Member FAQ | Avera Health Plans

Your Plan Payment: Monthly Premiums

A premium is the monthly amount that you pay for your health insurance plan. It's determined by where you live, your annual income and how many dependents you want to cover. In exchange, Avera Health Plans covers a set amount of health services based on your individual plan.

If you sign up for automatic withdrawal, your premium is taken out the fifth day of every month. Learn more on making your health insurance premium payment.

You pay a premium regardless of whether or not you've met your deductible for the year. Premiums also do not figure into your out-of-pocket maximum costs. Most of the time, your out-of-pocket maximum combines your co-pays, deductibles and coinsurance.

Your Plan Details: Summary of Benefits & Coverage

The Summary of Benefits and Coverage (SBC) is your go-to for all the information you need to know about your costs – such as co-pay, coinsurance, deductible and out-of-pocket maximums – and other benefit-related information.

To view your specific Summary of Benefits and Coverage, simply log in to the member portal, choose the Benefits tab and click on Summary of Benefits.

Your Member ID Card

You and each of your covered dependents – such as a spouse or children – will receive a member identification (ID) card that contains important information about your health plan. Be sure to always carry it with you, because you'll be asked to show it whenever you receive health services.

New Member Cards

Individual and Family Plan Members: You'll receive your member ID card(s) in the mail within 10 to 14 business days after your first premium payment is cleared.

Employer-Provided Insurance Members: If you receive Avera Health Plans insurance through your employer, your member ID card(s) will be mailed to you within 10 to 14 business days after processing the application and setting up your plan benefits.

Medicare Supplement Insurance Members: You’ll receive two mailings – one with your welcome kit and a second mailing containing your member ID card. If you’re reinstating a previous policy, you can continue to use your current member ID card.

Use Member ID Card to Create Member Portal Login

After you receive your member ID card, log in to the online member portal or through our Avera Health Plans mobile app for access to all of your personalized plan information. Your member ID card has the information you need to log in and create your new username and password.

If your policy is effective, but you haven't received your member ID card yet, contact us to request the information you need to log in.

Use Member ID Card in App

Download the Avera Health Plan mobile app for 24/7 access to member ID cards on your smartphone for you and all your dependents.

Ordering a Replacement Card

If you lose your member ID card, you can print a temporary card and order a replacement card by logging in to the member portal and choosing the "CLICK HERE to print a copy or order a replacement ID card" link in green. If you need further assistance, please contact us.

Preauthorizations – Do You Need Approval First?

In some circumstances, our approval – or preauthorization – is required before you receive a specific service, procedure, drug or medical supplies, before health insurance will provide coverage.

If you fail to receive a required preauthorization, you'll be responsible for paying the entire billed charge.
To find a list of services and medical equipment that require a preauthorization, log into the member portal or call 888-322-2115.
It's important to note that preauthorization does not guarantee benefits and that the preauthorization list is subject to change. Benefits are subject to all conditions of your individual health policy.

Health Plans Member Preauthorizations

Your provider must call or fax us if you need a preauthorization.
Our clinical review team will review the request and a letter will be mailed to you and your provider with the approval or reason for denial within 15 calendar days.
If approved, the letter will list which specific services, procedures and/or drugs have been approved. Please read the letter carefully so you know what services your provider has been authorized to perform.

Medicare Supplement Insurance Preauthorizations

If you have a Standard Medicare Supplement Insurance plan, you do not need a preauthorization to use any facility.

If you have a Select Medicare Supplement Insurance plan, you do not need a preauthorization if you use a facility listed in the Network Hospital Directory for Select Plans (pdf). If the facility is not listed in the directory, your physician will need to call for a preauthorization of services. This needs to be approved before you receive services at the out-of-network facility.

Urgent Preauthorizations

If your situation is urgent – meaning that a delay could jeopardize your life, health or ability to regain maximum function or would cause severe pain that could not be adequately managed without the requested care or treatment – our clinical review team will respond within 24 hours.

In the case that we are unavailable – such as on weekends, holidays or after business hours – your provider must contact us no later than two business days after you receive the services, supplies or procedures.

Learn more about your health care coverage in Navigating Your Health Care.

Your Explanation of Benefits

After each medical visit you'll receive an Explanation of Benefits (EOB) in the mail with information about how your claim was processed and how much you may owe. The Explanation of Benefits is not a bill or an invoice. You'll receive a separate invoice from your provider.

You can view all of your claims by logging in to the member portal or the Avera Health Plan mobile app. Once logged in, you can also choose to receive your EOBs digitally by clicking Preferences in the upper right corner and then selecting the Communication Preferences.

Need Something Else?

See all of our member resources online.

Member Resources Member Portal

Or contact our Customer Service team.

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