Sanford Simplicity $6,900 HSA/HDHP - 31195SD0110006 Health Insurance Plan
Sanford Health Plan health insurance plan with the Plan ID 31195SD0110006. The plan is called Sanford Simplicity $6,900 HSA/HDHP.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.40% (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 35.60% 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 | 31195SD0110006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | South Dakota | ||||||||||||||||||
| Health Insurance Issuer | Sanford Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 31195SD0110006-00 | ||||||||||||||||||
| Provider Network(s) | ['SDN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 31195SD0110006-00 Standard On Exchange Plan - 31195SD0110006-01 |
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| Last Plan Update Date | Tue, 29 Nov 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefits of Sanford Simplicity $6,900 HSA/HDHP Health Insurance Plan, 31195SD0110006-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
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 |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
Benefit includes serum, injections, testing and treatment |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| 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 | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | Tier 1: No Charge Tier 2: No Charge |
50.00% Coinsurance after deductible |
| Chemotherapy
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year Certain dental services may require authorization (pre-approval) by the plan. |
YES | Tier 1: No Charge Tier 2: No Charge |
50.00% Coinsurance after deductible |
| Diabetes Education
Limit: 8.0 Visit(s) per Benefit Period Quantity Limit: Two certified diabetes education programs per member per lifetime, and eight visits per benefit year for follow-up training once patient has participated in a diabetes education program. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
Equipment must primarily and customarily serve a medical purpose. Issuer determines whether to pay the rental amount or the purchase price amount for an item and determine the length of any rental term. Prior authorization may be required. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limited to 1 frame every other year. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Gender Affirming Care
Prior Authorization requried |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Generic Drugs
Preventive drugs have a $5 copay per prescription. Covers up to a 30-day supply. Generic cost is based on total drug cost per 30-day supply. Brand name drugs with generic equivalents require additional cost share. Difference in cost does not apply to deductible or out-of-pocket limit. There are no limitations or restrictions for use of manufacturer coupons if used in conjunction with our current benefit offering. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
100.00% |
| Habilitation Services
Treatment for Autism Spectrum Disorder (ASD) with speech therapy, occupational therapy, or physical therapy is covered. Use of Applied Behavioral Analysis (ABA) for the treatment of ASD is covered with the following minimum coverage limits: 1) through age 6: 1300 hours per benefit period; 2) ages 7-13: 900 hours per benefit period; 3) ages 14-18: 450 hours per benefit period. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Must have hearing loss that is not corrected by other covered procedures. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Home Health Care Services
Prior authorization required. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Hospice Services
Hospice respite care limited to 15 inpatient and 15 outpatient days per lifetime. Hospice respite care must be used in increments of not more than 5 days at a time. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
Prior authorization may be required |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Infusion therapy is covered when provided in the home (home infusion therapy). |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Prior authorization may be required |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
100.00% |
| Nutritional Counseling
Limit: 12.0 Visit(s) per Benefit Period |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Prior authorization may be required |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. Benefits are not available for Maintenance Care. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | Tier 1: No Charge Tier 2: No Charge |
50.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| 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 |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| 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 up to $200 |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Occupational therapy is only covered insofar as services to treat the upper extremities, which means the arms from the shoulders to the fingers. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Coverage includes rehabilitative speech therapy services when related to a specific illness, injury, or impairment and involve the mechanics of phonation, articulation, or swallowing. Services must be provided by a licensed or certified speech pathologist. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Vision examination is only covered when related to an illness or injury. |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | Tier 1: No Charge Tier 2: No Charge |
50.00% Coinsurance after deductible |
| Routine Foot Care
Covered when medically appropriate. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Skilled Nursing Facility
Limit: 90.0 Days per Year Preauthorization is required. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Specialty Drugs
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Transplant
Limit: 1.0 Exam(s) per Transplant Transplants are subject to Case Management. |
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| 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 | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Well Child Care to the Member's 6th birthday, 100% of Allowed Charge. |
YES | Tier 1: No Charge Tier 2: No Charge |
50.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | Tier 1: No Charge after deductible Tier 2: No Charge after deductible |
50.00% Coinsurance after deductible |
Sanford Simplicity $6,900 HSA/HDHP Health Insurance Plan Variant 31195SD0110006-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.643975745 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2023 |
| 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 | Not Applicable |
| 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 | SDF001 |
| Formulary URL | URL |
| HIOS Product ID | 31195SD011 |
| Import Date | 11/29/2022 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 31195 |
| 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 | Yes |
| National Network | Yes |
| Network ID | SDN001 |
| 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 with plan certification |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 31195SD0110006-00 |
| Plan Marketing Name | Sanford Simplicity $6,900 HSA/HDHP |
| Plan Type | PPO |
| Plan Variant Marketing Name | Sanford Simplicity $6,900 HSA/HDHP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $6,900 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,000 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 40% |
| Service Area ID | SDS001 |
| Source Name | SERFF |
| Plan ID | 31195SD0110006 |
| State Code | SD |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $55200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $27600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $27,600 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $27600 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $13800 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $13,800 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $13800 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6900 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,900 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $13800 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $6900 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $6,900 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $27600 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $13800 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $13,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $13800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $6900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $6,900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $55200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $27600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $27,600 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Sanford Simplicity $6,900 HSA/HDHP Health Insurance Plan, 31195SD0110006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Sanford Simplicity $6,900 HSA/HDHP, 31195SD0110006 Health Insurance Plan, 31195SD0110006
-
Does Sanford Simplicity $6,900 HSA/HDHP Health Insurance Plan, 31195SD0110006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (31195SD0110006) Health Insurance Plan, Variant (31195SD0110006-00) offer Disease Management Programs?
Does (31195SD0110006) Health Insurance Plan, Variant (31195SD0110006-00) have Out Of Country Coverage?
Does (31195SD0110006) Health Insurance Plan, Variant (31195SD0110006-00) have Out of Service Area Coverage?
Does (31195SD0110006) Health Insurance Plan, Variant (31195SD0110006-00) offer Disease Management Programs?
Does Sanford Simplicity $6,900 HSA/HDHP Health Insurance Plan, Variant (31195SD0110006-00) offer Disease Management Programs for Asthma?
Does Sanford Simplicity $6,900 HSA/HDHP Health Insurance Plan, Variant (31195SD0110006-00) offer Disease Management Programs for Heart disease?
Does Sanford Simplicity $6,900 HSA/HDHP Health Insurance Plan, Variant (31195SD0110006-00) offer Disease Management Programs for Diabetes?
Does Sanford Simplicity $6,900 HSA/HDHP Health Insurance Plan, Variant (31195SD0110006-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Sanford Simplicity $6,900 HSA/HDHP Health Insurance Plan, Variant (31195SD0110006-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 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