Welcome to Sanford Health Plan

Choosing the right health insurance plan is one of the most important things you can do to protect your health and your financial well-being. 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 monthly to maintain your coverage. This fee is called your premium. Make sure this amount fits your budget. You’ll also want to know what you may be required to pay toward the monthly premiums of covering a spouse 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 and 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 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. Our members get access to discounts on vision, dental, hearing and weight loss services. Also, we offer virtual care at no cost on certain plans and monthly gym reimbursements at participating organizations. These perks provide added savings for you.

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

The two factors that influence your health insurance cost the most are your premium – the monthly fee you pay 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 several 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:

• Are pregnant or planning to become pregnant during the plan year
• Have a chronic condition that requires frequent medical care or interventions
• Are planning to have surgery during the plan year
• Take prescription medications to treat frequent or chronic illnesses 
• 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 and don’t anticipate needing to access health care much in your plan year 
• 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

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

How does a Health Savings Account work?
Similar to a flexible spending account (FSA) or a 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.

Whether you’re traveling for pleasure or 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 near 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. 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. 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 can check 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’s reach and 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.

Even if you seek medical care close to home, make sure the provider who treats you is in your network. If they aren’t, you’ll be subject to your plan’s out-of-network rates.

Thanks to the Patient Protection and Affordable Care Act (commonly referred to as Obamacare), which went into effect in 2014, 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 the start date of new health coverage. They are chronic conditions like asthma, COPD, sleep apnea, diabetes or cancer. Before the ACA, providers could deny people coverage or charge significantly more for coverage of long-term illnesses.

What’s the bottom line? 

• All Marketplace plans through the ACA 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, an insurance 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?
The 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:

• During Open Enrollment, you can switch to a Marketplace plan that will cover them.
• You can buy a Marketplace plan outside Open Enrollment when your grandfathered plan ends and you qualify for a Special Enrollment Period.

It depends. Usually, your health insurer’s network contains physicians who practice near 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.

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 the two entities. In other words, an out-of-network provider is under no obligation to deliver services at your health plan’s approved rate.

If you choose an out-of-network provider and they charge a higher amount for services than your insurer’s approved amount, you will need to pay the difference between those two amounts.

None of this means that you 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.

To know if your preferred provider is in-network or out-of-network, closely read your policy. 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.