How Your Health Plan Works

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For guidance and answers to your health insurance questions, talk with one of our experts by calling 1-888-322-2115, Monday - Friday, 8 a.m. - 5 p.m. (CT) or email us.

Health insurance can be confusing and even overwhelming at times. But we're here to help you all along the way. When you take time to learn more about how your health plan works, you'll be equipped to make the most of your coverage.

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 about how to make a 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. The out-of-pocket maximum combines your co-pays, deductibles and coinsurance.

Your Plan Details - Summary of Benefits & Coverage

The Summary of Benefits and Coverage is your go-to for all the information you need to knwo 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. Be sure to carry it with you at all times because you'll be asked to present it whenever you receive health services.

If you're a new member, you'll receive your member ID card(s) in the mail within 10 to 14 business days after your first premium payment is cleared.

How to Order a Replacement Member ID Card

If you need a new 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, call 1-888-322-2115.

Preauthorizations - How to Know If You Need Approval First

In some circumstances, our approval - or preauthorization - is required before you receive a specific service, procedure, drug or medical supplies, in order for it to be covered by your health insurance. 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, login to the member portal or call 1-888-322-2115.

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.

Preauthorization Process for Health Plan Members

  1. Your provider must call or fax us if you need a preauthorization. The preauthorization phone and fax numbers are listed on your member ID card or at Avera.org/PA.
  2. 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.
  3. 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.

Preauthorization Process for Medicare Supplement Insurance

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 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 MyHealthPlan mobile app. Once logged in, you can also choose to receive your claims via email by clicking Profile in the upper right-hand corner and then selecting the Paperless EOB tab.