What is direct
specialty care?

No. It is a way to arrange, price, and pay for care. A self-funded employer can incorporate it into a health plan; a patient can also purchase a package directly. The arrangement itself does not replace comprehensive health insurance or provide coverage for every medical need.

A mid-year launch may be possible, subject to the plan’s amendment process and partner agreements. Document eligible members, covered services, direct providers, cost-sharing, authorization, claims, and appeals. Coordinate the plan amendment, Summary Plan Description (SPD), any Summary of Material Modifications, and applicable Summary of Benefits and Coverage notices with counsel and the TPA. Review DOL guidance.

Treatment depends on the policy and endorsements; a lower bundle price does not guarantee reimbursement. Before launch, obtain written confirmation of eligible expenses, pricing limits, payment timing, and required records. Align the plan document, provider agreement, and stop-loss terms. Berkley’s policy-alignment guidance illustrates why document alignment matters; it is not approval of a particular HealthMe contract.

It can. The TPA and HealthMe establish eligibility, authorization, benefit configuration, and reporting before launch. HealthMe can translate a bundle into an EDI claim and route it to the TPA. Agree how to record payment and deductible credit without duplicate claims.

It can be structured that way, but not every incentive qualifies. HSA-qualified high-deductible plans generally must preserve the required deductible for nonpreventive care unless an exception applies. Paying an eligible expense with HSA funds is a separate question from receiving employer-funded first-dollar benefits. The 2026 exception for qualifying direct primary care arrangements is not a blanket exemption for specialty bundles. IRS HSA rules; 2026 DPC guidance.

Not automatically. Ask your plan administrator before purchasing whether the service is covered, whether direct-pay or out-of-network expenses qualify, and what documentation is required. A receipt or redemption code confirms the purchase; it does not establish deductible credit. Keep the itemized receipt and the plan’s written response.

HealthMe packages specify the services included by the participating practice; scope varies by bundle. Do not assume that an unexpected admission, emergency treatment, revision surgery, or additional therapy is included. Ask for the package’s written complication terms and any separate warranty before purchase. The treating team directs clinical care; the applicable package and health plan determine payment for additional services.

No. Direct specialty care can begin with an office evaluation and include imaging, physical therapy, non-surgical procedures, and follow-up. Early specialist access can help members understand appropriate options. A surgical bundle does not commit a member to surgery.

HealthMe connects members with participating independent practices and available specialty services. Consider qualifications, relevant experience, location, access, and the member’s clinical needs. Employers should request the applicable network participation criteria and quality information during evaluation; a published price alone does not establish quality or suitability.

Not necessarily. HealthMe looks for appropriate local options where available. Geography, specialty, appointment availability, and clinical needs can make travel necessary. Confirm transportation, lodging, and follow-up arrangements before booking; these are not automatically part of a care bundle or every employer benefit.

Yes. A plan can use RBP for some claims and direct agreements for selected providers or episodes. Define which agreement controls, configure the TPA to honor the direct price, and prevent duplicate repricing. Member protections should be explicit in the provider contract. See the payment-model distinctions.

Choose the services, prices, participating clinicians and facilities, inclusions, exclusions, and scheduling contacts. Assign staff for estimates, checkout, referrals, and payment reconciliation. HealthMe Core supports the marketplace; CareNav Connect supports employer referrals. Start with a manageable service list and expand as the workflow becomes familiar.