Open Enrollment
Frequently Asked Questions
- Health care costs continue to rise faster than the funding available to the Plan. Without changes, the Plan would have faced significantly higher costs, requiring a 21% premium increase and benefit reductions for all members.
- Instead of asking every member to pay more, the Plan is changing how it purchases health care. Hospitals and health systems had the opportunity to compete to become Preferred Providers by offering high-quality care at a better overall value for Plan members.
- Members can still receive care from any provider in the network, but those who choose Preferred Providers will generally pay less out of pocket.
- By focusing on value rather than simply increasing premiums across the board, the Plan can better manage rising health care costs while continuing to provide members with access to quality care.
- The tiered network impacts members on the Standard and Plus PPO plans as well as Medicare retirees on the 70/30 Plan. This does not impact members on the Humana Medicare Advantage Plans or members in the High-Deductible Health Plan.
- The goal of the Preferred Provider Program was to use competition to help lower health care costs while maintaining access to high-quality care.
- In parts of the state where multiple health systems compete for patients, the Plan invited providers who have proven to have high-quality care to compete to become Preferred Providers. Those providers agreed to offer the Plan a better overall value. In return, members who choose those Preferred Providers will generally pay less out of pocket.
- In some areas of the state, there is little or no competition because one health system serves most of the community. In those areas, providers have less incentive to offer additional discounts or pricing arrangements because they already care for the majority of patients in that region. As a result, many of those providers are classified as Access Providers rather than Preferred Providers.
- For example, ECU Health provides excellent care and is the primary health system for much of eastern North Carolina. Because there are few competing hospital systems in that region, the same competitive pricing opportunities that exist in other parts of the state simply aren't available in Eastern North Carolina, which is why most providers in that area are Access Providers (the same benefit you have today).
- For active members: Individual monthly premiums are increasing by less than $2 to about $8, depending on your salary and plan. Family coverage is increasing by about $29 to $42 per month. The salary-based premium structure remains in place, helping reduce the financial burden on lower-paid employees.
- The increases are also proportionate to recent salary increases. For example, an employee earning $60,000 who recently received a 3% pay raise will pay $52.52 per month for individual Standard Plan coverage, compared with $50 today.
- There will not be any other health systems added as a Preferred Provider. The State Health Plan will continue to add Independent providers as Preferred providers when possible.
- UNC Health, Novant Health, and Iredell Health are in addition to the already existing Preferred Providers in place today. Find Preferred Providers. The Find a Doctor tool will be updated in September for 2027.
- If you are already seeing a Preferred Provider, then you don’t have to do anything.
- If you are seeing an Access provider, which is most providers, you can continue to see them at the current benefit level with a lower specialist copay.
- If you’re seeing a Non-Preferred Specialist, you will have to pay more to continue seeing that provider and may want to consider moving your care.
- For those members out of state, all out-of-state providers are considered in the Access tier.
- Beginning Jan. 1, 2027, if you’re seeing a Non-Preferred Provider, you will have to pay more if you choose to continue seeing that provider.
- As a reminder, Behavioral Health, Therapies, and Emergency Room copays are not impacted by the tiered network; copays remain the same.
- If you are going through cancer treatments, having a transplant, pregnant, or have a child in the NICU, you will not have to switch and will receive care at the Access tier level. You will be receiving information in the mail regarding that process and will need to complete a Transition of Care form.
- Members with certain complex conditions who are seeing Non-Preferred providers will be able to request an exception for the Access tier benefit. Members in this situation will be contacted directly by mail.
- This is why there are Access Providers; these providers are available to ensure access to care and are available with the same benefit you have today, and in many cases, your specialist copay will be lower.
- Most providers in North Carolina are access providers.
- All out-of-state providers are in the Access tier.
- In-network Deductibles and OOP limits will accumulate across all tiers simultaneously. For example, if a member on the Plus Plan hits their OOP max at a preferred provider ($3,000) and then goes to an access provider, they could spend up to an additional $2,000 in the access tier to reach their access OOP max ($5,000).
Contact Employee Benefits
Phone: 910.962.3160
Fax: 910.962.2911
Kassandra Brewer: Contact for employees last name A-L
Jan Bryan: Contact for employees last name M-Z