Avera Hlth Plans Inc Market Analysis: Market Share and Coverage by State

Payer Overview

Avera Hlth Plans Inc occupies a modest position in the national accident & health marketplace as the #135 ranked US A&H payer by premium. Their reported US premium is $287M, representing a US market share of 0.02%, and they operate in 3 states. The company reports an estimated total membership of 69.6K, and it does not operate through any affiliated subsidiaries (operates through 0 affiliated subsidiaries).

Avera Hlth Plans Inc's strongest presence is concentrated regionally rather than nationally, so their premium and membership are focused in a few contiguous states rather than spread across many markets. This concentrated footprint shapes how the payer negotiates with providers and where it can exert leverage on network reimbursement and narrow-network design.

Premium by Scope

Avera Hlth Plans Inc's premium footprint is exclusively within the US states and DC scope as reported. The payer reports $287M of premium in the US states & DC scope, representing 100.00% of the payer's total reported premium across all scopes. This concentration implies that provider strategy should focus on US-state contracting channels, with no reported exposure to US territories or foreign markets to consider.

National Market Footprint

Avera Hlth Plans Inc's premium and membership are highly concentrated in the upper Midwest, with $280M of premium and 68.6K estimated members in South Dakota alone. The insurer's presence in Iowa and Nebraska is minimal by comparison, totaling about $6.66M and $177K respectively in premium. For national-level provider contracting, this concentration suggests negotiations and network design should prioritize South Dakota markets where the payer carries material volume; efforts in Iowa and Nebraska are less likely to move network-wide economics given their relatively small membership and premium contributions.

Because the company's footprint is concentrated, multi-state provider groups should evaluate South Dakota-specific reimbursement arrangements and credentialing efficiencies first. Opportunities to standardize contracts across all three states will be limited by the dominant position in SD and the much smaller operational scale in IA and NE.

State-by-State Market Position

Avera Hlth Plans Inc shows its strongest presence in the Midwest, specifically in South Dakota where it holds a top-tier local share. The Northeast, Southeast, West, and Southwest regions do not feature meaningfully in the payer's reported footprint. With 9.51% market share and $280M in premium concentrated in South Dakota, the payer’s influence is localized rather than geographically diversified.

The Affordable Care Act (ACA) established federally-facilitated health insurance marketplaces ("exchanges") where individuals and small businesses can shop for and enroll in health plans, often with income-based subsidies. Issuers that participate in these marketplaces are required to report enrollment, claims, and denial data to CMS (Centers for Medicare & Medicaid Services) each year.

The sections below cover this payer's ACA marketplace-specific footprint — enrollment, plan portfolio, and claims/denial-rate data. This is a narrower, separate population from the NAIC-based commercial data shown earlier on this page (total premium, market share, and membership across all lines of business): ACA marketplace enrollment is typically a small fraction of a payer's total commercial book, and the two datasets should not be treated as equivalent. CMS claims-transparency reporting has also been inconsistent industry-wide since 2020 — many issuers have little or no data for 2021 onward, so a single reporting year is common and does not necessarily indicate anything about the payer's current ACA presence.

Estimated Member Demographics

Nationally, the largest age bands among AVERA HLTH PLANS INC members are 6–18 (12,231), 35–44 (9,591), and 55–64 (10,014). The under-6 and 26–34 bands are also substantial, reflecting a strong presence among families and working-age adults. The senior population (65+) is notably smaller, with 5,903 in the 65–74 band and 3,734 in the 75+ band.

State-level analysis shows that South Dakota's member profile closely mirrors the national distribution, as it accounts for the overwhelming majority of members. Iowa and Nebraska have much smaller member counts, but their age distributions are broadly similar, with a slight tilt toward younger age bands in Iowa. No state shows a pronounced skew toward older adults, reinforcing the payer's focus on families and working-age populations.

Estimated Members by State

The vast majority of AVERA HLTH PLANS INC's estimated members are located in South Dakota, which accounts for members—over 98% of the total. Iowa has an estimated members, while Nebraska has a negligible presence with just members. This distribution aligns closely with the payer's market share and premium volume, both of which are overwhelmingly concentrated in South Dakota.