Sanford Individual Simplicity $7,100 HSA Qualified - 89364ND0120006 Health Insurance Plan
Sanford Health Plan health insurance plan with the Plan ID 89364ND0120006. The plan is called Sanford Individual Simplicity $7,100 HSA Qualified.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.86% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 36.14% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 89364ND0120006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | North Dakota | ||||||||||||||||||
| Health Insurance Issuer | Sanford Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 89364ND0120006-03 | ||||||||||||||||||
| Provider Network(s) | NETWORK SIMPLICITY | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 89364ND0120006-00 Standard On Exchange Plan - 89364ND0120006-01 |
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| Last Plan Update Date | Thu, 17 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Sanford Individual Simplicity $7,100 HSA Qualified Health Insurance Plan, 89364ND0120006-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Elective abortion services are only covered when the mother?s life is endangered. Prior Authorization/certification required. |
NO | ||
| Accidental Dental
Oral surgical procedures limited to services required because of injury, accident or cancer that damages Natural Teeth. This is an Outpatient Surgery that requires Certification. Care must be received within twelve 12 months of the occurrence. Injury does not include injuries to Natural Teeth caused by biting or chewing. Associated radiology services are included. Coverage applies regardless of whether the services are provided in a Hospital or a dental office. Extractions when medically necessary because of injury, accident, or cancer when internal guidelines are met. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
Benefit includes serum, injections, testing and treatment. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies
Covered service for the treatment of Autism Spectrum Disorder. Prior Authorization required. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Bariatric Surgery
Surgery must be medically necessary. Not all procedures classified as weight reduction surgery are covered. Prior approval for weight reduction surgery is required. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | No Charge |
20.00% Coinsurance after deductible |
| Chemotherapy
Prior authorization is required. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 20.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Exam(s) per Benefit Period |
YES | No Charge |
20.00% Coinsurance after deductible |
| Diabetes Education
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Dialysis
Plan will pay first for the first 30 months after you become eligible to join Medicare. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Durable Medical Equipment
Coverage for DME prescribed by an attending Practitioner and/or Provider, which is Medically Necessary, not primarily and customarily used for non-medical purposes, designed for prolonged use, and for a specific therapeutic purpose in the treatment of an illness or injury. Limitations per Sanford Health Plan policy guidelines apply. Casts, splints, braces, crutches and dressings for the treatment of fracture, dislocation, torn muscles or ligaments and other chronic conditions per Sanford Health Plan policy. Prior authorization is required for certain items. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Limited to 1 frame every other year. Lenses or contact lenses limited to 1 item annually. Benefit ends at the end of the month when the member turns 19. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Gender Affirming Care
Prior Authorization requried |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Generic Drugs
Drugs on the preventive medications list are not subject to a deductible. Some preventative drugs are subject to copayment/coinsurance or nothing at all. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Home Health Care Services
Limit: 40.0 Visit(s) per Benefit Period Prior authorization is required in lieu of a Hospital or Skilled Nursing Facility stay. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Hospice Services
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
Prior authorization may be required. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Infertility Treatment
Testing for the diagnosis of infertility: Transvaginal ultrasound for structural evaluation (limit of 1 per calendar year) Sonogram (limit of 1 per calendar year) Screenings for stimulations of ovarian reserves and ovarian functions(limit of 1 per screening per calendar year) Screenings for assessment of polycystic ovarian syndrome (PCOS) (limit of 1 per calendar year) Semen Analysis (limit of 2 per calendar year) |
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior authorization is required. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services
Prior authorization is required. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
Limit: 12.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
20.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
20.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Private-Duty Nursing
Nursing care that is provided to a Member on a one-to-one basis by licensed nurse in an inpatient or home setting. Prior authorization is required. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Prosthetic Devices
Prosthetic limbs, sockets and supplies, and prosthetic eyes; Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy. Includes two (2) external prosthesis per Calendar Year and six (6) bras per Calendar Year. For double mastectomy: coverage extends to four (4) external prosthesis per Calendar Year and six (6) bras per Calendar Year. Devices permanently implanted that are not Experimental or Investigational Services such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy. Cranial Prosthesis, including wigs (limited to 1 per benefit period)Prosthetic limbs, sockets and supplies, and prosthetic eyes. Requires Prior Authorization. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Radiation
Prior authorization is required. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Reconstructive Surgery
Some services require prior authorization. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Vision examination is only covered when related to injury, accident or cancer that damages the eye. Dilated eye examination for diabetes-related diagnosis (limit of one exam per Member per year) |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | No Charge |
20.00% Coinsurance after deductible |
| Routine Foot Care
Covered when medically appropriate. |
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period Preauthorization is required. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Specialist Visit
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Specialty Drugs
Preferred and Non-Preferred specialty drugs may be subject to different cost sharing rates. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
For SUD, PA required for inpatient, residential, partial hospitalization, and intensive outpatient. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Transplant
Prior authorization is required. To be eligible for coverage, Transplants must meet United Network for Organ Sharing (UNOS) criteria and/or Medical Criteria. Transplants must be performed at contracted Centers of Excellence or otherwise identified and accepted by Sanford Health Plan as qualified facilities. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Services for the Treatment and Diagnosis of TMJ/TMD are covered subject to Medical Necessity. Manual therapy and osteopathic or chiropractic manipulation treatment if performed by physical medicine Providers. TMJ Splints and adjustments if your primary diagnosis is TMJ/TMD. Maximum Benefit Allowance of 1 splint per Member per Benefit Period. |
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Well Child Care to the Member's 6th birthday, 100% of Allowed Charges. |
YES | No Charge |
20.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
20.00% Coinsurance after deductible |
Sanford Individual Simplicity $7,100 LCS Health Insurance Plan Variant 89364ND0120006-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.638625738188694 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 0.99671085 |
| First Tier Utilization | 100% |
| Formulary ID | NDF003 |
| Formulary URL | URL |
| HIOS Product ID | 89364ND012 |
| Import Date | 2024-10-17 01:02:25 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 89364 |
| Issuer Marketplace Marketing Name | Sanford Health Plan |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | NDN003 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Only in Emergent Medical situations |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Only in Emergent Medical situations |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 89364ND0120006-03 |
| Plan Marketing Name | Sanford Individual Simplicity $7,100 HSA Qualified |
| Plan Type | PPO |
| Plan Variant Marketing Name | Sanford Individual Simplicity $7,100 LCS |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,100 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,000 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NDS003 |
| Source Name | HIOS |
| Plan ID | 89364ND0120006 |
| State Code | ND |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $56800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $28400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $28,400 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $28400 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $14200 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $14,200 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $14200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7100 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,100 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $28400 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $14200 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $14,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $56800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $28400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $28,400 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Sanford Individual Simplicity $7,100 HSA Qualified Health Insurance Plan, 89364ND0120006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Sanford Individual Simplicity $7,100 HSA Qualified, 89364ND0120006 Health Insurance Plan, 89364ND0120006
-
Does Sanford Individual Simplicity $7,100 HSA Qualified Health Insurance Plan, 89364ND0120006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (89364ND0120006) Health Insurance Plan, Variant (89364ND0120006-03) offer Disease Management Programs?
Does (89364ND0120006) Health Insurance Plan, Variant (89364ND0120006-03) have Out Of Country Coverage?
Does (89364ND0120006) Health Insurance Plan, Variant (89364ND0120006-03) have Out of Service Area Coverage?
Does (89364ND0120006) Health Insurance Plan, Variant (89364ND0120006-03) offer Disease Management Programs?
Does Sanford Individual Simplicity $7,100 LCS Health Insurance Plan, Variant (89364ND0120006-03) offer Disease Management Programs for Asthma?
Does Sanford Individual Simplicity $7,100 LCS Health Insurance Plan, Variant (89364ND0120006-03) offer Disease Management Programs for Heart disease?
Does Sanford Individual Simplicity $7,100 LCS Health Insurance Plan, Variant (89364ND0120006-03) offer Disease Management Programs for Diabetes?
Does Sanford Individual Simplicity $7,100 LCS Health Insurance Plan, Variant (89364ND0120006-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Sanford Individual Simplicity $7,100 LCS Health Insurance Plan, Variant (89364ND0120006-03) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API