State Health Plan of NC Salary Based Premiums Group Contact Submission Form

The NC State Health Plan has a need to have subject matter contacts for multiple business areas of a Group. The form below should be submitted for group subject matter area contacts.

The Plan’s Board of Trustees recently voted to approve the Plan’s ability to move forward with salary-based premiums. Implementing that strategy will require extra steps at the group and Plan level. The Plan’s Board of Trustees recently voted to approve the Plan’s ability to move forward with salary-based premiums. Implementing that strategy will require extra steps at the group and Plan level.

This effort will require technical changes for groups that have payroll integration with the Plan. For groups without payroll integration, there will be additional manual work needed to ensure all employees have the correct salary information in eBenefits for the start of Open Enrollment as well as ongoing updates. To ensure we are communicating requirements to the correct staff at each group, please submit the form below for each contact from your Group.

Type of Request Being Submitted

Salary Based Premium Contact Request Type

Salary Based Premium Contact

NoYes

Contact and Group Information

First Name

*

Group Name

Last Name

*

Mailing Address 1

*

Title

*

Mailing Address 2

*

Email Address

**

Mailing City

*

Primary Phone Number

*

Mailing State Abbreviation

*

Secondary Phone Number

*

Mailing ZIp Code

*

Previous Contact(s) You are Replacing for Your Group:

Are you replacing anyone?

NoYes

If yes, replacing who?

*

Please provide any information that will help process this request:

*

To view the Privacy Practices of the NC State Health Plan please visit the link below:

https://www.shpnc.org/notice-privacy-practices