A friendly reminder about our service area coverage rule, as outlined in the Certificate of Insurance (COI), for the individual Simplicity plans (IEX, IOX). Members are not eligible for out-of-network benefits when completed by a provider that is located out of the service area. We have approached this coverage rule with some flexibility for our members; however, effective Sept. 1, we will be observing it more closely and denying authorizations for providers outside the Sanford Health Plan (SHP) service area, outlined below. As a regional health plan committed to the communities we serve, we know our members can make the most of their coverage when they find care in-network within the service area. Our team of network referral nurses is available to members and conducts outreach to assist members with finding in-network, in-service-area providers. Members who need specialized care from an out-of-network, out-of-service-area provider can always request a network exception authorization, and members who currently have a prior authorization for out-of-network, out-of-service-area providers will continue to receive services. When the authorization expires, future requests will need to be reviewed with consideration for continuity-of-care needs.

The following exceptions also apply:

• The service needed is emergent or urgent.
• The member lives outside the service area (student attending college) and has an approved Out of Area request form on file.
• The provider is in-network with Simplicity (in provider directory) regardless of provider location.
• The provider has special status and is always available to members who qualify (Veteran’s Affairs, Indian Health Services, dentists, military bases, student health services on college campus).
• The service qualifies under the No Surprises Act (NSA).
• Flu shots are allowed anywhere; however, out-of-network member benefits will apply, and the member might be balance billed.