Section 3: Products & Services

3.1 Products & Services Overview

Sanford Health Plan offers a suite of products to individuals, businesses and government agencies to provide health care coverage in the form of products and services. Our products and services can be divided in to four basic categories: fully insured commercial, fully insured ACA, third party administration and government products.

Sanford Health Plan membership comes with perks. Through our +PERKS program, members enjoy discounts from local and national retailers on products and services in a variety of categories, including, but not limited to apparel, vision, dental, auto, electronics, entertainment, health and wellness, and restaurants.

3.2 Service Area

Our licensed service area is North Dakota, South Dakota and select counties in Minnesota and Iowa. For members outside of our service area, we may offer the Private Health Care Systems (PHCS) and MultiPlan national networks.

3.3 Privacy Regulation & Medical Records

Privacy Regulations
Participating providers must comply with HIPAA privacy requirements and all applicable state and federal privacy laws and regulations. These regulations control the internal and external use and disclosure of protected health information. These regulations may also create certain individual member rights that providers must accommodate. Information related to Sanford Health Plan’s privacy practices can be found HERE.

Medical Records
As necessary for care management, quality management, utilization management, peer review or other required operations, we may request medical records for purposes of treatment, payment or health care operations. Participating providers shall furnish to Sanford Health Plan, at no charge, the requested medical records as allowed by applicable laws, regulations and program requirements.

3.4. Accessing Provider Directory

Provider network To access the provider directory, go to sanfordhealthplan.com. On the home page, click on the “Menu” button in the top left-hand corner. Then choose “Find A Doctor”. On the provider directory home page, click on “I’m A Member” and enter the first 9 digits of the patient’s Member ID number and last name.

3.5 Sanford Health Plan Commercial Products

  

Sanford Health Plan Provider Networks

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 Multiplan’s nationwide networks for urgent and emergent coverage while traveling or for members residing outside the Sanford Health Plan service area. Members can choose to see any licensed provider for covered services without a referral, whether the provider is in-network or out-of-network. Remember that members will pay more if they seek services from a provider not listed in this directory.

TIERED NETWORK
Sanford Health Plan’s Broad network is grouped into two tiers. Member’s cost share is based on the tier of the provider from whom 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 members residing outside the Sanford Health Plan service area.

Members can choose to see any licensed provider for covered services without a referral, whether the provider is in-network or out-of-network. Remember that members will pay more if they seek services from a provider not listed in this directory.

FOCUSED NETWORK
Consists of providers in our large system of Sanford Health providers, facilities and others necessary to meet network adequacy requirements. This plan is offered to individuals in counties where we have ensured a robust focused provider network is available. The Sanford TRUE plans are offered at a lower cost since eligible individuals agree to use a more focused network of Sanford Health providers and facilities. Members can choose to see any licensed provider in the Sanford TRUE network for covered services without a referral. For routine or non-emergent medical services outside of the TRUE focused provider network, Members will need prior approval to receive in-network benefits. These plans do not have out-of-network benefits.

3.5.1 Sanford SAFEGUARD (Short-term Limited Duration)

 

Sanford SAFEGUARD Plans
“Sanford SAFEGUARD is a short-term, limited duration health plan that provides 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 (i.e., less than 12 months). 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. 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 a member is waiting for coverage to begin under an ACA-compliant plan.”

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

3.5.2 Simplicity Plans

 

Simplicity Plans
The Simplicity plans were developed after the Affordable Care Act (ACA) and are compliant with all the ACA regulations. These non-grandfathered plans are sold by local agents in the communities we serve and also available on the Marketplace at healthcare.gov. The Simplicity plans offer individuals and small employers a variety of options to meet their needs and budget. The plans vary in deductibles, coinsurance and co-pay options as well as maximum out-of-pocket expenses.

Availability
Simplicity individual plans: Offered only in North Dakota and South Dakota. Individuals can purchase plans directly with Sanford Health Plan or through the Marketplace at healthcare.gov where they may qualify for financial assistance. Simplicity small group employer plans: Offered in North Dakota, South Dakota, Western Minnesota and Northwest Iowa. Small group employers can purchase plans directly with Sanford Health Plan.

3.5.3 Sanford TRUE Plans

 

Sanford TRUE Plans
Sanford TRUE is our ACA qualified focused network plan offered to individuals and families living where we have ensured a robust focused provider network is available. The Sanford TRUE plans are offered at a lower cost since eligible individuals agree to use a more focused network of Sanford Health providers and facilities. You can choose to see any licensed provider in the Sanford TRUE network for covered services without a referral. For routine or non-emergent medical services outside of the TRUE focused provider network, you will need prior approval to receive in-network benefits. These plans do not have out-of- network benefits.

Availability
Sanford TRUE is offered to individuals and families living in the following states and counties:

  • South Dakota: Brown, Minnehaha, Lincoln.
  • North Dakota: Burleigh, Morton, Oliver, Cass, Traill.
  • Minnesota (Group Plans Only): Beltrami, Clearwater, Clay, Cottonwood, Hubbard, Jackson, Murray, Nobles, Pennington, Red Lake, Rock
  • Iowa (GroupPlans Only): Lyon, O’Brien, Sioux

3.5.4 Sanford PLUS Plans

 

Sanford PLUS Plans
Sanford PLUS plans are offered through Large Group plans, and to be eligible employees must reside within approved zip codes to enroll. Consists of our broad and focused provider networks to create a Tiered Network.

Tier 1 (lowest member cost-share) includes our large care system of Sanford Health providers and facilities, plus some additional independent providers across the Dakotas, Minnesota and Iowa, while Tier 2 (higher member cost-share) includes the broad network that 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.

Members 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.

Availability
Sanford PLUS service area consists of eligible zip code areas of South Dakota, North Dakota, Minnesota and Iowa.

3.5.5 Signature Series & Legacy Plans

 

Signature Series & Legacy Plans
Signature Series plans are sold to large employer groups through local community agents in South Dakota, North Dakota, northwest Iowa and western Minnesota. Employers are able to create their own unique benefits by selecting from a vast array of deductible, copay and out of pocket options that fit the insurance needs of their organization.

Legacy plans, such as Classic 1500, are grandfathered or transitional group plans sold prior to the ACA. They are no longer being sold, however you may still see members who are enrolled in these plans. Eventually, these businesses may lose or give up their ACA grandfathered status to purchase a plan that meets the Affordable Care Act requirements.

Availability
Signature and Legacy plan area offered in South Dakota and North Dakota, and select counties of Minnesota and Iowa.

3.5.6 Elite1 Plans

 

Elite1 Plans
Our elite1 plans are grandfathered plans that were developed before the ACA and are no longer actively sold. However, you may still see members who are enrolled in these grandfathered plans.

Availability
Elite1 plans are available in South Dakota and North Dakota.

3.6 Third Party Administrator (TPA) Services

 

Sanford Health Plan provides third party administrator (TPA) services to employer sponsored self-funded health plans. Benefits are determined by the client, not by the TPA, with the client absorbing the claims risk.

Plan Type
These services include claims adjudication, customer service functions, provider relations and medical management. Benefits are determined by the employer group, not Sanford Health Plan.

3.7.1 Medicare Plans

 

Plan type
Our Medicare Select plan is a Medicare supplement plan that requires members to use Sanford Health Plan contracted facilities for non-emergency hospital and surgical care (Part A). When members enroll in Sanford SELECT, they agree to use Sanford’s SELECT network. Members can see any physician (Part B) and are not restricted to a network. Local insurance agents sell Medicare Select to individuals who have Medicare Part A and B in the following states and counties:

  • South Dakota: Aurora, Beadle, Bon Homme, Brookings, Brown, Brule, Buffalo, Campbell, Charles Mix, Clay, Codington, Corson, Davison, Day, Deuel, Dewey, Douglas, Edmunds, Faulk, Grant, Gregory, Hamlin, Hanson, Hutchinson, Jerauld, Kingsbury, Lake, Lincoln, Lyman, Marshall, McCook, McPherson, Miner, Minnehaha, Moody, Roberts, Sanborn, Spink, Tripp, Turner, Union, Walworth or Yankton.
  • North Dakota: Barnes, Burleigh, Cass, Dickey, Emmons, Grand Forks, Grant, Griggs, Kidder, LaMoure, Logan, McIntosh, McLean, Mercer, Morton, Nelson, Oliver, Ransom, Richland, Sargent, Sheridan, Sioux, Steele or Traill.
  • Iowa: Clay, Dickinson, Emmet, Lyon, O’Brien, Osceola or Sioux 
  • Minnesota: Beltrami, Big Stone, Clay, Clearwater, Cottonwood, Grant, Jackson, Lac Qui Parle, Lincoln, Lyon, Mahnomen, Marshall, Martin, Nobles, Norman, Murray, Pennington, Pipestone, Red Lake, Redwood, Rock, Stevens, Traverse, Watonwan or Yellow Medicine

Provider network
Members can receive services from any providers accepting assignment (payment) from Medicare. Members should to seek services from in network facilities in order to receive maximum benefits. Facility expenses for members who receive non-emergency services at a non-network hospital or outpatient surgery center will be denied.

To access the provider directory, go to sanfordhealthplan.com.

  1. On the home page, click on the “Menu” button in the top left-hand corner. Then choose “Find A Doctor”. 
  2. On the provider directory home page, click on “I’m A Member” and enter the first 9 digits of the patient’s Member ID number and last name. OR select “I’m A Guest” on the directory homepage and choose Medicare-SELECT Supplement from the drop down menu.

Eligibility, benefits and claims status
Providers can create a secure online account to access eligibility, claims status and benefit information. Or, providers can call Customer Service at (800) 752-5863 from 8 a.m. to 5 p.m. CST, Monday through Friday.

Claims and payment methodology
Providers should bill Medicare as primary and Sanford Health Plan as secondary.

3.8 Government Products

With proficiency as an insurance company and TPA, combined with our unique perspective as part of an integrated health care system, we are able to provide solutions to government agencies. Sanford Health Plan has two different government products: North Dakota Medicaid Expansion and North Dakota Public Employee Retirement System (NDPERS).

3.8.1 North Dakota Medicaid Expansion

 

Plan Type
To fill gaps in the coverage for some individuals, the Affordable Care Act (ACA) created a new Medicaid group, called “Medicaid Expansion.” The new expansion program allowed about 20,000 residents in North Dakota to enroll in health insurance coverage. The North Dakota Department of Human Services (ND DHS) contracted with Sanford Health Plan beginning January 1, 2014 to administer benefits to Medicaid Expansion members. ND DHS manages the application process, and eligibility determination. Sanford Health Plan manages the following services: medical management, claims adjudication, customer service, provider relations and provider network. As of January 1, 2018, all network providers, suppliers and transportation providers must be enrolled with the ND DHS MCO program to receive payment from Sanford Health Plan on any claims specific to North Dakota Medicaid Expansion recipients. Please note the State of North Dakota’s Traditional Medicaid program and the program administered by Sanford Health Plan, known as North Dakota Medicaid Expansion, operate under different systems.

North Dakota Medicaid Expansion enrollment guidance for providers is available HERE. Enrollment with the ND DHS Medicaid program does not require a provider to render services to ND Fee-for-Services recipients. However, federal regulations [42 CFR §438.602(b)] requires Sanford Health Plan to confirm enrollment with ND DHS prior to payment for dates of service after January 1, 2018.

Out-of-Network Providers offering urgent or emergent services, family planning services, or covered services with authorization when suitable coverage is unobtainable do not need to enroll with the State.

Provider network
This plan is offered to members covered by North Dakota (ND) Medicaid Expansion only. As of January 1, 2020, the network for this plan consists of contracted providers who have completed enrollment with the state of ND Medicaid Program and are located within the defined ND Medicaid Expansion (NDME) Service Area of all of North Dakota and its bordering counties in Minnesota, South Dakota, and Montana. This plan does not have out-of-network benefits.

NDME Medical service area: includes providers located in North Dakota and counties that border North Dakota in Montana, Minnesota, and South Dakota.

To access the provider directory, go to sanfordhealthplan.com.

  1. On the home page choose “Find A Doctor”.
  2. On the provider directory home page, enter the first 9 digits of the patient’s Member ID number and last name. OR select ”I’m A Guest” on the directory homepage and choose North Dakota Medicaid Expansion Network from the drop down menu.

Eligibility and benefits
Individuals can apply:

  • Online at apply.dhs.nd.gov; 
  • By paper application which can be completed online, printed and mailed; 
  • By telephone (855) 794-7308 or ND Relay TTY (800) 366-6888; or 
  • In-person at a North Dakota Human Service Zone office.

 Individuals eligible for this coverage must meet the following criteria:

  • Are between the ages of 19 through 64;
  • Have incomes below 138% FPL (for a single person, that’s an annual income of $17,608);
  • Are legal U.S. residents;
  • Are not incarcerated; and
  • Are not entitled or enrolled in Medicare or traditional Medicaid.

All eligibility determinations and enrollment is done by the North Dakota Department of Human Services. Sanford Health Plan does not determine who is eligible for this program or when enrollment occurs. Once the State determines eligibility, enrollment information is sent to Sanford Health Plan for processing. Please note: Sanford Health Plan may be notified by NDDHS that a member has lost eligibility retroactively. When this happens, federal regulations require Sanford Health Plan, as the MCO, to recoup payments made on an individual determined by the state of North Dakota to be ineligible for coverage.

Providers can create a secure online account at sanfordhealth.org/Provider to access eligibility, claims status and benefit information. Or, providers can call Provider Relations at (800) 601-5086 Option 2, Option 4, from 8 a.m. to 5 p.m. CST, Monday through Friday.

Claims and payment methodology
Claims should be submitted to Sanford Health Plan, preferably electronically using Payor ID 91184. Paper claims can be submitted to Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110. You will be paid according to your contract. For questions about provider payment, call Provider Relations at (800) 605-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

3.8.2 North Dakota Public Retirement System Medicare Supplement

 

Plan type
The North Dakota Public Retirement System (NDPERS) selected Sanford Health Plan as its new insurance carrier effective July 1, 2015. Sanford Health Plan provides medical coverage for both the non-Medicare and Medicare Supplement members. Total covered lives, including spouses and dependents, average 65,000.

Retirees can opt to enroll in the NDPERS Medicare supplement plan if they have both Medicare Parts A and B; this includes those under 65 if they are on Social Security Disability and have both Medicare Parts A and B. Members who have the NDPERS Medicare Supplement plan will present an ID card with their specific information.

Provider network
NDPERS Medicare Supplement plan members can receive services from any provider accepting assignment (payment) from Medicare.

To access the provider directory, go to sanfordhealthplan.com

  1. On the home page, click on the “Menu” button in the top left-hand corner. Then choose “Find A Doctor”. 
  2. On the provider directory home page, click on “I’m A Member” and enter the first 9 digits of the patient’s Member ID number and last name. OR select “I’m A Guest” on the directory homepage and choose Medicare-Standard Supplement Network from the drop down menu.

Eligibility, benefits and claims status
The staff members at NDPERS will continue to administer the enrollment and eligibility. Providers can create a secure online account to access eligibility, claims status and benefit information. Or, providers can call Customer Service at (800) 499-3416 from 8 a.m. to 5:30 p.m. CST, Monday through Friday.

Claims and payment methodology
Providers should bill Medicare as primary and Sanford Health Plan as secondary.

3.8.3 North Dakota Public Employee Retirement System Non-Medicare

 

Plan type
The North Dakota Public Employees Retirement System (NDPERS) selected Sanford Health Plan as its new insurance carrier effective July 1, 2015. Sanford Health Plan will provide medical coverage for both the non-Medicare and Medicare members. Total covered lives, including spouses and dependents, are approximately 65,000.

The non-Medicare members have three plans options: grandfathered, non-grandfathered and high deductible. All non-Medicare members will present an ID card with their specific information on the card. Medicare supplement members will present with a different ID card.

Provider network
This plan is offered to members employed with NDPERS ONLY. The network for this plan consists of both PPO and Basic networks, including the MultiPlan national network (when traveling).

To access the provider directory, go to sanfordhealthplan.com.

  1. On the home page, click on the “Menu” button in the top left-hand corner. Then choose “Find A Doctor”. 
  2. On the provider directory home page, click on “I’m A Member” and enter the first 9 digits of the patient’s Member ID number and last name. OR select ”I’m A Guest” on the directory homepage and choose North Dakota Employee Retirement System (NDPERS) Network from the drop down menu.

Eligibility, benefits and claims status
The staff members at NDPERS will continue to administer the enrollment and eligibility. Providers can create a secure online account to access eligibility, claims status and benefit information. Or, providers can call Customer Service at (800) 499-3416 from 8 a.m. to 5:30 p.m. CST, Monday through Friday.

3.8.4 Medicare Supplement Plans

Plan type
Our Medicare Supplement plans are standard supplement plans and do not require the members to use a specific network. These plans are sold by local agents to individuals with Part A and Part B Medicare coverage in the following states and counties: 

  • South Dakota: All counties
  • North Dakota: All counties
  • Iowa: Clay, Dickinson, Emmet, Lyon, O’Brien, Osceola or Sioux
  • Minnesota: Beltrami, Big Stone, Clay, Clearwater, Cottonwood, Grant, Jackson, Lac Qui Parle, Lincoln, Lyon, Mahnomen, Marshall, Martin, Nobles, Norman, Murray, Pennington, Pipestone, Red Lake, Redwood, Rock, Stevens, Traverse, Watonwan or Yellow Medicine

Provider network
The Plan members can receive services from any providers accepting assignment (payment) from Medicare. There is no network with Sanford Supplement Plan.

To access the provider directory, go to sanfordhealthplan.com.

  1. On the home page, click on the “Menu” button in the top left-hand corner. Then choose “Find A Doctor”.
  2. On the provider directory home page, click on “I’m A Member” and enter the first 9 digits of the patient’s Member ID number and last name. OR select “I’m A Guest” on the directory homepage and choose Medicare Standard Supplement Network from the drop down menu.

Eligibility, benefits and claims status
Providers will be paid according to their contract. For questions about payment, call Provider Relations at (800) 601-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

Claims and payment methodology
Providers should bill Medicare as primary and Sanford Health Plan as secondary.