Sanford Individual TRUE Standardized $7,500 - 89364ND0090026 Health Insurance Plan

Sanford Health Plan health insurance plan with the Plan ID 89364ND0090026. The plan is called Sanford Individual TRUE Standardized $7,500.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.81% (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 36.19% 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 89364ND0090026
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 89364ND0090026-00
Provider Network(s) SHPTRUE NETWORK
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers North Dakota All US States
All 3753 67476
PCP 363 1274
Allergy N/A 3
OB/GYN 10 47
Dentists 46 106
Available Variants of the Health Plan

Standard Off Exchange Plan - 89364ND0090026-00

Standard On Exchange Plan - 89364ND0090026-01

Open to Indians below 300% FPL - 89364ND0090026-02

Open to Indians above 300% FPL - 89364ND0090026-03

Last Plan Update Date Thu, 17 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Sanford Individual TRUE Standardized $7,500 Health Insurance Plan, 89364ND0090026-00

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

50.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing

Benefit includes serum, injections, testing and treatment.

YES

50.00% Coinsurance after deductible

100.00%
Applied Behavior Analysis Based Therapies

Covered service for the treatment of Autism Spectrum Disorder. Prior Authorization required.

YES

50.00% Coinsurance after deductible

100.00%
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

50.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

No Charge

100.00%
Chemotherapy

Prior authorization is required.

YES

50.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Benefit Period

YES

$50.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Deductible Amount is waived when the newborn is released with the mother

YES

50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Exam(s) per Benefit Period

YES

No Charge

100.00%
Diabetes Education
YES

50.00% Coinsurance after deductible

100.00%
Dialysis

Plan will pay first for the first 30 months after you become eligible to join Medicare.

YES

50.00% 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. Prior authorization is required for certain items.

YES

50.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

50.00% Coinsurance after deductible

50.00% Coinsurance 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

50.00% Coinsurance after deductible

100.00%
Gender Affirming Care

Prior Authorization requried

YES

50.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$25.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

YES

$50.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

YES

50.00% Coinsurance after deductible

100.00%
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

50.00% Coinsurance after deductible

100.00%
Hospice Services
YES

50.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Prior authorization may be required.

YES

50.00% 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
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Prior authorization is required.

YES

50.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

50.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

50.00%

100.00%
Mental/Behavioral Health Inpatient Services

Prior authorization is required.

YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

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.

YES

$50.00

100.00%
Non-Preferred Brand Drugs
YES

$100.00 Copay after deductible

100.00%
Nutritional Counseling

Limit: 12.0 Visit(s) per Benefit Period

YES

50.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00%

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$50.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

YES

$50.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$50.00 Copay after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$50.00

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. Prior authorization is required.

YES

50.00% 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 (limited to 1 per benefit period)Prosthetic limbs, sockets and supplies, and prosthetic eyes. Requires Prior Authorization.

YES

50.00% Coinsurance after deductible

100.00%
Radiation

Prior authorization is required.

YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Some services require prior authorization.

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

YES

$50.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

YES

$50.00

100.00%
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

100.00%
Routine Foot Care

Covered when medically appropriate.

NO
Skilled Nursing Facility

Limit: 30.0 Days per Benefit Period

Preauthorization is required.

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$100.00

100.00%
Specialty Drugs

Preferred and Non-Preferred specialty drugs may be subject to different cost sharing rates.

YES

$500.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services

For SUD, PA required for inpatient, residential, partial hospitalization, and intensive outpatient.

YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$50.00

100.00%
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

50.00% Coinsurance after deductible

100.00%
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

50.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$75.00

70.00% 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

100.00%
X-rays and Diagnostic Imaging
YES

50.00% Coinsurance after deductible

100.00%

Sanford Individual TRUE Standardized $7,500 Health Insurance Plan Variant 89364ND0090026-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.638091065338329
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 Standard Bronze Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 0.99601594
First Tier Utilization 100%
Formulary ID NDF002
Formulary URL URL
HIOS Product ID 89364ND009
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 No
Network ID NDN004
Out of Country Coverage No
Out of Country Coverage Description Only in Emergent Medical situations
Out of Service Area Coverage No
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) 89364ND0090026-00
Plan Marketing Name Sanford Individual TRUE Standardized $7,500
Plan Type HMO
Plan Variant Marketing Name Sanford Individual TRUE Standardized $7,500
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $500
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $7,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,600
SBC Scenario, Having Diabetes, Deductible $100
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID NDS004
Source Name HIOS
Plan ID 89364ND0090026
State Code ND
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $15000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,500
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 $18400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9200 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,200
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Sanford Individual TRUE Standardized $7,500 Health Insurance Plan, 89364ND0090026

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Sanford Individual TRUE Standardized $7,500, 89364ND0090026 Health Insurance Plan, 89364ND0090026

  • Does Sanford Individual TRUE Standardized $7,500 Health Insurance Plan, 89364ND0090026 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (89364ND0090026) Health Insurance Plan, Variant (89364ND0090026-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (89364ND0090026) Health Insurance Plan, Variant (89364ND0090026-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: Only in Emergent Medical situations

    Does (89364ND0090026) Health Insurance Plan, Variant (89364ND0090026-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Only in Emergent Medical situations

    Does (89364ND0090026) Health Insurance Plan, Variant (89364ND0090026-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does Sanford Individual TRUE Standardized $7,500 Health Insurance Plan, Variant (89364ND0090026-00) offer Disease Management Programs for Asthma?

    Yes, the Sanford Individual TRUE Standardized $7,500 Health Insurance Plan Variant 89364ND0090026-00 offers Disease Management Program for Asthma.

    Does Sanford Individual TRUE Standardized $7,500 Health Insurance Plan, Variant (89364ND0090026-00) offer Disease Management Programs for Heart disease?

    Yes, the Sanford Individual TRUE Standardized $7,500 Health Insurance Plan Variant 89364ND0090026-00 offers Disease Management Program for Heart disease.

    Does Sanford Individual TRUE Standardized $7,500 Health Insurance Plan, Variant (89364ND0090026-00) offer Disease Management Programs for Diabetes?

    Yes, the Sanford Individual TRUE Standardized $7,500 Health Insurance Plan Variant 89364ND0090026-00 offers Disease Management Program for Diabetes.

    Does Sanford Individual TRUE Standardized $7,500 Health Insurance Plan, Variant (89364ND0090026-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Sanford Individual TRUE Standardized $7,500 Health Insurance Plan Variant 89364ND0090026-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Sanford Individual TRUE Standardized $7,500 Health Insurance Plan, Variant (89364ND0090026-00) offer Disease Management Programs for Pregnancy?

    Yes, the Sanford Individual TRUE Standardized $7,500 Health Insurance Plan Variant 89364ND0090026-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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