Sanford Health Plan Agent Manual Plan Year 2023

Sanford Health Plan

PO Box 91110

Sioux Falls, SD 57109-1110

(605) 328-6868 Toll-Free: (877) 305-5463 Fax: (605) 328-6811 sanfordhealthplan.com

Dear Valued Agent,

On behalf of the entire Sanford Health Plan team, thank you for your partnership. Your individual success drives our collective success, and we are grateful for your commitment to our shared goals.

This is an exciting time to be a part of Sanford Health Plan. In January, we officially launched our Medicare Advantage product, Align powered by Sanford Health Plan and, thanks to the incredible work of our agents, exceeded our enrollment goal. Medicare Advantage continues to be a priority area for us.

Through our integration with Sanford Health, we’re working to expand our regional footprint and become the premier rural payer in the United States. Many of our current members reside in rural areas but we know there is a need to bring comprehensive, affordable coverage to even more rural residents. We look forward to providing these members with innovative tools to ensure they have access to care when they need it, no matter where they live.

As we continue to evolve and improve our role as advocates and partners for your clients and members, we value your feedback. The work we do would not be possible without your commitment and dedication to building your business alongside ours.

Throughout open enrollment season and beyond, we are committed to helping you and our entire team succeed by making sure you have the support you need. Thank you for your ongoing partnership.

Sincerely,

John Snyder President, Sanford Health Plan

TABLE OF CONTENTS

TAB 1

LARGE

EMPLOYER

PLANS – 2023

General Information 9

Signature Series Plan Profile and Sales Fact Sheet 14

Sanford PLUS Plan Profile 16

Sales Fact Sheet ................................................. 17

Sanford PLUS Eligibility Maps ...................................... 20

Sanford TRUE Plan Profile and Sales Fact Sheet ....................... 28

Sanford TRUE Eligibility Maps 30 2023 Large Employer Options 38

Quoting & Selling Large Group 40

Late-Pay Termination Process 41

Renewal Information 41

Provider Network Information 42 Special Enrollment Periods 43 Dependent Eligibility .............................................. 44

TAB 2

SMALL EMPLOYER PLANS

General Information .............................................. 50

Simplicity Plan Profile and Sales Fact Sheet 53

Simplicity 2023 Plan Options 55

Sanford TRUE Plan Profile and Fact Sheet ............................ 61

Sanford TRUE 2023 Plan Options 63

Sanford TRUE Eligibility Maps 69

Quoting & Selling Small Group ...................................... 77

ACA Rating Information 77

Late-Pay Termination Process 82

Renewal Information 82

Provider Network Information ...................................... 83 Special Enrollment Periods 83 Dependent Eligibility 86

TAB 3

INDIVIDUAL PLANS

General Information 91

Simplicity Plan Profile ............................................. 93

Simplicity 2023 Plan Options 94

Sanford TRUE Plan Profile 105

Sanford TRUE 2023 Plan Options ................................... 106

Quoting and Selling an Individual Policy 116

Policy Changes and Terminations 117

ACA Rating Information 119

Premium Payment Information 120

Provider Network Information 122

– 2023

– 2023

LARGE EMPLOYER PLANS

General

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Signature

. . . . . . . . . . . . . . . . . . . 14 Sanford

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

. . . . . . . . . . . . . . . . . . . . . . 28

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 employer 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.

State Large Group Definition

Iowa 51 or more total employees

Minnesota 51 or more total employees

North Dakota 51 or more total employees

South Dakota 51 or more total employees

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.

When selecting the plans, the following restrictions will be in place for the spread:

• If non-HSAs are selected, then the maximum spread in deductibles is 2 times the least rich plan or $2,000 whichever is greatest.

• If a non-HSA and a 100% HSA is selected, the OPM for the highest deductible non-HSA in compliance with the first bullet point must be at least as high as the 100% HSA deductible.

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

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/xray 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 soption 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.

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.

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.

If the prior carrier allows, 2 reports can be submitted, 1 at initial enrollment and one just prior to the 60-day limit. Employee Explanation of Benefits (EOBs) are also accepted.

Plan 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

Broad 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

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

Sales Fact Sheet

Plan Name: SIGNATURE SERIES Provider Network: BROAD Service Area

The Sanford service area consists of South Dakota, North Dakota, and approved counties of Iowa and Minnesota (indicated below):

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

• Minnesota: 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.

Plan 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 sideby-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.

Sales Fact Sheet

Plan Name: SANFORD PLUS Provider Network: TIERED

Service Area

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

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:

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

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

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

d. North Dakota, Minnesota & Iowa: 50% of eligible employees must reside in the SanfordPLUS approved zip codes.

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

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

• 101+ employers 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 who cover college students who attend school out of the Sanford PLUS service area are eligible for the Sanford PLUS Plan, however, must acknowledge that most providers are at Tier 2 level.

2. An out-of-area verification form will be required to get access to our nationwide network. For urgent and emergent care services claims will process as a Tier 1 provider.

3. Subscribers who 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).

4. 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 members

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

5. Prior-Authorizations:

a. The presence of an authorization for out-of-network providers will apply to Tier 2.

b. Absence of a referral, when required, results in the claim being processed against the next lowest tier.

c. If a claim is appealed for reconsideration and approved, the claim will process according to the network level of the provider (unless emergency or access/ availability factor in).

Use of Tier 1=Tier 1 cost share

Use of Tier 2=Tier 2 cost share

Use of OON=OON.

Sanford-PLUS

Deductible

Coinsurance

$xxxx (see options grid) 2x the Tier 1 deductible amount 3x the Tier 1 deductible amount

90%/10% or 80%/20% 20% more than Tier 1 coinsurance 10% more than Tier 2 coinsurance – not to fall below 50% coinsurance.

MOOP See options grid See options grid 3x the Tier 1 MOOP

Office Visits $xx copay (see options grid) $20 more copay than Tier 1 copay amount

Ded/Coinsurance

South Dakota – PLUS Employee Eligibility Large Group Zip Codes

Zip 57001 57002 57003 57004 57005 57006 57007 57010 57012 57013 57014 57015 57016 57017 57018 57020 57021 57022 57024 57025 57026 57027 57028 57029 57030 57031 57032 57033 57034 57035 57036 57037 57038 57039 57040 57041 57042 57043 57045 57046

Zip 57047 57048 57049 57050 57051 57052 57053 57054 57055 57057 57058 57064 57065 57067 57068 57069 57070 57071 57072 57073 57075 57076 57077 57078 57101 57103 57104 57105 57106 57107 57108 57109 57110 57117 57118 57186 57193 57197 57198 57201

Zip 57212 57213 57216 57217 57218 57219 57220 57221 57223 57224 57225 57226 57227 57231 57232 57233 57234 57235 57236 57237 57238 57239 57241 57242 57243 57245 57246 57247 57248 57249 57251 57252 57255 57256 57257 57258 57259 57260 57261 57262

Zip 57263 57264 57265 57266 57268 57269 57270 57271 57272 57273 57274 57276 57278 57279 57317 57319 57322 57325 57326 57331 57335 57339 57341 57342 57348 57353 57355 57356 57365 57366 57368 57369 57370 57374 57375 57376 57380 57383 57401 57402

Zip 57421 57422 57424 57426 57427 57428 57429 57430 57432 57433 57434 57435 57436 57438 57439 57440 57441 57445 57446 57449 57451 57454 57460 57461 57465 57466 57468 57469 57471 57473 57474 57475 57476 57477 57479 57481 57523 57528 57529 57533

Zip 57534 57538 57541 57544 57548 57555 57563 57566 57568 57569 57570 57571 57572 57576 57580 57584

North Dakota – PLUS Employee Eligibility Large Group Zip Codes

Zip 58001 58002 58004 58005 58006 58007 58008 58009 58011 58012 58015 58016 58018 58021 58027 58029 58030 58031 58035 58036 58038 58041 58042 58045 58046 58047 58048 58051 58052 58053 58054 58056 58057 58058 58059 58060 58061 58062 58063

Zip 58064 58065 58068 58071 58074 58075 58076 58077 58078 58079 58081 58102 58103 58104 58105 58106 58107 58108 58109 58121 58122 58124 58125 58126 58201 58202 58203 58204 58205 58206 58207 58208 58212 58214 58218 58219 58223 58228 58230

Zip 58233 58235 58240 58244 58251 58254 58256 58257 58258 58261 58266 58267 58272 58274 58275 58277 58278 58361 58416 58425 58428 58429 58448 58452 58475 58477 58478 58482 58488 58494 58496 58501 58502 58503 58504 58505 58506 58507 58520

Zip 58521 58524 58528 58529 58530 58532 58535 58544 58545 58549 58552 58554 58558 58560 58563 58564 58566 58569 58570 58571 58572 58576 58577 58579 58631 58638

Minnesota – PLUS Employee

Eligibility Large Group Zip Codes

Zip 55785 56019 56022 56031 56039 56041 56060 56062 56073 56081 56083 56085 56087 56088 56101 56110 56111 56113 56114 56115 56116 56117 56118 56119 56120 56121 56122 56123 56125 56127 56128 56129 56131 56132 56134 56136 56137 56138 56139 56140 56141

Zip 56142 56143 56144 56145 56146 56147 56149 56150 56151 56152 56153 56155 56156 56157 56158 56159 56160 56161 56162 56164 56165 56166 56167 56168 56169 56170 56171 56172 56173 56174 56175 56176 56177 56178 56180 56181 56183 56185 56186 56187 56207

Zip 56208 56210 56211 56212 56214 56218 56219 56220 56221 56223 56224 56225 56227 56229 56232 56235 56236 56237 56239 56240 56241 56244 56245 56248 56255 56256 56257 56258 56263 56264 56266 56267 56270 56274 56276 56278 56280 56283 56287 56291 56292

Zip 56293 56294 56296 56297 56309 56311 56318 56324 56336 56339 56347 56360 56361 56433 56434 56435 56436 56437 56438 56440 56446 56452 56453 56458 56461 56464 56466 56467 56468 56470 56472 56473 56474 56477 56479 56481 56482 56484 56501 56502 56510

Zip 56511 56514 56515 56516 56517 56518 56519 56520 56521 56522 56523 56524 56525 56527 56528 56529 56531 56533 56534 56535 56536 56537 56540 56541 56542 56543 56544 56545 56546 56547 56548 56549 56550 56551 56552 56553 56554 56556 56557 56560 56561

Zip 56562 56563 56565 56566 56567 56568 56569 56570 56571 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

Zip 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

Zip 56754 56756 56757 56758 56759 56760 56761 56762 56763

Iowa – PLUS Employee Eligibility Large Group Zip Codes

Zip 50514 50531 50578 51001 51003 51009 51011 51012 51014 51022 51023 51024 51027 51028 51029 51031 51035 51036 51037 51038 51041 51046 51047 51048 51049 51050 51058 51062 51103 51108 51109 51201 51230 51231 51232 51234 51235

Zip 51237 51238 51239 51240 51241 51242 51243 51244 51245 51246 51247 51248 51249 51250 51301 51331 51333 51334 51338 51342 51345 51346 51347 51350 51351 51354 51355 51357 51358 51360 51363 51364 51365

Sales Fact Sheet

Plan Name: SANFORD TRUE Provider Network: FOCUSED

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:

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

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

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

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

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

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

• 101+ employers 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:

• 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 an 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 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

Zip 57001 57003 57004 57005 57010 57013 57014 57015 57018 57020 57021 57022 57025 57027 57030 57031 57032 57033 57034 57035 57036 57037 57038 57039 57040 57041 57043 57046 57047 57048 57049 57053 57055 57064 57065 57067 57068 57069 57070

Zip 57072 57073 57077 57078 57101 57103 57104 57105 57106 57107 57108 57109 57110 57117 57118 57186 57193 57197 57198 57213 57218 57226 57237 57238 57268 57401 57402 57422 57426 57427 57429 57432 57433 57434 57439 57441 57445 57446 57449

Zip 57451 57460 57461 57474 57479 57481

North Dakota – TRUE Employee Eligibility Large Group Zip Codes

Zip 58001 58002 58004 58005 58006 58007 58008 58009 58011 58012 58015 58016 58018 58021 58027 58029 58031 58035 58036 58038 58042 58045 58047 58048 58051 58052 58054 58057 58059 58061 58062 58063 58064 58068 58071 58074 58075

Zip 58076 58077 58078 58079 58081 58102 58103 58104 58105 58106 58107 58108 58109 58121 58122 58124 58125 58126 58218 58219 58223 58240 58257 58274 58275 58477 58482 58488 58494 58501 58502 58503 58504 58505 58506 58507 58520

Zip 58521 58524 58530 58532 58535 58544 58545 58554 58558 58560 58563 58566 58571 58572 58577 58579 58631 58638

Minnesota – TRUE Employee Eligibility Large Group Zip Codes

Zip 56019 56022 56083 56101 56110 56111 56114 56116 56117 56118 56119 56120 56122 56123 56125 56127 56128 56129 56131 56132 56134 56137 56138 56141 56143 56144 56145 56146 56147 56150 56151 56152 56153 56155 56156 56158 56159

Zip 56161 56165 56166 56167 56168 56172 56173 56174 56175 56180 56183 56185 56186 56187 56433 56436 56458 56461 56467 56470 56510 56514 56519 56525 56529 56536 56545 56546 56547 56548 56549 56550 56552 56560 56561 56562 56563

Zip 56574 56580 56581 56584 56585 56601 56619 56621 56630 56634 56644 56647 56650 56652 56663 56666 56667 56670 56671 56676 56678 56683 56685 56687 56701 56715 56725 56727 56742 56748 56750 56754 00164 00166

Iowa – TRUE Employee Eligibility Large Group Zip Codes

Zip 50514 50531 50578 51001 51003 51009 51011 51012 51014 51022 51023 51024 51027 51028 51029 51031 51035 51036 51037 51038 51041 51046 51047 51048 51049 51050 51058 51062 51103 51108 51109 51201 51230 51231 51232 51234 51235

Zip 51237 51238 51239 51240 51241 51242 51243 51244 51245 51246 51247 51248 51249 51250 51301 51331 51333 51334 51338 51342 51345 51346 51347 51350 51351 51354 51355 51357 51358 51360 51363 51364 51365

OPTIONS | SOUTH DAKOTA, NORTH DAKOTA, MINNESOTA , AND IOWA

NETWORK DESCRIPTION beyond the Sanford Health Plan service area. facilities, plus some

Sanford PLUS Plan

TIERED NETWORK (Sanford PLUS): Sanford Health Plan’s Broad network is grouped into two tiers. Member’s cost share is based on the tier of the provider from where they receive care. Tier 1 (lowest member cost share) includes our large care system of Sanford Health providers and facilities Tier 2 (higher member cost share) includes the broad network that expands beyond the Sanford Health system, including access to Multiplan’s nationwide networks for urgent and emergent coverage while traveling or for employees residing outside the Sanford Health Plan service area.

DEDUCTIBLE*

$1750 $250 $300 $500 $750 $1000 $1250 $1500 $1750 $2000 $2500 $3000 $3500

OUT OF POCKET

MAXIMUM*

family The Affordable Care Act annually publishes and allows a maximum OPM. SHP will not release a quote that exceeds the 2020 limits of $8,500 single & $ 16,300 family.

For Plans with $1,000 deductible or lower, choose from: 2.5x, 3x, 4x & 5x the deductible amounts for OPM limits.

For Plans with $1,250 deductible or higher, choose from: 1.5x, 2x the deductible amounts for OPM limits.

COINSURANCE (IN NETWORK)%

Tier 1 90/10%

2

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 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 paid and membership reports (reporting periods to match large claims data)

4. 2 years of large claim reports with member status (active/termed) and diagnosis (reporting periods to match claims period data)

Sold Paperwork

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.

• 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

• 834 File

• SHP Excel Template

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

Employee Decision Guide and Group Special Notices can be found on the agent portal. Group SBCs will be emailed to you directly.

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,

• 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.

• ACH will be required to effectuate/reinstate new policy.

• Groups will be sent to collections for payment of claims that have been reimbursed after the policy is terminated.

Renewal Information

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

Annual Renewal Process

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 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 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.

Required Renewal Paperwork:

• Renewal Attestation Form

• Renewal Plan Options & Rates (Exhibit B)

Reminder on Enrollment Options:

• 834 File

• SHP Excel Template

• Consumer Directed Health Plans Elections (Exhibit B)

• Employee Enrollment/Changes

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. Employee Decision Guide and Group Special Notices can be found on the agent portal.Group SBCs will be emailed to you directly. Out-of-Area Verification Form required for all employees and dependents residing outside the service area.

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.

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 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 .

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:

If . . . Then . . .

You give birth to/adopt a child

Your spouse loses his/her job

Your dependent child attains the limiting age

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

You must add your spouse within 31-days

You must drop coverage as of the end of that month

If . . . Then . . .

You change your marital status

Your spouse’s open enrollment occurs

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

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

Change takes effect . . .

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

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 dependent eligibility by state.

GRANDCHILD REQUIREMENTS N/A

If the unmarried parent of the grandchild is a covered eligible dependent AND both the parent and grandchild are primarily dependent on the subscriber. Dependent and dependent of dependent must reside with the subscriber

If the unmarried parent of the grandchild is a covered eligible dependent AND both the parent and grandchild are primarily dependent on the subscriber. Dependent and dependent of dependent must reside with the subscriber

N/A

“TO RESIDE WITH GRANDPARENT” N/A YES YES N/A

SMALL EMPLOYER PLANS

General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Simplicity Plan Profile and Sales Fact Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Simplicity 2023 Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Sanford TRUE Plan Profile and Fact Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Sanford TRUE 2023 Plan

Sanford TRUE

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

. . . . . . . .

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 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 1-50 total employees

Minnesota 1-50 total employees

North Dakota 2-50 total employees*

South Dakota 2-50 total employees*

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

Group Size Movement

Throughout the life of a group the total employee counts may fluctuate causing the group size definition to change. Below is a table mapping the type of movement to the plan designs that can be offered.

Group Size Movement

Small ACA NGF to Large NGF

Small NGF Transitional to Large NGF

Small GF to Large GF

Large NGF to Small ACA NGF

Large GF to Small GF

Large NGF to Small ACA NGF

Plan Movement

Small ACA to Signature Series

Signature Series to Signature Series

Signature Series to Signature Series

Signature Series to Small ACA

Signature Series to Signature Series

Signature Series to Small ACA

Plan 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 is grouped into two tiers. 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 for 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 under Tier 2 benefits. 11

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

Sales Fact Sheet

Plan Name: SIMPLICITY Provider Network: BROAD Service Area

The Sanford service area consists of South Dakota, North Dakota, and approved counties of Iowa and Minnesota (indicated below):

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

• Minnesota: 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.

Primary

Specialty

Tier 1: $50 Copay Tier 2: $70 Copay

after deductible

Get to know our Simplicity Plans

Who can purchase Simplicity small group plans?

Simplicity small group plans can be purchased by employers with 50 or fewer employees who reside in South Dakota, North Dakota and specific counties in Iowa and Minnesota. For a complete service area listing, visit sanfordhealthplan.com. Your eligibility and rates will depend on the state and county where you reside.

What is the BROAD provider network?

Sanford Health Plan’s Simplicity broad network is grouped into two tiers. 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 for 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. Is there a limit to how many plan options I can offer my employees?

Yes. Sanford Health Plan offers small employers the flexibility to choose up to three of our small group Simplicity plan options depending on group size. We understand that when it comes to health insurance, one plan doesn’t fit all. Your employees deserve a choice and we are here to meet those needs.

By using Sanford Health providers, you are not only receiving high quality care, but paying less for primary and specialty care visits. These are known as Tier 1 providers.

Simplicity gives you the freedom to choose the providers that work best for you and your health care needs, including nonSanford providers that are currently in our broad network. These are referred to as Tier 2 providers.

The Simplicity advantage

• Worldwide emergency coverage, 24-hours a day

• Flexibility to choose your own providers, including specialists, without a referral

• Access to over 60,000 pharmacies nationwide

• Fast, accurate and friendly customer service

• Interactive online enrollment platform

• COBRA Administration provided at no additional cost

• HRA, HSA, FSA Services

• Reduce costs for office visits by seeing Sanford Health providers

•

•

• Fitness center

• *$0 24/7 virtual care for acute and non-emergent care through sanfordvideovisits.com. Certain restrictions may apply.

• Coverage included for pediatric dental and vision

• In and Out of Network Benefits

• Access to a urgent and emergent coverage at an innetwork level while traveling outside of the service area

• Discounts from local and national retailers through +Perks

• $5 preventive drug benefit for HDHP plans

Where can you learn more about your small group plan options, rates and other information?

We encourage you to work with your local insurance agent. You can also visit our website at sanfordhealthplan.com or call (605) 333-1089 or toll free at (888) 535-4831.

Plan 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.

Provider Network: Consists of 2,200 providers, including 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.

Focused 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

Plan Name: SANFORD TRUE Provider Network: FOCUSED 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: Brown, Minnehaha, Lincoln

• North Dakota: 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

Getting to know our Sanford TRUE plans

Who can purchase Sanford TRUE small group plans?

Sanford TRUE small group plans can be purchased by employers with 50 or fewer employees who reside in approved counties in South Dakota, North Dakota, Minnesota and Iowa. Your eligibility and rates will depend on the state and zip code where you reside.

South Dakota counties: Brown, Lincoln, Minnehaha

North Dakota counties: Burleigh, Cass, Morton, Oliver, Traill Minnesota: Beltrami, Clay, Clearwater, Cottonwood, Hubbard, Jackson, Murray, Nobles, Pennington (TRF), Red Lake, Rock Iowa: Lyon, O’Brien, Sioux Network

The Sanford TRUE plans are offered to employers in counties where we have ensured a robust provider network is available. The Focused Network consists of 2,200 providers, including 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.

The Simplicity plans are offered to employers in all counties of South Dakota, North Dakota and specific counties of Iowa and Minnesota. The Broad Network consists of over 25,000 providers within the Dakotas, Minnesota and Iowa. The network expands beyond the Sanford Health care system, including access to a nationwide network while traveling or for employees residing outside the Sanford Health Plan service area. You can choose to see any licensed provider for covered services without a referral, whether the provider is in-network or out-of-network. Claims will pay according to the appropriate level of benefits. You may pay less if you see a Sanford Health provider.

Is there a limit to how many plan options I can offer my employees?

Yes. Sanford Health Plan offers small employers the flexibility to choose up to three of our small group Simplicity plan options side-by-side with our TRUE plans depending on group size. We understand that when it comes to health insurance, one plan doesn’t fit all. Your employees deserve a choice and we are here to meet those needs. Only employees who are domiciled in the approved counties or expanded zip codes are eligible for the Sanford TRUE plans.

The Sanford TRUE advantage

• Focused Network

• Worldwide emergency coverage, 24-hours a day

• Flexibility to choose your own in-network providers, including specialists, without a referral

• Access to over 60,000 pharmacies nationwide

• Fast, accurate and friendly customer service

• Interactive online enrollment platform

• COBRA Administration provided at no additional cost

Save more, do more Use +Perks Use +Perks and start saving with:

• HRA , HSA, FSA Services

• Coverage included for pediatric dental and vision

•

*$0 24/7 virtual care for acute and non-emergent care through sanfordvideovisits.com. Certain restrictions may apply.

• Discounts from local and national retailers through +Perks

• Behavioral health assistance

• $5 preventive drug benefit for HDHP plans

• Discounts and cash back at over 2,000 local and national retailers

• Sanford Health exclusive discounts from Profile, Sanford Wellness Centers and Great Shots

• Fitness center reimbursements

Where can you learn more about your small group plan options, provider network, rates and other information?

We encourage you to work with your local insurance agent. You can also visit our website at sanfordhealthplan.com or call (605) 333-1089 or toll free at (888) 535-4831.

*HSA-qualified High Deductible Health Plans (HDHP) are not eligible for $0 video visits but do qualify for discounted visits for which Health Savings Account (HSA) dollars may be used.

South Dakota – TRUE Small Group Employee Eligibility Zip Codes

Zip 57001 57003 57004 57005 57010 57013 57014 57015 57018 57020 57021 57022 57025 57027 57030 57031 57032 57033 57034 57035 57036 57037 57038 57039 57040 57041 57043 57046 57047 57048 57049 57053 57055 57064 57065 57067 57068 57069

Zip 57070 57072 57073 57077 57078 57101 57103 57104 57105 57106 57107 57108 57109 57110 57117 57118 57186 57193 57197 57198 57213 57218 57226 57237 57238 57268 57401 57402 57422 57426 57427 57429 57432 57433 57434 57439 57441 57445

Zip 57446 57449 57451 57460 57461 57474 57479 57481

North Dakota – TRUE Small Group Employee Eligibility Zip Codes

Zip 58001 58002 58004 58005 58006 58007 58008 58009 58011 58012 58015 58016 58018 58021 58027 58029 58031 58035 58036 58038 58042 58045 58047 58048 58051 58052 58054 58057 58059 58061 58062 58063 58064 58068 58071 58074 58075

Zip 58076 58077 58078 58079 58081 58102 58103 58104 58105 58106 58107 58108 58109 58121 58122 58124 58125 58126 58218 58219 58223 58240 58257 58274 58275 58477 58482 58488 58494 58501 58502 58503 58504 58505 58506 58507 58520

Zip 58521 58524 58530 58532 58535 58544 58545 58554 58558 58560 58563 58566 58571 58572 58577 58579 58631 58638

Minnesota – TRUE Small Group

Employee Eligibility Zip Codes

Zip 56019 56022 56083 56101 56110 56111 56114 56116 56117 56118 56119 56120 56122 56123 56125 56127 56128 56129 56131 56132 56134 56137 56138 56141 56143 56144 56145 56146 56147 56150 56151 56152 56153 56155 56156 56158 56159

Zip 56161 56165 56166 56167 56168 56172 56173 56174 56175 56180 56183 56185 56186 56187 56433 56436 56458 56461 56467 56470 56510 56514 56519 56525 56529 56536 56545 56546 56547 56548 56549 56550 56552 56560 56561 56562 56563

Zip 56574 56580 56581 56584 56585 56601 56619 56621 56630 56634 56644 56647 56650 56652 56663 56666 56667 56670 56671 56676 56678 56683 56685 56687 56701 56715 56725 56727 56742 56748 56750 56754 00164 00166

Iowa – TRUE Small Group

Employee Eligibility Zip Codes

Zip 50514 50531 50578 51001 51003 51009 51011 51012 51014 51022 51023 51024 51027 51028 51029 51031 51035 51036 51037 51038 51041 51046 51047 51048 51049 51050 51058 51062 51103 51108 51109 51201 51230 51231 51232 51234 51235

Zip 51237 51238 51239 51240 51241 51242 51243 51244 51245 51246 51247 51248 51249 51250 51301 51331 51333 51334 51338 51342 51345 51346 51347 51350 51351 51354 51355 51357 51358 51360 51363 51364 51365

Quoting & Selling Small Group

Quoting

1. Access your AgentAdvisor Portal (agents.sanford.com)

2. Click Start Quote under Small Group

3. Complete all required information. Required Information to Quote:

• Group Name

• Group County

• Group State

•

Requested Effective Date

• Employee Name, DOB, Zip Code

• Employee Dependent(s) Name, DOB, Zip Code

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.

Sold Paperwork

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 AgentAdvisor 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.

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

Methodology: For all states the total premium is developed using the per-member rating methodology for the members at the time of sale. For adults 21 and over the age rate is applied, and for the oldest 3 children ages 0-20 the 0-20 rates are used. For any one subscriber with 4+ children under 20, only the 3 oldest will have a rate and all others will be $0.00. The premium is then summed for the group and a total adjusted contract count is calculated based upon the tier distribution. The standard member counts by tier are found below:

Contract Count

Tier IA SD ND

Employee 1 1 1 Employee + Spouse 2.1 2.1 2.1 Employee + Children 1.8 1.8 1.8 Employee + Family 3 3 3

The total adjusted contract count is the sum of the product of the tier counts for the group and the contract counts from the table above. The total premium is then divided by the total adjusted contract count to arrive at the employee only (single contract) rate. The final 4 tier rates are then calculated by multiplying the employee only rate by the contract count factors above.

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 2023, the annual cost-sharing limits cannot exceed $9,100 for an individual and $18,200 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.

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

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

Contract Type South Dakota

North Dakota, Iowa, Minnesota

New 70% Recommendation 70% Requirement Renewal 70% Recommendation 70% Requirement

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 thirty 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.

All-Inclusive Lab & X-Ray Benefit on Certain TRUE Plans

On certain TRUE plans you will find an all-inclusive copayment benefit for certain lab & x-ray services.

• 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, if billed by a hospital, an additional copay will apply.

• Lab work and x-rays if not done the same day as an office visit, copay will apply as long as the claim is billed by a clinic. If billed by a hospital, deductible and coinsurance will apply.

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.

If the prior carrier allows, 2 reports can be submitted, 1 at initial enrollment and one just prior to the 60-day limit. Employee Explanation of Benefits (EOBs) are also accepted.

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

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,

• 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.

• Updated, ACH will be required to effectuate/reinstate new policy.

• Groups will be sent to collections for payment of claims that have been reimbursed after the policy is terminated.

Renewal Information

Annual Renewal Process

Sanford Health Plan is committed to keeping the renewal process simple. Renewals will be accessed and processed through AgentAdvisor Portal.

All required paperwork on the Renewal Checklist (indicated below) must be completed and received by Sanford Health Plan Sales via AgentAdvisor 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 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.

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.

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

Your spouse loses his/her job You must add your spouse within 31-days

Your dependent child attains the limiting age You must drop coverage as of the end of that month

You change your marital status You have 31-days to add/delete dependents, based on the situation

Your spouse’s open enrollment occurs 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

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 dependent eligibility by state.

STATE SD ND MN IA

“DEPENDENT AGE” 26 26 26 26

“STUDENT AGE” 29 Must be full-time student and unmarried 26 26 No age limit must be full-time student

UNMARRIED NO NO NO NO “FINANCIALLY DEPENDENT” NO NO NO NO “DISABLED DEPENDENT” YES YES YES YES

“ADOPTED CHILD” YES YES YES YES

STEP CHILDREN YES YES YES YES LEGAL GUARDIAN YES YES YES YES FOSTER CHILD YES YES YES YES COURT ORDERED TO PROVIDE BENEFITS YES YES YES YES

GRANDCHILD NO YES YES NO

GRANDCHILD REQUIREMENTS

N/A

If the unmarried parent of the grandchild is a covered eligible dependent AND both the parent and grandchild are primarily dependent on the subscriber. Dependent and dependent of dependent must reside with the subscriber

If the unmarried parent of the grandchild is a covered eligible dependent AND both the parent and grandchild are primarily dependent on the subscriber. Dependent and dependent of dependent must reside with the subscriber

N/A

“TO RESIDE WITH GRANDPARENT”

N/A YES YES N/A

INDIVIDUAL PLANS

General

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Simplicity

Simplicity

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Sanford

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

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 and is related to the subscriber as a child. Coverage will continue to the end of the month 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 costsharing 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 reside 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 reside 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

Plan 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.

Provider Network: Sanford Health Plan’s Simplicity broad network is grouped into two tiers. 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 for 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.

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

Pediatric

benefits

Dental and Vision

built into all plan options

Getting know our Simplicity plans

Who can purchase Simplicity Individual Plans?

Simplicity Individual Plans can be purchased by individuals who are South Dakota or North Dakota residents. Your eligibility and rates will depend on the state and county where you reside.

What is the BROAD provider network?

Sanford Health Plan’s Simplicity broad network is grouped into two tiers. 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 for 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.

By using Sanford Health providers, you are not only receiving high quality care, but paying less for primary and specialty care visits. These are known as Tier 1 providers.

Simplicity gives you the freedom to choose the providers that work best for you and your health care needs, including nonSanford providers that are currently in our broad network. These are referred to as Tier 2 providers.

The Simplicity advantage

• Broad Network

• Worldwide emergency coverage, 24-hours a day

• Flexibility to choose your own in-network providers, including specialists, without a referral

• Access to over 60,000 pharmacies nationwide

• Fast, accurate and friendly customer service

• Reduce costs for office visits by seeing Sanford Health providers

• Behavioral health assistance

• *$0 24/7 virtual care for acute and non-emergent care through sanfordvideovisits.com. Certain restrictions may apply.

• Coverage included for pediatric dental and vision

• In and Out of Network Benefits

• Access to urgent and emergent coverage at an innetwork level while traveling outside of the service area

• Discounts from local and national retailers through +Perks

NEW for 2023- $5 preventive drug benefit for HDHP

plans

High costs for medications should not keep you from taking vital prescriptions essential to your health. The IRS allows certain medications to be available at a low cost without having to meet your deductible on a High Deductible Health Plan. These medications include many that treat common conditions and diseases such as:

• High blood pressure

• High cholesterol

• Depression

• COPD

• Asthma

Save more, do more

Use +Perks and start saving with:

• Cancer

• Irritable bowel syndrome

• And many more. Medications that are both considered preventive and on our list of covered drugs, only cost $5 for each 30-day fill at an in-network pharmacy.

• Discounts and cash back at over 2,000 local and national retailers

• Sanford Health exclusive discounts from Profile, Sanford Wellness Centers and Great Shots

• Fitness center reimbursements

Where can you learn more about plan options, provider networks, rates and other information?

We encourage you to work with your local insurance agent. You can also visit our website at sanfordhealthplan.com or call (605) 333-1089 or toll free at (888) 535-4831.

*HSA-qualified High Deductible Health Plans (HDHP) are not eligible for $0 video visits but do qualify for discounted visits for which Health Savings Account (HSA) dollars may be used.

Standard Enhanced Care plans do not include tiered access

Plan 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.

Getting to know our Sanford TRUE plans

Who can

purchase

Sanford TRUE individual plans?

Individuals that reside in approved counties of South Dakota and North Dakota. Your eligibility and rates will depend on the state and county in which you reside.

South Dakota counties: Brown, Lincoln, Minnehaha

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

Network

The Sanford TRUE plans are offered to individuals in counties where we have ensured a robust provider network is available. The focused network consists of 2,200 providers, including 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.

The Sanford TRUE advantage

• Focused Network

• Worldwide emergency coverage, 24-hours a day

• Flexibility to choose your own in-network providers, including specialists, without a referral

• Access to over 60,000 pharmacies nationwide

• Fast, accurate and friendly customer service

NEW for 2023- $5 preventive drug benefit

•

*$0 24/7 virtual care for acute and non-emergent care through sanfordvideovisits.com. Certain restrictions may apply.

• Coverage included for pediatric dental and vision

• Discounts from local and national retailers through +Perks

• Behavioral health assistance

for HDHP plans

High costs for medications should not keep you from taking vital prescriptions essential to your health. The IRS allows certain medications to be available at a low cost without having to meet your deductible on a High Deductible Health Plan. These medications include many that treat common conditions and diseases such as:

• High blood pressure

• High cholesterol

• Depression

• COPD

• Asthma

•

• Cancer

• Irritable bowel syndrome

• And many more. Medications that are both considered preventive and on our list of covered drugs, only cost $5 for each 30-day fill at an innetwork pharmacy.

• Sanford Health exclusive discounts from Profile, Sanford Wellness Centers and Great Shots

• Fitness center reimbursements

Quoting and Selling an Individual Policy

Quoting an Individual Policy

To quote an individual, simply follow these simple steps:

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

4.Review Plan options to generate a quote

• Applicant DOB

• Applicant Tobacco Status

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:

Application must be made online through your secure AgentAdvisor portal. Applications must be submitted through AgentAdvisor portal in order for agents to receive commission and be tied to the application. An agent may 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 HIIPPA 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.

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 the member’s online account at 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 the member’s online account at healthcare.gov.

Termination due to Non-Payment - Outside of the Exchange

The ACH will be drafted on or around the 10th of each month. 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. A copy of the letter will be sent to the agent.

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

– 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

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 2023, the annual cost-sharing limits cannot exceed $$9,100 for an individual and $$18,200 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

Payment

Method Initial Payment Due

ACH/EFT Automatic Withdrawal

ACH Form and voided check must be provided with the application.

Premium Payments - Inside of the Exchange

Ongoing Payment Due

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

Payment Method Initial Payment Due Ongoing Payment Due

ACH/EFT Automatic Withdrawal

Paper check, cashier’s check or money order

Pre-paid Debit Cards, Credit Cards or eCheck

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 must be received and cleared prior to the effective date of the policy.

Transaction can be processed in our office or over the phone. Funds must be received and cleared prior to the effective date of the policy.

Pre-paid Debit Cards and Credit Cards can also be processed on our secure online payment portal. Visit sanfordhealthplan.com/ Exchangepayment

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

Post-marked as of the 1st of the month (i.e. January 1 for January premium).

Transaction must be processed by the 1st of the month (i.e. January 1 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 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.

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 Enrollment Period

Timeframe: November 1 – December 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

January 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. A Policy Change Request Form must be completed when the individual has an SEP and would like to make changes to their existing 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 their online account at healthcare.gov to notify the Exchange of the event. SEP Events, notification timeframes, documentation and forms needed will vary greatly from what is requested outside of the Exchange. The individual will need to contact the Exchange directly for assistance.

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

Who is Eligible1

Within 60 days after the event

Within 60 days after the event

Within 60 days after the event

Within 60 days after the event

Within 60 days after the event

Individual(s) who lost coverage

Individual(s) who lost coverage

Individual(s) who lost coverage

Individual(s) who lost coverage

Individual(s) who lost coverage

Within 60 days after the event

Individual, spouse and dependents

Within 60 days after the event

Individual, spouse and dependents

Establish new contract for newly divorced 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 Within 60 days after the event

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

Individual, spouse and dependents

Within 60 days after the event Newly Born / Adopted Child

Within 60 days after the event

Individual, spouse and dependents

Within 60 days after the event

Within 60 days after the event

Within 60 days after the event

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

Individual and dependents

Individual 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.

guidelines

ACA guidelines

Application; Certificate of Creditable Coverage or employer/previous carrier letter Change Form; Certificate of Creditable Coverage or employer/previous carrier letter

Application; Certificate of Marriage and proof of health coverage for one or more days during the 60-days before your marriage that meets Minimum Essential Coverage (MEC)

ACA guidelines

Application; Certificate of Marriage and proof of health coverage for one or more days during the 60-days before your marriage that meets Minimum Essential Coverage (MEC)

Change Form; Certificate of Marriage and proof of health coverage for one or more days during the 60-days before your marriage that meets Minimum Essential Coverage (MEC) ACA guidelines

Application; Divorce Decree with court official signature; Child custody order and proof of health coverage for one or more days during the 60-days before your divorce that meets Minimum Essential Coverage (MEC)

Eligibility

SANFORD SAFEGUARD

TABLE OF CONTENTS

General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

Quoting and Selling Sanford Safeguard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Sanford SAFEGUARD Brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

General Information

Short-term, limited duration health plans, such as Sanford SAFEGUARD, provide access to affordable bridge coverage during periods of uninsurance, such as when one is between jobs or when a student takes a semester off from school. By definition, these plans are meant to be temporary.

Short-term medical insurance is not a substitute for a major medical plan and are not required to meet the minimum essential coverage levels as defined by the ACA (major medical plans are). However, STLD plans can offer financial protection in the event of an unexpected injury or illness while you are waiting for coverage to begin under an ACA-compliant plan.

Service Area

The Sanford Safeguard service area consists of South Dakota and North Dakota. Network Broad

Applicant Requirements

To be eligible for Sanford SAFEGUARD an applicant must meet all the following requirements: -Applicants must reside within North Dakota and/or South Dakota. -Must be age 0 to 64.

-A child only plan is also available for children through age 17.

Rating

Rates are adjusted every 6 months, January and July.

Rates can vary by: -Effective date of policy. -Age of each member -Gender of each member

Member rates do not adjust during their policy term. Rates are based on effective date month versus calendar month. Example: Policy effective July 15th, their month will be July 15th – August 15th, etc.

Rates are not prorated if a policy terms early.

Pre-Existing Conditions

Sanford SAFEGUARD policies do not provide benefits for any loss caused by, or resulting from, a pre-existing condition. Pre-existing look back period is 12 months from the effective date of the policy. See product policy located on the secure agent portal for more details.

Policy Terms

Three month (SD & ND), six month (SD & ND) and a 12 month (SD only) terms are available.

South Dakota: Members may be allowed to reapply for and have continuous coverage for up to 36 months.

North Dakota: Members may be allowed to reapply for and have continuous coverage for up to 12 months.

Deductible Options

$2,500 or $5,000

Payment Options

All applicants must submit ACH information with their application. Once members have their member ID number they can use Sanford Health Plan’s secure payment portal to pay ahead using a credit, debit or E-check. Note: If there is a credit on the member’s account ACH will NOT draft.

Quoting and Selling Sanford Safeguard

Required Information to Quote

To quote an individual, simply follow these simple steps:

1. Visit sanfordhealthplan.com

2. Access your secure agent portal.

2a. Rate sheets are located under the Individual Tab.

Effective Date

Effective dates can be any date in the future following the application signature date, up to 60 days.

Writing a Short Term Limited Duration

Fillable paper application is available for download from the secure agent portal. Visit the Individual tab and Sanford SAFEGUARD to access the application. All applications must be sent securely to sales@sanfordhealth.org.

Acceptance Letters from Sanford Health Plan

An acceptance letter will be issued within 5 business days. This letter will be mailed directly to the policy holder indicating their confirmation of coverage, the effective date, plan selected, monthly premium, and covered dependent(s). Agents will also get emailed a copy of this letter for their records. This letter indicates the application has been approved and processed in our enrollment system.

Member ID Cards and Welcome Packets

Once the applicant and dependent(s) are entered into our system, ID Cards are ordered and sent to the Member’s home address. Standard timeframe once an application has been entered into our system, ID Cards will be issued within 7-10 business days. Plan and coverage materials are online and displayed on the members portal.

Temporary ID Cards

Member Satisfaction is our top priority. Therefore, Sanford Health Plan offers agents access to request Temporary ID Cards for member who may need this information prior to receiving their physical copies in the mail. These ID Cards can be issued upon request once a member is loaded in our system and has been issued a Member ID Number. Please email sales@sanfordhealth.org to request temp ID cards.

Members can also access their ID card through my Chart once they are enrolled in our system.

Policy Changes and Terminations

Policy Changes

Name, contact and banking information are the only policy changes that can take place once the policy is issued.

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.

Policy Holder Written Request to 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 requested termination date. If a date is not indicated the coverage will terminate at 11:59 pm on the last day of the month in which the request was received. Any premium refunds will be paid the month following termination.

Termination Due to Non-Payment

The ACH will be drafted on or around the 10th of each month. If the ACH is returned for non-sufficient funds, member have a 30 day grace period. A letter will be sent to the member informing them that their payment is past-due.

Reapplication and Nonrenewability

This coverage will not be renewed at the end of the coverage period. Although Sanford SAFEGUARD plans may be rewritten for new and completely separate Coverage Periods (as long as members meet the eligibility criteria described in the application), coverage does not continue from one certificate of coverage of insurance to another. This means that a new application must be submitted, a new Effective Date is given, a new Pre-Existing Condition exclusion period begins and a new Deductible and out-ofpocket expense must be met. Any medical condition which may have occurred and/or existed under a prior certificate of coverage will be treated as a pre-existing condition under the new policy.

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.

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 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.

Sanford SAFEGUARD

SHORT-TERM LIMITED-DURATION MEDICAL PLANS

This plan in not considered to be Minimal Essential Coverage as defined by the Patient Protection and Affordable Care Act (ACA). CONSUMER NOTICE: This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription dugs, and mental health substance use disorders. Your policy also might have lifetime and/or annual dollar limits on health benefits. If this coverage expires or your lose eligibility for this coverage, you might have to wait until on open enrollment period to get other health insurance coverage.

Sanford Health Plan encourages all consumers to work with a licensed agent to make certain all coverage and limitations of Short Term Major Medical plans are clearly understood prior to purchase.

GET TO KNOW

Sanford SAFEGUARD

Sanford SAFEGUARD is a short-term, limited-duration medical insurance plan that offers protection during coverage gaps when you may be temporarily uninsured. Coverage is sold in 3 or 6 month coverage periods within North Dakota and 3, 6 and 12 months within South Dakota.

What is short-term, limited-duration medical insurance?

Short-term, limited-duration insurance plans such as Sanford SAFEGUARD provide access to affordable coverage during periods without insurance, such as when someone is transitioning between jobs or when a student takes a semester off from school. These plans are meant to be temporary. Short-term medical insurance is not a substitute for a major medical plan that meets the minimum essential coverage levels as defined by the Patient Protection and Affordable Care Act, also known as ACA. However, it can offer financial protection in the event of an unexpected injury or illness while you are waiting for other insurance coverage to begin.

When to consider a short-term, limited-duration health plan:

MISSED OPEN ENROLLMENT

If you missed the opportunity for coverage during the open enrollment period, you may be ineligible to buy a major medical policy until the next open enrollment period, unless you have a qualifying life event.

NEW JOB – WAITING FOR COVERAGE TO START

An employer-sponsored plan may require employees to wait a month or more before their health insurance benefits begin.

WAITING FOR AFFORDABLE CARE ACT COVERAGE

Many plans on the Health Insurance Exchange (healthcare.gov) offer only one effective day, which is typically the first day of the month. Depending on when you submit your application, you may have to wait up to 45 days for your coverage to begin.

COVERAGE TO FILL THE GAPS

Coverage can begin as early as the day following the submission and approval of your application.

During these instances, Sanford SAFEGUARD may be the right plan to bridge your coverage gap.

Life is unpredictable. Sanford SAFEGUARD helps you face those unpredictable moments in life with confidence. Our short-term medical insurance plans provide the financial protection you need from unexpected medical bills and other health care expenses including:

Doctor visits

Emergency room and ambulance coverage

Urgent care benefits

$0 virtual care

Member discounts on hearing, vision and dental services**

** Participating providers only, certain restrictions may apply.

Who is eligible for coverage?

Sanford SAFEGUARD is available to applicants ages 18 to 64 along with spouses of similar age and dependent children under the age of 26. A child only plan is also available for children through age 17. Applicants must reside within North Dakota and/or South Dakota.

Why should I choose short-term medical insurance with Sanford SAFEGUARD?

What if I need to continue my coverage?

If your need for temporary health insurance continues, you can reapply for another short-term, limited-duration medical plan. All short-term medical applications are subject to eligibility requirements and state availability of the coverage. The next coverage period is not a continuation of the previous period. It is a new plan with a new deductible, coinsurance and limitations. For North Dakota members, renewal or continuation of coverage is available as an insured option, but the coverage period may not extend for more than 12 months from the original effective date of the policy. For South Dakota members, coverage may be renewed up to a total of 36 months but is subject to underwriting after each coverage period.

What network or providers can I see?

Sanford SAFEGUARD uses a broad network of providers. This network consists of over 25,000 providers in the Dakotas, Minnesota and Iowa in addition to a national network. To search for in-network providers, visit sanfordhealthplan.com.

Can my plan be canceled?

Coverage ends on the earliest of the date: the policy terminates; you become eligible for Medicare; the expiration date of your coverage; the premium is not paid when due, and exceeds the grace period; you enter full-time active duty in the armed forces; intentional fraud or material misrepresentation has been made in filing a claim for benefits; or, your death. A dependent’s coverage ends on the earliest of the date: your coverage terminates; the dependent becomes eligible for Medicare; or, the dependent ceases to be eligible.

Pre-Existing Condition Limitation

Sanford SAFEGUARD does not provide benefits for any loss caused by or resulting from a pre-existing condition.

“Pre-existing Conditions” means any medical condition or sickness for which:

1. Medical advice, care, diagnosis, treatment, consultation*, or medication was recommended by or received from a doctor within the 12 months immediately prior to a member’s effective date of coverage, or

2. Symptoms existed within the 12 months immediately prior to the member’s effective date of coverage, which would cause a reasonable person to seek diagnosis, care or treatment.

*A consultation is an evaluation, diagnosis or medical advice that was given with or without the necessity of a personal exam or visit.

Sanford SAFEGUARD Short Term Plans

Provider Network: BROAD

$2,500 SAFEGUARD $5,000 SAFEGUARD Limitations, Exceptions & Other Information

Maximum benefit $1,000,000 $1,000,000

In-network medical deductible Individual Family $2,500 $7,500 $5,000 $15,000

In-network coinsurance 20% 30%

In-network maximum out-of-pocket Individual Family $5,000 $15,000 $10,000 $30,000

Out-of-network medical deductible Individual Family $7,500 $22,500 $15,000 $45,000

Out-of-network coinsurance 50% 50%

Out-of-network maximum out-of-pocket Individual Family $15,000 $45,000 $30,000 $90,000

Primary ccare $50 Copay for one visit per covered person then deductible/coinsurance

Office visits

Emergency/urgent care

Laboratory outpatient and professional services

X-ray and diagnostic imaging

Outpatient prescription drugs

Prescription drugs received while confined to a hospital or surgery center

$50 Copay for one visit per covered person then deductible/coinsurance

Specialist visit Deductible/coinsurance Deductible/coinsurance

Chiropractic care Not covered Not covered

Preventive care Not covered Not covered

Emergency room care Deductible/coinsurance Deductible/coinsurance

Emergency medical transportation Deductible/coinsurance Deductible/coinsurance

Urgent care Deductible/coinsurance Deductible/coinsurance

Deductible/coinsurance Deductible/coinsurance

Deductible/coinsurance Deductible / Coinsurance

Maximum benefit over the term of this policy.

Not covered Not covered

Deductible/coinsurance Deductible/coinsurance

Copay limited to 1 visit per covered person per 3-month period

A discount plan for prescription drugs is included. Simply show your Sanford Health Plan ID card at the pharmacy.

The following outline is a summary of benefits for in-network coverage only. All covered benefits must either be provided by an in-network provider or authorized by Sanford Health Plan. Note: This information is a summary of coverage; please refer to your SBC for actual benefits. You can refer to your policy for limitations and exclusions.

To learn more, speak with your local agent or call (888) 535-4831.

Take the next step and contact your agent at (888) 535-4831 for more information.

BROKER REQUIREMENTS

TABLE OF CONTENTS

Agent Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Privacy Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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.

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.

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.

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. 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 PY2021 plans but does not have required recertification for PY2023, the agent would receive commission payments through the coverage end date(s) of the PY2021 plans sold and no longer receive commission payments in PY2023.

Example: If an Agent sold a plan on 11/1/21 for PY2023, but did not become properly certified to do so until 11/2/21, the Agent will not be paid for the 12 months’ worth of commissions relating to that member application.

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, which under HIPAA means PHI includes one or more of the following 18 identified (identified below). If these identifies are removed, the information is considered de-identified protected information, which is not subject to the restrictions of the HIPAA Privacy Rule.

1. Names;

2. All geographical subdivisions smaller than a State, including: street address, city, county, precinct, zip code, and their equivalent geocodes;

3. All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates indicative of such age;

4. Phone numbers; 5. Fax numbers; 6. Electronic mail addresses; 7. Social Security numbers; 8. Medical record numbers; 9. Health plan beneficiary numbers; 10. Account numbers; 11. Certificate/license numbers;

12. Vehicle identifiers and serial numbers, including license plate numbers; 13. Device identifiers and serial numbers; 14. Web Universal Resource Locators (URLs);

15. Internet Protocol (IP) address numbers;

16. Biometric identifiers, including finger and voice prints;

17. Full face photographic images and any comparable images; and

18. Any other unique identifying number, characteristic, or code (note this does not mean the unique code assigned by the investigator to code the data)

Personally Identifiable Information (PII)

Personally Identifiable Information (PII) is information that can be used to distinguish or trace an individual’s identity either alone or when combined with other information that is linked or linkable to a specific individual. Examples of PII include:

• Names

• Phone numbers

• Email addresses

• Income

• Birthdate

• Social Security Number (SSN)

Proper Use of Protected Information

Agents are permitted to create, collect, disclose, access, maintain, store, and use enrollee PHI and PII 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 or PII. 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 a suspected breach happens, Agents are expected to notify Sanford Health Plan Sales within 30 days of the suspected breach so Sanford Health Plan Sales can do a risk assessment of whether or not individual notification is required.

Connect with us

The Sanford Health Plan Sales and Service team is committed to providing our agents and clients with the highest level of service. Below is a summary of our direct contact information so you can get answers quickly and any process can be done efficiently.

Lori Karn

Senior Account Executive (605) 328-6893 lori.karn@ sanfordhealth.org

Kim Haug

Senior Account Executive (701) 417-6566 kim.haug@ sanfordhealth.org

Claude Oppegard

Senior Account Executive (701) 234-6754 claude.oppegard@ sanfordhealth.org

Ronda Rose-Kayser

Account Executive

(605) 328-7189 ronda.rose-kayser@ sanfordhealth.org

Senior Account Executive (701) 323-2087 jeremy.schneider@ sanfordhealth.org

Lorie Ellis

Account Manager (605) 328-6803

lorie.ellis@ sanfordhealth.org

Casey Houle

Account Manager (605) 312-2775 casey.houle@ sanfordhealth.org

Dawn Olson

Account Manager (605) 312-2787

dawn.olson@ sanfordhealth.org

Alicia Short

Account Manager (605) 328-6805 alicia.short@ sanfordhealth.org

Sue Thompson

Senior Account Manager (605) 328-7010 sue.thompson@ sanfordhealth.org

Deb Senior Account Manager (605) 328-7000 deborah.senior@ sanfordhealth.org

Jeremy Schneider

Project Team Leaders

Nikki Hendrix

Project Manager

(605) 328-7016

nikki.hendrix@sanfordhealth.org

Tanya Kennedy

Project Manager

(605) 328-7168

tanya.kennedy@sanfordhealth.org

Project Manager (701) 417-6569

jodi.mckibben@sanfordhealth.org

Broker Operations Assistant (605) 328-7000

mary.vanningen@sanfordhealth.org

Lisa Fraser

Manager, Broker Operations (605) 328-7011

lisa.fraser@sanfordhealth.org

Jennie Nickles

Director, Sales & Service (605) 328-7185

jennie.nickles@sanfordhealth.org

Hollie Scott

Manager, Broker Account Management

(605) 328-7009

hollie.scott@sanfordhealth.org

Director, Sales Operations (605) 328-6838

chelsea.asmus@sanfordhealth.org

Mary VanNingen

Chelsea Asmus

Jodi Mckibben