Individual & Family Health Insurance

Choosing the right health insurance plan for yourself and your family is one of the most important things you can do to protect your health and your financial wellbeing. When you’re shopping for your plan, you’ll want to know what to look for so you can get the most for your money and find a plan that addresses your unique health needs and lifestyle.

Here are a few things to think about as you consider your options:

What are my monthly premiums?

You will be required to pay on a monthly basis to maintain your coverage. This fee is called your premium. Make sure this amount fits into your budget. You’ll also want to know what you may be required to pay toward the monthly premiums of covering a spouse and/or dependents.

What are my deductible, copayments, coinsurance and out-of-pocket maximum under this plan?

These forms of cost-sharing only come into play when you receive medical care. Make sure they’re affordable for you, both for regular medical care as well as care for more serious or unexpected medical conditions.

• Deductible: This is the amount of money you pay out-of-pocket to health care providers before the insurance company will begin paying for covered health care services.

• Copayments: A copayment, or copay, is the flat fee you pay to the doctor or pharmacy when you access health care services. The fees vary between different plans, and they vary between different services.

• Coinsurance: This is the percentage of costs you are responsible to pay for certain services, and the percentage you pay after you meet the deductible; the insurance company pays the rest 

• Maximum out-of-pocket: This is the maximum dollar amount you’ll pay for health care in a plan year; your insurance company pays all of the costs of covered charges after this amount.

Is my doctor in the health plan’s network?

If you have a preferred doctor or hospital, make sure they’re in-network for any plan you’re considering. Otherwise your claims may be denied or paid at a lower level. Most health plans have tools to see which plans your doctor accepts.

Are my prescriptions covered under the plan?

Some plans cover different prescription drugs than others, or pay more toward them. Sanford Health Plan has a prescription drug coverage comparison tool that can show you what you’re estimated to pay based on your personal Rx needs.

What perks and discounts are available?

At Sanford Health Plan, we focus on going beyond health insurance coverage. Therefore, our members get access to discounts on vision, dental, hearing, weight loss services. In addition, we offer no cost virtual care on certain plans and monthly gym reimbursements at participating providers. These perks can all add up to added savings.

I'm self-employed: can I afford health insurance?

Adding health insurance to your regular business expenses might seem like risk you may not want to add, but the benefits of having the right plan can save you from potentially catastrophic financial challenges if you incur a major illness or injury. Learn more about what you should consider when exploring insurance plans.

If you are looking for individual or group health insurance, contact us at (888) 535-4831 to get in touch with an agent who can help you through the process, or request a quote at https://www.sanfordhealthplan.org/get-a-quote.

Current Sanford Health Plan members can access their SBC and other plan information in their secure member portals at sanfordhealthplan.com/memberlogin or by contacting customer service at the number listed on the back of your insurance member ID card.

There are pros and cons to selecting any kind of insurance plan, but finding the right kind of plan for your lifestyle and healthcare needs often comes down to your monthly budget and how much risk you’re comfortable assuming.

Let’s take a moment to unpack this a little.

When it comes to how much your health insurance is going to cost, the two factors that influence it the most are your premium—the monthly fee you pay in order to have insurance—and the deductible—the amount you’ll have to pay before insurance kicks in.

Whether you’ll want to choose a low-deductible plan or a high-deductible plan depends upon a number of factors.

Low-deductible plans typically have higher monthly premiums, but since your deductible is lower, your insurance company will begin paying a percentage of your medical bills sooner. A low-deductible plan may appeal to you:

• If you’re pregnant or planning to become pregnant during the plan year

• If you have a chronic condition that requires frequent medical care or interventions

• If you’re planning to have surgery during the plan year

• If you take prescription medications to treat frequent or chronic illnesses

• If you have children—especially if they participate in outdoor activities

In contrast to low-deductible plans, high-deductible plans typically have lower monthly premiums, but have a higher dollar threshold before your insurance begins to pay a percentage of your medical bills. A high-deductible plan may appeal to you:

• If you’re young, generally healthy, and don’t anticipate needing to access health care much in your plan year--since these plans generally have lower monthly premiums, they free up a little more cash to pay for things like groceries, gas and rent

  • The potential downside to this is while you pay less in premiums each month, having a high deductible means that if you do face a serious illness or injury, you’ll be responsible for paying more out-of-pocket for the care you receive. 

• If your financial situation allows you to afford to pay large, unexpected medical bills quickly

• If you are generally healthy and are also contributing to a Health Savings Account

How does a Health Savings Account work?

Similar to a flexible spending account (FSA) or 401(k), an HSA is a special bank account that allows you to save money on a pre-tax or tax-deductible basis to be used specifically for medical expenses in the future. Unlike FSAs, the money in an HSA rolls over every year and can also earn interest. By pairing an eligible plan with an HSA account, participants can save money on health care and earn a tax write-off.

If you are looking for individual or group health insurance, contact us at (888) 535-4831 to get in touch with an agent who can help you through the process, or request a quote at https://www.sanfordhealthplan.org/get-a-quote.

Current Sanford Health Plan members can access their SBC and other plan information in their secure member portals at sanfordhealthplan.com/memberlogin or by contacting customer service at the number listed on the back of your insurance member ID card.

Whether you’re traveling for pleasure or for business, sometimes accidents and illnesses happen while you’re away from home. How does receiving care outside the region in which you reside affect the amount you’ll have to pay?

It depends.

To understand what this means for you, you’ll first need to understand the term “network.”

Usually, your health insurer’s network contains physicians who practice in relatively close proximity to you. More specifically, your insurer’s network consists of health care providers who have agreed to accept the plan’s proposed amount for the services they provide.

Let’s say a doctor in your city charges $190 for a routine office visit. If your provider’s approved amount is $100, the doctor will agree to accept this reduced rate in exchange for the increased volume that comes with being part of the network.

If a provider isn’t in a health insurer’s network, no such agreements exist between them. So, if you’re traveling outside of your network, and the provider who serves your needs charges a higher amount for services than your insurer’s approved amount, you will, more than likely, need to pay the difference between those two amounts.

There are exceptions, of course—which is why we mentioned that the answer to the original question depends upon your specific situation. Some health plans contract with other networks for members who reside, travel or attend school outside of their usual service area. Other exceptions may include emergency medical services, approved referrals to out-of-network specialists and transplant services.

To find out if your health plan has an agreement with other networks, you may wish to take a look at your insurance identification card. If you see other networks listed on it, you can seek medical care from a provider that is participating with the additional network and still pay in-network rates. The very best way to be sure about your network—its reach and its limitations—is to closely read your policy. A little knowledge and preparation can go a long way toward ensuring a health issue doesn’t cause a catastrophic financial event for you.

Here’s one last thing to remember: Even if you seek medical care close to home, make sure the provider who is treating you is in your network. If he or she isn’t, you’ll be subject to your plan’s out-of-network rates.

If you are looking for individual or group health insurance, contact us at (888) 535-4831 to get in touch with an agent who can help you through the process, or request a quote at https://www.sanfordhealthplan.org/get-a-quote.

Current Sanford Health Plan members can access their SBC and other plan information in their secure member portals at sanfordhealthplan.com/memberlogin or by contacting customer service at the number listed on the back of your insurance member ID card.

Thanks to the Patient Protection and Affordable Care Act (commonly referred to as “Obamacare”), which went into effect in 2010, health insurance providers who operate in the United States cannot refuse to cover you or charge you more simply because you have a pre-existing condition. They also can’t charge women more than men for the same coverage.

What’s a pre-existing condition?

A pre-existing condition is a health problem you had before start date of new health coverage. Think chronic conditions like asthma, COPD, sleep apnea, diabetes or cancer. Prior to the ACA, providers could deny people coverage—or charge significantly more for coverage of—such long-term illnesses.

What’s the bottom line?

• All Marketplace plans through the Affordable Care Act must cover treatment for pre-existing medical conditions.

• No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started.

• Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health.

• Pregnancy is covered from the day your plan starts

  • If you’re pregnant when you apply, an insurance plan can’t reject you or charge you more because of your pregnancy.

  • Once you’re enrolled, your pregnancy and childbirth are covered from the day your plan starts.

Are there any exceptions?

Only exception to the pre-existing coverage rule is for grandfathered (purchased on or before March 30, 2010) individual health insurance plans—the kind you buy yourself, not through an employer. They don’t have to cover pre-existing conditions or preventive care.

If you have a grandfathered plan and want pre-existing conditions covered, you have two options:

• You can switch to a Marketplace plan that will cover them during Open Enrollment.

• You can buy a Marketplace plan outside Open Enrollment when your grandfathered plan year ends, and you’ll qualify for a Special Enrollment Period.

If you are looking for individual or group health insurance, contact us at (888) 535-4831 to get in touch with an agent who can help you through the process, or request a quote at https://www.sanfordhealthplan.org/get-a-quote.

Current Sanford Health Plan members can access their SBC and other plan information in their secure member portals at sanfordhealthplan.com/memberlogin or by contacting customer service at the number listed on the back of your insurance member ID card.

Our physicians are our partners in health and healing. They assist us through challenging illnesses and joyful occasions, like the birth of a child. They know our private concerns and the most personal details of our lives.

It’s only natural that the relationships we build with our health care providers are some of the more intimate, emotional bonds we forge in life. That kind of trust takes time to build. So, it makes sense that, for many of us, one of the key factors in choosing a health plan is whether or not we’ll be able to keep our current doctors.

The answer to this question—as in so many things in life—is “maybe.” To understand what this means for you, you’ll first need to understand the term “network.”

Usually, your health insurer’s network contains physicians who practice in relatively close proximity to you. More specifically, your insurer’s network consists of health care providers who have agreed to accept the plan’s proposed amount for the services they provide.

Let’s say a doctor in your town charges $190 for a routine office visit. If your provider’s approved amount is $100, the doctor will agree to accept this reduced rate in exchange for the increased volume that comes with being part of the network.

Your health insurer’s network may or may not include your family or personal doctor. What does that mean for you?

If your preferred provider is outside of your insurer’s network, no agreements exist between two entities. In other words, an out-of-network provider is under no obligation to deliver services at your health plan’s approved rate. So, if you choose a provider who is out-of-network and he or she charges a higher amount for services than your insurer’s approved amount, you will, more than likely, need to pay the difference between those two amounts.

None of this means that you absolutely have to give up your doctor if he or she is out of your plan’s network, but it probably means you’ll have to pay more out-of-pocket for the services they provide, which defeats the purpose of paying your insurance premiums each month.

How do you know if your preferred provider is in-network or out-of-network?

The best way to be sure is to closely read your policy. And make sure to reach out to your health insurance provider if you still don’t understand. You can also call ahead to the provider or the hospital to inquire about whether or not they’ll accept your health care coverage.

A little knowledge and preparation can go a long way toward ensuring a health issue doesn’t cause a catastrophic financial event for you.

Enrolling in health insurance is limited to certain times of the year. Learn about open enrollment periods below and when you may qualify for a special enrollment period.

Open Enrollment Period
Open enrollment is a window of time when you can sign up for health insurance, make changes to your current plan or cancel your plan altogether. Open enrollment periods happen once a year and usually start in the fall.

Once open enrollment ends, you cannot enroll in a new health plan until the next open enrollment period, unless you qualify for a special enrollment period.

Special Enrollment Period (SEP)
A Special Enrollment Period (SEP) is a time outside of the open enrollment period when you can enroll or change your health insurance based on certain life events.

If you qualify for an SEP, you have 60 days following the event to enroll or change your coverage. After 60 days, you must wait until the next open enrollment period.

What are qualifying life events?
Situations that qualify you for an SEP include:

• Adopting a child or having a baby
• Getting married or divorced
• Losing your health insurance coverage
• Moving 
• Turning 26

Some life events, such as an unexpected illness or medical injury, do not qualify.

Learn more about special enrollment periods.

If you or a family member no longer qualify for Medicaid or Children's Health Insurance Program (CHIP), you may be able to get health insurance—and financial assistance to help pay for it—with a Marketplace plan through Sanford Health Plan. Learn more at sanfordhealthplan.com/losingmedicaid.

Marketplace plans are:

• Affordable. 4 out of 5 enrollees can find plans that cost less than $10 per month.**
• Comprehensive. All Marketplace plans cover things like prescription drugs, doctor visits, urgent care, mental health services, hospital visits and more.

Visit marketplace.sanfordhealthplan.com to find an affordable plan that fits your needs.

** Source: Centers for Medicare & Medicaid Services in reference to national Marketplace enrollment. Subsidies to reduce premiums are based on income.

States like North Dakota and South Dakota are resuming eligibility reviews for Medicaid and Children’s Health Insurance Program (CHIP). This means some people with Medicaid or CHIP could be disenrolled from those programs and lose their Medicaid or CHIP insurance.

For more information on why this is happening, read our article and learn some actions you can take to prepare.