2025 SHP Agent Manual by Sanford Health Plan

Dear Agents,

On behalf of the entire Sanford Health Plan (SHP) team, I want to thank you for your partnership.

Our shared commitment to affordable, quality health insurance ensures the communities we serve have access to the resources and care they need to be well. I am grateful for your collaboration.

We have achieved some remarkable things together over the past year:

• Align powered by Sanford Health Plan received a 4.5-star rating from CMS in North Dakota and South Dakota; our commercial plans have a 4-star NCQA rating. These star ratings consider member experience and satisfaction – a significant part of that is connecting members with the plan that’s right for their circumstances and ensuring that they understand how to use the benefits available to them. Your partnership is vital on both counts. Thank you.

• With your feedback, we have strengthened and refined our benefit offerings, including introducing the Healthy Benefits flex card for Align members this past year. Member response to the flex card has been exceedingly positive – in large part because of your efforts educating members during the sales process.

• Sanford Health Plan achieved 46.2% of the ACA market share in South Dakota and 50% in North Dakota. Again, this is a testament to your work within our communities to ensure our friends and neighbors are connected to the resources they need.

• What else?

We have so much to look forward to in the year ahead. Sanford Health Plan is well positioned as a strategic partner for the health services delivery (HSD) side of the system as we increasingly focus on value-based care and the creative, effective care models necessary to serve our rural communities. Member experience will continue to be at the forefront of all we do, and we will be considering opportunities for growth where we find values alignment, be it with other health plans, independent provider groups or accountable care organizations.

In everything we do, however, it is important that we stay connected with what you, as our partners out in the community, are seeing and hearing. Please know that your perspective is incredibly valuable to me, and I welcome your feedback anytime.

With appreciation,

Tommy Ibrahim Executive Vice President and President/CEO Sanford Health Plan

LARGE GROUP PLANS

General Information

Sole Carrier

Sanford Health Plan must be the only group-sponsored health coverage offered

Types of Organizations Eligible for Coverage

Eligible groups are generally defined as:

• Organizations engaged in trade or business (i e Corporations)

• Religious institutions

• Charitable or non-profit institutions

• Educational institutions

• Governmental agencies and subdivisions

The organization must be a legal entity established for a strong, mutual, and continuing interest other than for insurance purposes . In addition, the business must maintain a bona fide employer-employee relationship with all persons insured under the group’s health care program

Each group must have a designated individual with contract signing authority and decision-making authority for health care coverage who normally works at the group’s location within Sanford Health Plan’s service area .

Types of Organizations Ineligible for Coverage

Any group failing to meet the requirements previously explained will be ineligible for coverage In addition, the following are also ineligible for group coverage:

• A group comprised of members as opposed to employees, such as societies and clubs

• Trusts

• Groups engaged in seasonal business which reduces operations for a portion of the year to the extent that no employee meets the employee eligibility

• Multiple employer groups and associations

• Groups that maintain only a Post Office Box residence in our service area

• Employee leasing groups/Professional Employment Organizations (PEO’s)

• Groups having more than one health carrier

Common Control

Companies with common ownership will be considered a single employer if the companies fall within the definition of common control provided under the Health Insurance Portability and Accountability Act (HIPAA) .

HIPAA states that all entities treated as a single entity under subsections (b), (c), (m) or (o) of section 414 of the Internal Revenue Code shall be considered as one employer If such an account meets this definition, all entities must be written together in a single account If they are not considered to be one employer, they may be written separately .

As a general rule there must be 80% common ownership between the companies for this requirement to apply The account may have to consult with its attorney or accountant to see if it meets the requirements of common control as defined by HIPAA It is the group’s responsibility to inform Sanford Health Plan if a common ownership group exists.

Underwriting will allow groups with more than 50% common ownership but less than 80% to be combined, if requested Family or marital relationships do not imply common ownership of different businesses

The addition of an affiliate or subsidiary to the group policy subsequent to the initial enrollment of the group may be permitted with Underwriting approval if the affiliate or subsidiary has more than 50% common ownership .

In all cases where subsidiaries or affiliates are to be included, they must be listed on the Employer Enrollment Application with the following information:

• the name of each company

• federal tax ID

• number of employees employed

Unless there is a subsequent change in ownership that makes the combination of affiliates or subsidiaries ineligible, groups will not be allowed to split

Location of Group

The group must be physically located and headquartered within the service area of Sanford Health Plan

There is one exception Groups headquartered out of area but with a separate branch office located within Sanford Health Plan’s service area may be considered separately . These groups can receive a quote for the in-area branch if decision making authority is delegated to an employee working in that branch Enrollment in these cases is limited to the employees working in the in-area office

As a general rule, groups with more than 50% of their enrolling employees working out of the service area will not be quoted .

Size Requirements

A large group is one that employs at least 51 total employees The table below outlines the specifics for each state within the Sanford coverage area . The actual count of the employees will be based upon the average of the twelve months directly proceeding the date at which the Renewal Preparation Form is completed, or the point in time at which the quote questionnaire is completed Exceptions to the 12-month average can be made if the group grows drastically due to merger, acquisition, etc .

MULTIPLE PLAN OPTIONS

Employees may select or change between multi-option products:

• upon initial enrollment

• on the group’s renewal date (open enrollment)

• if the group is adding, eliminating or changing a multi-option product mid-year and if the new product is a lower cost product than the product(s) currently being offered, employees enrolled in a higher or eliminated option will be allowed to transfer to one of the lower cost options

• when the employee or dependent becomes eligible for a qualified life event

• if there is a significant disruption of the provider network (to be determined at the sole discretion of Sanford Health Plan)

• changes to a deductible plan is limited to one per year

The number of plan choices that a group may select to offer to the employees of the group depends on employee size:

• 51-100 employees: The group may offer a maximum of 2 plan options

• 101+ employees: The group may offer a maximum of 3 plan options .

Lab & X-Ray Optional Rider

Employers can choose to purchase this additional benefit rider . Sanford Health Plan allows this benefit to be added at an additional cost on flat and split copayment options

• Lab work and x-rays will process under the office visit copay if done the same day as an office visit and billed by a clinic

• This rider has also incorporated the addition of certain surgical procedures done in an office visit of setting on the same date of service to also be covered under the “all-inclusive” office visit copay

• This rider will also incorporate claims to process with an additional copay, rather than deductible/coinsurance, if the covered lab/x-ray service is done in an office visit setting on the same date of service, but billed from a hospital versus a clinic .

• Lab work and x-rays that are not done on the same day as an office visit an office visit copay will apply whether the claim is billed by a clinic or hospital .

Employer Contribution for Group Health

The employer must contribute at least 50% of the Employee-Only cost for each enrolled employee

The contribution amount may vary based on for each employee’s age . The group may also vary the contribution amount by class of employee

If multiple plans are offered, the employer may make the contribution based on the plan of choice . However, the contribution must be a minimum of 50% of the employee cost for the lowest priced option that is available to the employee

Participation Requirements for Group Health

Sanford Health Plan requires a 70% minimum participation for new and renewal contracts in South Dakota, North Dakota, Minnesota and Iowa . The 70% minimum is calculated based on eligible employees minus any valid waivers (i e spouses plan, Medicare, VA plan or ACA Individual coverage)

Employee Waiting Periods

An employer may impose a waiting period for new employees of up to 60-days Since coverage always starts on the first of the month, the 60-day limit ensures compliance with the 90-day maximum waiting period under the Affordable Care Act

Waiting Period Options: First of the month following: Date of Hire, 30 Days, 60 Days

Employee Hourly Requirement

An employer cannot impose more than a maximum 30-hour per week employee eligibility requirement to comply as a large employer under the Affordable Care Act .

Deductible/Out-of-Pocket

Maximum Commercial Credit

Sanford Health Plan deductible runs calendar year Sanford Health Plan will give deductible/out-ofpocket credit from January 1st to the effective date of the group, provided the employer had a group health plan in place prior to electing coverage with Sanford Health Plan Deductible/out-of-pocket credit will only be given if we receive the prior carrier deductible/out-of-pocket report or copy of member’s EOB’s within 60-days of the group’s original effective date

Sanford Health Plan will hold claims for the first 60 days waiting for a report from the prior carrier of deductible and out of pocket values met for each member Member Explanation of Benefits (EOBs) are also accepted . It is the agent’s responsibility to request these reports be sent to Sanford Health Plan within 60 days of the group’s effective date .

SIGNATURE SERIES LARGE GROUP

Product Profile: Our Signature Series plans are offered to large employers with 51 or more total employees.

Provider Network: Sanford Health Plan’s Signature Series broad network expands beyond the Sanford Health system for access to providers and facilities within the Sanford Health Plan service area. To receive in-network benefits, see providers in this directory. Prior authorization for certain services is still required, regardless of where you receive care. If you or a dependent live outside of the Sanford Health Plan service area complete an Out-of-Area Form to request access to the nationwide network. If access is approved, nationwide network providers and facilities will process at the in-network benefit level.

1.8 million plan options

and

Access to a nationwide network for employees or dependents who reside outside the service area

COBRA Administration offered through WEX Health at no additional cost Broad Network

Video visits depend on your health insurance coverage. Credit, debit, HSA and FSA are accepted. Further details at sanfordhealthplan.com/ virtualcare

Sales Fact Sheet

Product Name: SIGNATURE SERIES Provider Network: BROAD

Eligibility Service Area

The Sanford Health Plan Signature service area consists of the following approved counties:

• South Dakota: all counties

• North Dakota: all counties

• Minnesota counties: Becker, Beltrami, Big Stone, Blue Earth, Brown, Chippewa, Clay, Clearwater, Cottonwood, Douglas, Grant, Hubbard, Jackson, Kandiyohi, Kittson, Lac Qui Parle, Lake of the Woods, Lincoln, Lyon, Mahnomen, Marshall, Martin, McLeod, Meeker, Murray, Nicollet, Nobles, Norman, Otter Tail, Pennington, Pipestone, Polk, Pope, Red Lake, Redwood, Renville, Rock, Roseau, Sibley, Stearns, Stevens, Swift, Traverse, Watonwan, Wilkin, and Yellow Medicine .

• Iowa counties: Clay, Dickinson, Emmet, Ida, Lyon, O’Brien, Osceola, Plymouth, Sioux, and Woodbury .

Employees living in the Service Area covering a spouse or dependent(s) living outside the Service Area need to submit the Out-of -Area Verification form for the spouse/dependents to receive access to nationwide network of providers .

SANFORD PLUS LARGE GROUP

NORTH DAKOTA, SOUTH DAKOTA, MINNESOTA AND IOWA

Product Profile: Our Sanford PLUS plans are offered to large employers with 51 or more total employees. Eligible employees must reside within approved zip codes to enroll in this plan. Sanford PLUS plans must always be packaged with similar side-by-side Signature Series plans to provide choices to employees customized to fit their insurance needs.

Provider Network: Sanford Health Plan’s PLUS plans offer a tiered network is grouped into two levels. Member cost share (copayments, deductibles, and coinsurance) is based on the tier of the provider from whom they receive care. Tier 1 Preferred (which has the lowest member cost-share) includes our large care system of Sanford Health providers and facilities. Tier 2 Affiliated (which has a higher member cost-share) includes a broad network that expands beyond the Sanford Health system and includes providers and facilities within the Sanford Health Plan service area. To receive in-network benefits, see providers in this directory. Prior authorization for certain services is still required, regardless of where you receive care. If you cover a college student who resides outside of the Sanford Health Plan service area complete an Out-of-Area Form to request access to the nationwide network. If access is approved, nationwide network providers and facilities will process under Tier 2 benefits.

Over 375,000 plan options

Video visits depend on your health insurance coverage. Credit, debit, HSA and FSA are accepted. Further details at sanfordhealthplan.com/ virtualcare

COBRA Administration offered through WEX Health at no additional cost Tiered Network Additional Lab & X-Ray Rider can be

Up to 13% in premium savings compared to Signature Series plans

Sales Fact Sheet

Product Name: SANFORD PLUS Provider Network: TIERED

Eligibility Service Area

The Sanford Plus service area consists of the following approved counties:

• South Dakota: all counties

• North Dakota: all counties

• Iowa counties: Clay, Dickinson, Emmet, Ida, Lyon, O’Brien, Osceola, Plymouth, Sioux, and Woodbury

Large Group Sanford PLUS Business Rules

• If an employer offers Sanford PLUS (tiered network), they are required to offer Signature Series (broad network) plan as a side-by-side The Signature Series plans must mirror the Tier 1 cost sharing on Sanford PLUS

• Employers cannot offer TRUE Plan side-by-side with a Sanford PLUS Plan

Sanford PLUS Eligibility Rules:

Employer Eligibility Rules:

 Business must be domiciled in counties where SHP is licensed (all counties of SD, ND and approved counties of Minnesota and Iowa )

 Groups must submit census to include gender, age, and each employee’s zip code

 South Dakota: 30% of eligible employees must reside in the Sanford-PLUS approved zip codes

 North Dakota, Minnesota & Iowa: 50% of eligible employees must reside in the Sanford-PLUS approved zip codes

The number of plan choices that a group may select to offer to the employees of the groups depends on employee size:

• 51-100 employees are only permitted to offer 2 Signature Series plans, and 2 Sanford PLUS plans, to a maximum of 4 plan options, no more

• 101+ employees are only permitted to offer 3 Signature Series plans, and 3 Sanford PLUS plans, to a maximum of 6 plan options, no more

Employee Eligibility Rules: Eligible employees reside in Sanford PLUS approved zip codes

Other Business Rules:

1 Subscribers that cover spouses and/or dependents who permanently reside out of the Sanford PLUS service area, are not eligible for the Sanford PLUS plan (i .e . court ordered spousal/ dependent coverage)

2 Subscribers that cover college students who attend school out of the Sanford PLUS service area are eligible for the PLUS plan, however, must acknowledge that most providers are at a Tier 2 level

3 College students outside the Sanford Service Area will need to complete an out-of-area verification form to get access to our nationwide network of providers in their Tier 2 network .

4 Urgent and Emergent care services claims will process as a Tier 1 provider

5 Members must notify SHP of their move out of the Sanford PLUS service area within 30 days

a . Member will automatically be moved to the equivalent Signature Series (Broad Network) Plan

b Member cannot switch deductible level plans

c . Accumulators will roll-over for group member .

d Members will receive a new ID card with a new Group ID and marketing brand scheme/color

South Dakota – PLUS Employee Eligibility Large Group Zip Codes

57580 57584

North Dakota – PLUS Employee

Large Group Zip Codes

Minnesota – PLUS Employee Eligibility Large Group Zip Codes

56572 56573 56574 56575 56576 56577 56578 56579 56580 56581 56583 56584 56585 56586 56587 56588 56589 56590 56591 56592 56593 56594 56601 56619 56621 56626 56630 56633 56634 56641 56644 56646

56647 56650 56651 56652 56655 56662 56663 56666 56667 56670 56671 56672 56673 56676 56678 56682 56683 56684 56685 56687 56701 56710 56713 56714 56715 56716 56721 56722 56723 56724 56725 56726 56727 56736 56737 56738 56742 56744 56748 56750 56751

56761 56762 56763

Iowa – PLUS Employee

Large Group Zip Codes

SANFORD TRUE LARGE GROUP

NORTH DAKOTA, SOUTH DAKOTA, MINNESOTA AND IOWA

Product Profile: Our Sanford TRUE plans are offered to large employers with 51 or more total employees. Eligible employees must reside within approved zip codes to enroll in this plan. Sanford TRUE plans must always be packaged with side-by-side Signature Series plans to provide choices to employees customized to fit their insurance needs.

Provider Network: Includes access to our large care system of Sanford Health providers and facilities, plus some additional independent providers across the Dakotas, Minnesota and Iowa. You can choose to see any licensed Sanford Health provider for covered services without a referral for in-network coverage. This plan does not have out-of-network coverage, except for urgent and emergent situations.

1.8 million plan options

No out-of-network coverage, except urgent and emergent services

COBRA Administration offered through WEX Health at no additional cost Focused Network

Video visits depend on your health insurance coverage. Credit, debit, HSA and FSA are accepted. Further details at sanfordhealthplan.com/ virtualcare

Additional Lab & X-Ray Rider can be purchased

Fitness Center Reimbursement and Wellness Services

Approximately 20% in premium savings compared to Signature Series plans

$5 Comprehensive Preventive Drug Benefit for HSA Qualified Plans

Sales Fact Sheet

Product Name: SANFORD TRUE Provider Network: FOCUSED

Eligibility Service Area

The Sanford service area consists of South Dakota, North Dakota and approved counties of Minnesota and Iowa

Large Group Sanford TRUE Business Rules

• If an employer offers Sanford TRUE (focused network), they are required to offer Signature Series (broad network) plan as a side-by-side

• Employers cannot offer TRUE Plan side-by-side with a Sanford PLUS Plan

Sanford TRUE Eligibility Rules:

Employer Eligibility Rules:

 Business must be domiciled in counties where SHP is licensed (all counties of SD, ND and approved counties of Minnesota and Iowa .)

 Groups must submit census to include gender, age, and each employee’s zip code

 South Dakota: 30% of eligible employees must reside in the TRUE counties or expanded zip codes

 North Dakota, Minnesota & Iowa: 50% of eligible employees must reside in the TRUE counties

The number of plan choices that a group may select to offer to the employees of the groups depends on employee size:

• 51-100 employees are only permitted to offer 2 Signature Series plans, and 2 Sanford TRUE plans, to a maximum of 4 plan options, no more

• 101+ employees are only permitted to offer 3 Signature Series plans, and 3 Sanford TRUE plans to a maximum of 6 plan options, no more .

Employee Eligibility Rules: Eligible employees reside in Sanford TRUE approved zip codes

Other Business Rules:

1 Subscribers who cover spouses and/or dependents who permanently reside out of the TRUE service area are not eligible for the TRUE plan (i .e . court ordered spousal coverage or dependent coverage)

2 Subscribers who cover college students who attend school out of the TRUE service area are eligible for the TRUE Plan, and acknowledge that coverage will only be for urgent/emergent care and that all elective services must be received at an in-network provider in the TRUE service area

3 Members must notify SHP of their move out of the TRUE service area within 30 days

a . Member will automatically be moved to the equivalent Signature Series (Broad Network) Plan .

b Member cannot switch deductible level plans

c Accumulators will roll-over for group members

d Members will receive a new ID card with new Group ID and marketing brand scheme/color

South Dakota – TRUE Employee Eligibility Large Group Zip Codes

North Dakota – TRUE Employee Eligibility Large Group Zip Codes

Minnesota – TRUE Employee Eligibility Large Group Zip Codes

56650 56652 56663 56666 56667 56670 56671 56676 56678 56683 56685 56687 56701 56715 56725 56727

56742 56748 56750 56754

Iowa – TRUE Employee Eligibility Large Group Zip Codes

Quoting & Selling Large Group

Required Information to Quote

To quote a large group, regardless of state, the following information is necessary:

1 . Completed quote questionnaire

2 Complete census with DOB, gender, type of coverage (i e single/family) and employee zip codes

• Employee zip codes allow our Underwriting Department to determine if the employer is eligible to offer Sanford PLUS/TRUE to employees .

3 2 years of claims experience (most recent 24 months), include data within 6 months of requested effective date . All reports must reflect the same reporting period with no overlap or gaps .

a . Large claim reports: Member status (active/terminated) along with diagnosis and if available prognosis Reports must reflect 12 month reporting period

b Total claims paid reports: Reports must reflect month by month data

c Membership reports: Reports must reflect month by month data

4 . Current SBC’s and Plan designs .

5 Copy of current and renewal premiums by tier for each plan offered

6 In the event that claims data is not available, health applications will be required for all eligible employees and family members

Required Sold Paperwork

For an effective date of the first of the month, all required paperwork (indicated below) must be completed and received by Sanford Health Plan Sales no later than the 15th of the month prior to their effective date

• If the 15th falls on a Saturday, then required paperwork is due on Friday the 14th If the 15th of the month falls on Sunday, required paperwork is due on Monday the 16th If a due date falls on a holiday, the due date will be the next business day .

• If required paperwork isn’t received by the 15th of the month prior to the effective date, Sanford Health Plan will push the effective date to the first of the following month

Required Sold Group Paperwork:

 Employer Group Application

 HMO Contract/Exhibit B

• Agents Please Confirm Commission Structure Sold

• Consumer Directed Health Plans Elections (Exhibit B)

 WEX Cobra Enrollment Form or Cobra Addendum

 Reconciled Quarterly Tax & Wage

 Any policies (ex: Medical Leave)

 Employee Enrollment

• New Sales: SHP formatted Excel template

• Renewals: myEnrollment or 834 EDI enrollment file

Pre-Sale Broker Requirement: Agents are required to provide pre-enrollment documents to the group prior to their effective date These documents include:

• Employee Decision Guide

• Group Special notice

• Group SBCs (It is your responsibility to ensure that each benefit eligible employee receives a copy of each plan SBC . These will be sent via email .)

• Out of Area Verification forms for employees enrolled in Signature Series plan that have dependents living outside the Sanford Service Area . These forms can be found on the agent portal

IMPORTANT: If requesting printed materials for meetings the order must be requested at a minimum of 10-business days prior to the due date . The order must be submitted with all sold/renewal paperwork If the request falls inside that 10-business day requirement it is the agents responsibility to accommodate, all necessary materials (except large group SBC’s) can be accessed from our secure agent portal .

Late-Pay Termination Process

Active policies will “remain in full force” until the 31-day grace period has ended (meaning coverage will not be rescinded or revoked and medical and pharmacy claims continue to be reimbursed)

NOTE: Per ND regulations, Sanford Health Plan must pay providers within 15 days of clean claim submissions

Non-effectuated groups (those that have NOT made their first payment or a binder payment) will not have claims reimbursed

Additionally,

• ACH (automatic withdrawal) of premium will be required to reinstate the policy

• The delinquent premium in addition to the current month premium must be paid in full to be reinstated

• If a group is terminated due to non-payment of premium, a 6-month waiting period is required before applying for coverage at Sanford Health Plan

Renewal Information

Large group renewals are emailed to the agent securely It is the agent’s responsibility to deliver renewals to the group prior to their renewal date .

Annual Renewal Process

Large group renewals will be released via email to the Agent only within 75 days of the client’s renewal date, unless a special exception has been granted . It is the Agent’s responsibility to provide the renewal to the client A Renewal Checklist is provided to indicate items to review on Group Health and additional information

All required paperwork on the Renewal Checklist must be completed and received by Sanford Health Plan Sales no later than the 15th of the month prior to their effective date

• If the Renewal Attestation Form and Exhibit B are not returned by the 15th of the month prior to the group renewal date, or a 30-day notification of termination is not provided, the group will be auto-renewed with the current (or closest matching plan available) at the renewal rate per the Sanford Health Plan contract Changes to the plan will not be accepted after the 15th of the month prior to the renewal date .

Required Renewal Paperwork:

 Renewal Attestation Form

 Renewal Plan Options & Rates (Exhibit B)

 Consumer Directed Health Plans Elections (Exhibit B)

 Employee Enrollment/Changes

Reminder on Enrollment Options:

• 834 File

• myEnrollment Portal

• Paper

Broker Requirement:

Agents are required to provide pre-enrollment documents to the group prior to their effective date . These documents include:

• Employee Decision Guide

• Group Special Notices

• Group SBCs

• Out-of-Area Verification Form required for all employees and dependents residing outside the service area .

Employee Decision Guide, Group Special Notice and Out-of-Area Verification Form can be found on the agent portal .

IMPORTANT: If requesting printed materials for meetings the order must be requested at a minimum of 10-business days plus shipping time prior to the due date The order must be submitted with all sold/renewal paperwork . If the request falls inside that 10-business day requirement it is the agents responsibility to accommodate, all necessary materials (except large group SBC’s) can be accessed from our secure agent portal Agents will also receive all electronic documents via email

Provider Network Information

Access & Availability Rule

Appropriate access for Primary Care Physicians and Hospital Provider sites is within (ND-50, SD-30, MN-30, IA-30 miles) of a member’s residence . Appropriate access for Specialty Providers is within (ND-50, SD-90, MN-60, IA-60 miles) of a member’s residence If there are no Providers participating with Sanford Health Plan within the specified mile radius, then the member will be allowed to seek treatment at any Provider practicing in the same mile radius .

Mayo Clinic Health System, Rochester, Rochester Methodist & St . Mary’s Members must have certification/prior authorization from Sanford Health Plan to make an appointment and receive services from the Mayo Clinic Health System, Rochester, or St Mary’s Contact our Utilization Management Department at (605) 328-6807 or toll free at (800) 805-7938 for certification/prior authorization should a members Practitioner refer them to the Mayo Clinic Health System for services A physician referral only is not sufficient

To request prior approval, the member’s primary care provider will need to submit a request to receive care at an out-of-network provider through their Sanford Health Plan provider portal as a “SHP 2nd Opinion OON” or “SHP Network Exception” referral with medical justification The request is reviewed for appropriate medical necessity or continuity of care If approved, the service will process at innetwork benefit level .

Network Options Outside of the Sanford Health Plan Service Area

PHCS Healthy Directions and MultiPlan Networks

Visit sanfordhealthplan com under the ‘If You Reside Outside the Service Area’ section to locate a participating provider outside of the Sanford Health Plan service area Please note that this network is only available to members residing or attending school outside of the plan’s service area An out-ofarea verification form is required to be completed for review and in-network authorization

TLC Network

Sanford Health Plan provides additional provider network access using the TLC Advantage network for access and availability in limited areas of South Dakota Members with access to the TLC Advantage network providers will see the TLC Advantage network logo on the back of their ID Card . These additional TLC Advantage providers can be seen at an in-network benefit level and will be viewable to the members when logged in to Sanford Health Plan’s online provider directory using their member ID

Please note these additional network options can depend on plan selection .

Reporting

Sanford Health Plan values transparency with brokers allowing them to service their clients Following are the business rules for reporting on Large Groups . The below standard reports are automated and distributed by the 15th day of the month The automated reports are generated and distributed either monthly or quarterly depending on group size

Automated Reports

Client Loss Ratio Report (CLR)

 Must have 25 or more active contracts

 Service and Paid Dates: Rolling 12 months ending the last day of the prior month

 Includes IBNR (Incurred but Not Reported) values of projected outstanding claims for services that month

• The same standard actuarial calculation is used for all groups

• The IBNR value is not used by underwriting during renewal

High Cost Claimant Report (HCC) aka Member Cost Detail

 Must have 50 or more active contracts

 Must have 12 months of claims data

 Service and Paid Dates: Rolling 12 months ending the last day of the prior month

 Threshold will be the group’s pooling point

 Diagnostic Category is based on the 1st diagnosis code for the highest paid claim during the designated time period of the report

 Groups with 200 or more members will include the Relationship Code

 Unable to provide HCC reports until a client has 12 rolling months of claims data

Contract Count by Tiers

 Must have 25 or more active contracts

 Enrollment by contract and tier for the current month

Other report requests should be emailed to your Account Executive and depending on request, please allow up to 14 business days for processing . Note all reporting includes active employees, dependents, spouses and COBRA members

Special Enrollment Periods

Special Enrollment Rights

Each year during open enrollment, members may elect benefits coverage for the coming year . Once enrolled, a member cannot change his/her health insurance election unless they have a ‘qualifying event’ as listed below:

Change in family status affecting covered persons such as:

• Marriage or Divorce

• Annulment

• Death of a spouse or dependent child

• Birth or adoption of a child

• Loss of dependent status (a child reaches the age limit under the plan or is no longer eligible as a dependent)

Change in your employment status affecting your benefits such as:

• Beginning or returning from an unpaid leave of absence

• Sabbatical

• Change to/from part-time employment

Change in your spouse’s employment status causing a gain or a loss of health coverage for you or your dependents:

• Beginning or ending employment

• Increasing or decreasing hours

• Strike or lockout

• Open enrollment

Changes associated with a spouse’s open enrollment period including changes in the type and cost of coverage:

• Gain or loss of eligibility for Medicare/Medicaid for yourself, spouse, or child

What changes are allowed?

If a member has a qualifying event, the change made to the plan must be consistent with and appropriate for the new circumstances (see examples below) and it must be done within 31-days of the event:

Dependent Eligibility

Below is the table for large group dependent eligibility by state

“STUDENT AGE”

Legal Spouse

Disabled dependent children older than age 26 Yes; for continuation coverage only If a dependent’s coverage is already terminated due to turning 26, the dependent would not be allowed to come back onto the parent’s plan if they become disabled after age 26

Legally adopted children and children placed with you or your covered spouse for adoption

Biological children and stepchildren

Children for whom you or your covered spouse have been appointed legal guardian

Foster children placed with you or your covered spouse

Children allowed to obtain health coverage by a court order

Children of an unmarried eligible dependent (i e , grandchild) who are not otherwise covered by situations listed above

Yes; if the unmarried parent of the grandchild is a covered eligible dependent and both the parent and grandchild are primarily dependent on the subscriber

Who is an Eligible Dependent?

• Spouse

• Children (under age 26) by: adoption, marriage, or legal guardianship

o Stepchildren are allowed on the plan if the child(ren)’s biological parent is covered under Sanford Health Plan policy

o If a dependent is disabled, they are eligible to stay on the plan by submitting an enrollment request

• If you believe your dependent qualifies as a disabled dependent under the criteria of your benefit plan, you will be required to submit the enrollment request and provide any requested documentation to continue coverage for your dependent after age 26

• Coverage for a disabled dependent is only allowed for continuation coverage only If a dependent’s coverage is already terminated due to turning 26, the dependent would not be allowed to come back onto the parent’s plan if they become disabled after age 26

• Grandchild(ren):

o Allowed if the parent of the grandchild is unmarried, covered under the benefit plan, and the parent is primarily dependent on the subscriber for support

o If the parent of the grandchild who is covered under the plan is no longer eligible to remain on the plan (e g , turns 26, gets married), then the grandchild would no longer be eligible to remain on the plan

SMALL GROUP PLANS

General Information

Sole Carrier

Sanford Health Plan must be the only group-sponsored health coverage offered

Types of Organizations Eligible for Coverage

Eligible groups are generally defined as:

• Organizations engaged in trade or business (i e Corporations)

• Religious institutions

• Charitable or non-profit institutions

• Educational institutions

• Governmental agencies and subdivisions

The organization must be a legal entity established for a strong, mutual, and continuing interest other than for insurance purposes

In addition, the business must maintain a bona fide employer-employee relationship with all persons insured under the group’s health care program

Each group must have a designated individual with contract signing authority and decision making authority for health care coverage who normally works at the group’s location within Sanford Health Plan’s service area

Types of Organizations Ineligible for Coverage

Any group failing to meet the requirements previously explained will be ineligible for coverage In addition, the following are also ineligible for group coverage:

• A group comprised of members as opposed to employees, such as societies and clubs

• Trusts

• Groups engaged in seasonal business which reduces operations for a portion of the year to the extent that no employee meets the employee eligibility

• Multiple employer groups and associations

• Groups that maintain only a Post Office Box residence in our service area

• Employee leasing groups/Professional Employment Organizations (PEO’s)

• Groups having more than one health carrier .

Common Control

Underwriting will allow groups with more than 50% common ownership but less than 80% to be combined, if requested Family or marital relationships do not imply common ownership of different businesses

In all cases where subsidiaries or affiliates are to be included, they must be listed on the Employer Enrollment Application with the following information:

• the name of each company

• federal tax ID

• number of employees employed

Unless there is a subsequent change in ownership that makes the combination of affiliates or subsidiaries ineligible, groups will not be allowed to split .

Location of Group

The group must be physically located and headquartered within the service area of Sanford Health Plan

There is one exception Groups headquartered out of area but with a separate branch office located within Sanford Health Plan’s service area may be considered separately These groups can receive a quote for the in-area branch if decision making authority is delegated to an employee working in that branch Enrollment in these cases is limited to the employees working in the in-area office

As a general rule, groups with more than 50% of their enrolling employees working out of the service area will not be quoted

Size Requirements

A small employer is one that employs 50 or less total employees The table below outlines the specifics for each state within the Sanford coverage area The actual count of the employees will be based upon the average of the twelve months directly proceeding the date at which the Renewal Preparation Form is completed, or the point in time at which the quote questionnaire is completed Exceptions to the 12-month average can be made if the group grows drastically due to merger, acquisition, etc

State Small Group Definition

Iowa

Minnesota

North Dakota

South Dakota

1-50 total employees

2-50 total employees*

(*) These states allow a business of one to be written even though the state definition is 2-50

SIMPLICITY SMALL GROUP

IOWA, MINNESOTA, NORTH DAKOTA, AND SOUTH DAKOTA

Product Profile: Our Simplicity plans are offered to small employers with 50 or less total employees. These are qualified health plans that offer a variety of cost-sharing options. Employers with more than five total employees have the capability to choose up to three plan options for their employees.

Provider Network: Sanford Health Plan’s Simplicity broad network expands beyond the Sanford Health system for access to providers and facilities within the Sanford Health Plan service area. To receive in-network benefits, see providers in the directory. Prior authorization for certain services is still required, regardless of where you receive care. If you or a dependent live outside of the Sanford Health Plan service area complete an Out-of-Area Form to request access to the nationwide network. If access is approved, nationwide network providers and facilities will process at the in-network benefit level.

11 plan options

Broad Network

Video visits depend on your health insurance coverage. Credit, debit, HSA and FSA are accepted. Further details at sanfordhealthplan.com/ virtualcare

Fitness Center Reimbursement and Wellness Services

Access to a nationwide network for employees who reside outside the service area

COBRA Administration offered through WEX Health at no additional cost

$5 Comprehensive Preventive Drug Benefit for HSA Qualified Plans

Lab and X-ray copay on copay plans

Pediatric Dental and Vision benefits built into all plan options

Sales Fact Sheet

Product Name: SIMPLICITY

Eligibility Service Area

Provider Network: BROAD

The Sanford Simplicity service area consists of the following approved counties:

• South Dakota: all counties

• North Dakota: all counties

• Iowa counties: Clay, Dickinson, Emmet, Ida, Lyon, O’Brien, Osceola, Plymouth, Sioux, and Woodbury .

Employees living in the Service Area covering a spouse or dependent(s) living outside the Service Area need to submit the Out-of-Area Verification form for the spouse/dependents to receive access to nationwide network of providers .

SANFORD TRUE SMALL GROUP

SOUTH DAKOTA, NORTH DAKOTA, MINNESOTA AND IOWA

Product Profile: Sanford TRUE plans are offered to small employers with 50 or less total employees. Eligible employees must reside within approved zip codes to enroll in this plan. Employers with more than five total employees have the capability to choose up to three plan options for their employees, along with the same Simplicity plan options.

11 plan options

No out-of-network coverage, except urgent and emergent services

COBRA Administration offered through WEX Health at no additional cost Focused Network

Video visits depend on your health insurance coverage. Credit, debit, HSA and FSA are accepted. Further details at sanfordhealthplan.com/ virtualcare

Fitness Center Reimbursement and Wellness Services

Approximately 20% in premium savings compared to Simplicity plans

Lab and X-ray copay on copay plans

$5 Comprehensive Preventive Drug Benefit for HSA Qualified Plans

Pediatric Dental and Vision benefits built into all plan options

Sales Fact Sheet

Product Name: SANFORD TRUE Provider Network: FOCUSED

Eligibility Service Area

The Sanford service area consists of the following approved counties:

• South Dakota counties: Brown, Lincoln, Minnehaha

• North Dakota counties: Burleigh, Morton, Oliver, Cass, Traill

• Minnesota counties: Beltrami, Clay, Clearwater, Cottonwood, Hubbard, Jackson, Murray, Nobles, Red Lake, Rock, Pennington

• Iowa counties: Lyon, O’Brien, and Sioux .

Group Sanford TRUE Business Rules

• If an employer offers Sanford TRUE (focused network), they are required to offer the same Simplicity (broad network) plan as a side-by-side

• There are no minimum requirements for employee eligibility to offer these plans side by side in the small group market

Sanford TRUE Eligibility Rules

Employer Eligibility Rules:

Business must be domiciled in approved counties where SHP is licensed to sell TRUE products

• South Dakota counties: Brown, Minnehaha, Lincoln

• North Dakota counties: Burleigh, Morton, Oliver, Cass, Traill

• Minnesota counties: Beltrami, Clay, Clearwater, Cottonwood, Hubbard, Jackson, Murray, Nobles, Red Lake, Rock, Pennington

• Iowa counties: Lyon, O’Brien, and Sioux

Employee Eligibility Rules: Eligible employees reside in Sanford TRUE approved zip codes

Other Business Rules:

• Subscribers who cover spouses and/or dependents who permanently reside out of the TRUE service area, are not eligible for the TRUE plan (i e court ordered spousal coverage or dependent coverage) .

• Subscribers who cover college students who attend school out of the TRUE service area are eligible for the TRUE Plan, and acknowledge that coverage will only be for urgent/emergent care and that all elective services must be received at in-network provider in the TRUE service area

• Members must notify SHP of their move out of the TRUE service area within 30 days

a Member will automatically be moved to the equivalent Simplicity (Broad Network) Plan

b . Member cannot switch metal level plans or deductible level plans .

c Accumulators will roll-over for group members

d Members will receive a new ID card with new Group ID and marketing brand scheme/color

South Dakota – TRUE Small Group

North Dakota – TRUE Small Group

Employee Eligibility Zip Codes

Minnesota – TRUE Small Group

Employee Eligibility Zip Codes

Iowa – TRUE Small Group

Employee Eligibility Zip Codes

Quoting & Selling Small Group

Quoting

1 Access our Small Group Online Quote Request under your Broker Portal at sanfordhealthplan com

2 Complete Employer Information: Name, State, Number of Employees, and Effective Date

3 . Complete employee census template with:

• Employee Name

• DOB

• Zip Code

• Relationship

• Coverage Type

4 Once the quote information is submitted through our online link, our sales team will generate the quote and return to the submitter .

Required Sold Paperwork

• Employer Group Application

• HMO Contract/Exhibit B

• Access from online secure agent portal

• Reconciled Quarterly Tax & Wage

• Any policies (ex: Medical Leave)

• Employee Enrollment Applications

• Paper Application

• myEnrollment

Groups may request a coverage effective date of the first of any month subject to the timely receipt of the following:

• For an effective date of the first of the month, all required paperwork (indicated below) must be completed and received by Sanford Health Plan Sales no later than the 15th of the month prior to their effective date All sold paperwork will be submitted through the broker portal

• If the 15th falls on a Saturday, then required paperwork is due on Friday the 14th . If the 15th of the month falls on Sunday, required paperwork is due on Monday the 16th If a due date falls on a holiday, the due date will be the next business day

• If required paperwork isn’t received by the 15th of the month prior to the effective date, Sanford Health Plan will push the effective date to the first of the following month .

Broker Requirement:

Agents are required to provide pre-enrollment documents to the group prior to their effective date

These documents include:

• Employee Decision Guide

• Group Special Notices

• Group SBCs

All documents are located on the agent portal .

IMPORTANT: If requesting printed materials for meetings the order must be requested at a minimum of 10-business days prior to the due date The order must be submitted with all sold/renewal paperwork If the request falls inside that 10-business day requirement it is the agents responsibility to accommodate, all necessary materials (except large group SBC’s) can be accessed from our secure agent portal . Agents will also receive all electronic documents via email

Multiple Plan Options

The number of plan choices that a group may select to offer to the employees of the group depends on employee size:

• 1-5 total employees: The group may offer a maximum of 1 plan options 2 plan options when electing TRUE plans side by side Simplicity

• 6-50 total employees: The group may offer a maximum of 3 plan options . 6 plan options when electing TRUE plans side by side Simplicity

IMPORTANT: Plan options offered must be in a consecutive metal level (Bronze and Silver, Silver and Gold, Gold and Platinum)

Employees may select or change between multi-plan options:

• Upon initial enrollment

• On the group’s renewal date (open enrollment)

• If the group is adding, eliminating or changing a multi-option product mid-year and if the new product is a lower cost product than the product(s) currently being offered, employees enrolled in a higher or eliminated option will be allowed to transfer to one of the lower cost options

• When the employee or dependent becomes eligible for a qualified life event

• If there is a significant disruption of the provider network (to be determined at the sole discretion of Sanford Health Plan)

• Changes to a deductible plan is limited to one per year

• Restricting products by class of employee is not recommended, and will be evaluated upon request

Mid-Year Plan Changes

Employers are allowed to make changes to their small employer plan offerings one time per year outside their open enrollment The quarterly rates for that plan change will be enforced

Deductible/Out-of-Pocket Maximum Commercial Credit

Sanford Health Plan deductible runs calendar year Sanford Health Plan will give deductible/out-ofpocket credit from January 1st to the effective date of the group, provided the employer had a group health plan in place prior to electing coverage with Sanford Health Plan . Deductible/out-of-pocket credit will only be given if we receive the prior carrier deductible/out-of-pocket report or copy of member’s EOB’s within 60-days of the group’s original effective date

It is the agent responsibility to request these reports be sent to Sanford Health Plan within 60 days of the group’s effective date .

ACA Rating Information

Rate Information

• Rates will reset annually upon renewal .

• Rates can only vary by:

– Age of each member

– Children: A single age band for individuals age 0 through 14; and one-year age bands for individuals age 15 through 20 Adults: One-year age bands for individuals age 21 through 63 Older adults: A single age band for individuals age 64 and older

– Family Structure (when quoting a family, the number of premiums collected per child is capped at three, regardless of how many children age 20 and under are covered on the contract)

– Geographic Area (SD has rating regions)

– Tobacco Status (SHP does not have tobacco vs non-tobacco rate variation)

– Quarterly rates are filed annually in the small group market

Composite Rating

For the states of Iowa, South Dakota, and North Dakota composite rating is available as a pricing option . The specifics are below:

• Iowa and South Dakota: 4 tier rates, only one plan design may be selected

• North Dakota: adult/child rates or 4 tier rates, only one plan design may be selected

• Minnesota - not available

Actuarial Value (AV)

This is the amount on average that Sanford Health Plan will pay for medical costs after premium payments .

Essential Health Benefits (EHB)

These are the health benefit categories that must be required in all qualified health plans, but are not limited to:

• Ambulatory Patient Services, such as doctor’s visits

• Hospitalization

• Mental Health and Substance Use Disorder Services, Including Behavioral Health Treatment

• Rehabilitative and Habilitative Services and Devices

• Laboratory Services

• Emergency Services

• Maternity and Newborn Care

• Prescription Drugs

• Preventive and Wellness Services and Chronic Disease Management

• Pediatric Services including oral care, offered as part of a package or as a stand-alone plan

Maximum Out-Of-Pocket (MOOP)

For 2025, the annual cost-sharing limits cannot exceed $9,200 for an individual and $18,400 for families . This includes deductible, coinsurance, medical and pharmacy copay amounts

Employer Contribution for Group Health

The employer must contribute at least 50% of the Employee-Only cost for each enrolled employee The contribution amount may vary based on each employee’s age . The group may also vary the contribution amount by class of employee

Participation Requirements for Group Health

Below is a table containing the participation requirements/recommendations for the Sanford Health Plan service area

Contract Type

New

Renewal

South Dakota

70% Recommendation

North Dakota, Iowa, Minnesota

70% Requirement

The 70% minimum is calculated based on eligible employees, minus any valid waivers (i e spouses plan, Medicare, VA plan or ACA Individual coverage )

Specific Rules for Minnesota: Minnesota mandates a minimum participation level . However, Sanford Health Plan has chosen to be more lenient than the federal government and is applying it uniformly For states in which there is a minimum participation requirement (ND, IA, and MN) there will be an annual open-enrollment period from November 15-December 15 where new groups may apply for coverage regardless of participation percentage This open enrollment period will only apply to new groups, and the participation requirement will still be enforced at renewal

Employee Waiting Periods

An employer may impose a waiting period for new employees of up to 60-days . Since coverage always starts on the first of the month, the 60-day limit ensures compliance with the 90-day maximum waiting period under the Affordable Care Act

Waiting Period Options: First of the month following: Date of Hire, 30 Days, 60 Days

Employee Hourly Requirement

Sanford Health Plan currently offers coverage to small employers in SD and ND and certain counties within MN and IA Each state has specific law/criteria regarding hourly requirements for eligibility Please see below for your states criteria to ensure that you are compliant with this requirement . South Dakota and Minnesota: The small employer has the flexibility to choose their eligibility requirements in regards to what they define as an eligible employee North Dakota and Iowa: The small employer must offer coverage to eligible employees and their dependents An eligible employee is an employee who works on a full-time basis and has a normal work week of 30 or more hours Small employers must offer coverage at a minimum to those who meet these requirements .

Writing A Business of One

A one life group may be eligible if there is at least one common law employee who is eligible for coverage, i e , works an average of 30 hours per week

A common law employee is any W-2 employee that appears of the employer’s payroll and quarterly unemployment report Children of owners are considered to be common law employees, regardless of their age In a Corporation both owners and their spouses are considered to be common law employees as

long as they receive a W-2 Common law employees must appear on either the group’s payroll or Wage and Tax Report in accordance with state regulations .

All groups must have at least one common law employee in order to qualify as an employer and offer group health . Whether that employee enrolls with SHP is not a concern .

A sole proprietor, as defined by the Affordable Care Act, is any employer with no common law employees who work enough hours to be eligible for coverage .

Sole Proprietors, which include Husband-Wife groups, are not eligible for small group coverage

Late-Pay Termination Process

Active policies will “remain in force” until the 31-day grace period has ended (meaning coverage will not be rescinded or revoked and medical and pharmacy claims continue to be reimbursed)

NOTE: Per ND regulations, Sanford Health Plan must pay providers within 15 days of clean claim submissions

Non-effectuated groups (those that have NOT made a first payment) will not have claims reimbursed . Additionally,

• ACH (automatic withdrawal) of premium will be required to reinstate the policy .

• The delinquent premium in addition to the current month premium must be paid in full to be reinstated

• If a group is terminated due to non-payment of premium, a 6-month waiting period is required before applying for coverage at Sanford Health Plan

Renewal Information

Annual Renewal Process

Sanford Health Plan is committed to keeping the renewal process simple . A Renewal Checklist will be provided to indicate items to review on Group Health and additional information All required paperwork on the Renewal Checklist (indicated below) must be completed and received by Sanford Health Plan Sales no later than the 15th of the month prior to their effective date .

• If the Renewal Attestation Form and Exhibit B are not returned by the 15th of the month prior to the group renewal date or a 30-day notification of termination is not provided, the group will be autorenewed with the current (or closest matching plan available) at the renewal rate per the Sanford Health Plan contract Changes to the plan will not be accepted after the 15th of the month prior to the renewal date If the 15th falls on a Saturday, then required paperwork is due on Friday the 14th If the 15th of the month falls on Sunday, required paperwork is due on Monday the 16th . If a due date falls on a holiday, the due date will be the next business day

Required Renewal Paperwork:

• Renewal Attestation Form

• Renewal Plan Options & Rates (Exhibit B)

• Employee Enrollment (New, Changes, Terminations)

• Consumer Directed Health Plans Elections (Exhibit B)

• Employee Enrollment Options:

• Paper Application

• 834 File

• myEnrollment – paperwork due 30 day prior to the effective date for this option .

Provider Network Information

Access & Availability Rule

Appropriate access for Primary Care Physicians and Hospital Provider sites is within (ND-50, SD-30, MN-30, IA-30 miles) of a member’s residence Appropriate access for Specialty Providers is within (ND-50, SD-90, MN-60, IA-60) of a member’s residence If there are no Providers participating with Sanford Health Plan within the specified mile radius, then the member will be allowed to seek treatment at any Provider practicing in the same mile radius

Mayo Clinic Health System, Rochester, Rochester Methodist & St . Mary’s

Members must have certification/prior authorization from Sanford Health Plan to make an appointment and receive services from the Mayo Clinic Health System, Rochester, or St Mary’s Contact our Utilization Management Department at (605) 328-6807 or toll free at (800) 805-7938 for certification/prior authorization should a members Practitioner refer them to the Mayo Clinic Health System for services A physician referral only is not sufficient

To request prior approval the member’s primary care provider will need to submit a request to receive care at an out-of-network provider through their Sanford Health Plan provider portal as a “SHP 2nd Opinion OON” or “SHP Network Exception” referral with medical justification The request is reviewed for appropriate medical necessity or continuity of care . If approved, the service will process at innetwork benefit level

Network Options Outside of the Sanford Health Plan Service Area

PHCS Healthy Directions and MultiPlan Networks

Visit sanfordhealthplan com to locate a participating provider outside of the Sanford Health Plan service area Please note that this network is only available to members residing or attending school outside of the plan’s service area An out-of-area verification form is required to be completed for review and in-network authorization

TLC Network

Sanford Health Plan provides additional provider network access using the TLC Advantage network for access and availability in limited areas of South Dakota . Members with access to the TLC Advantage network providers will see the TLC Advantage network logo on the back of their ID Card These additional TLC Advantage providers can be seen at an in-network benefit level and will be viewable to the members when logged in to Sanford Health Plan’s online provider directory using their member ID .

Please note these additional network options can depend on plan selection .

Special Enrollment Periods

Special Enrollment Rights

Each year during open enrollment, members may elect benefits coverage for the coming year Once enrolled, a member cannot change his/her health insurance election unless they have a special enrollment period as listed below:

Change in family status affecting covered persons such as:

• Marriage or Divorce

• Annulment

• Death of a spouse or dependent child

• Birth or adoption of a child

• Loss of dependent status (a child reaches the age limit under the plan or is no longer eligible as a dependent)

Change in your employment status affecting your benefits such as:

• Beginning or returning from an unpaid leave of absence

• Sabbatical

• Change to/from part-time employment

Change in your spouse’s employment status causing a gain or a loss of health coverage for you or your dependents:

• Beginning or ending employment

• Increasing or decreasing hours

• Strike or lockout

• Open enrollment

Changes associated with a spouse’s open enrollment period including changes in the type and cost of coverage:

• Gain or loss of eligibility for Medicare/Medicaid for yourself, spouse, or child

What changes are allowed?

If a member has a qualifying event, the change made to the plan must be consistent with and appropriate for the new circumstances (see examples below) and it must be done within 31-days of the event:

If Then

You give birth to/adopt a child

Your spouse loses his/her job

Your dependent child attains the limiting age

You change your marital status

Your spouse’s open enrollment occurs

You must add the child within 31days of the birth/adoption

You must add your spouse within 31-days

You must drop coverage as of the end of that month

You have 31-days to add/delete dependents, based on the situation

Change takes effect

The day of the birth or adoption

The first of the month coincident with or following the qualifying event

Coverage ends the last day of the child’s birth month

The first of the month coincident with or following the qualifying event

Note: This is only a summary; please refer to plan documents for full details .

Dependent Eligibility

Below is the table for small group dependent eligibility by state .

“DEPENDENT AGE”

“STUDENT AGE”

Legal Spouse

Disabled dependent children older than age 26

Legally adopted children and children placed with you or your covered spouse for adoption

Biological children and stepchildren

Children for whom you or your covered spouse have been appointed legal guardian

Foster children placed with you or your covered spouse

Children allowed to obtain health coverage by a court order

Children of an unmarried eligible dependent (i e ., grandchild) who are not otherwise covered by situations listed above

Who is an Eligible

• Spouse

Dependent?

Yes; for continuation coverage only If a dependent’s coverage is already terminated due to turning 26, the dependent would not be allowed to come back onto the parent’s plan if they become disabled after age 26

Yes; if the unmarried parent of the grandchild is a covered eligible dependent and both the parent and grandchild are primarily dependent on the subscriber

• Children (under age 26) by: adoption, marriage, or legal guardianship

o Stepchildren are allowed on the plan if the child(ren)’s biological parent is covered under Sanford Health Plan policy

o If a dependent is disabled, they are eligible to stay on the plan by submitting an enrollment request

• Grandchild(ren):

o Allowed if the parent of the grandchild is unmarried, covered under the benefit plan, and the parent is primarily dependent on the subscriber for support

INDIVIDUAL PLANS

General Information

Simplicity Service Area

The Sanford service area consists of South Dakota and North Dakota .

TRUE Service Area

The Sanford service area consists of approved counties in South Dakota and North Dakota:

• South Dakota: Brown, Minnehaha, Lincoln

• North Dakota: Traill, Cass, Oliver, Burleigh and Morton

Applicant Requirements

To be eligible for individual plans an applicant must meet all the following requirements:

• Be a United States citizen or have a permanent green card

• Maintain a physical address in SD/ND

• Reside at that address for 9 or more months of the year (Sanford Health Plan reserves the right to verify and require proof of residency)

U . S . Citizenship Criteria

If an applicant does not have a United States Social Security Number, the applicant must prove they have a legal right to be in the United States Health coverage will not be offered until proof of citizenship in the United States is provided Acceptable documents for proof of citizenship or legal status in the United States are as follows:

• Valid U S Passport or Passport Card

• U . S . State or local government issued Certificate of Birth .

• Valid I-551, permanent resident card (issued by the Department of Homeland Security/U S Citizenship and Immigration Services) Non-expiring I-551 (issued 1977-1989) cards are acceptable .

• U S Certificate of Naturalization (federal form N-550)

• Certificate of U S Citizenship (federal from N-560)

• Un-expired foreign passport with a valid un-expired U . S . Visa affixed accompanied by the approval I-94 form documenting the applicant’s most recent admittance into the U S

Dependent Requirements

An adult dependent is eligible to become a covered person on a family plan if the dependent is under age 26 Coverage will continue to the end of the year the dependent child turns age 26 In SD, state law allows dependent children to continue coverage through age 29 if they meet full-time student status requirements .

Child-Only Policies

• For child-only coverage, the child must be under age 21 as of the effective date

• For multiple child-only coverage (sibling coverage), the children must be under age 26 as of the effective date Only those children covered under the age of 21 on the policy will be subject to the premium cap of 3

Splitting Contracts on Family Policies

Sanford Health Plan monitors the splitting of family contracts very closely We reserve the right to reach out to you or your clients directly to verify members are aware of the additional cost-sharing that may apply when contracts are separated . Sanford Health Plan requires members to be on different plans in order to split contracts

Catastrophic

Plan Requirements

Those who are considered eligible for catastrophic coverage are individuals under the age of 30 as of the effective date of the policy, or those who cannot afford coverage and obtain a hardship waiver from the Exchange at healthcare gov

Members Who Travel and/or Full-time Students out of the Service Area

Simplicity Members: Full-time students covered under a policyholder who are a resident of SD/ND are allowed to purchase and remain on our individual plans An out-of-area verification form is required to be completed for review and in-network authorization to our nationwide network

Sanford TRUE Members: Full-time students covered under a policyholder who are a resident of SD/ND are allowed to purchase and remain on our individual plans . Sanford TRUE members have urgent and emergent services covered at an in-network level while outside our service area These members do not have any out-of-network benefits or a nationwide network for any other services when outside the service area .

Members Who Establish Residency out of the Service Area

Members who establish residency outside the service area must notify Sanford Health Plan within a timely manner to ensure no disruption in coverage . Members become ineligible for our individual coverage once they have established residency outside of the service area or have lived outside of the service area for more than 90 consecutive days

SIMPLICITY INDIVIDUAL

NORTH DAKOTA AND SOUTH DAKOTA

Product Profile: Simplicity individual plans are offered to individuals in the Dakotas. These plans are a great option for the self-employed, those between jobs, early-retired, families or those no longer eligible for health insurance coverage under their parent’s plan. The Simplicity plans are qualified health plans that offer a variety of costsharing options.

9 plan options available: Off Exchange

9 plan options available: On Exchange; healthcare.gov

Broad Network

Video visits depend on your health insurance coverage. Credit, debit, HSA and FSA are accepted. Further details at sanfordhealthplan.com/virtualcare

Fitness Center Reimbursement and Wellness Services

Access to a nationwide network for dependents who reside outside the service area

$5 Comprehensive Preventive Drug Benefit for HSA Qualified Plans

Lab and X-ray copay on non-standardized copay plans

Pediatric Dental and Vision benefits built into all plan options

SANFORD TRUE INDIVIDUAL NORTH DAKOTA AND SOUTH DAKOTA

Product Profile: Sanford TRUE plans are offered to individuals in approved counties of the Dakotas. These plans are a great option for the self-employed, those between jobs, early-retired, families or those no longer eligible for health insurance coverage under their parent’s plan. The Sanford TRUE plans are qualified health plans that offer a variety of cost-sharing options.

9 plan options available: Off Exchange

9 plan options available: On Exchange; healthcare.gov

Focused Network

Video visits depend on your health insurance coverage. Credit, debit, HSA and FSA are accepted. Further details at sanfordhealthplan.com/virtualcare

Fitness Center Reimbursement and Wellness Services

No out-of-network coverage, except urgent and emergent services

Approximately 20% in premium savings compared to Simplicity plans

$5 Comprehensive Preventive Drug Benefit for HSA Qualified Plans

Lab and X-ray copay on non-Standardized copay plans

Pediatric Dental and Vision benefits built into all plan options

Quoting and Selling an Individual Policy

Quoting an Individual Policy

1 Access your AgentAdvisor Portal (agents sanford com)

2 Click Start Quote under Individual & Family

3 . Complete all required information

Required Information to Quote:

• Applicant Name

• Applicant State

• Applicant County

• Applicant DOB

4 .Review Plan options to generate a quote

5 Print or email quote proposal to your clients and/or prospects

Note: You can save your quote for later and resume at any time .

Writing an Individual Policy

Applying

for coverage directly

with Sanford Health Plan:

Applications must be submitted through the AgentAdvisor portal in order for agents to receive commission and be tied to the application . Log into AgentAdvisor to quote and enroll .

• An agent is encouraged to assist with the completion and submission of the application, however the applicant must sign and approve that all statements/disclosures are correct

• Parents must also sign the application and HIPPA section of the application for a child only policy

As an agent we encourage you to print a final PDF version of the online application at the end of your submission for you and your client’s records .

NOTE: Paper applications are only allowed if you have received an exception .

Acceptance Letters from Sanford Health Plan

An acceptance letter will be issued within 5-7 business days during open enrollment, and once an application is considered ‘complete’ during special enrollment periods This letter will be mailed directly to the policyholder indicating their confirmation of coverage, the effective date, plan selected, monthly premium, and covered dependent(s) . An agent will also get emailed a copy of this letter for their records This letter indicates the application has been processed in our enrollment system

Applying for coverage through the Exchange at healthcare .gov:

When applying for coverage through the Exchange at healthcare gov you must follow federal guidelines . Effective dates and enrollment periods are the same, but there will be differences when it comes to making changes to a policy, how premium billing is initially collected etc If you are assisting your clients with application through the Exchange, you must provide your clients with your National Producer Number (NPN) . Your client will submit your NPN as part of the online Exchange application to ensure commissions are appropriately contributed to you/your agency prior to any application submissions Visit healthcare gov for more information

Note: Marketplace/Exchange coverages are passively enrolled early October every year therefore, Marketplace/Exchange FFM training must be complete by October 1st every year in order to receive commission for Marketplace/Exchange business .

Member ID Cards and Welcome Packets

Once the applicant and dependent(s) are entered into our system, a Member Welcome Packet and ID cards are ordered and sent to the Member’s home address . The ID cards and packets are mailed separately Standard timeframe once an application has been entered into our system, ID Cards and Welcome packets will be issued within 7-10 business days However, significant delays can occur during the annual open enrollment period .

Note: Exchange members will not follow the above timelines . Member ID cards will not be issued for these members until their binder payment has been processed at Sanford Health Plan .

Temporary ID Cards

Member satisfaction is our top priority Therefore, Sanford Health Plan allows members to view a copy of their ID card via mySanfordChart as soon as their coverage has been loaded into the system Additionally, for those who do not have myChart access, agents can request a copy of their temporary ID card by emailing their account manager or sales@sanfordhealth org

Policy Changes and Terminations

Policy Changes

Name, contact and banking information are the only policy changes, other than special enrollment periods, that can take place outside annual open enrollment . Benefit changes can only be made during the annual open enrollment period Once an individual has made a benefit selection within the annual open enrollment period, they are locked into that plan until the next open enrollment period Changes cannot be made after Dec . 15, unless there is qualification for a special enrollment period .

Policyholder Changes

Anytime the policyholder needs to be changed on a current policy a new application is required to be submitted to Sanford Health Plan . We require the current plan to remain the same outside of the annual open enrollment period and no spouse or dependents may be added to the policy unless they meet and qualify for a special enrollment period Anytime the policyholder changes throughout the year it’s important to know when new policy goes into effect the correct premium age of each covered member will be adjusted

Cost-Sharing Accumulators

Simplicity

On Exchange Off Exchange No Off Exchange On Exchange No On Exchange

Right to Cancel and Return Policy

Applicants may cancel within ten (10) days after receiving the policy by mail A policyholder may decline coverage by returning the policy and ID cards to Sanford Health Plan . A written notice should accompany the policy and ID cards, stating the decision to not accept the policy The policy will be considered void from the original effective date and premiums paid will be refunded If claims have been paid during the inspection period, Sanford Health Plan has the right to recover any amount paid . Policies purchased through the Exchange must be canceled through healthcare gov

Policy Holder Written Request for Termination

The policyholder must provide Sanford Health Plan a written request for termination prior to the termination date The coverage will terminate at 11:59 pm on the last day of the month in which the request is received unless a later date has been requested . Any premium refunds will be paid the month following termination Mid-month terminations will not be accepted Policies purchased through the Exchange must be terminated through healthcare gov

Termination due to Non-Payment - Outside of the Exchange

ACH is required for all individual policies If the ACH is returned for non-sufficient funds, members have a 30-day grace period A letter will be sent to the member informing them that their payment is past-due .

If three non-sufficient funds transactions occur in a 12-month period, Sanford Health Plan reserves the right to terminate coverage . Any ACH payment in which the member subsequently revokes the payment or issues a stop payment will result in immediate termination

Termination due to Non-Payment - Inside of the Exchange

There are differences in how the grace period for non-payment of premiums would work for individuals receiving advance premium tax credits (APTC) inside the Exchange

Sanford Health Plan must provide a grace period of three (3) consecutive months if a member is receiving advance premium tax credits (APTC) and has previously paid at least one-month’s premium during the benefit year We will pay all appropriate claims during the first month of the grace period because they are receiving the advance payment of premium tax credits . However, Sanford Health

Plan will pend claims in the second and third months of the grace period If premiums are not paid by the end of the grace period, the member’s coverage is retroactively terminated to the first day of the second month in the grace period .

Exchange members not receiving advance premium tax credits (APTC) are given a 30-day grace period A letter will be sent to the member informing them that their payment is past-due . If payment is not received within the 30-day grace period, the member will be terminated

Reapplication

When a policy is terminated due to non-payment of premium, an applicant cannot reapply for coverage until the next annual open enrollment period .

ACA Rating Information

Rate Information

• Rate and age adjustments will reset annually on January 1

• Rates can only vary by:

– Age of each member

– Family Structure (when quoting a family, the number of premiums collected per child is capped at three, regardless of how many children age 20 and under are covered on the contract)

– Geographic Area (SD has rating regions)

– Tobacco Status (SHP does not have tobacco vs non-tobacco rate variation)

Actuarial Value (AV)

This is the amount on average that Sanford Health Plan will pay for medical costs after premium payments .

Essential Health Benefits (EHB)

These are the health benefit categories that must be required in all qualified health plans, but are not limited to:

• Ambulatory Patient Services, such as doctor’s visits

• Hospitalization

• Mental Health and Substance Use Disorder Services, Including Behavioral Health Treatment

• Rehabilitative and Habilitative Services and Devices

• Laboratory Services

• Emergency Services

• Maternity and Newborn Care

• Prescription Drugs

• Preventive and Wellness Services and Chronic Disease Management

• Pediatric Services including oral care, offered as part of a package or as a stand-alone plan

Maximum Out-Of-Pocket (MOOP)

For 2025, the annual cost-sharing limits cannot exceed $9,200 for an individual and $18,400 for families . This includes deductible, coinsurance, medical and pharmacy copay amounts

Premium Payments

Payments

Premium payments vary depending on if the individual plan is submitted through Sanford Health Plan directly or through the Exchange at healthcare gov

Premium Payments - Outside of the Exchange

ACH/EFT Automatic Withdrawal

ACH Form and voided check must be provided with the application

Premium Payments - Inside of the Exchange

ACH/EFT Automatic Withdrawal

ACH Form must be received by the 10th of the month prior to the effective date of the policy Funds withdrawn on the 20th of the month prior to the effective date of the policy

Funds withdrawn on the 10th of the month in which it is due (i e January premium will be withdrawn on January 10th)

Paper check, cashier’s check or money order

Pre-paid Debit Cards, Credit Cards or eCheck

Funds must be received by the last day of the month the policy is effective or within 30 days of application . (i .e . Effective March 1 due by March 31 .

Transaction can be processed in our office or over the phone . Funds must be received by the last day of the month the policy is effective or within 30 days of application (i e Effective March 1 due by March 31

Binder payments can be paid through healthcare gov account, check, or by calling customer service at (800) 752-5863

Funds withdrawn on the 20th of the previous month (i e February premium will be withdrawn on January 20th)

Any binder payments, past due amounts, and new premium would be drafted upon next draft date ACH is received It is important to pay all amounts prior to setting up ACH to prevent larger then expected drafts

Received by the 5th of the month (i e January 5 for January premium)

Transaction must be processed by the 5th of the month (i .e . January 5 for January premium)

Note: Exchange members will receive a monthly invoice for their premium if they are not set up for monthly ACH/EFT Automatic Withdrawal. Invoice will generate around the 18th of the month.

Special Enrollment Period applicants must pay their 1st month’s premium payment to effectuate coverage. Applicants have 30 days from the date of their application submission to make this payment.

Premium Payments – Outside of the Exchange for Retro Effective Dates

Applicant will pay balance due at the first draft date For example, if the first draft occurs a month after their effective date, they will have an ACH withdrawal of two months to make their premium payments current . Sanford Health Plan has pro-rated premiums that will apply for a mid-month effective date .

Premium Payments – Inside of the Exchange for Retro Effective Dates

Applicant has 10 days from the date of the payment letter to submit premium for any retro effective date sold through the Exchange

Provider Network Information

Access & Availability Rule

Appropriate access for Primary Care Physicians and Hospital Provider sites is within (ND-50 miles, SD-30 miles) of a member’s residence Appropriate access for Specialty Providers is within (ND-50 miles, SD-90 miles) of a member’s residence If there are no Providers participating with Sanford Health Plan within the specified mile radius, then the member will be allowed to seek treatment at any Provider practicing in the same mile radius

Mayo Clinic Health System, Rochester, Rochester Methodist & St . Mary’s

Network Options Outside of the Sanford Health Plan Service Area

PHCS Healthy Directions and MultiPlan Networks

Visit sanfordhealthplan com to locate a participating provider outside of the Sanford Health Plan service area Please note that this network is only available to dependents residing outside of the plan’s service area . An out-of-area verification form is required to be completed for review and innetwork authorization

TLC Network

Sanford Health Plan provides additional provider network access using the TLC Advantage network for access and availability in limited areas of South Dakota Members with access to the TLC Advantage network providers will see the TLC Advantage network logo on the back of their ID Card These additional TLC Advantage providers can be seen at an in-network benefit level and will be viewable to the members when logged in to Sanford Health Plan’s online provider directory using their member ID

Please note these additional network options can depend on plan selection .

Annual Open Enrollment Period

Annual Enrollment Period

Timeframe: November 1 – January 15

Important: This is the only time throughout the year that benefit changes can be made outside of special enrollment periods Once an individual has made their final benefit selection within the open enrollment period, they are locked into that plan until the next open enrollment period

Annual Enrollment Effective Date

If you apply and application is received by this date… Your policy will be effective…

November 1 – December 15

December 16 – January 15

January 1

February 1

Special Enrollment Periods – Outside of the Exchange

If you have a qualifying life event, a special enrollment period is available where individuals can enroll in a new plan, dis-enroll in their current plan or make plan changes A new application must be completed when the individual has an SEP and would like to enroll in a new plan . The application and/or policy change request form must be signed and received by Sanford Health Plan within 60-days after the event Any additional documentation (i e proof of SEP) must be received by Sanford Health Plan within 60-days after the event as well .

Special enrollment periods are triggered by any of the following events indicated on our SEP grid . This grid will also reflect the required documentation and effective date that will be offered based on the qualified life event

Special Enrollment Periods - Inside of the Exchange

The individual must visit healthcare gov to notify the Exchange of the event SEP Events, notification timeframes, documentation and forms needed will vary from what is requested outside of the Exchange The individual will need to contact the Exchange directly for assistance

Simplicity & Sanford TRUE Individual Special Enrollment Periods (Qualifying Events) –

Outside the Exchange

SEP Event

Loss of Minimum Essential Coverage

Loss of group coverage

Discontinuation of a non-calendar individual plan

Exhaustion of COBRA

Loss of Medicaid or CHIP eligibility

Loss of dependent status (age off plan)

Marriage

Establish new contract for newly married

Addition of spouse and/or dependents

Divorce

Establish new contract for newly divorced

Event Notification

Within 60 days after the event

Who is Eligible1

Individual(s) who lost coverage

Individual, spouse and dependents

Within 60 days after the event

Individual and dependents

Removal of spouse and/or dependents

Within 60 days after the event

Individual and dependents Birth / Adoption / Foster

Establish a new Family contract

Establish a new Child Only contract

Addition of dependent

Death

Establish a new contract for remaining family members

Removal of policyholder to convert or make plan changes for remaining family members

Death of spouse or dependents

Within 60 days after the event

1 Eligible individual(s) can make changes to their current plan or apply for new coverage

Individual, spouse and dependents

Newly Born / Adopted Child

Individual, spouse and dependents

Individual and dependents

2 Receipt date between the 1st and 15th of the month, policy is effective first of the month following receipt Receipt date between the 16th of the month and end of the month, policy is effective the first of the second month following receipt

Simplicity & Sanford TRUE Individual Special Enrollment Periods (Qualifying Events) – Outside the Exchange

MEDICARE ADVANTAGE

Product Profile: Align powered by Sanford Health Plan Medicare Advantage-Prescription Drug (MA-PD) plans offer standard Medicare benefits and more to Medicare beneficiaries in select counties in Minnesota, North Dakota, South Dakota, and Iowa Two plan options are available in each state: Align ChoicePlus and Align ChoiceElite .

Provider Network: All plans in each state are PPO plans which include both in-network and out-ofnetwork benefits A network provider must be utilized to receive in-network benefits The provider network can be found by visiting align sanfordhealthplan com

Over-the-counter benefits: Quarterly allowance for OTC products – at participating retail stores, online or via OTC catalog.

Dental coverage: Covered exams and cleanings and x-rays, with comprehensive services annual allowance.

Hearing benefits: Hearing exam and annual allowance for hearing aids.

Vision benefits: Covered routine exam and annual allowance for eyewear or contacts

Health navigator services: Acts as your personal health assistant, ready to answer questions and connect with the right resources

Meal services: Meal program when recovering at home after a hospital stay

Fitness incentives: Discounted fitness center membership and digital home options

Travel: Travel up to 6 consecutive months in U.S. and receive in-network benefits

Sales Fact Sheet

Plan Name: ALIGN POWERED BY

SANFORD HEALTH PLAN

Service Area

The service area for Align powered by Sanford Health Plan consists of approved counties in South Dakota, North Dakota, Minnesota, and Iowa

• Iowa: Lyon, O’Brien, Osceola and Sioux

• South Dakota: Brookings, Clark, Clay, Day, Deuel, Douglas, Hanson, Hutchinson, Kingsbury, Lake, Lincoln, McCook, Miner, Minnehaha, Moody, Roberts, Sanborn and Turner

• North Dakota: Barnes, Burleigh, Cass, Grand Forks, Griggs, McLean, Mercer, Morton, Nelson, Oliver, Ramsey, Ransom, Richland, Steele, Stutsman, Traill, and Walsh

• Minnesota: Becker, Beltrami, Big Stone, Clay, Clearwater, Hubbard, Lac Qui Parle, Mahnomen, Marshall, Nobles, Norman, Otter Tail, Pennington, Pipestone, Polk, Red Lake, Rock, Traverse and Wilkin

Eligibility

The following criteria must be met for an individual to be eligible for enrollment:

1 . Must be enrolled in Medicare Part A and Part B

2 Must continue to pay Part B premium

3 Must reside in the service area for at least six months per year

Sanford Health Plan will verify eligibility with CMS Enrollee will receive an acknowledgment and confirmation letter from Sanford Health Plan acknowledging the receipt of the application and confirm Medicare’s approval of the enrollment . If Sanford Health Plan receives notice of a permanent move outside of the service area the member will be automatically disenrolled from the plan

Quoting and Selling Medicare Advantage

Ready to Sell

1 . LICENSED: Agent is licensed in each state they are soliciting SHP products and has provided copies of licenses to SHP

2 . CONTRACTED: Agent is actively appointed with SHP and has passed a background check and provided proof of E&O coverage

3 . TRAINED: Agent has satisfactorily completed Medicare + Fraud, Waste, and Abuse training through AHIP or Pinpoint and SHP Medicare product-specific training

Do not sell MA-PD plans until you have received a “Ready to Sell” notification from Sanford Health Plan via e-mail

Enrollment

ELECTRONIC ENROLLMENT

Agents are required to submit enrollments electronically through the link in their AgentAdvisor portal A Scope of Appointment (SOA) should be completed in accordance with CMS’s Medicare Marketing Guidelines and uploaded at the end of the electronic enrollment process Enrollments may be initially recorded on a paper application and entered into the electronic enrollment portal within 24 hours of the initial application

A Primary Care Provider (PCP) should be selected during enrollment to ensure the beneficiary’s primary provider is in-network A PCP is essential for coordinated care that is well managed

PLAN CHANGES

To change plans, a member must submit a new application and have a valid enrollment election . The member will automatically be disenrolled from the existing plan

Trial Rights

Medicare Advantage Trial Rights apply to members who are enrolled in a Medicare Advantage Plan, but want to go (back) to Original Medicare during the first 12-months of their enrollment

Trial Rights apply in the following situations:

1 . A Member joined an MA Plan when they were first eligible for a Medicare Part A at 65 . Within the 12-months of joining the MA Plan, they decide they want to switch to Original Medicare (Trial Right) 2 A Member drops a Medicare Supplement Policy (not including Medicare Select) to join an MA plan for the first time . Within the first 12-months of joining the MA Plan, they decide they want to go back to a Medicare Supplement Policy (Trial Right)

During a Trial Right period, a member can go back to their previous Medicare Supplement plan (if they had one) or choose a new Medicare Supplement A member cannot use a Trial Right if they have already used it previously

Marketing Materials

Agents may only use Sanford Health Plan’s enrollment applications, forms, and marketing materials that have been approved by Sanford Health Plan . Agents and Agencies may not modify or incorporate any non-approved materials into any approved materials without Sanford Health Plan’s prior written consent

Approved marketing materials are located in the broker portal

Ordering Supplies

Printed materials should be ordered from your upline . If you have a direct contract with Sanford Health Plan you can e-mail sales@sanfordhealthplan .com to request materials be mailed to you Electronic materials are also available in the broker portal at sanfordhealthplan .com

Enrollment kits are specific to each state Be sure to order materials for each state you sell and only quote benefits based on the beneficiary’s resident state

Premium Payment

A member will elect to pay their premium via a monthly direct bill or Social Security/ Railroad Retirement deduction at enrollment .

Following their initial enrollment, a member who chose a monthly direct bill may switch to monthly ACH by completing a form available in the member portal This form is also available in the broker portal Key points on invoice/ACH dates for billing:

• All invoices are mailed on the 15th of the month prior to the effective period (i e invoice mailed on December 15 for a January 1 effective date)

• All invoices are due by the 10th of the month (effective coverage period) (i e in the above scenario, invoice would be due by January 10th)

• ACH withdrawals are all done on the 5th of the effective coverage period month (i e March 5th for March coverage)

• Members who enroll during the latter half of the month would not be billed until the following month, even though their coverage will be effective . The first bill will include costs of 2 months to catch up

It may take up to three months for new payment methods to be updated . Members who make a change to their method of payment should continue to pay any invoice they receive Members may pay for more than one month at a time, at their discretion .

Important Benefit Information

• ChoicePlus and ChoiceElite plan benefits vary by state Be sure to quote correct benefits based on the beneficiary’s resident state specific plan

• In-network and out-of-network cost sharing contributes to the maximum out-of-pocket (MOOP)

• Prescription drug costs do not contribute to the medical MOOP

• Referrals are not required to see an in-network specialist

• Direct Access benefit allows members to receive select in-network services without prior authorization if ordered and performed at a Sanford facility The prior authorization listing is available at align sanfordhealthplan com

• A prior authorization is required to see an out-of-network provider at an in-network benefit level .

• Member Navigator – A Member Navigator acts as a personal assistant to answer questions, arrange transportation, and even connect the member with a Health Guide to accompany them to their medical appointments

Prescription Drug Coverage

• All Align powered by Sanford Health Plan ChoicePlus and ChoiceElite plans include prescription drug coverage .

• Mail order is available through OptumRx Members can also save more when using preferred pharmacies, including CVS, Gateway Pharmacy, Lewis Drug, Sanford Health Pharmacy, Seip Drug and Thrifty White Cost sharing for mail order is the same as a retail pharmacy

Supplemental Benefits

Please utilize the FAQs located in the “Additional Benefits” portion of the broker portal for details on Supplemental Benefits that are included at no additional cost in both the ChoicePlus and ChoiceElite plans

Provider Network

• The providers and pharmacies in the Align powered by Sanford Health Plan network are listed in the Provider Directory at align .sanfordhealthplan .com

• A network pharmacy must be used for pharmacy benefits Unique to SHP’s MA-PD plans, Walgreens is in-network for prescription drugs

• If the member uses an out-of-network provider, the share of the costs for their covered services may be higher

• Please note: While members can get their care from an out-of-network provider, out-of-network/ non-contracted providers are under no obligation to treat Align powered by Sanford Health Plan members, except in emergency situations .

• A member may request a prior authorization to receive in-network services at an out-of-network provider subject to Access and Availability rules .

Traveling Outside the Service Area

Sanford Health Plan allows members to travel outside of SD, ND, IA and MN up to six (6) cumulative months of the calendar year and receive in-network benefits from any provider who accepts Medicare . Out-of-network/non-contracted providers are under no obligation to treat Align powered by Sanford Health Plan members, except in emergency situations If a member plans to travel for more than one (1) month outside SD, ND, IA or MN, Sanford Health Plan asks they contact customer service to ensure claims process accurately

Urgent care and emergency room visits for covered services received in the United States are always covered at an in-network benefit level These plans do not cover services received outside the United States

Enrollment Periods

When can a member apply?

You can find information about Election Period options by visiting medicare .gov or click HERE

Star Rating

You Can Positively Impact Star Rating

Star Ratings are important well beyond using them as a sale’s tool . Star Ratings impact plan funding and our ability to invest additional funds into supplemental benefits, reduced premiums, and reduced out-of-pocket costs CMS bases these ratings on a multitude of criteria, most of which is member experience .

As an agent you are often the first interaction a member has with Sanford Health Plan The way you represent the plan, especially your representation of the benefits, can have a direct effect on Star Ratings It is important you are professional and accurate As a trusted advisor, you can also encourage a member to complete their health risk assessment which will guide our care team in making recommendations to the member, helping them fully utilize their benefits and seek services to properly care for their conditions

Important

Phone Numbers

Customer Service Phone: (888) 278-6485 | TTY: (888) 279-1549

Hours: 8 a .m . — 8 p .m . local time, 7 days per week October 1 — March 31; Monday — Friday April 1 — September 30

OptumRx (844) 642-9090 (TTY: 711), 24 hours a day, 7 days a week

BROKER REQUIREMENTS

General Requirements

Dedicated Team

As an appointed Agent you have a dedicated Sales & Retention team to reach out to ensure you have the support and resources needed to succeed . Your dedicated Account Executive will work closely with you on all sales opportunities, collaboration, strategic initiatives, and client reporting and ongoing needs Your dedicated Account Manager will handle all day-to-day support for all your client and individual/MAPD member needs . If you are unsure who your dedicated team is, please reach out to sales@sanfordhealth .org

License and Appointments

A writing agent who submits application for any line of business must be properly contracted and certified in the product in which the employer group or individual/MAPD consumer enrolled . A writing agent must be licensed with an active health-related line of authority and appointed with Sanford Health Plan in the state(s) in which the employer group or individual/MAPD consumer resides, as of the application date of the policy .

As an appointed agent, you are responsible for informing Sanford Health Plan Sales immediately in the event your state agency or agent license lapses Upon lapse of license, the state(s) automatically terminate your appointment To ensure you continue to receive commission you must notify Sanford Health Plan Sales upon license reinstatement for us to reappoint you with Sanford Health Plan .

Annual Requirements

Online Training and Exams

Sanford Health Plan releases Online Training and Exams modules annually and the testing is required for all appointed agents The products you have been trained to represent, along with your current business with Sanford Health Plan will determine which modules you are required to complete

In order to remain a writing agent for a line of business, you must pass the required online annual agent training and exams You will receive an email once training has been launched with directions on how to login . The online training and exams must be completed within 30 days . Choosing to not complete these annual trainings could result in termination of your appointment with Sanford Health Plan

Summer Sneak Peek (In-Person)

Sanford Health Plan Summer Sneak Peek are in-person events that provide agents an exclusive preview of all the exciting changes and strategic initiatives cooking for the upcoming plan year . Our gatherings are designed to be both informative and enjoyable for our valued agents, providing you with exciting insights and new connections . We have fun activities and drawings for prizes for our in-person attendees These events are typically hosted in July and give agents and our entire Sales & Retention team the opportunity to meet face to face

Fall Agent Training (Virtual)

Sanford Health Plan Fall Agent Training is held virtually . This annual event will dive into the latest rate changes, plan updates, and other crucial information to equip you for the upcoming open enrollment season These events are typically hosted in September

Minimum Book of Business

With the exception of General Agencies (GA’s), agencies producing for Sanford Health Plan must maintain a minimum book of business with Sanford Health Plan of at least five (5) contracts of either individual, Medicare Advantage or group is required Contracts are counted at the agency level Failure to maintain this requirement will result in the agency and all appointed agents within that agency to be terminated Agencies will not be considered for reappointment for two (2) years . The minimum book of business requirements are reviewed on an annual basis

GA’s will be reviewed on an annual basis and work alongside Sanford Health Plan to determine production standards specific to production ability and by product line

Weekly Agent Newsletter

Every Friday, Sanford Health Plan emails agent’s a weekly electronic newsletter with important updates This is our standard notification process to keep you informed of important items to include: all line of business updates, important operational and business rule changes, upcoming requirements and events Always keep your email address up to date in our system to ensure no disruption in communication It is your responsibility to report to your Account Executive if you are not receiving these weekly communications

Resources and Marketing Material

All resources and marketing materials are available through our secure agent portals Depending on the lines of business you are approved to sell will determine which portal to access .

Legacy Portal login requires your agent ID and password This portal provides access to resources and materials for Large & Small Group, Individual and Medicare Advantage . AgentAdvisor login requires email address and password This portal provides access to resources and materials specific to Individual and Medicare Advantage only . This portal also allows you to enroll Individual and Medicare Advantage prospects

If you are unsure of your login credentials, please reach out to your dedicated team for assistance .

Agent Compensation

A writing agent who submits application for any line of business is only eligible for a commission if he/she is properly contracted and certified in the product in which the employer group or individual consumer enrolled . A writing agent must be licensed with an active health-related line of authority and appointed with Sanford Health Plan in the state(s) in which the employer group or individual consumer resides, as of the application date of the policy In order to remain a writing agent for a line of business, you must pass the required online annual agent exams . If you fail, you do have the option to attend a new agent training to remain approved

You are required to service our clients and members to the highest level in order to receive a commission We reserve the right to remove you as the agent of record and to discontinue paying you commissions if it is determined that you are not meeting our expectations .

Sanford Health Plan does not allow any arrangements to share or split any payment or commission with our clients or members .

For full details on our commission schedule by line of business, please refer to your Agent Appointment contract .

In addition to the above guidelines that are required for all lines of business, there is additional guidance on some of the lines of business below that are very important for your review .

Line of Business Requirements

Large Group

Upon quote submission of a large group, the agent commission structure (standard, net, PCPM) must be clearly indicated on the quote questionnaire and cannot be revised once the group has been underwritten The quote released from Sanford Health Plan will indicate the commissions requested It is the writing agent’s responsibility to review the commissions quoted for accuracy prior to presenting to the employer group and at time of final sale per the contract guidelines .

Individual Marketplace – On Exchange

An agent is entitled to receive commissions for the entirety of the Plan Year (PY) they are appropriately certified for so long as the agent has completed FFM registration and certification, including required training for the applicable plan year, before the application date of assisting consumers

Passive (renewal) enrollment files are usually loaded mid-October for the upcoming Plan Year In order to receive commissions for passive (renewal) enrollments the agent must be certified prior to the passive enrollment load into our system . To ensure no disruption in commissions, we strongly encourage agents to complete their annual FFM registration and certification no later than October 1st for the upcoming Plan Year

If an agent is properly licensed and certified to sell PY2024 plans but does not have required recertification for P2025, the agent would receive commission payments through the coverage end date(s) of the PY2024 plans sold and no longer receive commission payments in PY2024.

Example: If an Agent sold a plan on 11/1/23 for P2025, but did not become properly certified to do so until 11/2/24, the Agent will not be paid for the 12 months’ worth of commissions relating to that member application.

Agent Compliance Monitoring:

As an appointed agent with Sanford Health Plan there are various terms and conditions related to oversight for our Federally Facilitated Marketplace (FFM) individual line of business . Agents are considered delegated or downstream entities on behalf of Sanford Health Plan and shall participate in any oversight or monitoring as described in the retail agent agreement Sanford Health Plan monitors agent performance through various areas of quality of service, compliance with regulations, policies, and procedures on a routine basis to ensure compliance and areas for process improvement

Sanford Health Plan selects a random sampling of agents during these active monitoring periods . The monitoring periods for the upcoming calendar are communicated annually in our January weekly agent newsletter

Medicare Advantage

AHIP Certification:

In order to sell Medicare Advantage and Part D plans for the current and upcoming plan year, an agent must complete the annual Medicare and Fraud, Waste, and Abuse (FWA) training that is compliant with the CMS Sanford will require a copy of your AHIP Certificate to ensure you are aware of and understand the latest CMS guidelines and regulations

First Look Training:

Annually in August, Sanford Health Plan provides virtual training to inform agents about the exciting updates coming for the Align powered by Sanford Health Plan Medicare Advantage new plan year . This provides agents an opportunity to ask questions to become ready to sell for AEP

The Sales Workshop training will be provided at the end of the First Look training for those agents that want to Host a Workshop

Host a Workshop:

As an appointed agent for Align Powered by Sanford Health Plan, you have the opportunity to host a workshop for potential enrollees . By choosing your own date, time and venue, you can put the success of your business in your own hands We will equip you with everything you need to host a successful Medicare Advantage educational sales event These events have shown great success in the past for generating high quality leads for our valued agents .

In order to participate simply:

• submit your AHIP training certificate

• complete the Medicare Advantage annual online training and exam

• attend the annual First Look training for the upcoming plan year

• complete the annual Sales Workshop training

Reach out to your Account Executive for more information and the link to register to host an event Once your location and information is received by Sanford Health Plan we will include your events in our event marketing efforts to help drive potential business You will have access to place ads in local media, send email invitations, or hang flyers using our pre-approved templates

Agent Compliance Monitoring:

As an appointed agent with Sanford Health Plan there are various terms and conditions related to oversight for our Medicare Advantage (MA) line of business Retail agents are considered delegated or downstream entities on behalf of Sanford Health Plan and shall participate in any oversight or monitoring as described in the retail agent agreement . Sanford Health Plan monitors agent performance through various areas of quality of service, compliance with regulations, policies, and procedures on a routine basis to ensure compliance and areas for process improvement

Sanford Health Plan selects a random sampling of agents during these active monitoring periods The monitoring periods for the upcoming calendar are communicated annually in our January weekly agent newsletter .

Agent of Record Requests (AOR)

Group

Group AOR requests must be submitted using Sanford Health Plan’s Employer Agent of Record (AOR) Request form Sanford Health Plan will not process AOR requests submitted in any other format The form must be completed in full and signed by the employer

The requested new agent must be licensed, appointed and trained with Sanford Health Plan prior to the submission and approval of this form Upon approval, the effective date will be determined based on receipt date of the completed form . If the complete Employer AOR request is received on or before the 10th of the month, the change will become effective on the first of the month immediately following unless otherwise rescinded by employer

Individual

Individual AOR requests must be submitted using the Sanford Health Plan Agent Request form . Sanford Health Plan will not process AOR requests submitted in any other format The form must be completed in full and signed by the contract holder

The requested new agent must be licensed, appointed and trained with Sanford Health Plan prior to the submission and approval of this form Upon approval, the agent change will be effective the first of the month following the process and approval of the AOR request . The current agent will receive written notification of this AOR transfer and effective date of change If request is denied the requested new agent and client will receive written notification

Note: For Marketplace members, you are responsible to update you Agent NPN on the member’s Marketplace account for the AOR to remain active . If a new file feed (active or passive) is received by CMS for the member, then we must use the NPN listed on the member’s Marketplace record as source of truth .

Medicare Advantage

Sanford Health Plan does not allow AOR requests for Medicare Advantage policies Reach out to your dedicated team to determine if this business rule has changed since the publish dates of this manual

Privacy Information

Overview

This section is intended to give an overview of what protected information is, what constitutes protected information misuse, and how Agents should work with Sanford Health Plan Sales to protect individual information

Definition of Protected Information

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires HIPAA covered entities and their business associates to protect all individually identifiable health information and to provide notification following a breach of unsecured protected health information

Protected Health Information (PHI)

Under HIPAA, protected health information (PHI) is considered to be individually identifiable information relating to the past, present, or future health status of an individual that is created, collected, transmitted, or maintained by a HIPAA covered entity in relation to the provision of healthcare, payment for health services, or use in the health operations PHI is any health information that can be tied to an individual .

Proper Use of Protected Information

Agents are permitted to create, collect, disclose, access, maintain, store, and use enrollee PHI only to perform functions that they are authorized to perform as Agent . This includes assisting a potential insurance enrollee in applying for health care coverage, enrolling in coverage, and helping with questions related to member use of their coverage Agents should handle this information with care and should not disclose it to parties who they do not have authorization to release it to or for functions outside of what they were given consent for its use

Definition of Breach

A breach is, generally, an impermissible use or disclosure under HIPAA that compromises the security or privacy of PHI An impermissible use or disclosure of protected information is presumed to be a breach unless it can be demonstrated that there is a low probability that the protected health information has been compromised . Privacy breaches may occur as a result of:

• system failure (example: an automated letter-stuffing machine jams and causes letters to be inserted into the wrong envelopes)

• theft (example: a laptop containing personal information is stolen from the office)

• employee error (example: an email containing a client’s information is sent to the wrong email address),

• intentional employee action (example: an employee purposefully accesses an individual’s data when there is no operational requirement to do so)

Information Security Expectations

When acting on behalf of Sanford Health Plan Sales in the service of health insurance enrollees and members, Agents are expected to treat individual data with the utmost care and diligence In the event of a suspected breach, Agents are expected to notify Sanford Health Plan Privacy Officer without delay Sanford Health Plan Privacy Officer will complete a data breach risk assessment to determine if further individual and state and federal agency notification is required