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Avera leaving Sanford Health Plan

As of next year, health care provided by Avera Health physicians in South Dakota will no longer be covered by insurance offered through the Sanford Health Plan.

Avera announced on Friday it was leaving the network, a decision that comes one month after Sanford Health cut ties with Avera's two insurance plans.

"We realize that Avera leaving Sanford Health Plan's network provides a hardship for people who are insured for Sanford Health Plans and being cared for by Avera providers, and for that, we are sorry," said Avera Medical Group's Chief Medical Officer Tad Jacobs.

The change will take effect on Jan. 1, giving patients covered by the Sanford Health Plan time to find a new health care provider or a new insurance company.

According to Rob Bates, Avera's senior vice president of managed care services, the move will affect 1,500 households across the state and just under 300 physicians, mostly in Sioux Falls and Pierre.

Like many of Avera's regional hospitals, Avera Queen of Peace Hospital in Mitchell was never covered by Sanford Health Plan, so it will be unaffected by the change. The largest hospital affected is St. Mary's in Pierre, Bates said, adding that any facilities managed, not owned, by Avera are excluded from the decision and could choose to remain in the plan.

Patients covered by other insurance providers, like Wellmark Blue Cross Blue Shield of South Dakota, will be unaffected, and Jacobs said patients with complex plans requiring continuative care, like those with cancer or women in the second or third trimester of pregnancy, may receive exemptions from Sanford Health Plan to continue seeing their physicians.

Avera facilities in Iowa, Minnesota and Nebraska will remain in the Sanford Health Plan network, as will Avera Behavioral Health in Sioux Falls and Avera-employed Behavioral Health physicians, as it is the only behavioral health inpatient facility in the state.

Jacobs said Sanford Health's decision to pull its services from Avera's DakotaCare and Avera Health Plans last month was the catalyst for Avera's decision.

"This gives us an opportunity to refocus on primarily our medical group, our hospitals, our health plan," Jacobs said.

According to Jacobs, open enrollment for the federal insurance marketplace begins Nov. 1, and patients may select another insurance plan, like Avera's DakotaCare or Avera Health Plans, which provide access to all Avera providers.

"As difficult as this sort of disruption is, this is the absolute right time of year for it to happen," Bates said. "To the extent people wish to make a decision or need to make a decision, this is the exact right time of year to be doing that."

Bates said smaller, narrower insurance networks are taking hold across the nation, as they are able to provide a better value to patients. He said Wellmark left the individual marketplace earlier this week after struggling to compete.

"This is just South Dakota really aligning with what we're seeing in networks all over the country," Bates said.

Jacobs called the trend "unprecedented," and although these changes may be challenging, it is up to consumers to determine the best move for their health needs.

"This isn't something that is Avera and Sanford at each other," Jacobs said. "This is really a reflection of changes taking place across the entire country that makes it challenging for patients, and we sure understand that."