Sanford Health Plan health insurance plan with the Plan ID 89364ND0090008. The plan is called Sanford TRUE $3,500.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 87.71% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 12.29% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.80% (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 12.20% 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 | 89364ND0090008 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
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 | 89364ND0090008-05 | ||||||||||||||||||
Provider Network(s) | ['NDN002'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 89364ND0090008-00 Standard On Exchange Plan - 89364ND0090008-01 Open to Indians below 300% FPL - 89364ND0090008-02 Open to Indians above 300% FPL - 89364ND0090008-03 73% AV Silver Plan - 89364ND0090008-04 |
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Last Plan Update Date | Wed, 29 Mar 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
Elective abortion services are only covered in cases of rape, incest, or when mother?s life is endangered. Prior Authorization/certification required. |
NO | ||
Accidental Dental
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 |
YES | 30.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
Benefit includes serum, injections, testing and treatment |
YES | 30.00% Coinsurance after deductible |
100.00% |
Applied Behavior Analysis Based Therapies
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Surgery must be medically necessary. Not all procedures classified as weight reduction surgery are covered. Prior approval for weight reduction surgery is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
YES | No Charge |
100.00% |
Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 20.0 Visit(s) per Benefit Period Chiropractic services provided on an inpatient or outpatient basis when Medically Appropriate and Necessary and within the scope of licensure and practice of a Chiropractor, to the extent services would be covered if provided by a Physician. |
YES | $5.00 |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
A newborn is covered from birth through 60 days on the subscriber's plan until they are appropriately enrolled. Deductible Amount is waived when the newborn is released with the mother. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | No Charge |
100.00% |
Diabetes Education
Limit: 8.0 Visit(s) per Benefit Period |
YES | 30.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
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 |
YES | 30.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
Medically Appropriate and Necessary Ambulance Services to the nearest facility equipped to provide the required level of care, including transportation: from the home or site of an Emergency Medical Condition; between hospitals; and between a Hospital and Skilled Nursing Facility. |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 30.00% Coinsurance after deductible |
100.00% |
Gender Affirming Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Generic Drugs
Prescription Medications or Drugs and nonprescription diabetic supplies are subject to a dispensing limit of a 90-day supply. |
YES | $5.00 |
100.00% |
Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services) up through the age of 18. |
YES | $5.00 |
100.00% |
Hearing Aids
Limit: 1.0 Item(s) per 3 Years Must have hearing loss that is not corrected by other covered procedures. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
Limit: 40.0 Visit(s) per Benefit Period Covered Services include: 1. The professional services of an R.N., Licensed Vocational Nurse or L.P.N.; 2. Physical, Occupational or Speech Therapy; 3. Medical and surgical supplies; 4. Administration of prescribed drugs; 5. Oxygen and the administration of oxygen; and 6. Health aide services for a Member who is receiving covered Skilled Nursing Services or Therapy Services. A visit is considered up to 4 continuous hours. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Hospice Services
Hospice benefits are provided only for the treatment of Members diagnosed with a condition where there is a life expectancy of 6 months or less. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
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
Covered Services include the provision of nutrients, antibiotics, and other drugs and fluids intravenously, through a feeding tube, or by inhalation; all Medically Appropriate and Necessary supplies; and therapeutic drugs or other substances. Covered Services also include Medically Appropriate and Necessary enteral feedings when such feedings are the sole source of nutrition for a Member. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
100% Covered when performed during Office Visit, otherwise deductible/coinsurance |
YES | No Charge |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Inpatient Services
For psychiatric services, prior authorization required for inpatient, residential treatment, and partial hospitalization. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
For psychiatric services, prior authorization required for inpatient, residential treatment, and partial hospitalization. |
YES | $5.00 |
100.00% |
Non-Preferred Brand Drugs
|
YES | $80.00 |
100.00% |
Nutritional Counseling
Limit: 12.0 Visit(s) per Benefit Period |
YES | 30.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Limit: 1.0 Treatment(s) per Lifetime Only for the treatment of improper alignment of biting or chewing surfaces of upper and lower teeth through the installation of orthodontic appliances. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $5.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. Benefits are not available for Maintenance Care. |
YES | $5.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
|
YES | $45.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
Preventive Care/Screening/Immunization
Preventive screening services for Members age 6 and older according to A or B Recommendations of the U.S. Preventive Services Task Force and issued by the Health Resources and Services Administration. |
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $5.00 |
100.00% |
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 |
YES | 30.00% Coinsurance after deductible |
100.00% |
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 up to $200 |
YES | 30.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
Reconstructive surgery to restore bodily function or correct deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. Benefits are not available for Maitenance Care. |
YES | $5.00 |
100.00% |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. |
YES | $5.00 |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
Vision examination is only covered when related to an illness or injury. |
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | No Charge |
100.00% |
Routine Foot Care
Covered when medically appropriate |
NO | ||
Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $25.00 |
100.00% |
Specialty Drugs
Specialty Drugs are subject to a dispensing limit of a 30-day supply. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
Benefits are available for the inpatient treatment of substance abuse, including medically managed inpatient detoxification, medically monitored inpatient detoxification, medically managed intensive inpatient treatment or medically monitored intensive inpatient treatment, when provided at an appropriately licensed and credentialed Substance Abuse Facility. Benefits available for residential treatment for members under age 21. Benefits available for partial hospitalization. Preauthorization is required. For SUD, PA required for inpatient, residential, partial hospitalization, and intensive outpatient. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
Outpatient benefits include diagnostic, evaluation and treatment services provided by a Physician, Licensed Clinical Psychologist or Licensed Addiction Counselor, including for gambling addiction. |
YES | $5.00 |
100.00% |
Transplant
Services must be performed at a qualified transplant center. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Limit: 1.0 Item(s) per Benefit Period 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 | 30.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $20.00 |
$20.00 |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
Well Child Care to the Member's 6th birthday, 100% of Allowed Charge. |
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
100% Covered when performed during Office Visit, otherwise deductible/coinsurance |
YES | No Charge |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.878044522 |
Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | 87% AV Level Silver Plan |
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 | 1 |
First Tier Utilization | 100% |
Formulary ID | NDF034 |
Formulary URL | URL |
HIOS Product ID | 89364ND009 |
Import Date | 3/29/2023 4:01 |
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 Actuarial Value | 87.71% |
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 | Silver |
Multiple In Network Tiers | No |
National Network | No |
Network ID | NDN002 |
Out of Country Coverage | No |
Out of Country Coverage Description | Emergency only |
Out of Service Area Coverage | No |
Out of Service Area Coverage Description | Emergency or urgent care only with plan certification |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 89364ND0090008-05 |
Plan Marketing Name | Sanford TRUE $3,500 |
Plan Type | HMO |
Plan Variant Marketing Name | Sanford TRUE $3,500 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,100 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $1,450 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $800 |
SBC Scenario, Having Diabetes, Deductible | $100 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $80 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,450 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | NDS002 |
Source Name | HIOS |
Plan ID | 89364ND0090008 |
State Code | ND |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $5000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $2500 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $2,500 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $2900 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $1450 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $1,450 |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2900 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1450 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,450 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $5000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $2500 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $2,500 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
Unique Plan Design | Yes |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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