State Health Plan Clear Pricing Project

What is the State Health Plan’s Clear Pricing Project?

As a State Health Plan member in 2021, you will have access to the North Carolina State Health Plan Network, which is made up of providers who signed up for the Plan’s Clear Pricing Project (CPP), and Blue Cross NC’s Blue Options network. CPP providers have agreed to get rid of secret contracts, making health care more affordable and transparent. In an effort to lower health care costs for members and to support CPP providers, the Plan will be offering significant copay reductions for members who visit a CPP provider in 2021. The CPP is applicable to members on the 70/30 Plan and 80/20 Plan.

What does this mean for Medicare-eligible members?

This does not impact members on the Medicare Advantage plans. This would only be applicable to Medicare-eligible members on the 70/30 Plan.

What geographical area does the Clear Pricing Project cover?

The CPP is only applicable to North Carolina providers, including Primary Care Provider (PCP) offices, specialist offices, participating hospitals and urgent care facilities. Outside of North Carolina, you would still have access to in-network providers in the Blue Options network.

Can I just go to any Clear Pricing Project provider to get a copay reduction?

You can go to any CPP Specialist, Chiropractor, Speech or Occupational Therapist to receive a copay reduction. To qualify for the $0  CPP PCP copay, you must have selected a CPP PCP which appears on your State Health Plan ID card and then see that PCP for your office visit. You will need to select a CPP PCP during the Open Enrollment process for your 2021 benefits.

How do I get a CPP provider listed on my ID card?

You are able to select a CPP provider during the online Open Enrollment process. You will receive a new ID card prior to January 1, 2021. If you desire a CPP provider for a dependent, make sure you enter a CPP provider for that dependent during the Open Enrollment process. Beginning January 1, 2021, you will be able select a new provider any time during the year – CPP or non-CPP – by using eBenefits, the Plan’s enrollment system.

How can I locate a Clear Pricing Project provider?

There are two ways to locate a CPP Provider:

1. Find a Doctor tool

• Visit www.shpnc.org. Click the Find a Doctor link at the top of the home page.
• Scroll down to select your health plan to access your Find a Doctor Tool.
• The Find a Doctor Tool opens. Select the plan type by clicking the Individuals, Families, & Groups button.
• Choose North Carolina State Health Plan in the drop-down box and click Submit.
• Click the Find a Doctor or Facility button.
• From there, you can search by Category or by Name.
• CPP providers will say “Clear Pricing Project Provider” next to their name. Note: You cannot specifically search for a CPP provider by that designation.

2. Clear Pricing Project Provider Search Tool

• Visit www.shpnc.org. Find the Clear Pricing Project page and click on the green CPP provider search tool box.
• Click on the box for the region in which you wish to search for providers: Mountain, Piedmont or Coastal Plains.
• A large list of providers for the selected region will appear in a table.
• You may narrow the search results by typing in the search box. The table will automatically filter your results.

What if you select a CPP provider and then find that they are not taking new patients?

You can change your provider anytime throughout the benefit year (2021), so you will be able to select another provider.  You can also research a new provider by using the Find a Doctor tool or contacting the provider’s office to see if they are accepting new patients.  

What if my CPP provider or specialist has multiple locations?

CPP providers and specialists within a practice joined the CPP via the practice level. This means you can see any provider within that practice and still have the copay reduction. Please note that the address is very important. When selecting your provider, make sure you intend to see the provider at the address reflected for that provider. Not all practices that your provider may be affiliated with joined the CPP. 

When do the CPP copay reductions start?

Copay reductions begin January 1, 2021, the start of the new benefit year.

What does this mean for my prescriptions?

This does not impact your pharmacy benefits with the State Health Plan.

Can multiple CPP providers be listed on my ID card?

No. There can only be one provider reflected on your ID card as your PCP.

If a provider or hospital is not a part of the CPP, will that provider be considered out of network?

No. As long as the provider is part of the Blue Options network, provider will not be considered out-of-network. You will have the normal copayment applied. For emergency situations, service at the nearest hospital would be processed at an in-network benefit.

What if my provider didn't sign on to the CPP?

If your provider didn’t sign on to the Clear Pricing Project, they are still considered in-network for 2021, if they are currently in the Blue Options network, but the CPP copay reductions would not apply.

How does the CPP affect my out-of-pocket maximum and deductible?

Using a CPP provider will lower your out-of-pocket amount for your copayment, which is applied to your out-of-pocket maximum, but it does not impact your deductible.