Avera Health Plans Members Rights and Responsibilities

You have the right to:

  • Information about your plan, its services, participating providers and other health care professionals providing care.
  • Be treated with respect and recognition of dignity and right to privacy.
  • Participate in decisions with your providers about your health care. You should receive enough information to make an informed decision before receiving any treatment. The information should include the specific
  • procedures of treatment, medical alternatives and associated risks, regardless of the cost or benefits coverage.
  • Voice and discuss complaints and appeals about the organization or the care of its providers.
  • Make recommendations regarding our Member Rights and Responsibilities policy.
  • Not be discriminated against because of age, gender, cultural background, educational or economic status, religious or sexual orientation, or mental or physical disability.
  • Not have genetic information used to determine eligibility coverage, underwriting or premiums, or to have genetic information used as a pre-existing condition.
  • Timely, proper medical care without discrimination of any kind, regardless of health status or condition.
  • Receive advice or assistance in a prompt, courteous and responsible manner.
  • Confidentiality. We will protect your medical records and personal information.
  • Information about the diagnosis, treatment and expected outcomes in terms that you understand.
  • If your provider determines that the information could be harmful to you, the information will be given to a person designated by you or someone with legal authority. Have a guardian, next of kin or legally authorized person exercise rights on your behalf if a medical condition makes you incapable of understanding or exercising your rights.
  • Designate any primary care provider who participates in our network and who is available to accept you or your family members.
  • Designate a pediatrician as the primary care provider for your children.
  • Obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology without a referral.

You have the responsibility to:

  • Confirm your provider is participating in our network before every service in order to receive the best benefit possible.
  • Treat all Avera Health Plans and provider staff and other members with respect and courtesy.
  • Carry your Avera Health Plans member ID card at all times and never permit anyone else to use it.
  • Pay your deductible or coinsurance promptly.
  • Review and follow your Certificate (Evidence) of Coverage or Individual Health Insurance Policy to receive your best benefits.
  • Promptly notify us of any changes such as address changes or changes in family status due to marriage, birth, adoption or divorce.

    If you applied through healthcare.gov, you must contact the Federal Marketplace at 1-800-318-2596 to make any changes to your plan.

    If you applied directly with Avera Health Plans or your employer, complete the member Change Form.

  • Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.
  • Follow your provider’s instructions about for care that you have agreed to with your providers.
  • Understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.