State Health Plan retirees and Medicare in North Carolina

Quick answers

Which State Health Plan options can Medicare retirees choose for 2027?

Three: the group Medicare Advantage PPO Base Plan, the group Medicare Advantage PPO Enhanced Plan (both with drug coverage), or the 70/30 Plan, which pays after Original Medicare.

Do State Health Plan retirees need Medicare Part B?

Yes, in practice. Parts A and B must be in effect to be in either Medicare Advantage option, and on the 70/30 Plan without Part B the Plan pays as if Part B had paid, leaving you the difference.

Does the State Health Plan pay my Part B premium?

No. The Plan says you must keep paying the Part B premium to the federal government, plus any income-related amount (IRMAA).

What happens if I join an outside Medicare Advantage or Part D plan?

Your Plan Medicare Advantage coverage is canceled and you are moved to the 70/30 Plan. You stay a Plan member, but your costs may change a lot.

When can I change State Health Plan options?

At the Plan's own Open Enrollment (for 2027 it was October 12 to 30, 2026), after a qualifying life event, or in the window before your Medicare starts. Medicare's October 15 to December 7 period does not reopen Plan choices.

Who gets State Health Plan coverage in retirement?

The State Health Plan for Teachers and State Employees is part of the North Carolina Department of State Treasurer. Under N.C.G.S. 135-48.1, a "retiree" for Plan purposes is a retired teacher, state employee or legislator who receives a monthly benefit from one of these systems and earned contributory retirement service in it before January 1, 2021 (and did not withdraw that service):

• TSERS, the Teachers' and State Employees' Retirement System (teachers, state agencies, community colleges and the UNC System). You need at least 5 years of TSERS contributions; unused sick leave and service transferred from LGERS don't count toward the 5.
• CJRS, the Consolidated Judicial Retirement System.
• LRS, the Legislative Retirement System (Retirement Systems says a "first hired" date before February 1, 2007, and at least 5 years of service).
• The Optional Retirement Programs under G.S. 135-5.1 and 135-5.4.

LGERS (local government) retirees are not in this list; see local government retirees below. Eligible retirees and covered dependents are enrolled automatically at retirement; to decline, you opt out through ORBIT or the Plan's Eligibility and Enrollment Support Center.

How your hire date and service set your share of the premium

"Non-contributory" means the Plan pays the retiree's own premium for the 70/30 Plan; the Plan notes that other options may need a partial contribution, and covered family members carry their own premiums. The Plan publishes its 2027 Medicare-primary rate sheets for retirees who pay 0%, 50% or 100%. More: are state employees hired after 2021 eligible?

The Plan's three Medicare options for 2027

When Medicare becomes your primary coverage, the Plan's non-Medicare PPOs no longer apply to you. Instead you choose one of three Medicare-primary options. All three include prescription drug coverage, so the Plan says you don't need a separate Part D plan.

The two Medicare Advantage options are national PPOs: the Plan says you can see any provider who accepts Medicare and agrees to bill the plan. For 2027:

• Retirees already in the Base Plan or Enhanced Plan stay in it unless they chose otherwise during Open Enrollment.
• Medicare-primary members on the 70/30 Plan are moved to the Base Plan on January 1, 2027, unless they took action during Open Enrollment.
• The 70/30 Plan adds a three-tier provider network, so what you pay can depend on the provider's tier. The Plan says the tiers don't affect the Medicare Advantage options.
• The Plan lists changes to some Medicare Advantage copays and to the yearly out-of-pocket maximums. Your 2027 Annual Notice of Changes and the Plan's 2027 comparison chart show them.

Comparing the Plan with buying your own coverage? See State Health Plan vs. individual Medicare plans and what Medicare plans the State Health Plan offers.

Parts A and B: what the Plan requires

• Medicare Advantage options: Part A and Part B must be in effect, and you must keep paying your Part B premium to the federal government ($202.90 a month for most people in 2026, more with IRMAA). The Plan does not pay or reimburse it.
• 70/30 Plan without Part B: the Plan processes claims as if you had Part B, so you owe what Part B would have paid.
• Retiring at 65 or older: Medicare becomes primary in your first month of retirement, while you're still on your agency's coverage, so the Plan says to have Part A and Part B in place as of your retirement date. If they aren't, or if your retirement is approved late, you may be defaulted into the 70/30 Plan for the rest of the plan year.
• Still working for the State at 65: the Plan stays primary, so you can take Part A and delay Part B until you retire without a penalty. See working past 65.
• Medicare because of a disability: the Plan becomes secondary from your Medicare date. Without Part B, you owe what Part B would have paid.

Details: do state retirees need Part B? and does the Plan pay for Part B?

Turning 65 when you're already retired

1. Sign up for Part A and Part B. Your Initial Enrollment Period starts 3 months before the month you turn 65. Apply with Social Security; if you already get Social Security benefits, you're enrolled automatically.
2. Watch for the Plan's letter. The Plan assigns you to the Base Plan for the month Medicare becomes primary and notifies you about 80 to 90 days ahead.
3. Decide by 30 days before. To choose the Enhanced Plan or the 70/30 Plan instead, tell the Plan no later than 30 days before your Medicare starts. After that, you generally wait for the next Plan Open Enrollment.

More: what happens to Plan coverage at 65 and turning 65 in North Carolina.

If you join an outside Medicare plan

Medicare lets you be in only one Medicare Advantage or Part D plan at a time. The Plan's 2027 materials spell out what that means:

• Enrolling in an outside Medicare Advantage plan or a standalone Part D plan cancels your Plan Medicare Advantage coverage and moves you automatically to the 70/30 Plan, which the Plan warns "may have a significant financial impact." You stay a State Health Plan member.
• Joining the Plan's Medicare Advantage option ends any other Medicare Advantage or Part D plan you have.
• A Medigap policy can't be used with any Medicare Advantage plan, including the Plan's.
• Individual dental, vision, cancer, hospital indemnity or long-term care policies don't affect your Plan Medicare Advantage coverage.

If you decide to leave the Plan for individual coverage, Medicare's rules decide when you can join, and North Carolina has no Medigap birthday rule, so health questions can apply outside your Medigap open enrollment or a guaranteed-issue right. Read can I drop the State Health Plan and buy my own plan? before you act.

Two different open enrollment periods

Medicare's period is still open, but it does not reopen State Health Plan choices. Joining an individual plan now would still trigger the move to the 70/30 Plan described above. Outside the Plan's Open Enrollment, Plan changes generally need a qualifying life event (retirement is one). See Medicare Open Enrollment in North Carolina and all enrollment periods.

Spouses and dependents

Covered dependents are enrolled with you at retirement. The Plan's rules for families:

• A Medicare-eligible spouse follows the same rules you do: Parts A and B must be in place for the Medicare Advantage options, or the spouse is defaulted to the 70/30 Plan. Medicare-primary family members are enrolled in the same option.
• A spouse or child not yet on Medicare keeps non-Medicare coverage (the Standard PPO Plan or Plus PPO Plan) while you are on a Medicare option. The Plan calls this a "split family."
• Dependents can be added or dropped only at Plan Open Enrollment or after a qualifying life event, with eligibility documents.

More: can my spouse stay on the Plan when I go on Medicare?

Local government (LGERS) retirees

Retirement Systems says LGERS retirees should check with their employer or former employer about retiree health coverage, "if any." Some local governments put their employees on the State Health Plan under G.S. 135-48.47, which covers employees and their dependents; retiree coverage is a separate question for your former employer. If your former employer offers retiree coverage, ask whether you must have Part B and what happens if you join an individual Medicare plan. See do LGERS retirees get State Health Plan coverage?

Federal retirees in North Carolina

Federal retirees use a different program. Under the Federal Employees Health Benefits (FEHB) Program, OPM says enrolling in Medicare Part B is your decision, but once you retire Medicare pays first and FEHB pays second, and a late Part B enrollment brings a lifelong penalty. Postal Service retirees in the Postal Service Health Benefits (PSHB) Program generally must enroll in Part B to keep PSHB, with some exceptions. See do federal retirees need Part B with FEHB?

Social Security and Medicare for North Carolina public employees

Unlike public workers in some states, most North Carolina public employees pay into Social Security: in 2023, 92.7% of the state's state and local government employees had Social Security coverage, according to the Congressional Research Service. Most therefore qualify for Part A with no premium through their own or a spouse's work. The Social Security Fairness Act (signed January 5, 2025) repealed the Windfall Elimination Provision and Government Pension Offset; it changes Social Security benefits, not Medicare eligibility.

Proposed legislation: Senate Bill 139

Senate Bill 139 of the 2025–2026 session, "Restore State Emp/Teacher Retiree Med Benefit," was filed February 24, 2025, and referred to the Senate Rules and Operations Committee the next day. As of November 13, 2026, it has had no further action. It is proposed, not law: the January 1, 2021 cutoff in G.S. 135-48.1 still applies.

Where to get help

• State Health Plan Eligibility and Enrollment Support Center: 855-859-0966, for Plan options, eligibility and enrollment.
• Retirement Systems Division: (919) 814-4590, for retirement dates and service credit.
• Social Security: 1-800-772-1213 (TTY 1-800-325-0778), to sign up for Part A and Part B.
• Medicare: 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) or Medicare.gov.
• To compare individual Medicare plans from the companies they work with, and how they would fit with your Plan coverage, you can request a call from a licensed insurance agent.

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 — Planning for retirement (pre-65) presentation, 2026
• State Health Plan — Retiree Health Benefits Fact Sheet
• State Health Plan — 70/30 Plan for Medicare Retirees
• N.C. General Statutes 135-48.1, definitions (retiree)
• N.C. General Statutes 135-48.47, local government participation
• NC Retirement Systems — Health benefit coverage for eligible retirees
• NC Retirement Systems — Health benefit coverage for other retirement system retirees
• North Carolina General Assembly — Senate Bill 139 (2025–2026 session), status
• OPM — Medicare for federal annuitants
• Congressional Research Service — Social Security Coverage of State and Local Government Employees (R46961)
• Social Security Administration — Social Security Fairness Act
• Medicare.gov — Special Enrollment Periods

Every question in this guide

• Are NC state employees hired after 2021 eligible for retiree health coverage?
• Can I drop the State Health Plan and buy my own Medicare plan in NC?
• Can my spouse stay on the State Health Plan when I go on Medicare?
• Do federal retirees in North Carolina need Medicare Part B with FEHB?
• Do LGERS retirees get State Health Plan coverage with Medicare?
• Do North Carolina state retirees need Medicare Part B?
• Does the NC State Health Plan pay for Medicare Part B?
• What happens to my State Health Plan coverage when I turn 65?
• What Medicare plans does the NC State Health Plan offer retirees?

Frequently asked questions

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