Guidance for Practice Managers on Navigating the 2026 Network Transition

Practice managers should be fully prepared for the substantial changes coming to the North Carolina State Health Plan (NCSHP) network in 2026. The Plan is facing a $507 million deficit, prompting a thorough evaluation of existing programs and reimbursement models. Sincere gratitude is extended to all organizations that have supported both the Plan and its members during these times. This post outlines what’s changing, why, and what practical steps your practice may need to take.

Clear Pricing Project (CPP) Ending December 2025

The Clear Pricing Project (CPP), launched in 2020, promoted transparent healthcare pricing and aimed to incentivize quality primary and behavioral health care by offering zero copays to members who visited participating providers. While this model brought increased reimbursement rates for many providers, it has not been financially sustainable. As a result, CPP will conclude on December 31, 2025. After that point, providers will no longer receive current elevated reimbursement rates, and members will not have a $0 copay structure for behavioral health services.

Preferred Providers: New Structure in 2026

Effective in 2026, the State Health Plan will roll out the Preferred Provider initiative. The only way for practices to become Preferred Providers will be through affiliation with CCPN (Community Care Physician Network), Aledade, or The Alliance. Practices outside these partnerships will still be considered in-network, but cost shares for members will be different—typically higher than those for Preferred Providers.

Key Action: Review your current affiliations and consider whether joining CCPN, Aledade, or The Alliance is right for your practice. Preferred Providers will grant patients access to lower copays starting in 2026.

Behavioral Health Access Program (BHAP)

To continue supporting behavioral health, the Plan is launching the Behavioral Health Access Program (BHAP) in 2026. This program creates a custom fee schedule for behavioral health providers, specialties, and a specific set of CPT codes:

• 140% of current NC Medicare rates (updated annually, effective May 1) for key codes: psychotherapy, evaluation & management, psychological testing
• ABA services reimbursed at NC Medicaid rates
• TMS codes reimbursed at Aetna Market Fee Schedule (AMFS) rates (same as current CPP)

Action for Behavioral Health Practices: If interested in joining BHAP, visit the Aetna website for enrollment details and next steps.

Working with Aetna: Network Participation & Resources

Aetna will serve as the third-party administrator for the Plan starting January 2026. Practices must be part of Aetna’s Choice POS II network to remain in-network for State Health Plan patients. If not already participating, please visit the Aetna website to begin the enrollment process.

Additional Resources for Practice Managers:

• 2025 NCSHP Network Participation Agreement (Aetna)
• 2025 NCSHP Network Rate Schedule (Aetna)
• 2025 NCSHP Network Professional Fee Schedule (Aetna)
• Aetna Provider Website
• Signup for Aetna emails
• OfficeLinks Updates Newsletters
• Aetna Provider State Health Plan site
• Aetna Resources

For contract, reimbursement, or benefits questions, contact Aetna Provider Line at 888-632-3862. For clinical or precertification information, refer to Aetna’s clinical information and prior review resources. Email NorthCarolinaNetwork@aetna.com for network queries, or SHPProviderNetwork@nctreasurer.com for State Health Plan questions.

What Practice Managers Should Do Now

• Evaluate providers’ current affiliations and consider joining CCPN, Aledade, or The Alliance for Preferred Provider status.
• For behavioral health, review the BHAP program and assess if it matches the needs of your practice.
• Ensure participation in Aetna’s Choice POS II network before January 2026 to maintain in-network status.
• Stay updated on policy changes, copay and reimbursement structures, and communicate these changes to your team and patients.

UnitedHealthcare’s New Remote Monitoring Policy

UnitedHealthcare (UHC), one of the nation’s largest health insurers, has announced an updated policy change regarding coverage for remote patient monitoring services. As of the latest update, UHC will end coverage for most remote patient monitoring (RPM) when it is determined to be “unproven and not medically necessary,” specifically targeting standard cases of Type 2 diabetes and hypertension. This decision has broad implications for healthcare professionals, patients, and those tracking healthcare policy developments.

Details of the Policy Change

UHC’s new policy discontinues coverage for remote patient monitoring in cases where the service is considered unproven or not medically necessary, focusing chiefly on routine management of Type 2 diabetes and most hypertension cases. However, there are notable exceptions:

• Heart Failure: Remote monitoring will continue to be covered for patients diagnosed with heart failure, reflecting evidence supporting improved outcomes in this population.
• Hypertensive Disorders of Pregnancy: Coverage remains in place for pregnant individuals with hypertensive disorders, a group for whom remote management has shown benefit and can mitigate risks to both mother and child.

These exceptions underscore UHC’s commitment to supporting RPM where research demonstrates clear clinical value. The policy applies to new and existing patients as of the effective date, which is detailed in UHC’s provider communications.

Impact on Members: Who Is Affected?

The policy affects UHC members across several plan types, including those enrolled in Medicare Advantage, commercial employer-sponsored insurance, individual exchange (Marketplace) plans, and Medicaid. For most individuals with Type 2 diabetes or standard hypertension, remote monitoring devices and associated services will no longer be reimbursed unless a specific exception applies. Providers and patients should carefully review plan details to understand ongoing eligibility and coverage for RPM.

CMS Rule Changes: Upcoming Service Rate Adjustments

The Centers for Medicare & Medicaid Services (CMS) is expected to implement new rules that adjust payment rates for remote patient monitoring services in 2025. These changes may influence how payers and providers structure RPM programs and could impact future coverage decisions. Stakeholders are watching closely to understand how these federal updates will interact with insurer policies like UHC’s.

Implications for Patients and Providers

UnitedHealthcare’s revised remote patient monitoring policy marks a notable shift in coverage for chronic disease management. While the decision narrows access for many with Type 2 diabetes and hypertension, it maintains support for populations where RPM has proven benefits. As CMS finalizes new rules and advocacy groups push for policy reconsideration, patients and providers should stay informed about coverage updates and seek guidance to ensure continuity of care where remote monitoring remains essential.

What Healthcare Professionals Need to Know About the Latest Medicare Flexibility Extensions

The federal government has officially reopened following the recent shutdown, bringing relief and important updates for healthcare professionals and policy watchers. As part of the reopening, significant developments regarding telehealth billing and Medicare flexibilities have been enacted that are crucial for providers to understand.

Legislative Update: Passage and Signing of H.R. 5371

On November 2025, Congress passed and the President signed H.R. 5371, a Continuing Resolution that ended the government shutdown. This legislation not only funds the government but also extends several Medicare telehealth flexibilities that were set to expire, ensuring continuity of care and operational stability for providers across the country.

Medicare Telehealth Flexibilities Extended Through January 2026

H.R. 5371 extends select Medicare telehealth flexibilities through January 30, 2026. This extension allows providers to continue delivering vital services remotely, supporting patient access and practice sustainability.

Detailed Flexibilities Extended

• Home as an Originating Site: Patients can receive telehealth services from their home, maintaining convenience and access.
• No Geographic Restrictions: The requirement that patients be located in rural or certain geographic areas to receive telehealth services is suspended, broadening eligibility nationwide.
• FQHCs and RHCs as Distant-Site Providers: Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) may continue to serve as distant-site telehealth providers, expanding care delivery options.
• Audio-Only Visits: Providers can bill for eligible audio-only telehealth visits, supporting patients who may lack video access.
• Telehealth for Hospice Recertification: Telehealth remains available for conducting hospice recertification assessments, streamlining care for seriously ill patients.
• Expanded Provider Eligibility: A wider range of practitioners, including therapists and allied health professionals, can continue to furnish telehealth services under Medicare.
• Acute Hospital Care at Home Program: The program allowing hospitals to provide inpatient-level care at home is extended, sustaining hospital capacity and patient-centered care.

Behavioral Health In-Person Visit Requirement Aligned

The requirement for an in-person visit prior to and during ongoing behavioral health telehealth services is also delayed until January 30, 2026. This alignment offers continuity for behavioral telehealth care without disrupting established patient relationships.

Looking Ahead: Pending CMS Guidance

While these extensions provide immediate clarity, further guidance from the Centers for Medicare & Medicaid Services (CMS) is expected. Upcoming updates will cover operational details, billing instructions, and any additional compliance requirements. Providers should stay tuned for future announcements to ensure continued adherence with federal policies.

In Short:

The extension of Medicare telehealth flexibilities following the government shutdown offers critical support for healthcare delivery through January 2026. Providers are encouraged to review these changes on the CMS website, maintain compliance, and monitor for further CMS guidance. 

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