Sanford Individual Simplicity $4,750 - 89364ND0120005 Health Insurance Plan
Sanford Health Plan health insurance plan with the Plan ID 89364ND0120005. The plan is called Sanford Individual Simplicity $4,750.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 94.84% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 5.16% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 89364ND0120005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 89364ND0120005-06 | ||||||||||||||||||
| Provider Network(s) | NETWORK SIMPLICITY | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 13 May 2025 06:05 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 89364ND0120005-00 Standard On Exchange Plan - 89364ND0120005-01 Open to Indians below 300% FPL - 89364ND0120005-02 Open to Indians above 300% FPL - 89364ND0120005-03 73% AV Silver Plan - 89364ND0120005-04 |
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| Last Plan Update Date | Fri, 14 Mar 2025 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 13 May 2025 06:05 GMT |
Sanford Individual Simplicity $4,750 Health Insurance Plan Variant 89364ND0120005-06 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 5 |
| 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 | 94% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | NDF008 |
| Formulary URL | URL |
| HIOS Product ID | 89364ND012 |
| Import Date | 2025-03-14 02:01:36 |
| 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 | 94.84% |
| 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 | 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) | 89364ND0120005-06 |
| Plan Marketing Name | Sanford Individual Simplicity $4,750 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Sanford Individual Simplicity $4,750 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,800 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $20 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $40 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NDS003 |
| Source Name | HIOS |
| Plan ID | 89364ND0120005 |
| State Code | ND |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $36400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $18200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $18,200 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $19000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $9500 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $9,500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $19000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $9500 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $9,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $3600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $36400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $18200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $18,200 |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Sanford Individual Simplicity $4,750 Health Insurance Plan, 89364ND0120005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Sanford Individual Simplicity $4,750, 89364ND0120005 Health Insurance Plan, 89364ND0120005
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Does Sanford Individual Simplicity $4,750 Health Insurance Plan, 89364ND0120005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (89364ND0120005) Health Insurance Plan, Variant (89364ND0120005-06) offer Disease Management Programs?
Does (89364ND0120005) Health Insurance Plan, Variant (89364ND0120005-06) have Out Of Country Coverage?
Does (89364ND0120005) Health Insurance Plan, Variant (89364ND0120005-06) have Out of Service Area Coverage?
Does (89364ND0120005) Health Insurance Plan, Variant (89364ND0120005-06) offer Disease Management Programs?
Does Sanford Individual Simplicity $4,750 Health Insurance Plan, Variant (89364ND0120005-06) offer Disease Management Programs for Asthma?
Does Sanford Individual Simplicity $4,750 Health Insurance Plan, Variant (89364ND0120005-06) offer Disease Management Programs for Heart disease?
Does Sanford Individual Simplicity $4,750 Health Insurance Plan, Variant (89364ND0120005-06) offer Disease Management Programs for Diabetes?
Does Sanford Individual Simplicity $4,750 Health Insurance Plan, Variant (89364ND0120005-06) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Sanford Individual Simplicity $4,750 Health Insurance Plan, Variant (89364ND0120005-06) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 13 May 2025 06:05 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