Sanford Simplicity $4,750 - 89364ND0120005 Health Insurance Plan

Sanford Health Plan health insurance plan with the Plan ID 89364ND0120005. The plan is called Sanford Simplicity $4,750.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 86.80% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 13.20% 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 86.79% (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 13.21% 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 89364ND0120005
Health Insurance Plan Year 2022
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 89364ND0120005-05
Provider Network(s) ['NDN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT).

Providers North Dakota All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
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

87% AV Silver Plan - 89364ND0120005-05

94% AV Silver Plan - 89364ND0120005-06

Last Plan Update Date Fri, 17 Dec 2021 00:00 GMT
Last Import Date Tue, 22 Oct 2024 06:47 GMT

Sanford Simplicity $4,750 Health Insurance Plan Variant 89364ND0120005-05 Attributes

Plan Attribute Value
AV Calculator Output Number 0.867910797
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type 87% AV Level Silver Plan
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 60%
Formulary ID NDF002
Formulary URL URL
HIOS Product ID 89364ND012
Import Date 12/17/2021 1:01
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 86.80%
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 Yes
National Network Yes
Network ID NDN001
Out of Country Coverage No
Out of Country Coverage Description Emergency Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency or Urgent Care Only or With Plan Certification
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 89364ND0120005-05
Plan Marketing Name Sanford Simplicity $4,750
Plan Type PPO
Plan Variant Marketing Name Sanford Simplicity $4,750
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,400
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $600
SBC Scenario, Having Diabetes, Deductible $100
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $100
SBC Scenario, Treatment of a Simple Fracture, Copayment $80
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 40%
Service Area ID NDS001
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 $34800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $17400 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $17,400
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 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $1,500
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 $5800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $2900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $2,900
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $5800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $2900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $2,900
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $34800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $17400 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $17,400
Unique Plan Design Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Sanford Simplicity $4,750 Health Insurance Plan, 89364ND0120005

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

Frequently Asked Questions(FAQ) about Sanford Simplicity $4,750, 89364ND0120005 Health Insurance Plan, 89364ND0120005

  • Does Sanford 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 (89364ND0120005-05) offer Disease Management Programs?

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

    Does (89364ND0120005) Health Insurance Plan, Variant (89364ND0120005-05) have Out Of Country Coverage?

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

    Does (89364ND0120005) Health Insurance Plan, Variant (89364ND0120005-05) have Out of Service Area Coverage?

    Yes. Details: Emergency or Urgent Care Only or With Plan Certification

    Does (89364ND0120005) Health Insurance Plan, Variant (89364ND0120005-05) 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 Simplicity $4,750 Health Insurance Plan, Variant (89364ND0120005-05) offer Disease Management Programs for Asthma?

    Yes, the Sanford Simplicity $4,750 Health Insurance Plan Variant 89364ND0120005-05 offers Disease Management Program for Asthma.

    Does Sanford Simplicity $4,750 Health Insurance Plan, Variant (89364ND0120005-05) offer Disease Management Programs for Heart disease?

    Yes, the Sanford Simplicity $4,750 Health Insurance Plan Variant 89364ND0120005-05 offers Disease Management Program for Heart disease.

    Does Sanford Simplicity $4,750 Health Insurance Plan, Variant (89364ND0120005-05) offer Disease Management Programs for Diabetes?

    Yes, the Sanford Simplicity $4,750 Health Insurance Plan Variant 89364ND0120005-05 offers Disease Management Program for Diabetes.

    Does Sanford Simplicity $4,750 Health Insurance Plan, Variant (89364ND0120005-05) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Sanford Simplicity $4,750 Health Insurance Plan Variant 89364ND0120005-05 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Sanford Simplicity $4,750 Health Insurance Plan, Variant (89364ND0120005-05) offer Disease Management Programs for Pregnancy?

    Yes, the Sanford Simplicity $4,750 Health Insurance Plan Variant 89364ND0120005-05 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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