Aetna promising smooth transition as SHP TPA | Eastern North Carolina Now

    Publisher's Note: This post appears here courtesy of the Carolina Journal. The author of this post is Theresa Opeka.

    Jim Bostian, Aetna's market president for North Carolina, addressed the State Health Plan Board of Trustees at their meeting Wednesday, with promises of building upon a seamless transition as the new SHP third-party administrator beginning on Jan. 1, 2025.

    Aetna ousted Blue Cross and Blue Shield of North Carolina after more than 40 years as the TPA for the SHP.

    "We are thrilled to have this opportunity to serve a state health plan and its members who teach, protect, and serve this great state of North Carolina," Bostian said. "Aetna is fully committed to a smooth transition, and to that end, our work has already well begun. I want to make it clear that our goal primarily is to deliver on our promise to delight your members with better service, better cost control, and a better overall experience."

    He said Aetna, which is the health benefit arm of CVS Health, has been in business in North Carolina since 1899 and has its market headquarters in Cary. There are about 325,000 employees nationwide, including over 10,000 in North Carolina, including a major service center in High Point. Aetna serves over 800,000 medical members in North Carolina, including over 200,000 seniors on Medicare Advantage plans. Over 38 million members depend on Aetna for their benefits across the U.S.

    He also noted that Aetna had given over $33 million in recent North Carolina community investment dollars for the specific focus on programs that improve overall health and well-being.

    A team of 600 employees has invested over 500 hours preparing for the transition with weekly internal meetings and, sometimes, daily meetings with the state health plan staff, including work within the company, including enrollment operations, IT, claims, network management, banking, and marketing.

    Bostian, a native of Salisbury, has over 35 years of experience working in the healthcare industry, including half of those years at Aetna. He stressed that besides being a lifelong North Carolinian, his experience makes him well-qualified to lead Aetna into becoming the SHP third-party administrator.

    "Having run network management teams in North Carolina for over half of my career, including eight years here as the local network VP for Aetna, I will challenge you to find anyone who understands this better than I do, especially in North Carolina," he said.

    Based on actual state health plan claims data for 2021 that was provided to all the bidders on this most recent request for proposal (RFP), Bastian said they confirmed Aetna's in-network status for 98% of the paid claims and 99% of total claims dollars paid to in-network Aetna providers.

    Bastian said Aetna's robust statewide and national provider network with provider discounts, with access to every acute care hospital in the state, will benefit state health plan members.

    "We will provide state health and members with access to our concierge customer service team," he said. "99% of member questions are resolved with this team on the first call. They will also provide access to our robust self-service member portal, and in keeping with our goal of supporting transparency, this tool will allow members to get clear cost estimates on upcoming medical services. Additionally, state health plan members will always have access to clinicians through our 24-hour nurse line."

    Bastian said they also plan to continue expanding the state's Clear Pricing Project, which includes honoring the visitation status for all current CPP providers. There are also no anticipated plan changes for 2025, so the benefits will continue for permanent employees with the current base PPO and the enhanced PPO plans.

    He said they are also committed to enhancing their network by continuing to add qualified providers, including those in neighboring states like Virginia, South Carolina, and Tennessee states where some SHP members currently see some providers.

    The State Health Plan's current TPA, BCBSNC, and UMR both had their bids rejected by plan board members. BCBSNC, which has protested the decision, plans to take their fight to court. The healthcare company filed paperwork last week with the state Office of Administrative Hearings and Durham County Superior Court. A Blue Cross news release argues the plan and state taxpayers "will pay more" and "get less."