RALEIGH — The North Carolina State Health Plan will move most Atrium Health facilities to its out-of-network tier Jan. 1, 2027, shifting potential financial exposure away from the taxpayer-funded plan while relying on Atrium’s promise to hold members harmless.
The change affects a plan serving about 770,000 state employees, retirees and family members. Atrium serves about 80,000 plan members, according to WUNC. Twelve children’s and rural facilities covered by an earlier agreement will remain in the plan’s Access tier.
Atrium’s affordability program says plan members using most Atrium providers would receive lower copays and waivers of coinsurance and deductibles even with the health system outside the network. The State Health Plan said members should see the same coverage if Atrium follows through on that commitment.
The plan estimates keeping most Atrium facilities in its prior tier while the program operates could add as much as $250 million in 2027 costs. Moving those facilities out of network reduces the plan’s payment responsibility, while any protection from higher member costs depends on Atrium honoring the program.
The decision follows a judge’s refusal to block Atrium’s program and lands during open enrollment, which runs through Nov. 6. Emergency care remains in the Access tier. Behavioral health, speech therapy, occupational therapy, chiropractic care, physical therapy and urgent care are outside the new tiered-network structure, according to the plan.
The action changes the reimbursement relationship between one of North Carolina’s largest health systems and the taxpayer-funded plan. It creates an immediate enrollment decision for tens of thousands of members and a potentially nine-figure financial consequence for the plan, Atrium or both, depending on how the affordability program is implemented.