Nov. 29, 2023

This paid piece is sponsored by Avera Health.

During open enrollment for health insurance, it’s decision-making time for many employees and individuals. Direct health insurance plans that couple a local value network with more affordable monthly premiums are growing in popularity.

Direct plans can reduce costs for individuals, families and businesses without limiting services. The value received with a direct plan typically involves a clinically integrated network of care, such as Avera.

Direct plans may be an option selected by employers to offer their workers. Direct plans also are available for those who shop for individual or family health care coverage through the federal Health Insurance Marketplace. Many people can qualify for tax credits that reduce monthly premiums if they don’t have access to affordable health insurance through their employer or their spouse’s employer.

Open enrollment on the Marketplace extends through Dec. 15 for coverage starting Jan. 1, 2024, or through Jan. 15 for coverage starting Feb. 1.

“Direct plans are a win-win for those who want quality care at the best price,” said Jordan Anderson, vice president of sales and account management at Avera Health Plans. “With a value network, the insurance provider can often negotiate lower reimbursements, which means lower costs for members – both in terms of lower premiums and lower out-of-pocket costs.”

With Avera direct plans, average savings of as much as 20 percent are possible. Yet direct plans are not just about price.

Other aspects to consider:

• A single health system’s coordinated care saves time and money.
• Connected care from doctors and facilities in the same network means that all your medical records are within one patient portal.
• Easier referrals are possible for images and procedures within the network.

Like any health insurance coverage, you need to consider your health needs for yourself and your family. Questions you might ask yourself include:

• What can I afford in monthly premiums and potential out-of-pocket costs?
• Are the providers and facilities in the plan network ones I trust?
• What special medical needs do I or a family member have that require specialty care?
• Do I anticipate medical expenses in the year to come, like elective surgery or the birth of a child?

Direct plans also encourage you to develop a relationship with a primary care provider. This can help you achieve and maintain your health and wellness goals. It can save costs in the long term by catching health problems before they become more serious. In compliance with the Affordable Care Act, and like all ACA plans, direct plans cover 100 percent of preventive services such as recommended screenings and immunizations.

Those who enroll need to live in the specific geographic area the health system covers. People who already are patients in a system often consider a direct plan because they’re already in-network.

You also should understand some guidelines. If you enroll in a direct plan, it will not cover claims for care outside your network. In comparison, many broad-network plans reimburse out-of-network claims at lower percentages.

Direct plans make allowances for needs like urgent and emergency care when traveling outside of the service area. And if you need the care of a specialist who is not in-network, you can seek an authorization to be considered for in-network coverage. Because of extensive nationwide prescription networks, members can get the medications they need while out of the area – for example, a dependent who is attending college out of state.

Direct plan networks offer specialists for most health needs and conditions, from cancer to heart, orthopedics, surgery, OB-GYN, pediatrics and more. “In fact, the Avera network has physicians in more than 60 specialties and subspecialties,” Anderson said.

A direct plan may offer value-added benefits, such as:

• Employee assistance programs.
• Discounts for memberships at gyms or fitness centers.
• Health coaching.
• Virtual visits.
• Care management.

You may have opportunities to purchase additional coverage such as dental and vision to complement your direct plan health coverage.

“The robust nature of a direct plan has led many people to consider one or make a change,” Anderson added. “Care options remain strong, and costs are lower. That’s why they continue to grow in popularity.”

Learn more about health insurance plans through Avera.