Specialist Copay

The Clear Pricing Project

Specialist Copay Definition
Specialist Copay
Specialist Copay Blue Cross Blue Shield
Bcbs Federal Specialist Copay

Depending on the insurance plan of the mental health patient, that new patient will need to pay a recurring fee to their insurance company as will probably need to pay you a small sum in person to see you as a specialist. The amounts of each are determined by their behavioral health insurance plan. A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. How it works: Your plan determines what your copay is for different types of services, and when you have one. You may have a copay before you’ve finished paying toward your deductible. What is a copay? A copay (or copayment) is a flat fee that you pay on the spot each time you go to your doctor or fill a prescription. For example, if you hurt your back and go see your doctor, or you need a refill of your child's asthma medicine, the amount you pay for that visit or medicine is your copay.

Learn more about how you can save money in 2021 by visiting a Clear Pricing Project Provider!

The State Health Plan’s Clear Pricing Project (CPP) was developed to secure the Plan’s financial future and to promote quality, accessible health care. The goal is to ensure that members have this valuable benefit for years to come, while bringing transparency to health care expenses and addressing the rising health costs that you and your family face every day.

This effort resulted in more than 26,000 providers partnering with the Plan for transparent and affordable health care. These provider partners are included in the North Carolina State Health Plan Network, which is made up of providers who signed up for the Plan's Clear Pricing Project, and Blue Cross NC's Blue Options network.

Starting January 1, 2021, in an effort to help members control their health costs and to support our CPP providers, members will be able to enjoy the following copay waivers and reductions in 2021.

If you select a Clear Pricing Project provider as your Primary Care Provider listed on your ID card, your visits are free!
If you visit a Clear Pricing Project specialist, 80/20 Plan members will pay only $40 for a CPP specialist ($80 for a non-CPP specialist), and 70/30 Plan members will pay $47 for a CPP specialist ($94 for a non-CPP specialist).

Compare the difference and check out the savings!

CLEAR PRICING PROJECT PROVIDER COPAY COMPARISON CHART
Provider	80/20 Plan	70/30 Plan
Primary Care Provider (PCP)	$0 for Clear Pricing Project (CPP) PCP on ID card; $10 for non-CPP PCP on ID card; $25 for any other PCP	$0 for Clear Pricing Project (CPP) PCP on ID card; $30 for non-CPP PCP on ID card; $45 for any other PCP
Specialist	$40 for CPP Specialist; $80 for other Specialists	$47 for CPP Specialist; $94 for other Specialists
Speech, Occupational, Chiropractor and Physical Therapy	$26 for CPP Providers; $52 for other Providers	$36 for CPP Providers; $72 for other Providers

Please note the following:

The Clear Pricing Project does not affect members on Medicare Advantage plans.
The NC State Health Plan Network is composed of CPP providers and Blue Options providers. There is an indicator in the Find A Doctor tool that identifies CPP providers. That CPP designation DOES need to be noted in the Find a Doctor tool for the provider to be a CPP Primary Care Provider (PCP).
Providers joined the CPP at the practice level, so members should be able to see any provider in that listed CPP practice. However, a lot of providers practice at multiple locations and different practices. If members see their CPP PCP at a NON-CPP practice, the member will not receive the $0 copay. Members are encouraged to check with their provider on their CPP status.

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Frequently Asked Questions

What is the State Health Plan’s Clear Pricing Project?

As a State Health Plan member in 2021, you will have access to the North Carolina State Health Plan Network, which is made up of providers who signed up for the Plan’s Clear Pricing Project (CPP), and Blue Cross NC’s Blue Options network. CPP providers have agreed to get rid of secret contracts, making health care more affordable and transparent. In an effort to lower health care costs for members and to support CPP providers, the Plan will be offering significant copay reductions for members who visit a CPP provider in 2021. The CPP is applicable to members on the 70/30 Plan and 80/20 Plan.

What does this mean for Medicare-eligible members?

This does not impact members on the Medicare Advantage plans. This would only be applicable to Medicare-eligible members on the 70/30 Plan.

What geographical area does the Clear Pricing Project cover?

The CPP is only applicable to North Carolina providers, including Primary Care Provider (PCP) offices, specialist offices, participating hospitals and urgent care facilities. Outside of North Carolina, you would still have access to in-network providers in the Blue Options network.

Can I just go to any Clear Pricing Project provider to get a copay reduction?

You can go to any CPP Specialist, Chiropractor, Speech or Occupational Therapist to receive a copay reduction. To qualify for the $0 CPP PCP copay, you must have selected a CPP PCP which appears on your State Health Plan ID card and then see that PCP for your office visit. You will need to select a CPP PCP during the Open Enrollment or initial enrollment process for your 2021 benefits. Here's how to select or update your Primary Care Provider!

How do I get a CPP provider listed on my ID card?

You are able to select a CPP provider during the online Open Enrollment or initial enrollment process. You will receive a new ID card prior to January 1, 2021. If you desire a CPP provider for a dependent, make sure you enter a CPP provider for that dependent during the Open Enrollment or initial enrollment process. Beginning January 1, 2021, you will be able select a new provider any time during the year – CPP or non-CPP – by using eBenefits, the Plan’s enrollment system. Here's how to select or update your Primary Care Provider!

How can I locate a Clear Pricing Project provider?

There are two ways to locate a CPP Provider:

1. Find a Doctor tool

Visit www.shpnc.org. Click the Find a Doctor link at the top of the home page.
Scroll down to select your health plan to access your Find a Doctor Tool.
The Find a Doctor Tool opens. Select the plan type by clicking the Individuals, Families, & Groups button.
Choose North Carolina State Health Plan in the drop-down box and click Submit.
Click the Find a Doctor or Facility button.
From there, you can search by Category or by Name.
CPP providers will say “Clear Pricing Project Provider” next to their name. Note: You cannot specifically search for a CPP provider by that designation.

2. Clear Pricing Project Provider Search Tool

Visit www.shpnc.org. Find the Clear Pricing Project page and click on the green CPP provider search tool box.
Click on the box for the region in which you wish to search for providers: Mountain, Piedmont or Coastal Plains.
A large list of providers for the selected region will appear in a table.
You may narrow the search results by typing in the search box. The table will automatically filter your results.

What if you select a CPP provider and then find that they are not taking new patients?

You can change your provider anytime throughout the benefit year (2021), so you will be able to select another provider. You can also research a new provider by using the Find a Doctor tool or contacting the provider’s office to see if they are accepting new patients.

What if my CPP provider or specialist has multiple locations?

CPP providers and specialists within a practice joined the CPP via the practice level. This means you can see any provider within that practice and still have the copay reduction. Please note that the address is very important. When selecting your provider, make sure you intend to see the provider at the address reflected for that provider. Not all practices that your provider may be affiliated with joined the CPP.

When do the CPP copay reductions start?

Specialist Copay Definition

When do the CPP copay reductions start?

Copay reductions begin January 1, 2021, the start of the new benefit year.

What does this mean for my prescriptions?

This does not impact your pharmacy benefits with the State Health Plan.

Can multiple CPP providers be listed on my ID card?

No. There can only be one provider reflected on your ID card as your PCP.

If a provider or hospital is not a part of the CPP, will that provider be considered out of network?

No. As long as the provider is part of the Blue Options network, provider will not be considered out-of-network. You will have the normal copayment applied. For emergency situations, service at the nearest hospital would be processed at an in-network benefit.

What if my provider didn't sign on to the CPP?

If your provider didn’t sign on to the Clear Pricing Project, they are still considered in-network for 2021, if they are currently in the Blue Options network, but the CPP copay reductions would not apply.

How does the CPP affect my out-of-pocket maximum and deductible?

Specialist Copay

How does the CPP affect my out-of-pocket maximum and deductible?

Using a CPP provider will lower your out-of-pocket amount for your copayment, which is applied to your out-of-pocket maximum, but it does not impact your deductible.

Not all health care services are created equal. A routine visit to your family doctor’s office is much different than a trip to a specialist, so it makes sense that they wouldn’t cost the same. Our plans with tiered copays connect the amount you pay to the type of care you receive.

What does this mean for me?

If your plan offers tiered copays, you’ll find a few kinds of payments when you pay for your health care. The lowest copays will be for office visits to a primary care physician, physician’s assistant or nurse practitioner. If you need to visit urgent care or see a specialist like a cardiologist or an immunologist, your copay will be a little higher. The most expensive copays will come when you visit the emergency room.

What primary care physicians and practitioners are in the lowest tier of copays?

There are many doctors and practitioners with a primary care specialty. An office visit to any of the following kinds of health care professionals will be in the lowest tier of copays:

Family practice

Adolescent medicine
Family practice
Geriatric medicine – Family practice
General practice
Family nurse practitioner
Preventive medicine

General practice

Adolescent medicine
Family practice
General practice
Public health / General preventive medicine
Preventive medicine

Geriatric medicine

Geriatric medicine – Family practice
Geriatric medicine – Internal medicine

Internal medicine

Adolescent medicine
Geriatric medicine – Internal medicine
Internal medicine
Internal medicine – Pediatrics

Obstetrics and gynecology

Obstetrics and gynecology
OB/GYN nurse practitioner

Pediatrics

Adolescent medicine
Pediatrics
Pediatric nurse practitioner

Nurse practitioner

Certified nurse practitioner
Family nurse practitioner
OB/GYN nurse practitioner
Pediatric nurse practitioner

Specialist Copay Blue Cross Blue Shield

Physician assistant

Bcbs Federal Specialist Copay

All provider specialties

Tiered copays are not available for all Blue Cross Blue Shield of Michigan health plans. Check your plan riders or call the phone number on the back of your member ID card to find out if your plan has tiered copays.