2019 Sanford Simplicity $5,000 HSA/HDHP Plan Details - HealthPocket

Sanford Simplicity $5,000 HSA/HDHP

$359.34/mo

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Zip Code58103
Applicant6/25/1984 Male
Coverage Start6/27/2019
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameSanford Simplicity $5,000 HSA/HDHP
Plan IDhhs-89364ND0120006
Plan Year2019
Insurance ProviderSanford Health Plan
Metal LevelExpanded Bronze
Plan TypePPO
Deductible$5,000
Out-of-Pocket Maximum$6,550
Personal Score

Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness40.00% Coinsurance after deductible
Specialist Visit40.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging40.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans40.00% Coinsurance after deductible
Deductible - Family$10000 per group
Out-of-Pocket Maximum - Family$13100 per group

Prescription drug coverage

Generic Drugs40.00% Coinsurance after deductible
Preferred Brand Drugs40.00% Coinsurance after deductible
Non-Preferred Brand Drugs40.00% Coinsurance after deductible
Specialty Drugs40.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://www3.viiad.com/shp/public/
Does this plan have access to a national provider network?Yes
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Yes - Emergency or Urgent Care Only or With Plan Certification
Does this plan cover services outside the country?No - Emergency Only

Hospital services

Emergency Room Services40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)40.00% Coinsurance after deductible
Inpatient Physician and Surgical Services40.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service40.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care40.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services40.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services40.00% Coinsurance after deductible
Substance use disorder outpatient services40.00% Coinsurance after deductible
Substance use disorder inpatient services40.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Durable Medical Equipment
Hospice Services
Routine Foot Care
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Well Baby Visits and Care
More Limited BenefitsSkilled Nursing Facility
Bariatric Surgery
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Chiropractic Care
Nutritional Counseling
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Hearing Aids
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Weight Loss Programs
Abortion for Which Public Funding is Prohibited
PremiumPlan NameDeductible
from $179
Simplicity $5,000
$5,000.00Select
from $191
BlueDirect 100 5200
$5,200.00Select
from $229
Sanford TRUE $5,000 HSA/HDHP
$5,000.00Select
from $280
Sanford TRUE $5,000 HSA/HDHP
$5,000.00Select
from $294
Sanford Simplicity $5,000 HSA/HDHP
$5,000.00Select
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  • Phone Number
    (701) 364-3300
  • Office Locations
    1702 University Dr S
    Fargo, ND 58103
1702 University Dr S Fargo ND, 58103

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (NASDAQ: HIIQ)

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (NASDAQ: HIIQ)