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 | ||||||||||||||||||
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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). |
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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, 17 Dec 2021 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Plan Attribute | Value |
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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 |
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, 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