With Duke and Aetna fighting, NC State Health Plan lays out contingency plan

As a contract dispute between Duke Health and Aetna threatens access to care for state employees, the North Carolina State Health Plan board voted Friday to ensure “white glove service” for members who may lose in-network access — offering extra support to help them navigate their options.

Unless the two sides reach a deal by Oct. 20, Duke will go out of network for Aetna-insured members, including many state employees, driving up out-of-pocket costs. The State Health Plan’s two main options — a base plan and an enhanced plan — are both administered by Aetna. Those plans cover active employees as well as some retirees.

At an impromptu board meeting Friday, State Treasurer Brad Briner placed the blame on Duke for failures to reach a deal.

“Duke has chosen to try and force Aetna to pay them substantially higher rates on top of what are already some of the highest rates we pay,” Briner said. “Duke is demanding a significant raise on the backs of our hard-working employees. If we end up out of network, Duke is the one who made that choice. They will have made that choice that their financial goals are more important than their mission to serve.”

Briner criticized Duke’s approach, saying the hospital system initiated the negotiation and then used “very aggressive tactics” aimed at scaring members, referring to “multiple letters” and “incessant” radio ads urging patients to pressure Aetna.

Duke Health says on its website it is “seeking fair reimbursement rates that reflect the true cost of providing quality care and exceptional outcomes.”

Insurers pay hospitals and doctors based on negotiated rates, often at a discount. Patients’ out-of-pocket costs for in-network care — the portion not covered by insurance — are calculated from that discounted rate. If Duke goes out of Aetna’s network, patients could face higher bills because insurance may cover little or nothing for out-of-network care.

Treasurer’s office communications director Loretta Boniti said around 22,000 State Health Plan members list Duke as a primary-care provider and around 40,000 members filed a claim with Duke in the last year.

Briner said “at this moment” he did not think Aetna and Duke were close to an agreement, so the health plan was making contingency preparations.

He said about 2,800 State Health Plan members who use Duke Health have courses of treatment protected under state law, primarily cancer patients and those in maternity care. For the foreseeable future, “they will not be turned away, but there is some paperwork that’s required to do that,” he said.

For those who do not qualify for continuation of care, Briner said Friday’s motion authorizes the health plan to hire a transition services vendor to personally assist each affected member. He said that’s a step the plan has never taken before.

Asked for more details on this, Boniti told The News & Observer that staff “is still working through what outreach Aetna will be doing and if we need to supplement their effort.”

“If the Plan does need to supplement through another vendor, we will utilize one we already have contracted so we can act quickly,” she said.

Members who could be affected — those who have Duke as their primary care provider or who filed a claim at Duke this year — have already begun receiving letters about the possibility of Duke going out of network, said Beth Horner, State Health Plan chief of staff. The notices include instructions on how to request a “transition of care” form, which must be completed by the member and their physician and then returned to Aetna.

Horner said the plan has asked Aetna to dedicate a special team to call affected patients, with priority outreach for those in active treatment — such as cancer care, maternity care or who have scheduled surgeries. Team members will help complete paperwork. The plan ultimately intends to call all affected members, helping them either complete the transition-of-care process or find a new provider if they currently see a Duke doctor, Horner said.

Executive Director Thomas Friedman said he has been working with leadership at UNC Health and WakeMed, as well as other providers, who have “stepped up. They’re putting plans in place to serve virtually or in person more State Health Plan members and ensure our members have access to care.”

Friedman added that premiums — raised in August to address a $500 million deficit for 2026 — will not change again next year. The Duke negotiations could affect 2027 premiums but not 2026, he said.

Other contract disputes are also unfolding, including between UNC Health and Cigna, and between WakeMed and UnitedHealthcare.

Aetna, in a statement to The N&O, previously said it is negotiating “in good faith,” stressing its responsibility to keep health care affordable and noting that payments to providers participating in its networks directly impact costs.

“North Carolina has among the highest health care costs in the country and Aetna is unwavering in our effort to protect our North Carolina members from additional escalations in costs,” the company said.

The N&O has reached out for further comment from Duke and Aetna but did not immediately hear back.

©2025 Raleigh News & Observer. Visit newsobserver.com. Distributed by Tribune Content Agency, LLC.