Starting in 2025, North Carolina State Health Plan members will face higher out-of-pocket costs when seeking care at WakeMed Health & Hospitals. The State Health Plan, which provides medical coverage for state employees, retirees, and their dependents, has designated WakeMed as a "non-network" provider due to a failure to reach a new contract agreement. According to the North Carolina State Health Plan, this change takes effect January 1, 2025, and applies to all WakeMed facilities, including hospitals, clinics, and outpatient centers.
Impact on State Health Plan Members
Members who choose to receive non-emergency care at WakeMed facilities will be subject to higher coinsurance and deductibles starting next year. Because WakeMed will no longer be considered an in-network provider, the State Health Plan will not cover services at the negotiated rates previously in place.
The State Health Plan notes that members can still access WakeMed for emergency services, which will continue to be covered at in-network benefit levels under federal and state law. However, for elective procedures, routine diagnostic tests, or specialist visits, members will face increased financial responsibility if they choose to remain with a WakeMed provider.
Reasons for the Contract Impasse
The shift stems from stalled contract negotiations between the State Health Plan and WakeMed. While the State Health Plan seeks to control rising healthcare costs for taxpayers and public employees, health systems often argue that reimbursement rates must keep pace with inflation, labor costs, and the expenses associated with providing complex medical care.
According to official communications from the State Health Plan, the organization maintains a "clear pricing" strategy designed to ensure that medical providers are reimbursed fairly while keeping premiums stable for state employees. WakeMed has stated that they remain committed to providing high-quality care to all patients, though they have expressed concerns regarding the proposed reimbursement structures.
Options for Affected Patients
State Health Plan members currently receiving ongoing treatment at WakeMed should review their care plans immediately. To mitigate the impact of these changes, the State Health Plan website offers the following guidance:
- Check Provider Status: Use the online "Find a Provider" tool to identify in-network facilities and specialists in the Wake County area.
- Transition of Care: Members with complex medical conditions or those currently in the middle of a treatment cycle may be eligible for "continuity of care" provisions. Contacting the State Health Plan member services department is recommended to determine if your specific situation qualifies for a temporary extension of in-network benefits.
- Review Plan Benefits: Log into the State Health Plan portal to compare the cost-sharing differences between in-network and out-of-network providers for your specific plan type.
Key Takeaways for 2025
- Effective Date: The change in status for WakeMed begins January 1, 2025.
- Coverage Status: WakeMed will be classified as an out-of-network provider for non-emergency services.
- Emergency Care: Emergency medical services remain covered at in-network rates.
- Next Steps: Members should confirm if their current physicians are part of other in-network hospital systems to avoid unexpected costs.
The State Health Plan continues to encourage members to utilize the Blue Cross and Blue Shield of North Carolina provider network to find alternative facilities that maintain in-network status for the 2025 plan year. Members are encouraged to monitor the official State Health Plan website for any last-minute contract updates or changes to the provider network.