Seeking Affordable Health Insurance? Consider a Direct Plan

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.

What Types of Direct Plans Are Available?

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

Open enrollment on the Marketplace extends through Dec. 15 for coverage starting Jan. 1 of the new year. You can enroll 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, Senior Director of Group Sales, 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% are possible.

Benefits of a Coordinated Network

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 for images and procedures within the network.

Questions to Ask About Direct Plans

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 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% of preventive services, like recommended screenings and immunizations.

Avera Health Plans direct plans are available in Brown, Minnehaha and Lincoln counties. People who already are patients in a system often consider a direct plan because they’re already in-network.

Understanding Basic Principles of Direct Plans and Value Networks

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 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.

Direct plans make allowances for needs like urgent and emergency care, too. For example, emergency room care provides for the same benefit coverage level if you use either a participating or non-participating provider. This can help you when you travel outside of the service area.

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. Due to 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.

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

The savings achieved when offering direct plans can help workers offset the cost to purchase additional coverage, such as dental and vision. Tailoring a cost-effective value network with these desirable features is part of the reason direct plans are increasing in popularity.

“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.”