Q&A: Open enrollment is now active. What NC’s State Health Plan members should expect.

It was noon and it was starting to rain. Just a few people remained under the cover of the white gazebos in front of an Aetna-themed bus parked outside the North Carolina Department of State Treasurer’s office in late July.

But for Hannah Bowen — senior account manager with Aetna for the State Health Plan — the event kicking off Aetna’s and the State Health Plan’s bus tour had been successful. She said that since 9 a.m., about 450 people had rolled in to ask questions of Aetna and State Health Plan staff about the upcoming transition.

Aetna is set to take over administration from Blue Cross NC of the state’s health insurance plan starting Jan. 1. Open enrollment runs from Sept. 30 through Oct. 25.

Bowen, who said she had organized this event and more in the future as part of a bus tour across the state, said, “The goal is really to make sure that people feel comfortable about the transition.”

State employees and other members of the State Health Plan should expect changes with that transition, considering Blue Cross NC has been the plan’s third-party administrator for more than 40 years.

Bowen said people she spoke with were mostly concerned with any cost upticks and benefit changes.

“The great news is that the answers are ‘no’ and ‘no.’ The cost isn’t going up ... and your benefits are staying the same.”

We’ve pulled together some questions and answers regarding the transition, for a user’s guide to the changes that are on the way.

Q: Why is the change happening?

Following concerns with Blue Cross NC’s transparency and financial challenges, the state decided to put the plan’s contract out for bids. The contract was ultimately awarded to Aetna for three years starting in 2025, with the option to renew for two, one-year terms.

Blue Cross NC filed a complaint over the decision, but it lost that case and has said it will not appeal a judge’s decision handed down in early July.

Q: Who’s affected?

This change will touch members who are enrolled in the Base PPO Plan (70/30), Enhanced PPO Plan (80/20) and the High Deductible Health Plan, all currently administered by Blue Cross NC.

Q: What’s a third-party administrator?

A third-party administrator handles the administrative tasks associated with health insurance, including issuing cards, processing claims and setting up technological systems.

In the case of North Carolina’s State Health Plan, the administrator also establishes the network of providers, laying out contracts with them and negotiating the prices paid for health care services.

The state in turn pays the administrator a fixed per-member cost. The state also pays the health care claims, which are sent to it by the administrator.

Q: Will the network of providers change?

Yes. Some providers will likely fall out of the network and others will become in-network.

There are different ways to compare provider networks, including analyzing what providers people use. Aetna conducted such an analysis in 2022, finding that about 99% of State Health Plan claims processed over a year would have been paid to in-network providers under Aetna, according to the SHP website.

Aetna spokesperson Pat Ryan said in late July that since Aetna was awarded the contract, it has added — or is in the process of adding — an additional 5,200 providers.

Q: How can I tell if my providers are in-network?

Plan members can check if their providers are still in-network through the plan’s website, SHP spokesperson Frank Lester says.

The link to the Find a Doctor page is here.

But since open enrollment is now underway, members can also search for and select a provider online through the plan’s enrollment system, Lester said Oct. 1.

Q: Will my benefits or premiums change?

The State Health Plan Board of Trustees, which has 10 members, makes decisions related to premiums and benefits. Therefore, those should not be changing — except if the board votes to do so in the future.

Lester told The N&O in late July that benefit coverage — including medical services covered by the plan — will be staying the same.

Also staying the same is the out-of-pocket limit (the maximum amount a patient can pay for covered services during a coverage period), co-pays (the fixed fee you pay for a health care service) and deductibles (the amount you pay before your insurance kicks in). Premiums, or the amount you pay for your health insurance every month, will also not be changing.

State Treasurer Dale Folwell has previously said that the state had frozen premiums for five years despite the rising costs of the State Health Plan.

In June — citing financial challenges faced by the plan — the SHP raised premiums for some retired state employees and their dependents under the State Health Plan’s Medicare Advantage plans offered by Humana.

Q: So what differences should I expect?

Members should expect new program offerings through Aetna. This includes access to a 24/7 Nurse Line, Teladoc Services and expanded programs for disease management and case management, Lester said.

Also changing will be the member’s health portal. Aetna’s portal will display electronic medical and health records, nurse notes on disease management, and case management notes.

Blue Cross NC’s portal did not have all the same tools, Lester said in late July.

“Aetna custom-built this functionality for the State Health Plan,” Ryan said in late July. “The goal is to really improve the information that State Health Plan members have at their disposal all in one place, instead of having to bounce between different provider portals to keep track of health records,” Ryan said.

Blue Cross NC, in response to technical questions in the State Health Plan’s request for proposal — a document that solicits proposals during a bidding process — did not confirm various requirements including on functionalities for the member’s portal. Aetna did confirm these requirements, indicating that should it win the contract, it would provide these features.

Ryan said another “major undertaking” is transitioning away from a member ID number that is unique to the insurer to a “universal personal ID” number, or UPID. Members will notice this number on their ID cards and it will be used by providers, said Ryan.

Q: Will retirees on the plans administered by Humana or Blue Cross NC be affected?

Medicare members eligible for retiree health benefits previously could choose between the two plans offered by Humana and the 70/30 plan offered by Blue Cross NC.

Retirees on the Humana Medicare plans should not be affected by the transition to Aetna, as those plans will remain under Humana.

But retirees on plans administered by Blue Cross NC will see changes, as Aetna will be taking over these.

According to the SHP website, Medicare members enrolled in the 70/30 plan will be moved to the Humana Medicare Advantage Base Plan (90/10) unless they take action during open enrollment to move into a different plan option, such as the new ones to be offered by Aetna.

Eligible retirees not on Medicare can access 70/30 and 80/20 plans.

When will open enrollment begin? What should I expect?

According to Lester, members can expect the same enrollment process as they have seen for several years.

The SHP website reminds people to make sure information such as their mailing address, email address and phone number are up to date in eBenefits, the plan’s enrollment system.

During open enrollment, changes to benefits can also be made by calling the State Health Plan’s Eligibility & Enrollment Support Center at 855-859-0966 (TTY: 711).

This story was originally published July 26, 2024 at 5:00 AM.

Luciana Perez Uribe Guinassi

The News & Observer

Luciana Perez Uribe Guinassi is a politics reporter for the News & Observer. She reports on health care, including mental health and Medicaid expansion, hurricane recovery efforts and lobbying. Luciana previously worked as a Roy W. Howard Fellow at Searchlight New Mexico, an investigative news organization.