program as of December 1, 2023, increasing eligibility for adults aged 19 through 64 who meet specific income thresholds. Children previously covered by NC Health Choice transitioned to Medicaid on April 1, 2023.

Individuals can also purchase health insurance directly from private insurers outside the Marketplace. These direct plans may offer different benefits or networks and typically do not qualify for premium tax credits or cost-sharing reductions. Compare these options carefully with Marketplace offerings.

Health insurance plans are structured in various ways. A Health Maintenance Organization (HMO) generally requires members to choose a primary care provider (PCP) within the plan’s network, who then coordinates all care and provides referrals to specialists. HMOs often feature lower monthly premiums but offer no coverage for out-of-network care, except in emergencies.

Preferred Provider Organization (PPO) plans offer more flexibility, allowing members to see specialists without a referral and providing some coverage for out-of-network services, albeit at a higher cost. PPO plans typically have higher monthly premiums than HMOs due to this broader access.

Exclusive Provider Organization (EPO) plans blend aspects of both HMOs and PPOs, requiring members to stay within a specific network for covered services but often not mandating referrals for specialists. Point of Service (POS) plans act as a hybrid, combining elements of HMOs and PPOs. These plans usually require a PCP and referrals for in-network specialist visits, but they also offer some coverage for out-of-network care at a higher coinsurance rate.

Key Considerations for Evaluating Plans

Evaluating health insurance plans involves reviewing financial and coverage aspects to determine the most suitable option. Understanding cost components is fundamental to assessing affordability.

The premium is the fixed monthly payment for health insurance coverage. Plans with lower monthly premiums typically come with higher deductibles, while those with higher premiums often have lower deductibles.

A deductible is the specific dollar amount an individual must pay for covered medical services before the insurance plan begins to contribute to costs, excluding preventive care. Once the deductible is met, the plan typically starts sharing costs through copayments or coinsurance.

Copayments are fixed fees paid for specific services, such as doctor’s office visits or prescription medications. Coinsurance is a percentage of the cost for covered services after the deductible has been met.

The out-of-pocket maximum is the ceiling on the amount an individual or family will pay for covered healthcare services within a plan year. This limit includes amounts paid towards deductibles, copayments, and coinsurance. Once this maximum is reached, the insurance plan covers 100% of all subsequent covered services for the remainder of the plan year. However, premiums and costs for services not covered by the plan or received out-of-network do not count towards this maximum.

The provider network is also important when evaluating plans. Health insurance plans contract with a network of doctors, hospitals, and other healthcare providers. In-network care generally results in lower costs, while out-of-network care can lead to higher out-of-pocket expenses. Verify that preferred doctors and hospitals are included in a plan’s network before enrolling.

Prescription drug coverage is a significant factor. Plans have a formulary, a list of covered medications often organized into tiers with different cost-sharing levels. Lower-tier drugs usually have lower copayments, while higher-tier or specialty drugs incur greater costs. Understanding a plan’s formulary and how it covers necessary medications is important.

Individuals should also consider their health status and anticipated medical needs. Those with chronic conditions or expected medical events, such as surgery or pregnancy, might prioritize plans with lower deductibles or comprehensive coverage for specific services. All individual and small group health plans, including those on the ACA Marketplace, are required to cover ten categories of essential health benefits (EHBs). These categories include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services, laboratory services, preventive and wellness services, and pediatric services. Plans cannot impose annual or lifetime caps on the amount of money paid for these EHBs.

Navigating Enrollment and Financial Assistance

Enrolling in health insurance and accessing financial assistance involves specific processes. For plans purchased through the ACA Marketplace, there is an annual Open Enrollment Period (OEP). This period typically runs from November 1st to January 15th, during which individuals can select or change their health plans for the upcoming year.

Individuals who miss the Open Enrollment Period may still be able to enroll in a plan if they experience a Special Enrollment Period (SEP). A SEP is triggered by qualifying life events, allowing enrollment outside the standard OEP. Common qualifying life events include:
Losing existing health coverage (due to job loss, divorce, or aging off a parent’s plan)
Getting married
Having a baby
Adopting a child
Moving to a new area

Individuals generally have a 60-day window before or after the qualifying event to enroll in a new plan.

Applying for coverage through the ACA Marketplace in North Carolina is done via HealthCare.gov. The application process involves providing income information to determine eligibility for plans and financial assistance. For employer-sponsored plans, enrollment is managed through the employer’s human resources department.

Financial assistance is available to individuals and families who enroll in plans through the ACA Marketplace. Premium Tax Credits (PTCs), also known as subsidies, reduce monthly premium costs. Eligibility for these credits is based on household income relative to the federal poverty level (FPL).

Cost-Sharing Reductions (CSRs) provide additional financial assistance by lowering out-of-pocket expenses like deductibles, copayments, and coinsurance. CSRs are available to individuals and families with household incomes up to 250% of the federal poverty level who enroll in Silver-level plans on the Marketplace. If eligible, CSRs are automatically applied to Silver plans, resulting in reduced cost-sharing and increasing the actuarial value of the plan.