North Carolina State Health Plan

What North Carolina State Health Plan does

The North Carolina State Health Plan is a state government-administered health benefit program that provides comprehensive medical, pharmacy, and wellness coverage to North Carolina state employees, retirees, and their dependents. Operated under the authority of the North Carolina State Treasurer's office and governed by a Board of Trustees, the plan delivers a multi-tiered product portfolio that includes Standard PPO, Plus PPO, and High Deductible Health Plan options for active employees and non-Medicare retirees, a 70/30 cost-sharing plan for Medicare retirees, and Humana Group Medicare Advantage PPO Base and Enhanced plans for Medicare-eligible retirees. Additional offerings include COBRA continuation coverage, directly invoiced member plans, the Lantern Surgical Benefit for no-cost planned surgeries, and a set of resource centers addressing diabetes, cancer prevention, behavioral health, opioid awareness, and high blood pressure. The plan also operates a Pharmacy Resource Center in coordination with CVS Caremark for prescription drug benefits.

The plan's operating model relies on third-party vendor partnerships for core administrative and clinical functions: Aetna administers the PPO and HDHP provider networks and claims processing infrastructure, CVS Caremark manages pharmacy benefits, Humana distributes Medicare Advantage plans, and Lantern provides surgical benefit navigation. Members access benefits through the eBenefits self-service enrollment portal, view ID cards via Aetna's member portal and mobile app, and receive ongoing communication through a monthly e-newsletter called Member Focus. Health Benefit Representatives (HBRs) are embedded in state agencies to support enrollment and qualifying life events, while a Teacher Ambassador Program extends outreach into the educational workforce.

Revenue is generated through three primary streams: employee premium contributions via payroll deduction, state government contributions toward employee and retiree benefits, and Medicare subsidies supporting retiree Medicare Advantage coverage. The plan is funded through these combined contributions rather than equity or third-party investment, consistent with its status as a government entity. Specific premium amounts, deductibles, and total financial scale are not publicly disclosed; coverage is guaranteed to eligible state employees and retirees without medical underwriting.

Name

North Carolina State Health Plan

Legal name

North Carolina State Health Plan

Website

https://shpnc.org

Company type

Private

Operating status

Operating

Headcount range

11–50 employees

Short description

The North Carolina State Health Plan is a state government-administered health benefit program providing medical, pharmacy, and wellness coverage to North Carolina state employees, retirees, and their dependents, administered through the NC State Treasurer's office via partnerships with Aetna, CVS Caremark, and Humana.

Ownership category

akta.pro rank

Product category

Government Health Insurance

NAICS

Direct Health and Medical Insurance Carriers (524114), Health and Welfare Funds (52512)

SIC

Hospital & Medical Service Plans (6324), Accident & Health Insurance (6321)

akta.pro primary industry

Medicare Advantage (MA) Plans (FSAIAGAA)

akta.pro secondary industry

MA PPO Plans (Local/Regional PPO) (HLAEACAB)

Keywords

• Government health plan
• State employee benefits
• Retiree health coverage
• PPO health insurance
• Medicare Advantage plans

Headquarters

HQ city

Raleigh

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2C

Offering type

Services

Cost components

Operations, Personnel, Technology or R&D, Marketing or Sales, Others

Revenue model

1. Employee Premium Contributions: State employees pay premiums for their health coverage through payroll deductions, contributing to the funding of the State Health Plan.
2. State Government Contributions: The State of North Carolina contributes funding toward employee and retiree health benefits as part of the state employee benefits package.
3. Medicare Subsidies: For Medicare-eligible retirees enrolled in Humana Group Medicare Advantage plans, Medicare subsidies provide additional funding to support retiree coverage.

Go-to-market motion1 record

Distribution channels4 records

Marketing channels7 records

Core offering

The North Carolina State Health Plan is a state-government-sponsored health benefit program that provides medical, pharmacy, preventive care, and wellness coverage to active North Carolina state employees, retirees, and their dependents. It offers multiple plan options including Standard PPO, Plus PPO, High Deductible Health Plans, a 70/30 Plan for Medicare retirees, and Humana Group Medicare Advantage plans, supplemented by value-added benefits such as the Lantern Surgical Benefit and wellness resource centers.

Product overview

The North Carolina State Health Plan is a government-sponsored health insurance program providing comprehensive medical coverage to state employees, retirees, and their dependents. The Plan operates a multi-tiered product portfolio consisting of PPO plans (Standard and Plus variants), High Deductible Health Plans, and Medicare Advantage options through Humana. Additional offerings include the Lantern Surgical Benefit for no-cost planned surgeries, COBRA continuation coverage, and wellness resource centers covering diabetes, cancer prevention, behavioral health, and pharmacy benefits through CVS Caremark. Members access their accounts through the eBenefits self-service portal for enrollment, claims viewing, and ID card management.

Differentiator

Problem solved

Functional benefit

Products and services

• Standard PPO Plan for Employees A preferred provider organization health plan for active North Carolina state employees offering in-network and out-of-network coverage options, including medical, pharmacy, preventive care, and wellness benefits.
• Plus PPO Plan for Employees An enhanced preferred provider organization plan for active state employees with additional benefits beyond the Standard PPO.
• High Deductible Health Plan A health plan with higher deductible and lower premiums, paired with a health savings account option for active state employees.
• Standard PPO Plan for Non-Medicare Retirees A preferred provider organization plan providing health coverage for state retirees who are not yet Medicare-eligible.
• Plus PPO Plan for Non-Medicare Retirees An enhanced preferred provider organization plan with expanded coverage for non-Medicare-eligible state retirees.
• 70/30 Plan for Medicare Retirees A cost-sharing health plan for Medicare-eligible retirees in which the State Health Plan covers 70% and the member covers 30% of costs.
• Humana Group Medicare Advantage Base Plans Medicare Advantage PPO base plans administered by Humana for Medicare-eligible North Carolina state retirees, integrated with Medicare subsidies.
• Humana Group Medicare Advantage Enhanced Plans Enhanced Medicare Advantage PPO plans administered by Humana with additional benefits beyond the base Humana plan for Medicare-eligible state retirees.
• Lantern Surgical Benefit A surgical benefit program connecting State Health Plan members to high-quality surgeons for no-cost ($0) planned, non-emergency surgeries.
• COBRA Plan Continuation coverage options for former employees and dependents who lose eligibility, allowing them to maintain health benefits under federal COBRA rules.
• Directly Invoiced Members Plan Health coverage for members who are directly invoiced for their premiums rather than paying through an employer or payroll deduction.

Segments4 records

Ideal customer profiles3 records

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Integration4 records

Partnerships

Four partnerships are on record, tiered core and minor.

• AetnacoreTechnology or IntegrationAetna serves as the third-party administrator and preferred provider network for the State Health Plan's PPO and HDHP plans. Members access the Aetna member portal and mobile app to view their ID cards, claims, and EOBs. The partnership provides the medical provider network and claims processing infrastructure for the plan.
• CVS CaremarkcoreTechnology or IntegrationCVS Caremark provides pharmacy benefit management services for the State Health Plan. A dedicated Pharmacy Resource Center on the SHP website provides plan members with information about their prescription drug benefits, mail-order options, and pharmacy network details.
• HumanacoreChannel Partner/ Reseller/ DistributorHumana administers Group Medicare Advantage PPO plans (Base and Enhanced options) for Medicare-eligible retirees under the State Health Plan. This partnership provides Medicare integration for retirees who prefer Medicare Advantage coverage options.
• LanternminorStrategic or Co-development PartnerLantern is a surgical benefit program that connects State Health Plan members to high-quality surgeons for no-cost ($0) planned, non-emergency surgeries. This is a value-added benefit program designed to reduce member out-of-pocket costs for certain surgical procedures.

Recent moves5 records

Expansion highlights3 records

Direct peers

• New York State Health Insurance Program (NYSHIP): New York's state employee health insurance program administered by the Department of Civil Service. Offers Empire Plan and NYSHIP HMOs to state employees and retirees, structurally similar to NC State Health Plan.
• South Carolina Public Employee Benefit Authority (PEBA): South Carolina's state agency administering health and retirement benefits for public employees. Comparable regional peer offering similar plan structures (PPO, HDHP, Medicare Supplement) to state employees and retirees.
• Virginia State Employee Health Plans: Virginia's state employee health benefits program administered by the Department of Human Resource Management. Offers comparable health plan options to state employees and retirees, including Medicare Advantage partnerships.
• CalPERS Health Benefits Program: California's public sector health benefits program for state employees and retirees, administered under the CalPERS system. Directly comparable to NC State Health Plan as both are large state government health benefit plans serving public employees with similar PPO, HMO, and Medicare Advantage options.
• Texas Employees Group Benefits Program (GBP): Texas's health benefits program for state employees and retirees, administered by the Employees Retirement System of Texas. Offers similar PPO, HDHP, and Medicare Advantage plans with comparable member services and vendor partnerships.
• Georgia State Health Benefit Plan (SHBP): Georgia's state employee health benefit plan administered by the Department of Community Health. Provides health coverage to state employees, retirees, and dependents with multiple plan options including PPO, HMO, and Medicare Advantage.
• Washington State Public Employees Benefits Board (PEBB): Washington state's health benefits program for public employees, retirees, and dependents. Offers comparable PPO, consumer-directed health plans, and Medicare Advantage options through a state government structure.
• Florida State Group Insurance Program: Florida's state employee health insurance program administered by the Department of Management Services. Provides health coverage to state employees and retirees with PPO, HMO, and Medicare Advantage options.

Broad incumbents

• Government Employees Health Association (GEHA): National health insurance provider serving federal employees, retirees, and their families. Comparable in serving government employee populations with similar plan designs and vendor partnership models.
• Federal Employees Health Benefits Program (FEHBP): Federal government employee health benefits program administered by the Office of Personnel Management. While broader in scope, it serves a similar function for federal employees and provides model structures for state-level programs.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat4 records

Key risks5 records

Key highlights6 records

Customer concentration

Revenue estimate

Valuation estimate

Number of profiles

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 North Carolina State Health Plan