MedCost

What MedCost does

MedCost is a Winston-Salem, North Carolina-based benefit solutions company founded in 1983 that operates two integrated lines of business for self-funded employers across the Southeastern United States. MedCost Benefit Services, the company's third-party administrator (TPA) entity, delivers claims processing, member eligibility, utilization management, precertification, pharmacy benefit management, stop-loss placement, and customer service for employer-sponsored health plans. MedCost Network is a preferred provider organization (PPO) and the largest independent provider network in the NC, SC, and VA tristate region, with contracted physicians, hospitals, home health agencies, and ancillary providers offering discounted fees; the network is also leased to 50+ payer partners including Aetna (Virginia), Humana (Virginia), ACS Benefit Services, Allied Benefit Systems, Healthgram, MedBen, Claritev, and Preferred Health Plan of the Carolinas.

The technology stack combines member-facing digital tools with provider and payer integrations. Members access services through the secure HealthX member portal and My MedCost mobile app (iOS and Android), the MyCarePath care-management portal, the WebMD ONE well-being platform with health risk assessments, fitness tracking (FitBit, Jawbone, 100+ devices) and digital coaching, the Active&Fit Direct fitness network (12,700+ centers, 12,000+ on-demand videos), telemedicine, and a Cost Comparison Tool that meets Payer Transparency in Coverage and No Surprises Act requirements. Providers and payers connect through the ClaimGateway web portal, Availity as the exclusive EDI gateway (Payer IDs 56162 and 56205, replacing Change Healthcare following its February 2024 cybersecurity incident), Zelis Payments for electronic remittance, and CAQH Universal Provider Datasource for credentialing. Care management modules (Personal Care Management, Complex Case Management, SmartStarts Maternity, Transitional Care, Healthy Mind behavioral health, and Specialty Rx Management) are bundled into plan administration.

MedCost generates revenue through three managed-services streams: TPA administration fees charged to self-funded employer plan sponsors (custom-priced per contract based on group size, industry, claims history, and plan design), network leasing and claims repricing fees from 50+ payer partners, and care management programs embedded in plan administration. Go-to-market combines direct enterprise field sales to self-funded employers, a dedicated broker/consultant channel, and B2B2B distribution through payer-partner network leasing. MedCost is URAC-accredited for Health Utilization Management (2025-2028), AICPA SOC certified, HIPAA compliant, and No Surprises Act compliant. Following the 2022 acquisition of Virginia Health Network (rebranded MedCost Virginia), MedCost was itself acquired by Health Plans, Inc. (HPI), a national TPA based in Westborough, Massachusetts, in July 2025; MedCost Benefit Services employer groups are migrating to HPI's claims administration system in phased rollouts across 2026.

Name

MedCost

Legal name

MedCost LLC

Website

https://medcost.com

Company type

Private

Founded year

1983

Operating status

Operating

Headcount range

251–500 employees

Short description

MedCost is a Winston-Salem-based third-party administrator and the largest independent PPO provider network in the NC/SC/VA tristate region, serving self-funded employers with claims administration, network leasing to 50+ payer partners, and integrated care management programs.

Ownership category

akta.pro rank

Product category

Health Benefits Administration (Third-Party Administrator Services)

NAICS

Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292)

SIC

Hospital & Medical Service Plans (6324)

akta.pro primary industry

Ancillary Benefits TPA (Dental/Vision/Life/Accident/Critical Illness) (HLAEALAN)

akta.pro secondary industry

National PPO Networks (HLAEANAA)

Keywords

• Third-party administration
• Self-funded health plans
• PPO provider network
• Care management services
• Health benefits administration

Headquarters

HQ city

Winston Salem

HQ country

United States

HQ region

North America

Offices4 records

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Operations, Technology or R&D, Infrastructure, Marketing or Sales, Supply Chain

Revenue model

1. Third-Party Administration (TPA) Services: MedCost Benefit Services serves as a third-party administrator for self-funded employer health plans, handling claims processing, member eligibility, utilization management, and customer service. Admin fees are charged to employer plan sponsors.
2. Network Leasing: MedCost's provider network is leased to over 50 payer partners (insurance carriers, TPAs, and other benefit administrators) who resell network access to their members. MedCost reprices claims on behalf of leased payers and earns network access and repricing fees.
3. Care Management Programs: Integrated care management programs (Personal Care Management, Complex Case Management, SmartStarts Maternity, Transitional Care, Behavioral Health) provided as part of employer plan administration at no additional charge, supporting member retention and differentiation.

Pricing tiers

Go-to-market motion2 records

Distribution channels4 records

Marketing channels5 records

Core offering

MedCost Benefit Services acts as a third-party administrator (TPA) for self-funded employer health plans, delivering claims administration, member enrollment, eligibility management, utilization management, and customer service. MedCost also operates the MedCost Network, the largest independent PPO provider network in the NC, SC, and VA tristate region, which is leased to over 50 payer partners and is paired with bundled care management programs, pharmacy benefits, dental and vision coverage, wellness tools, telemedicine, and cost transparency features.

Product overview

MedCost operates as a benefit solutions company offering two core integrated services: (1) MedCost Benefit Services, a third-party administrator (TPA) managing self-funded health plans for employers including claims administration, member enrollment, and pharmacy benefits; and (2) MedCost Network, a PPO provider network — the largest independent network in the NC/SC/VA tristate region — offering discounted fees through contracted providers. Supporting these core services are module-level digital tools including the My MedCost Mobile App, MyCarePath member portal, WebMD ONE well-being platform, Cost Comparison Tool, and Telemedicine. Care management modules (Personal Care Management, Complex Case Management, SmartStarts Maternity, Transitional Care) are integrated into the benefit administration platform. The company was acquired by Health Plans Inc. (HPI) in July 2025, with administrative systems transitioning to HPI in 2026.

Differentiator

Problem solved

Functional benefit

Brands

• MyCarePath: A secure platform helping employees manage their health with tools to evaluate symptoms, research medications and conditions, track activities, and calculate fitness and stress levels.
• Healthy Mind
• SmartStarts
• 4MOST Health Network

Products and services

• MedCost Benefit Services (TPA)
• MedCost Network
• MedCost Virginia Network
• Self-Funded Health Plans
• Level Funding Plans
• Pharmacy Benefits Management
• Dental and Vision Benefits
• Claims Repricing Services
• Payer Partner Network Leasing
• Telemedicine/Telehealth
• Care Management Programs

Quantifiable outcome

• Preterm birth rate: 10.5% of US births in 2021 were premature (CDC data cited by MedCost), and the SmartStarts program aims to reduce preterm births and NICU days.
• +3 more outcomes

Named customers1 record

Segments4 records

Ideal customer profiles2 records

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Integration5 records

AI capability1 record

Feature6 records

Partnerships

15 partnerships are on record, tiered flagship, core and supporting.

• Health Plans Inc. (HPI)flagshipStrategic or Co-development Partner · 1 July 2025In July 2025, Health Plans Inc. (HPI), a national third-party administrator based in Westborough, Massachusetts, acquired MedCost LLC (including MedCost Benefit Services). Throughout 2026, MedCost Benefit Services employer groups are transitioning to HPI's claims administration system in phases (May, July, and October 2026). Provider network participation (MedCost and MedCost Virginia networks) remains unchanged. HPI provides the underlying claims platform while MedCost maintains its network brand.
• AvailitycoreTechnology or IntegrationAvaility is MedCost's exclusive EDI (electronic data interchange) gateway for electronic claims submission. All EDI claims (institutional and professional) for MedCost Payer IDs 56162 and 56205 are received through Availity. MedCost directs providers to contact Availity Client Services at 1-800-282-4548 for assistance with electronic claims submissions.
• Zelis PaymentscoreTechnology or IntegrationMedCost partners with Zelis Payments to provide expedited electronic payment delivery and remittance data to providers. Providers are enrolled with Zelis Payments to receive electronic payments when MedCost is the payer. Zelis offers payment options designed to increase cash flow and reduce overhead expenses for providers.
• WebMD ONEcoreTechnology or IntegrationMedCost offers the WebMD ONE online well-being platform to plan participants. WebMD ONE provides health risk assessments with scores and recommendations, wellness content, exercise videos, healthy recipes, mental health podcasts, on-demand webinars, drug interaction checker, fitness tracking (FitBit, Jawbone, 100+ devices), digital coaching, and personal health record tools.
• Active&Fit Direct (American Specialty Health)supportingTechnology or IntegrationMedCost offers the Active&Fit Direct program, giving plan members access to 12,700+ participating fitness centers and studios nationwide, plus 12,000+ on-demand workout videos for $28/month plus enrollment fee. The program is member self-directed.
• Change HealthcaresupportingTechnology or IntegrationChange Healthcare was MedCost's EDI gateway for electronic claims submission. In February 2024, Change Healthcare experienced a cybersecurity incident that suspended all connections. MedCost directed providers to use Availity as an alternative. By September 2024, MedCost confirmed all EDI claims are received through Availity, effectively replacing Change Healthcare as the EDI partner.
• Zelis Claims Cost SolutionssupportingTechnology or IntegrationMedCost Benefit Services directs providers to Zelis Claims Cost Solutions for billing and editing/coding dispute appeals (integral part of primary service, mutually exclusive, services not eligible for separate reimbursement, incidental denial, surgical global period denial, re-bundling appeals). Address: 2 Crossroads Drive, Bedminster, NJ 07921.
• ACS Benefit Services, LLCsupportingChannel Partner/ Reseller/ DistributorACS Benefit Services leases the MedCost provider network as a payer partner, offering in-network benefits to its members through MedCost's NC, SC, and VA network.
• Aetna (Virginia Only)supportingChannel Partner/ Reseller/ DistributorAetna leases the MedCost Virginia provider network in Virginia, offering in-network benefits to Aetna members in that state through MedCost's Virginia network.
• Allied Benefit SystemssupportingChannel Partner/ Reseller/ DistributorAllied Benefit Systems leases the MedCost provider network as a payer partner, offering in-network benefits to its members through MedCost's NC, SC, and VA network.
• HealthgramsupportingChannel Partner/ Reseller/ DistributorHealthgram leases the MedCost provider network as a payer partner, offering in-network benefits to its members through MedCost's regional network.
• Humana (Virginia Only)supportingChannel Partner/ Reseller/ DistributorHumana leases the MedCost Virginia provider network in Virginia, offering in-network benefits to Humana members in that state through MedCost's Virginia network.
• Claritev (Virginia Only)supportingChannel Partner/ Reseller/ DistributorClaritev (formerly NIA) leases the MedCost Virginia provider network in Virginia, offering in-network benefits to its members.
• MedBensupportingChannel Partner/ Reseller/ DistributorMedBen leases the MedCost provider network as a payer partner, offering in-network benefits to its members through MedCost's regional network.
• Preferred Health Plan of the Carolinas Inc.supportingChannel Partner/ Reseller/ DistributorPreferred Health Plan of the Carolinas Inc. leases the MedCost provider network, offering in-network benefits to its members through MedCost's North Carolina and South Carolina network.

Scale indicators5 records

Recent moves6 records

Expansion highlights5 records

Direct peers

• Health Plans, Inc. (HPI): National third-party administrator based in Westborough, Massachusetts that acquired MedCost in July 2025. HPI administers self-funded health plans using its own claims platform, making it the closest functional peer and now MedCost's parent.
• MedBen: Mid-size TPA focused on self-funded employer health plans. MedBen is also a payer partner that leases the MedCost network, making it both a competitor (for employer clients) and a distribution channel.
• Allied Benefit Systems: Third-party administrator serving self-funded employer health plans. Allied leases the MedCost provider network, illustrating its position as both a TPA competitor and a distribution partner in NC, SC, and VA.
• WebTPA: Independent third-party administrator providing self-funded plan administration, claims processing, and network access for employers nationwide. Comparable in mid-size TPA positioning to MedCost.
• Lucent Health: Third-party administrator focused on self-funded employer health plans with integrated care management and network solutions. Competes in the same mid-market self-funded segment as MedCost.
• ACS Benefit Services: Third-party administrator that leases the MedCost provider network to offer in-network benefits to its members. Operates as a peer TPA leveraging MedCost's regional network footprint.
• Healthgram: Health benefits administrator and TPA that leases the MedCost network. Competes in employer health plan administration while using MedCost as its regional network backbone.

Broad incumbents

• UMR (UnitedHealthcare): Largest third-party administrator in the United States, part of UnitedHealth Group. Serves self-funded employer health plans with national scale, integrated PBM, and stop-loss capabilities that compete head-to-head with MedCost for mid-market and large employer accounts.
• MultiPlan: National PPO network operator and cost management company. Competes with MedCost Network as a leasing alternative for payers seeking national rather than regional network access.

Emerging players

• Zelis: Healthcare technology company providing claims cost solutions, electronic payments, and network/repricing services. Partners with MedCost on payments and appeals, and increasingly competes in adjacent repricing and network services.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat5 records

Key risks6 records

Key highlights7 records

Customer concentration

• Xx.com/medcostllc
• LinkedInlinkedin.com/company/medcost

Compliance4 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles1 record

Subsidiaries1 record

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about MedCost