State Health Plan Clear Pricing Project

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

The State Health Plan is changing how it pays providers like doctors and hospitals for the medical services you receive as a Plan member. These changes will take place beginning January 1, 2020, and will only affect members on the 80/20 Plan, the 70/30 Plan and the High Deductible Health Plan.

We are making these changes in order to reduce the cost of health care and to increase transparency in the cost of medical services. We call it the Clear Pricing Project.

The Plan – through its third-party administrator, Blue Cross NC – currently pays providers whatever they charge based on rates they consider to be confidential. That means providers won’t tell us the price of their services and what they’re charging us. This can lead to a wide range of costs for the same service.

We will be setting our own rates instead of paying providers rates that are set under confidential contracts. These rates will be based on a percentage above what Medicare pays providers. To accomplish this, the Plan has set up its own custom North Carolina State Health Plan Network. The deadline for providers to join this new network was July 1, 2019.

Some doctors or hospitals did not want to partner with the Plan on these new, transparent rates. As a result, effective January 1, 2020, they will be considered out-of-network. Out-of-network providers can charge any amount they choose and, if the Plan doesn’t cover the entire amount, they can bill you for the rest.

Members will be able to search for providers that will be in-network as of January 1, 2020, beginning October 1, 2019 (Open Enrollment) via the online Find a Doctor look up tool. The Plan is still processing the contracts that were received and does not have specific information regarding the number of providers or hospitals that joined at this time. State Health Plan members should not be concerned at this time as the Plan is working on consumer protections to assist members with accessing health care services at a transparent and affordable price.

Below you will find informational videos, recent announcements and FAQs regarding the Clear Pricing Project.

The Clear Pricing Project: An Introduction

The Clear Pricing Project: What It Means for You

State Treasurer Dale R. Folwell, CPA on the Clear Pricing Project

Clear Pricing Project Frequently Asked Questions

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

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

The State Health Plan is going to be changing how we pay providers. The Plan will be setting our own rates instead of paying providers rates that are set under confidential contracts.

These rates will be based on a percentage above what Medicare pays providers.  Medicare, like the State Health Plan, is a government payer. Medicare rates are published every year for all to see, and they are adjusted for quality, cost and location. By using Medicare rates as a reference point, you and the Plan will get consistent and fair prices for health care services.

Providers who agree to partner with us will remain in-network for Plan members.

Members will be able to search for providers that will be in-network as of January 1, 2020, beginning October 1, 2019 (Open Enrollment) via the online Find a Doctor look up tool. The Plan is still processing the contracts that were received and does not have specific information regarding the number of providers or hospitals that joined at this time. State Health Plan members should not be concerned at this time as the Plan is working on consumer protections to assist members with accessing health care services at a transparent and affordable price.

Why is the State Health Plan doing this?

Why is the State Health Plan doing this?

The goal of this effort is to promote transparency, control rising health care costs and protect the Plan’s long-term financial health.  The State Health Plan has a duty to its more than 727,000 members and dependents to ensure that the Plan isn’t being overcharged. Provider rates are kept confidential under our current contracts, so the Plan can’t tell if it is being charged correctly.

This has the potential to save members almost $57 million a year in out-of-pocket costs and save the Plan almost $258 million a year in reduced fees for services. These savings will be reinvested into the Plan to make health care more affordable for members.

Who does this affect?

Who does this affect?

State Health Plan members who are enrolled in the 70/30 Plan, the 80/20 Plan and the High Deductible Health Plan will be affected.

What does this mean for my prescriptions?

What does this mean for my prescriptions?

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

What about members on UnitedHealthcare (UHC) Medicare Advantage Plans?

What about members on UnitedHealthcare (UHC) Medicare Advantage Plans?

This does not affect members on the UHC Medicare Advantage Plans.  

What does it mean to me, specifically?

What does it mean to me, specifically?

If a provider is in-network, you will continue to pay copays and applicable out-of-pocket expenses as you do now. However, what providers charge for certain services may decrease, which means your out-of-pocket costs may decrease.

If a provider or hospital chooses not to participate in the network, they will be considered out-of-network after January 1, 2020. You may still visit that provider or hospital but you will pay more and be subject to being balanced billed, which means the provider can charge you the difference between what the State Health Plan pays and the amount you owe.

How is this different from what we have today?

How is this different from what we have today?

Today, the Plan, through Blue Cross NC, pays providers based on rates they consider to be confidential. That means providers won’t tell us the price of their services and what they’re charging us. This can lead to a wide range of costs for the same service. For example, a knee replacement could cost substantially more in one part of the state than another. 

The Plan is trying to change that by setting our own provider rates for the medical services you receive.

Is my provider in the new network? How can I find out?

Is my provider in the new network? How can I find out?

Changes in the network will not occur until January 1, 2020. Details on who is in that new network will not be available until Open Enrollment, which will be held in October 2019. 

Members will be able to search for providers that will be in-network as of January 1, 2020, beginning October 1, 2019 (Open Enrollment) via the online Find a Doctor look up tool. The Plan is still processing the contracts that were received and does not have specific information regarding the number of providers or hospitals that joined at this time. State Health Plan members should not be concerned at this time as the Plan is working on consumer protections to assist members with accessing health care services at a transparent and affordable price.

What if there is not an in-network provider, hospital or specialist close by that I can see?

What if there is not an in-network provider, hospital or specialist close by that I can see?

The Plan will continue to adhere to access-to-care standards, which means that in certain scenarios where an in-network provider is not available, the Plan will pay the provider at an in-network rate and the member will be held responsible for the in-network out-of-pocket expenses.  

What if you have an emergency and you visit an out-of-network hospital?

What if you have an emergency and you visit an out-of-network hospital?

By law, emergency rooms are required to treat patients regardless of coverage. If it is a true emergency, then the State Health Plan will pay at the in-network rate.