Blue Cross fights back: It’s appealing NC’s pick of Aetna for health plan. What comes next?

Blue Cross NC, a Durham-based insurance company that has long administered North Carolina’s State Health Plan, filed a protest Thursday appealing the state’s decision to replace it with Aetna.

The protest claims North Carolina’s request for proposals, or RFP, “represented a significant departure from the State Health Plan’s previous procurement and contracting process,” Sara Lang, a Blue Cross NC spokesperson, said in a news release.

The company further accused the state of making its decision based on “limited information and arbitrary scoring.”

“Blue Cross NC is proud of our long record of serving North Carolina’s teachers, state employees, first responders, county and city employees, and their families,” said Dr. Tunde Sotunde, Blue Cross NC’s president and CEO, in the release. “State Health Plan members are more than customers, they are our neighbors, our friends and our family, and we have filed this protest to ensure the best outcome for them, for taxpayers, and for our state.”

READ MORE: What NC teachers, state employees, retirees need to know about the health insurance change

North Carolina Treasurer Dale Folwell announced the State Health Plan board’s decision Jan. 4 to replace Blue Cross with Aetna. The decision evoked immediate consternation and speculation from many state employees as to whether the move was in their best interests.

But Folwell argued the shift would save money and improve health care access for state workers.

“Partnering with Aetna, which already employs over 10,000 people in North Carolina, will create a lot of new opportunities for the Plan and the members we serve,” he said in a release.

In response to Blue Cross NC’s protest, Folwell affirmed his department’s decision and restated a commitment to transparency, a frequent theme in his speeches.

“We welcome the opportunity to engage in a factual, thoughtful and transparent review of the State Health Plan’s contracting process for third party administration services going into effect two years from now,” Folwell said in a statement. “Just like Blue Cross Blue Shield of North Carolina has the right to point fingers at everyone else for losing the contract after 44 years, the State Health Plan, Board of Trustees, professional staff and I all have a duty to seek the best financial value and member service for those that teach, protect and serve as well as taxpayers like them.”

Lang questioned why the request for proposals, during the bidding process, reduced the evaluation of the company “to a list of yes or no questions” and collected “no further information or details on service levels and capabilities.”

In an email to The News & Observer, Jim Bostian, Aetna’s North Carolina president, said the company “intends to deliver” on its proposal, ensuring state workers have access to high-quality, affordable benefits.

“The hundreds of Aetna employees dedicated to this seamless transition will continue their work without distraction,” Bostian said.

Another bidder, United Healthcare, also filed a protest, Folwell’s office said in a news release Friday evening.

What happens next

Following a formal protest, the state can either choose to accept the company’s request for a meeting, or deny the appeal within 10 days, according to the RFP.

“If the protest meeting is granted, the Executive Administrator will attempt to schedule the meeting within 30 calendar days after receipt of the letter, or as soon as possible thereafter,” the RFP says. “Within 10 calendar days from the date of the protest meeting, the Executive Administrator will respond to Vendor in writing with the Executive Administrator’s decision.”

State Health Plan Director Sam Watts, the executive administrator responsible for evaluating protest meeting requests, said Thursday he couldn’t comment at that time beyond Folwell’s latest statement.

Blue Cross NC also said while its first step is the appeal via the treasurer’s office, it would pursue other available remedies. Asked what those remedies were, Lang said she would need to follow up on that question but did not respond to subsequent inquiries about the question.

Provider networks

Aetna and Blue Cross NC have given differing accounts of how extensively provider networks would change in 2025.

In a press release, Blue Cross NC argued that its “network of provider locations” was 38% larger than Aetna’s. Blue Cross said that could force some plan members to change doctors or travel farther for in-network coverage.

Aetna countered that statistic with its own, which says that 98% of Blue Cross NC’s 2021 claims came from providers in Aetna’s network. Aetna also said that it’s working to add more providers to its network.

Fielder said it’s possible that both statistics are true but that Aetna’s measure is probably the most relevant one to plan members.

However, he added that it matters what types of services are included in the 2% of claims out of Aetna’s network.

“If they’re especially high-cost or high-value services that can’t be easily obtained elsewhere, then enrollees might still care quite a lot even though the number of claims is small,” he said.

Allison Rice, an emeritus law professor at Duke who studies health policy, said it’s also possible that Aetna covers most of the same providers as Blue Cross in urban areas, where the bulk of the claims are coming from, but lags behind in rural areas. That would explain why Aetna matches up with the majority of claims but are outmatched by Blue Cross on provider locations.

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