Sanford Health offers this marketplace health insurance plan (Plan ID 89364ND0120009) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.
Metal level: CatastrophicPlan type: PPOCSR: Standard Catastrophic On Exchange PlanIssuer: Sanford Health
Telehealth
Data pending
HSA eligible
No
Dental
Child
Vision
Child
Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in North Dakota). Submit changes before the deadline to avoid a coverage gap.
Enroll by Dec 15 for Jan 1 starts.
Finalize plan switches before the window closes.
Special Enrollment Periods
You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).
Report the event within 60 days.
Keep documentation handy for Healthcare.gov or your state exchange.
CSR & subsidy reminders
Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.
Enter accurate income to maximize Advanced Premium Tax Credits.
Standard Catastrophic On Exchange Plan plans like this one keep deductibles and copays lower if you qualify.
Thinking about switching?
Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.
Match provider networks so ongoing care isn’t disrupted.
Confirm prescriptions stay on-formulary or budget for tier changes.
Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.
Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).
Variant 89364ND0120009-01 (Standard On Exchange Plan) currently displayed.
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Benefits
Covered services & limitations
Everyday care
Office visits, preventive care, labs, imaging, and home health.
Chiropractic Care
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 20.0 Visit(s) per Benefit Period
nan
Exclusions: nan
Diabetes Education
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Home Health Care Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 40.0 Visit(s) per Benefit Period
Prior authorization is required in lieu of a Hospital or Skilled Nursing Facility stay.
Exclusions: nan
Laboratory Outpatient and Professional Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Other Practitioner Office Visit (Nurse, Physician Assistant)
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
First 3 office visits $50 copay in the combined categories of Primary Care, Habilitation, and Rehabilitation.
Exclusions: nan
Preventive Care/Screening/Immunization
No Charge
Tier 1 in-networkNo Charge
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Primary Care Visit to Treat an Injury or Illness
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
First 3 office visits $50 copay in the combined categories of Primary Care, Habilitation, and Rehabilitation.
Exclusions: nan
Rehabilitative Occupational and Rehabilitative Physical Therapy
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 30.0 Visit(s) per Year
nan
Exclusions: nan
Rehabilitative Speech Therapy
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 30.0 Visit(s) per Year
nan
Exclusions: nan
Specialist Visit
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Urgent Care Centers or Facilities
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
X-rays and Diagnostic Imaging
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Hospital & urgent
Emergency room, inpatient stays, ambulance, and surgeries.
Chemotherapy
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Prior authorization is required.
Exclusions: nan
Delivery and All Inpatient Services for Maternity Care
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Deductible Amount is waived when the newborn is released with the mother
Exclusions: nan
Dialysis
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Plan will pay first for the first 30 months after you become eligible to join Medicare.
Exclusions: nan
Durable Medical Equipment
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
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.
Exclusions: nan
Emergency Room Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-networkNo Charge after deductible
nan
Exclusions: nan
Emergency Transportation/Ambulance
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-networkNo Charge after deductible
nan
Exclusions: nan
Hospice Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Inpatient Hospital Services (e.g., Hospital Stay)
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Prior authorization is required.
Exclusions: nan
Inpatient Physician and Surgical Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Mental/Behavioral Health Inpatient Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Prior authorization is required.
Exclusions: nan
Mental/Behavioral Health Outpatient Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
First 5 office visits covered at 100% in the combined categories of Mental/Behavioral Health and SUD. The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for additional information.
Exclusions: nan
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Outpatient Rehabilitation Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 30.0 Visit(s) per Benefit Period
First 3 office visits $50 copay in the combined categories of Primary Care, Habilitation, and Rehabilitation.
Exclusions: nan
Outpatient Surgery Physician/Surgical Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Radiation
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Prior authorization is required.
Exclusions: nan
Skilled Nursing Facility
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 30.0 Days per Benefit Period
Preauthorization is required.
Exclusions: nan
Substance Abuse Disorder Inpatient Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
For SUD, PA required for inpatient, residential, partial hospitalization, and intensive outpatient.
Exclusions: nan
Substance Abuse Disorder Outpatient Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
First 5 office visits covered at 100% in the combined categories of Mental/Behavioral Health and SUD.
Exclusions: nan
Transplant
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
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.
Exclusions: nan
Pregnancy & family
Maternity, newborn, pediatric dental and vision extras.
Basic Dental Care - Child
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Hearing Aids
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 1.0 Item(s) per 3 Years
nan
Exclusions: nan
Major Dental Care - Child
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Prenatal and Postnatal Care
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Routine Eye Exam for Children
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 1.0 Exam(s) per Benefit Period
nan
Exclusions: nan
Well Baby Visits and Care
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Well Child Care to the Member's 6th birthday, 100% of Allowed Charges.
Exclusions: nan
Pharmacy & drugs
Generic, brand, specialty, and mail order tiers.
Generic Drugs
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network100.00%
nan
Exclusions: nan
Non-Preferred Brand Drugs
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network100.00%
nan
Exclusions: nan
Preferred Brand Drugs
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network100.00%
nan
Exclusions: nan
Specialty Drugs
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network100.00%
Preferred and Non-Preferred specialty drugs may be subject to different cost sharing rates.
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.
Exclusions: nan
Basic Dental Care - Adult
Coverage details pending
nan
Exclusions: nan
Dental Check-Up for Children
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 2.0 Exam(s) per Benefit Period
nan
Exclusions: nan
Infusion Therapy
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Major Dental Care - Adult
Coverage details pending
nan
Exclusions: nan
Nutritional Counseling
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 12.0 Visit(s) per Benefit Period
nan
Exclusions: nan
Orthodontia - Adult
Coverage details pending
nan
Exclusions: nan
Orthodontia - Child
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
nan
Exclusions: nan
Prosthetic Devices
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
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.
Exclusions: nan
Routine Dental Services (Adult)
Coverage details pending
nan
Exclusions: nan
Weight Loss Programs
Coverage details pending
nan
Exclusions: nan
Additional benefits
Other plan-specific services and limitations.
Abortion for Which Public Funding is Prohibited
Coverage details pending
Elective abortion services are only covered when the mothers life is endangered. Prior Authorization/certification required.
Exclusions: nan
Acupuncture
Coverage details pending
nan
Exclusions: nan
Allergy Testing
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Benefit includes serum, injections, testing and treatment.
Exclusions: nan
Applied Behavior Analysis Based Therapies
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Covered service for the treatment of Autism Spectrum Disorder. Prior Authorization required.
Exclusions: nan
Bariatric Surgery
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Surgery must be medically necessary. Not all procedures classified as weight reduction surgery are covered. Prior approval for weight reduction surgery is required.
Exclusions: nan
Cosmetic Surgery
Coverage details pending
nan
Exclusions: nan
Eye Glasses for Children
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
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.
Exclusions: nan
Gender Affirming Care
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Prior Authorization requried
Exclusions: nan
Habilitation Services
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Limit: 30.0 Visit(s) per Benefit Period
First 3 office visits $50 copay in the combined categories of Primary Care, Habilitation, and Rehabilitation.
Exclusions: nan
Imaging (CT/PET Scans, MRIs)
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Prior authorization may be required.
Exclusions: nan
Infertility Treatment
Coverage details pending
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)
Exclusions: nan
Long-Term/Custodial Nursing Home Care
Coverage details pending
nan
Exclusions: nan
Private-Duty Nursing
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
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.
Exclusions: nan
Reconstructive Surgery
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
Some services require prior authorization.
Exclusions: nan
Routine Eye Exam (Adult)
Coverage details pending
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)
Exclusions: nan
Routine Foot Care
Coverage details pending
Covered when medically appropriate.
Exclusions: nan
Treatment for Temporomandibular Joint Disorders
No Charge after deductible
Tier 1 in-networkNo Charge after deductible
Out-of-network20.00% Coinsurance after deductible
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.
Begin Primary Care Cost-Sharing After Number Of Visits
0
Child-Only Offering
Allows Adult and Child-Only
Composite Rating Offered
No
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%
Import Date
2025-03-14 02:01:36
Limited Cost Sharing Plan Variation - Estimated Advanced Payment
$0.00
HSA Eligible
No
New/Existing Plan
Existing
Notice Required for Pregnancy
No
Is a Referral Required for Specialist?
No
Plan Effective Date
2025-01-01
Plan Expiration Date
2025-12-31
Plan Type
PPO
QHP/Non QHP
Both
Source Name
HIOS
Plan ID
89364ND0120009
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group
$36800 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person
$18400 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual
$18,400
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group
$18400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person
$9200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual
$9,200
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group
$36800 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person
$18400 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual
$18,400
Unique Plan Design
Yes
Wellness Program Offered
No
Copay & coinsurance
Pharmacy cost sharing by tier
Drug tier
Pharmacy type
Copay amount
Copay option
Coinsurance rate
Coinsurance option
Mail order
Questions & answers
Frequently asked questions
How do I choose the right ACA plan in North Dakota?
Sanford Individual Simplicity $9,200 (89364ND0120009) is a Catastrophic PPO from Sanford Health in North Dakota for the 2025 coverage year.
Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.
Does Sanford Individual Simplicity $9,200 support telehealth or virtual urgent care?
The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.
Is Sanford Individual Simplicity $9,200 HSA-eligible and does it include dental or vision coverage?
It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.
Dental add-ons: Child.
Vision add-ons: Child.
Does Sanford Individual Simplicity $9,200 support mail-order prescriptions?
Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.
Which disease management programs come with Sanford Individual Simplicity $9,200?
The issuer lists disease management resources for: Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy.
Is there out-of-country coverage for Sanford Individual Simplicity $9,200?
No, out-of-country services are not covered for this plan. Details: Only in Emergent Medical situations
Does Sanford Individual Simplicity $9,200 cover care outside the service area?
Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Only in Emergent Medical situations
How do I enroll in or manage payments for Sanford Individual Simplicity $9,200?
Use the issuer portal https://hix.sanfordhealthplan.com/ to pay premiums or start enrollment, then return to HealthPorta for benefit comparisons.
Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
