HP-0490 NDPERS NGF-HDHP LG Group
1 7-2023
North Dakota
Public Employees
Retirement System
(NDPERS)
2023-2025 Certificate of Insurance
Non-Grandfathered
High Deductible Health Plan
Help understanding this document is free.
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Table of Contents
NOTICE OF PRIVACY PRACTICES ................................................................................................... 15
INTRODUCTION ..................................................................................................................................... 18
HOW TO CONTACT SANFORD HEALTH PLAN [THE “PLAN”]................................................. 18
MEMBER RIGHTS ............................................................................................................................. 21
MEMBER RESPONSIBILITIES ......................................................................................................... 22
SERVICE AREA .................................................................................................................................. 23
MEDICAL TERMINOLOGY .............................................................................................................. 23
DEFINITIONS ..................................................................................................................................... 23
CONFORMITY WITH STATE AND FEDERAL STATUTES ........................................................... 23
SPECIAL COMMUNICATION NEEDS ...................................................................................... 24
TRANSLATION SERVICES ........................................................................................................ 24
NOTICE REGARDING HIGH DEDUCTIBLE HEALTH PLAN (HDHP) AND A HEALTH
SAVINGS ACCOUNT (HSA) ...................................................................................................... 24
HEALTH SAVINGS ACCOUNT (HSA) ELIGIBILITY ............................................................. 24
FRAUD ................................................................................................................................................ 25
PHYSICAL EXAMINATION .............................................................................................................. 26
CLERICAL ERROR ............................................................................................................................ 26
VALUE-ADDED PROGRAM ............................................................................................................. 26
SUMMARY OF THIS PLAN DESCRIPTION ................................................................................... 26
NOTICE OF NON-DISCRIMINATION ............................................................................................. 27
SECTION 1. .............................................................................................................................................. 28
ENROLLMENT ........................................................................................................................................ 28
1.1 ELIGIBILITY AND WHEN TO ENROLL ................................................................................... 28
1.2 HOW TO ENROLL ........................................................................................................................ 29
1.3 WHEN COVERAGE BEGINS ...................................................................................................... 29
1.4 ELIGIBILITY REQUIREMENTS FOR DEPENDENTS ............................................................. 29
1.5 NONCUSTODIAL SUBSCRIBERS ............................................................................................. 30
1.6 STATUS OF MEMBER ELIGIBILITY ......................................................................................... 31
1.7 WHEN AND HOW TO ENROLL DEPENDENTS ....................................................................... 31
1.8 WHEN DEPENDENT COVERAGE BEGINS .............................................................................. 31
1.9 QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) PROVISION .......................... 33
1.10 SPECIAL ENROLLMENT PROCEDURES AND RIGHTS ...................................................... 34
1.11 CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT OF 2009
(CHIPRA) .................................................................................................................................... 37
1.12 MICHELLE’S LAW .................................................................................................................... 38
SECTION 2 ............................................................................................................................................... 39
HOW YOU GET CARE ........................................................................................................................... 39
2.1 IDENTIFICATION CARDS .......................................................................................................... 39
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2.2 CONDITIONS FOR COVERAGE ................................................................................................ 39
2.3 IN-NETWORK COVERAGE ........................................................................................................ 40
2.4 APPROPRIATE ACCESS .............................................................................................................. 40
2.5 CASE MANAGEMENT ................................................................................................................ 41
2.6 BENEFIT DETERMINATION REVIEW PROCESS ................................................................... 41
2.7 ROUTINE (NON-URGENT) PRE-SERVICE BENEFIT REQUESTS ........................................ 42
2.8 ROUTINE POST-SERVICE BENEFIT REQUESTS .................................................................... 42
2.10 PROSPECTIVE (PRE-SERVICE) REVIEW OF SERVICES (CERTIFICATION PRIOR
AUTHORIZATION) .................................................................................................................... 43
2.11 PHARMACY PRE-APPROVAL (CERTIFICATION) REQUESTS ........................................... 44
2.12 ADDITIONAL INFORMATION REGARDING FORMULARY EXCEPTION REQUESTS ... 46
2.13 MEDICAL PRE-APPROVAL (CERTIFICATION) REQUESTS ................................................ 46
2.14 ONGOING (CONCURRENT) PREAUTHORIZATION REQUESTS (CERTIFICATION) OF
HEALTH CARE SERVICES ....................................................................................................... 48
2.15 WRITTEN NOTIFICATION PROCESS FOR ADVERSE DETERMINATIONS ..................... 51
SECTION 3 ............................................................................................................................................... 53
COVERED SERVICES – OVERVIEW ................................................................................................. 53
3.1 HEALTH CARE SERVICES PROVIDED BY PRACTITIONERS AND PROVIDERS ........... 53
3.1.1 ARTIFICIAL NUTRITION .................................................................................................. 53
3.1.2 ALLERGY CARE BENEFITS ............................................................................................. 53
3.1.3 CHIROPRACTIC SERVICES ............................................................................................. 54
3.1.4 CLINICAL TRIALS ............................................................................................................. 54
3.1.5 DIABETES SUPPLIES, EQUIPMENT AND EDUCATION BENEFITS .......................... 55
3.1.6 DIAGNOSTIC AND TREATMENT SERVICES ............................................................... 56
3.1.7 DIALYSIS BENEFIT ........................................................................................................... 56
3.1.8 DURABLE MEDICAL EQUIPMENT (DME) BENEFITS ................................................ 56
3.1.9 EYE CARE SERVICES ....................................................................................................... 56
3.1.10 FAMILY PLANNING BENEFITS .................................................................................... 57
3.1.11 FOOT CARE SERVICES ................................................................................................... 57
3.1.12 HEARING SERVICES (TESTING, TREATMENT, AND SUPPLIES) ........................... 58
3.1.13 HOME HEALTH SERVICES ............................................................................................ 59
3.1.14 IMPLANTS/STIMULATORS ........................................................................................... 59
3.1.15 INFERTILITY BENEFITS ................................................................................................ 59
3.1.16 LAB, X-RAY AND OTHER DIAGNOSTIC TESTS ........................................................ 59
3.1.17 ONCOLOGY TREATMENT BENEFITS ......................................................................... 60
3.1.18 NEWBORN CARE BENEFITS ......................................................................................... 60
3.1.19 ORTHOTIC AND PROSTHETIC DEVICES .................................................................... 60
3.1.20 OTHER TREATMENT THERAPIES NOT SPECIFIED ELSEWHERE ......................... 61
3.1.21 OUTPATIENT NUTRITIONAL CARE SERVICES ....................................................... 61
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3.1.22 PEDIATRIC (CHILD) HEARING SERVICES (TESTING, TREATMENT, AND
SUPPLIES) .................................................................................................................................... 61
3.1.23 PEDIATRIC (CHILD) VISION SERVICES ..................................................................... 61
3.1.24 PHENYLKETONURIA (PKU) AND AMINO ACID-BASED ELEMENTAL ORAL
FORMULAS COVERAGE BENEFITS ....................................................................................... 62
3.1.25 PHYSICAL, CARDIAC SPEECH AND OCCUPATIONAL THERAPIES ..................... 62
3.1.26 PRENATAL AND MATERNITY SERVICES .................................................................. 63
3.1.27 PREVENTIVE CARE, ADULTS & CHILDREN ............................................................. 64
3.1.28 PRIVATE DUTY NURSING ............................................................................................. 65
3.1.29 TELEHEALTH SERVICES (VIRTUAL VISITS) ........................................................... 65
3.1.30 TOBACCO CESSATION TREATMENT BENEFITS ...................................................... 66
3.1.31 WELLNESS NUTRITIONAL COUNSELING SERVICES ............................................. 66
3.2 SERVICES PROVIDED BY A HOSPITAL OR OTHER FACILITY ......................................... 67
3.2.1 ADMISSIONS ...................................................................................................................... 67
3.2.2 ANESTHESIA ...................................................................................................................... 67
3.2.3 HOSPICE CARE .................................................................................................................. 67
3.2.4 ORAL AND MAXILLOFACIAL SURGERY ..................................................................... 68
3.2.5 OUTPATIENT HOSPITAL OR AMBULATORY SURGICAL CENTER ........................ 69
3.2.6 RECONSTRUCTIVE SURGERY ....................................................................................... 69
3.2.7 SKILLED NURSING CARE FACILITY BENEFITS ......................................................... 70
3.2.8 TRANSPLANT SERVICES ................................................................................................. 70
3.3 EMERGENCY SERVICES/ACCIDENTS ....................................................................................... 72
3.3.1 BENEFIT DESCRIPTION ................................................................................................... 72
3.3.2 EMERGENCY WITHIN OUR SERVICE AREA ............................................................... 72
3.3.3 PARTICIPATING EMERGENCY PROVIDERS/FACILITIES ......................................... 73
3.3.4 NON- PARTICIPATING EMERGENCY PROVIDERS/FACILITIES .............................. 73
3.3.5 EMERGENCY OUTSIDE OUR SERVICE AREA ............................................................. 73
3.3.6 URGENT CARE SITUATION ............................................................................................ 73
3.3.7 PARTICIPATING PROVIDERS/FACILITIES ................................................................... 74
3.3.8 NON- PARTICIPATING PROVIDERS/FACILITIES ........................................................ 74
3.4 MENTAL HEALTH AND SUBSTANCE USE DISORDER BENEFITS ..................................... 75
3.4.1 MENTAL HEALTH BENEFITS ......................................................................................... 75
3.4.2 APPLIED BEHAVIOR ANALYSIS FOR TREATMENT OF AUTISM SPECTRUM
DISORDER .......................................................................................................................... 76
3.4.3 SUBSTANCE USE DISORDER BENEFITS ...................................................................... 76
3.5 OUTPATIENT PRESCRIPTION DRUG BENEFITS .................................................................... 78
3.5.1 BENEFIT DESCRIPTION ................................................................................................... 78
3.5.2 COVERED MEDICATIONS AND SUPPLIES ................................................................... 80
3.5.3 COVERED TYPES OF PRESCRIPTIONS ......................................................................... 80
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3.6 DENTAL BENEFITS ......................................................................................................................... 81
3.6.1 BENEFIT DESCRIPTION ................................................................................................... 81
3.6.2 PEDIATRIC (CHILD) DENTAL CARE ............................................................................. 82
3.7 SCHEDULE OF BENEFITS ............................................................................................................. 83
3.7.1 GENERAL ............................................................................................................................ 83
3.7.2 OVERVIEW OF COST SHARING AMOUNTS AND HOW THEY ACCUMULATE .... 83
3.7.3 BENEFIT SCHEDULE ........................................................................................................ 84
3.7.4 HOW PPO VS. BASIC PLAN DETERMINES BENEFIT PAYMENT.............................. 84
3.7.5 PARTICIPATING HEALTH CARE PROVIDERS ............................................................. 85
3.7.6 NON-PARTICIPATING HEALTH CARE PROVIDERS ........................................................ 85
3.7.7 NON-PARTICIPATING HEALTH CARE PROVIDERS WITHIN THE STATE OF NORTH
DAKOTA .......................................................................................................................................... 85
3.7.8 NON-PARTICIPATING HEALTH CARE PROVIDERS OUTSIDE THE STATE OF NORTH
DAKOTA ............................................................................................................................... 85
3.7.9 NON-PARTICIPATING PROVIDERS OUTSIDE THE SANFORD HEALTH PLAN
SERVICE AREA ................................................................................................................... 86
3.7.10 HEALTH CARE PROVIDERS OUTSIDE THE UNITED STATES ............................... 86
3.7.11 NON-PAYABLE HEALTH CARE PROVIDERS ........................................................... 87
3.7.12 MEDICARE PRIVATE CONTRACTS ............................................................................. 87
3.7.13 COST SHARING AMOUNTS-DETAILS & DEFINITIONS ........................................... 87
3.7.14 COINSURANCE ................................................................................................................ 87
3.7.15 COINSURANCE MAXIMUM AMOUNTS ...................................................................... 88
3.7.16 DEDUCTIBLES ................................................................................................................. 88
3.7.17 OUT OF POCKET MAXIMUM AMOUNTS ................................................................... 88
3.7.18 PRESCRIPTION MEDICATIONS AND COINSURANCE ............................................. 88
3.7.19 INFERTILITY SERVICES COINSURANCE/DEDUCTIBLE ......................................... 88
SECTION 4 ............................................................................................................................................. 101
LIMITED AND NON-COVERED SERVICES ................................................................................... 101
4.1 GENERAL MEDICAL EXCLUSIONS ....................................................................................... 101
4.2 GENERAL PHARMACY EXCLUSIONS .................................................................................. 108
4.3 SPECIAL SITUATIONS AFFECTING COVERAGE ................................................................ 109
4.4 SERVICES COVERED BY OTHER PAYORS ........................................................................... 110
4.5 SERVICES AND PAYMENTS THAT ARE THE RESPONSIBILITY OF MEMBER ............... 110
SECTION 5 ............................................................................................................................................. 111
HOW SERVICES ARE PAID FOR UNDER THE CERTIFICATE OF INSURANCE .................. 111
5.1 REIMBURSEMENT OF CHARGES BY PARTICIPATING PROVIDERS ............................... 111
5.2 REIMBURSEMENT OF CHARGES BY NON-PARTICIPATING PROVIDERS ..................... 111
5.3 PAYMENTS FOR AIR AMBULANCE CHARGES ................................................................... 112
5.4 BALANCE BILLING FROM NON-PARTICIPATING PROVIDERS ....................................... 112
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5.5 HEALTH CARE SERVICES RECEIVED OUTSIDE OF THE UNITED STATES ................... 113
5.6 TIMEFRAME FOR PAYMENT OF CLAIMS ............................................................................ 113
5.7 WHEN WE NEED ADDITIONAL INFORMATION ................................................................. 113
5.8 MEMBER BILL AUDIT PROGRAM ......................................................................................... 114
SECTION 6 ............................................................................................................................................. 115
COORDINATION OF BENEFITS ....................................................................................................... 115
6.1 APPLICABILITY ........................................................................................................................ 115
6.2 DEFINITIONS (FOR COB PURPOSES ONLY) ........................................................................ 115
6.3 ORDER OF BENEFIT DETERMINATION RULES .................................................................. 117
6.4 EFFECT OF COB ON THE BENEFITS OF THIS PLAN .......................................................... 119
6.5 CALCULATION OF BENEFITS, SECONDARY PLAN ........................................................... 120
6.6 COORDINATION OF BENEFITS WITH GOVERNMENT PLANS AND BENEFITS ........... 120
6.7 COORDINATION OF BENEFITS WITH MEDICARE ............................................................. 120
6.8 MEMBERS WITH END STAGE RENAL DISEASE (ESRD) ................................................... 122
6.9 COORDINATION OF BENEFITS WITH MEDICAID .............................................................. 122
6.10 COORDINATION OF BENEFITS WITH TRICARE ............................................................... 123
SECTION 7 ............................................................................................................................................. 124
SUBROGATION AND RIGHT OF REIMBURSEMENT ................................................................. 124
7.1 SANFORD HEALTH PLAN’S RIGHTS OF SUBROGATION ................................................. 124
7.2 SANFORD HEALTH PLAN’S RIGHT TO REDUCTION AND REIMBURSEMENT ............ 125
7.3 ERRONEOUS PAYMENTS ........................................................................................................ 125
7.4 MEMBER’S RESPONSIBILITIES ............................................................................................. 125
7.5 SEPARATION OF FUNDS .......................................................................................................... 126
7.6 PAYMENT IN ERROR ................................................................................................................ 126
SECTION 8 ............................................................................................................................................. 127
HOW COVERAGE ENDS ..................................................................................................................... 127
8.1 TERMINATION BY THE SUBSCRIBER .................................................................................. 127
8.2 TERMINATION, NONRENEWAL, OR MODIFICATION OF MEMBER COVERAGE ......... 127
8.3 MEMBER APPEAL OF TERMINATION ................................................................................... 128
8.4 TERMINATION OF MEMBER COVERAGE ............................................................................ 128
8.5 CONTINUATION ........................................................................................................................ 129
8.6 CONTINUATION OF COVERAGE FOR CONFINED MEMBERS ......................................... 130
8.7 EXTENSION OF BENEFITS FOR TOTAL DISABILITY ........................................................ 130
8.8 CANCELLATION OF THIS OR PREVIOUS BENEFIT PLANS .............................................. 130
8.9 NOTICE OF CREDITABLE COVERAGE ................................................................................. 130
8.10 NOTICE OF GROUP TERMINATION OF COVERAGE ........................................................ 131
SECTION 9 ............................................................................................................................................. 132
OPTIONS AFTER COVERAGE ENDS .............................................................................................. 132
9.1 FEDERAL CONTINUATION OF COVERAGE PROVISIONS (“COBRA”) ........................... 132
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SECTION 10 ........................................................................................................................................... 136
PROBLEM RESOLUTION ................................................................................................................... 136
10.1 MEMBER APPEAL PROCEDURES - OVERVIEW ................................................................ 136
10.2 DESIGNATING AN AUTHORIZED REPRESENTATIVE ...................................................... 137
10.3 AUDIT TRAILS ......................................................................................................................... 137
10.4 DEFINITIONS ........................................................................................................................... 138
10.5 COMPLAINT (GRIEVANCE) PROCEDURES ........................................................................ 139
10.6 ORAL COMPLAINTS ............................................................................................................... 139
10.7 WRITTEN COMPLAINTS ........................................................................................................ 139
10.8 COMPLAINT INVESTIGATIONS ........................................................................................... 139
10.9 APPEAL PROCEDURES .......................................................................................................... 140
10.10 CONTINUED COVERAGE FOR CONCURRENT CARE .................................................... 140
10.11 INTERNAL APPEALS OF ADVERSE DETERMINATION (DENIAL) ............................... 140
10.12 APPEAL RIGHTS AND PROCEDURES ................................................................................ 141
10.13 APPEAL NOTIFICATION TIMELINES ................................................................................. 142
10.14 EXPEDITED INTERNAL APPEAL PROCEDURE ............................................................... 142
10.15 WRITTEN NOTIFICATION PROCESS FOR INTERNAL APPEALS .................................. 143
10.16 EXTERNAL PROCEDURES FOR ADVERSE DETERMINATIONS OF
PHARMACEUTICAL EXCEPTION REQUESTS ................................................................... 144
10.17 STANDARD EXTERNAL REVIEW REQUEST PROCESSES & PROCEDURES ............. 144
10.18 EXTERNAL APPEAL REVIEW PROGRAM PROCEDURES ............................................. 145
10.19 EXPEDITED EXTERNAL REVIEW REQUESTS ................................................................ 148
SECTION 11 ........................................................................................................................................... 150
DEFINITIONS OF TERMS WE USE IN THIS CERTIFICATE OF INSURANCE ...................... 150
ATTACHMENT I. SUMMARY OF BENEFITS AND COVERAGE ............................................... 163
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10
Notice
Your employer has established an employee welfare benefit plan for Eligible Employees and their Eligible
Dependents. The following Summary Plan Description/Certificate of Insurance (COI) is provided to you in
accordance with the Employee Retirement Income Security Act of 1974. Every attempt has been made to
provide concise and accurate information.
This COI and the NDPERS Service Agreement are the official benefit plan documents for the employee
welfare benefit plan established by the Plan Administrator. In case of conflict between this Certificate of
Insurance/Summary Plan Description and the NDPERS Service Agreement, the provisions of the NDPERS
Service Agreement will control.
Although it is the intention of the Plan Administrator to continue the employee welfare benefit plan for an
indefinite period of time, the Plan Administrator reserves the right, whether in an individual case or in general,
to eliminate the Benefit Plan.
Sanford Health Plan shall construe and interpret the provisions of the Service Agreement, the COI and related
documents, including doubtful or disputed terms; and to conduct any and all reviews of claims denied in whole
or in part. NDPERS shall determine all questions of eligibility.
Plan Name
North Dakota Public Employees Retirement System Dakota Plan
Name and Address of Employer (Plan Sponsor)
North Dakota Public Employees Retirement System
1600 E. Century Avenue, Suite 2
PO Box 1657
Bismarck, ND 58503
Plan Sponsor’s IRS Employer Identification Number
45-0282090
Plan Number Assigned By the Plan Sponsor
N/A
Type of Welfare Plan
Health
Type of Administration
This employee welfare benefit plan is fully insured by Sanford Health Plan and issued by Sanford Health Plan.
Sanford Health Plan is the Claims Administrator for this employee welfare benefit plan.
Name and Address of Sanford Health Plan
Sanford Health Plan
300 Cherapa Place, Suite 201
Sioux Falls, SD 57103
(877) 305-5463 (toll-free)
TTY/TDD: 711 (toll-free)
11
Plan Administrator’s Name, Business Address and Business Telephone Number
North Dakota Public Employees Retirement System
1600 E. Century Avenue, Suite 2
PO Box 1657
Bismarck, ND 58503
(701) 328-3900
Name and Address of Agent for Service of Legal Process
Title of Employees Authorized To Receive Protected Health Information
• Administrative Services
Division
• Accounting & IT Division
• Benefit Programs Division
• Benefit Program Development
& Research
• Executive Director
• Internal Audit Division
This includes every employee, class of employees, or other workforce person under control of the Plan
Sponsor who may receive the Member’s Protected Health Information relating to payment under, health care
operations of, or other matters pertaining to the Benefit Plan in the ordinary course of business.
These identified individuals will have access to the Member’s Protected Health Information only to perform
the plan administrative functions the Plan Sponsor provides to the Benefit Plan. Such individuals will be
subject to disciplinary action for any use or disclosure of the Member’s Protected Health Information in breach
or in violation of, or noncompliance with, the privacy provisions of the Benefit Plan. The Plan Sponsor shall
promptly report any such breach, violation, or noncompliance to the Plan Administrator; will cooperate with
the Plan Administrator to correct the breach, violation and noncompliance to impose appropriate disciplinary
action on each employee or other workforce person causing the breach, violation, or noncompliance; and will
mitigate any harmful effect of the breach, violation, or noncompliance on any Member whose privacy may
have been compromised.
Statement of Eligibility to Receive Benefits
As provided in N.D.C.C. §54-52.1-01(4) and §54-52.1-18, individuals eligible to receive benefits are every
permanent employee who is employed by the state, and political subdivisions which elect the HDHP option,
whose services are not limited in duration, who is filling an approved and regularly funded position in the state,
and political subdivisions which elect the HDHP option, and who is employed at least seventeen and one-half
hours per week and at least five months each year or for those first employed after August 1, 2003, is
employed at least twenty hours per week and at least twenty weeks each year of employment.
An eligible employee includes members of the Legislative Assembly, judges of the Supreme Court, paid
members of state boards, commissions, or associations, or political subdivision boards, commissions, or
associations which elect the HDHP option, full-time employees of political subdivisions which elect the HDHP
Plan Administrator
Sanford Health Plan
North Dakota Public Employees
Retirement System
Sanford Health Plan
ATTN: President
1600 E. Century Avenue, Suite 2
300 Cherapa Place, Suite 201
PO Box 1657
PO Box 91110
Bismarck, ND 58503
Sioux Falls, SD 57109-1110
12
option, elective state officers as defined by N.D.C.C. §54-06-01(2), disabled permanent state employees and
disabled employees of political subdivisions which elect the HDHP option, who are receiving compensation
from the North Dakota workforce safety and insurance.
A temporary employee of a political subdivision which elects the HDHP option, who is employed before
August 1, 2007, may elect to participate in the uniform group insurance program by completing the necessary
enrollment forms and qualifying under the medical underwriting requirements of the program if such election
is made before January 1, 2015, and if the temporary employee is participating in the uniform group insurance
program on January 1, 2015.
In order for a temporary employee of a political subdivision which elect the HDHP option, who is employed
after July 31, 2007, to qualify to participate in the uniform group insurance program, the employee must be
employed at least twenty hours per week; must be employed at least twenty weeks each year of employment;
must make the election to participate before January 1, 2015; and must be participating in the uniform group
insurance program as of January 1, 2015.
To be eligible to participate in the uniform group insurance program, a temporary employee of a political
subdivision which elects the HDHP option, who is first employed after December 31, 2014, or any temporary
employee not participating in the uniform group insurance program as of January 1, 2015, must meet the
definition of a full-time employee under §4980H(c)(4) of the Internal Revenue Code [26 U.S.C. 4980H(c)(4)].
Temporary employees employed by the state of North Dakota are not eligible to participate in this Benefit
Plan.
An eligible employee is entitled to coverage the first of the month following the month of employment,
provided the employee submits an application for coverage within the first 31 days of employment or
eligibility for a special enrollment period as set forth in N.D.A.C. §71-03-03. Each eligible employee may elect
to enroll his/her Eligible Dependents.
Eligible employees also include non-Medicare eligible retired and terminated employees, and their Eligible
Dependents, who remain eligible to participate in the uniform group insurance program pursuant to applicable
state law, as provided in N.D.C.C. §54-52.1-03 and federal regulations. For a comprehensive description of
eligibility, refer to the NDPERS web site at www.ndpers.nd.gov.
Eligibility to receive benefits under the Benefit Plan is initially determined by the Plan Administrator. When an
eligible employee meets the criteria for eligibility, a membership application must be completed. NDPERS has
the ultimate decision making authority regarding eligibility to receive benefits.
Description of Benefits
See the Schedule of Benefits and the Covered Services Sections. Refer to the Table of Contents for page
numbers.
Sources of Premium Contributions to the Plan and the Method by Which the Amount of Contribution
Is Calculated
The contributions for single or family for state employees are paid at 100% by the state. The contributions for
employees of participating political subdivisions are at the discretion of the subdivision and subject to the
minimum contribution requirements and participation requirements of Sanford Health Plan. The contributions
for temporary employees are either at their own expense, or their employer may pay the premium, subject to its
budget authority.
End of the Year Date for Purposes of Maintaining the Plan’s Fiscal Records
13
June 30
Clerical Error
Any clerical error by either the Plan or Claims Administrators, or the aforementioned entities’ designees, in keeping
pertinent records or a delay in making any changes will not invalidate coverage otherwise validly in force or continue
coverage validly terminated. An equitable adjustment of contributions will be made when the error or delay is discovered.
If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount, Sanford Health Plan and
NDPERS retain contractual rights to the overpayment. The person or institution receiving the overpayment
will be required to return the incorrect amount of money.
Recovery of Benefit Payments
Pursuant to N.D.A.C. §71-03-05-06, whenever benefits are paid in noncompliance with the Contract,
NDPERS, which is the Plan Administrator, or an agent of the Plan Administrator, retains the right to recover
the payments from the party responsible.
If Sanford Health Plan, which is the Claims Administrator and Payor, or an agent of Sanford Health Plan, is at
fault, the amount of overpayment will be withheld from the administrative fees paid by NDPERS.
If overpayments are made because of false or misleading information provided by a Member, Sanford Health
Plan, or an agent of Sanford Health Plan, shall attempt to recover the amount. Any moneys recovered shall be
credited to NDPERS.
If an overpayment is made because of a mistake or deliberate act by a Health Care Provider, Sanford Health
Plan shall collect the money from the Provider and credit that amount to NDPERS.
If fraud is suspected, Sanford Health Plan shall inform NDPERS and NDPERS may turn the evidence over to
the North Dakota State’s Attorney or Attorney General’s office for possible prosecution.
Amending and Terminating this Benefit Plan
As Plan Administrator, NDPERS has delegated responsibility for determinations regarding covered benefits,
and the amount and manner of the payment of benefits, including the appeal of denied claims, to Sanford
Health Plan, the insurer of the plan.
NDPERS reserves the right to terminate the plan, or amend or eliminate benefits under the North Dakota
Public Employees Retirement System Dakota Plan, as insured and issued by Sanford Health Plan, at any time
and at its discretion, upon mutual agreement between NDPERS and Sanford Health Plan. Should this Benefit
Plan be amended or terminated, such action shall be by a written instrument duly adopted by both NDPERS
and Sanford Health Plan, or the aforementioned entities’ designees
Fiduciary Definitions
Claims Administrator Is a Fiduciary
Except for direct member appeals regarding an infertility services deductible, the North Dakota Public
Employees Retirement Board has delegated to the Claims Administrator, herein known as Sanford Health
Plan, benefit claims and appeals. Sanford Health Plan is a Plan fiduciary for these benefit claims and appeals
only. As such, the Claims Administrator has the final and discretionary authority to determine these claims and
appeals, and has the final and discretionary authority to interpret all terms of the Plan and make factual
determinations necessary to make the claim and appeal determinations. The decision made by the Claims
14
Administrator on review is final and binding, subject to your right to file a lawsuit under other applicable laws.
This decision making authority is limited only by the duties imposed. Any determination by the Claims
Administrator is intended to be given deference by courts to the maximum extent allowed under applicable
laws.
Summary Notice and Important Phone Numbers
This COI describes in detail your Employer’s health care benefit Plan and governs the Plan’s coverage. This
COI, any amendments, and related documents comprise the entire Plan between the Employer and the Claims
Administrator.
A thorough understanding of your coverage will enable you to use your benefits wisely. Please read this COI
carefully. If you have any questions about the benefits, please contact Sanford Health Plan’s Customer Service.
This COI describes in detail the Covered Services provisions and other terms and conditions of the Plan.
15
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
This Notice of Privacy Practices (“Notice”) applies to Sanford Health Plan including Align powered by
Sanford Health Plan and Great Plains Medicare Advantage. If you have questions about this Notice,
please contact Customer Service at (800) 752-5863 (toll-free) | TTY/TDD 711.
This Notice describes how we will use and disclose your health information. The terms of this Notice
apply to all health information generated or received by Sanford Health Plan, whether recorded in our
business records, your medical record, billing invoices, paper forms, or in other ways. Unless otherwise
provided by law, any data or information pertaining to the health, diagnosis, or treatment of a Member
under a policy or contract, or a prospective Member, obtained by Sanford Health Plan from that person or
from a health care Provider, regardless of whether the information is in the form of paper, is preserved on
microfilm, or is stored in computer-retrievable form, is confidential and may not be disclosed to any
person except as set forth below.
HOW WE USE AND DISCLOSE YOUR HEALTH INFORMATION
We use or disclose your health information as follows (In Minnesota we will obtain your prior consent):
• Help manage the health care treatment you receive: We can use your health information and share
it with professionals who are treating you. For example, a doctor may send us information about your
diagnosis and treatment plan so we can arrange additional services.
• Pay for your health services: We can use and disclose your health information as we pay for your
health services. For example, we share information about you with your Primary Care Practitioner
and/or Provider to coordinate payment for those services.
• For our health care operations: We may use and share your health information for our day-to-day
operations, to improve our services, and contact you when necessary. For example, we use health
information about you to develop better services for you. We are not allowed to use genetic
information to decide whether we will give you coverage and the price of that coverage. This does not
apply to long-term care plans.
• Administer your plan: We may disclose your health information to your health plan sponsor for
plan administration. For example, your company contracts with us to provide a health plan, and we
provide your company with certain statistics to explain the Premiums we charge.
We may share your health information in the following situations unless you tell us otherwise. If you are
not able to tell us your preference, we may go ahead and share your information if we believe it is in your
best interest or needed to lessen a serious and imminent threat to health or safety:
• Friends and Family: We may disclose to your family and close personal friends any health
information directly related to that person’s involvement in payment for your care.
• Disaster Relief: We may disclose your health information to disaster relief organizations in an
emergency.
We may also use and share your health information for other reasons without your prior consent:
• When required by law: We will share information about you if State or federal law require it,
including with the Department of Health and Human services if it wants to see that we’re complying
with federal privacy law.
• For public health and safety: We can share information in certain situations to help prevent disease,
assist with product recalls, report adverse reactions to medications, and to prevent or reduce a serious
threat to anyone’s health or safety.
16
• Organ and tissue donation: We can share information about you with organ procurement
organizations.
• Medical examiner or funeral director: We can share information with a coroner, medical examiner,
or funeral director when an individual dies.
• Workers’ compensation and other government requests: We can share information to employers
for workers’ compensation claims. Information may also be shared with health oversight agencies
when authorized by law, and other special government functions such as military, national security
and presidential protective services.
• Law enforcement: We may share information for law enforcement purposes. This includes sharing
information to help locate a suspect, fugitive, missing person or witness.
• Lawsuits and legal actions: We may share information about you in response to a court or
administrative order, or in response to a subpoena.
• Research: We can use or share your information for certain research projects that have been
evaluated and approved through a process that considers a Member’s need for privacy.
We may contact you in the following situations:
• Treatment options: To provide information about treatment alternatives or other health related
benefits or Sanford Health Plan services that may be of interest to you.
• Fundraising: We may contact you about fundraising activities, but you can tell us not to contact you
again.
YOUR RIGHTS THAT APPLY TO YOUR HEALTH INFORMATION
When it comes to your health information, you have certain rights.
• Get a copy of your health and claims records: You can ask to see or get a paper or electronic copy
of your health and claims records and other health information we have about you. We will provide a
copy or summary to you usually within thirty (30) calendar days of your request. We may charge a
reasonable, cost-based fee.
• Ask us to correct your health and claims records: You can ask us to correct health information
that you think is incorrect or incomplete. We may deny your request, but we’ll tell you why in
writing. These requests should be submitted in writing to the contact listed below.
• Request confidential communications: You can ask us to contact you in a specific way (for
example, home or office phone) or to send mail to a different address. Reasonable requests will be
approved. We must say “yes” if you tell us you would be in danger if we do not.
• Ask us to limit what we use or share: You can ask us to restrict how we share your health
information for treatment, payment, or our operations. We are not required to agree to your request,
and we may say “no” if it would affect your care. If you are not able to tell us your preference, for
example if you are unconscious, we may go ahead and share your information if we believe it is in
your best interest. We may also share your information when needed to lessen a serious and imminent
threat to health or safety.
• Get a list of those with whom we’ve shared information: You can ask for a list (accounting) of the
times we’ve shared your health information for six (6) years prior, who we’ve shared it with, and
why. We will include all disclosures except for those about your treatment, payment, and our health
care operations, and certain other disclosures (such as those you asked us to make). We will provide
one (1) accounting a year for free, but we will charge a reasonable cost-based fee if you ask for
another within twelve (12) months.
• Get a copy of this privacy notice: You can ask for a paper copy of this Notice at any time, even if
you have agreed to receive it electronically. We will provide you with a paper copy promptly.
• Choose someone to act for you: If you have given someone medical power of attorney or if
someone is your legal guardian, that person can exercise your rights and make choices about your
health information. We will make sure the person has this authority and can act for you before we
take any action.
17
• File a complaint if you feel your rights are violated: You can complain to the U.S. Department of
Health and Human Services Office for Civil Rights if you feel we have violated your rights. We can
provide you with their address. You can also file a complaint with us by using the contact information
below. We will not retaliate against you for filing a complaint.
Contact Information:
Sanford Health Plan
Customer Service
PO Box 91110
Sioux Falls, SD 57109-1110
(800) 752-5863 (toll-free) | TTY/TDD 711
OUR RESPONSIBILITIES REGARDING YOUR HEALTH INFORMATION
• We are required by law to maintain the privacy and security of your health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security
of your health information.
• We must follow the duties and privacy practices described in this Notice and offer to give you a copy.
• We will not use, share, or sell your information for marketing or any purpose other than as described in
this Notice unless you tell us to in writing. You may change your mind at any time by letting us know
in writing.
CHANGES TO THIS NOTICE
We may change the terms of this Notice, and the changes will apply to all information we have about you.
The new Notice will be available upon request and online at www.sanfordhealthplan.com.
EFFECTIVE DATE
This Notice of Privacy Practices is effective February 1, 2022.
18
INTRODUCTION
HOW TO CONTACT SANFORD HEALTH PLAN [THE “PLAN”]
Method
Sanford Health Plan Contact Information
CALL
(800) 752-5863 calls to this number are free
TTY
711
HOURS
8 a.m. to 5 p.m. Central time, Monday – Friday
WEBSITE
www.SanfordHealthPlan.com
TRANSLATION
SERVICES
(800) 752-5863
WRITE
Sanford Health Plan
PO Box 91110
Sioux Falls, SD 57109-1110
PHYSICAL
ADDRESS
Sanford Health Plan
300 N Cherapa Place
Suite 201
Sioux Falls, SD 57103
How to contact Customer Service
For assistance with claim inquiries/status, eligibility and enrollment, provider access, and order ID cards,
please call or write to Customer Service. A confidential voicemail is available after hours and on
weekends. All inquiries will be returned within one business day.
Method
Customer Service Contact Information
CALL
(800) 499-3416 calls to this number are free
TTY
711
FAX
(605) 328-6812
HOURS
8:00 a.m. to 5:30 p.m. Central time, Monday – Friday
WEBSITE
www.SanfordHealthPlan.com
WRITE
Sanford Health Plan
Customer Service
PO Box 91110
Sioux Falls, SD 57109-1110
19
How to contact us with questions about Certification (prior authorization)
Some of the services listed in this document are covered only if your doctor or other network provider
gets approval in advance (called Certification or prior authorization) from us. The Utilization
Management department handles all certification requests. A confidential voicemail is available after
hours and on weekends. All inquiries will be returned within one business day.
Method
Utilization Management Contact Information
CALL
(800) 805-7938 calls to this number are free
TTY
711
FAX
(605) 328-6813
HOURS
8 a.m. to 5 p.m. Central time, Monday – Friday
WRITE
Sanford Health Plan
Utilization Management
PO Box 91110
Sioux Falls, SD 57109-1110
How to contact Pharmacy Management
For assistance with pharmacy benefit questions, formularies, or drug pre-authorization, please call or
write to Pharmacy Management.
Method
Pharmacy Management Contact Information
CALL
(800) 752-5863 calls to this number are free
TTY
711
FAX
(701) 234-4568
HOURS
8 a.m. to 5 p.m. Central time, Monday – Friday
WRITE
Sanford Health Plan
Pharmacy Management
PO Box 91110
Sioux Falls, SD 57109-1110
20
How to contact Appeals and Grievances
For assistance with Complaints (grievances) and appeal rights, contact the Appeals and Grievances
department. A confidential voicemail is available after hours and on weekends. All inquiries will be
returned within one business day.
Method
Appeals and Grievances Contact Information
CALL
(800) 752-5863 calls to this number are free
TTY
711
HOURS
8 a.m. to 5 p.m. Central time, Monday – Friday
WRITE
Sanford Health Plan
Appeals and Grievances Department
PO Box 91110
Sioux Falls, SD 57109-1110
How do I request an external review
Members may file a request for Adverse Determinations of Prospective (Pre-service) or Retrospective (Post-
service) Review with Sanford Health Plan or with the Division of Insurance. Refer to Section 10
PROBLEM RESOLUTION for more information.
Members have the right to contact the North Dakota Insurance Department at any time.
Method
North Dakota Insurance Department Contact Information
CALL
(800) 247-0560 (toll-free)
TTY
(800) 366-6888 (toll-free)
WRITE
North Dakota Insurance Department
600 E. Boulevard Ave.
Bismarck, ND 58505-0320
EMAIL
insurance@nd.gov
21
MEMBER RIGHTS
Sanford Health Plan is committed to treating Members in a manner that respects their rights. In this regard,
Sanford Health Plan recognizes that each Member (or the Member’s parent, legal guardian or other
representative if the Member is a minor or incompetent) has the right to the following:
• Members have the right to receive impartial access to treatment and/or accommodations that are
available or medically indicated, regardless of race; ethnicity; national origin; color; gender; gender
identity; age; sex; sexual orientation; medical condition, including current or past history of a mental
health and substance use disorder; disability; religious beliefs; or sources of payment for care.
• Members have the right to considerate, respectful treatment at all times and under all circumstances with
recognition of their personal dignity.
• Members have the right to be interviewed and examined in surroundings designed to assure reasonable
visual and auditory privacy.
• Members have the right, but are not required, to select a Primary Care Physician (PCP) of their choice. If
a Member is dissatisfied for any reason with the PCP initially chosen, he/she has the right to choose
another PCP.
• Members have the right to expect communications and other records pertaining to their care, including
the source of payment for treatment, to be treated as confidential in accordance with the guidelines
established in applicable North Dakota law.
• Members have the right to know the identity and professional status of individuals providing service to
them and to know which Physician or other Provider is primarily responsible for their individual care.
Members also have the right to receive information about our clinical guidelines and protocols.
• Members have the right to a candid discussion with the Practitioners and/or Providers responsible for
coordinating appropriate or Medically Necessary treatment options for their conditions in a way that is
understandable, regardless of cost or benefit coverage for those treatment options. Members also have
the right to participate with Practitioners and/or Providers in decision making regarding their treatment
plan.
• Members have the right to give informed consent before the start of any procedure or treatment.
• When Members do not speak or understand the predominant language of the community, Sanford
Health Plan will make its best efforts to access an interpreter. Sanford Health Plan has the responsibility
to make reasonable efforts to access a treatment clinician that is able to communicate with the Member.
• Members have the right to receive printed materials that describe important information about Sanford
Health Plan in a format that is easy to understand and easy to read.
• Members have the right to a clear Grievance and Appeal process for complaints and comments and to
have their issues resolved in a timely manner.
• Members have the right to Appeal any decision regarding Medical Necessity made by Sanford Health
Plan.
• Members have the right to terminate coverage, in accordance with Employer and/or Plan guidelines.
22
• Members have the right to make recommendations regarding the organization’s Member’s rights and
responsibilities policies.
• Members have the right to receive information about Sanford Health Plan, its services, its Practitioners
and Providers, and Members’ rights and responsibilities.
MEMBER RESPONSIBILITIES
Each Member (or the Member’s parent, legal guardian or other representative if the Member is a minor or
incompetent) is responsible for cooperating with those providing Health Care Services to the Member, and shall
have the following responsibilities:
• Members have the responsibility to provide, to the best of their knowledge, accurate and complete
information about present complaints, past illnesses, Hospitalizations, medications, and other matters
relating to their health. They have the responsibility to report unexpected changes in their condition to
the responsible Provider. Members are responsible for verbalizing whether they clearly comprehend a
contemplated course of action and what is expected of them.
• Members are responsible for carrying their Plan ID cards with them and for having Member
identification numbers available when telephoning or contacting the Plan.
• Members are responsible for following all access and availability procedures.
• Members are responsible for seeking emergency care at a Plan participating Emergency Facility
whenever possible. In the event an ambulance is used, direct the ambulance to the nearest participating
emergency Facility unless the condition is so severe that the Member must use the nearest emergency
Facility. State law requires that the ambulance transport you to the Hospital of your choice unless that
transport puts you at serious risk.
• Members are responsible for notifying Sanford Health Plan of an emergency admission no later than
forty-eight (48) hours after becoming physically or mentally able to give notice or as soon as reasonably
possible.
• Members are responsible for keeping appointments and, when they are unable to do so for any reason,
for notifying the responsible Practitioner or the Hospital.
• Members are responsible for following their treatment plan as recommended by the Practitioner
primarily responsible for their care. Members are also responsible for participating in developing
mutually agreed-upon treatment goals, and to the degree possible, for understanding their health
conditions, including mental health and/or substance use disorders.
• Members are responsible for their actions if they refuse treatment or do not follow the Practitioner’s
instructions.
• Members are responsible for notifying NDPERS within thirty-one (31) days of name, address, or
telephone number changes.
• Members are responsible for notifying NDPERS of any changes of eligibility that may affect their
membership or access to services. The Plan Sponsor is responsible for notifying Sanford Health Plan.
23
GRANDFATHERED VERSUS NON-GRANDFATHERED PLANS
A “Grandfathered” health plan is a health plan that was in place prior to March 23, 2010. Grandfathered plans
are able to make routine changes to policies but are exempt from some of the Affordable Care Act’s (ACA)
health insurance reforms.
A “Non-Grandfathered” health plan is a health plan that must comply with all the Patient Protection and
Affordable Care Act’s health insurance reforms.
Please refer to your Summary of Benefits and Coverage (SBC) to find out if you have a grandfathered or non-
grandfathered health plan.
SERVICE AREA
The Service Area for SOUTH DAKOTA and NORTH DAKOTA includes all counties in the state.
The Service Area for IOWA includes the following counties:
Clay
Dickinson
Emmet
Ida
Lyon
O’Brien
Osceola
Sioux
Plymouth
Woodbury
The Service Area for MINNESOTA includes the following counties:
Becker
Beltrami
Big Stone
Blue Earth
Brown
Chippewa
Clay
Clearwater
Cottonwood
Douglas
Grant
Hubbard
Jackson
Kandiyohi
Kittson
Lac Qui Parle
Lake of the Woods
Lincoln
Lyon
Mahnomen
Marshall
Martin
McLeod
Meeker
Murray
Nicollet
Nobles
Norman
Otter Tail
Pennington
Pipestone
Polk
Pope
Red Lake
Redwood
Renville
Rock
Roseau
Sibley
Stearns
Stevens
Swift
Traverse
Wilkin
Watonwan
Yellow Medicine
MEDICAL TERMINOLOGY
All medical terminology referenced in this Certificate of Insurance follows the industry standard definitions of
the American Medical Association.
DEFINITIONS
Capitalized terms are defined in Section 11 of this Policy.
CONFORMITY WITH STATE AND FEDERAL STATUTES
Any provision in this Policy not in conformity with North Dakota laws or rules may not be rendered invalid but
must be construed and applied as if it were in full compliance with any applicable State and Federal statutes. If,
on the effective date of this policy, any provision of this policy is in conflict with federal statutes, or the statutes
of the State of North Dakota, then this Policy shall be considered amended to conform to the minimum
requirements of such laws and regulations.
24
GOVERNING LAW
To the extent not superseded by the laws of the United States, this Policy will be construed in accordance with
and governed by the laws and rules of the United States of America and the state of North Dakota. Any action
brought because of a claim under this Policy will be litigated in state or federal courts located in the state of
North Dakota and in no other.
SPECIAL COMMUNICATION NEEDS
Please call the Plan if you need help understanding written information at (800) 499-3416 (toll-free) |
TTY/TDD 711 (toll-free). We can read forms to you over the phone and we offer free oral translation in any
language through our translation services. Anyone with any disability, who might need some form of
accommodation or assistance concerning the services or information provided, please contact the NDPERS
ADA Coordinator at (701) 328-3900.
TRANSLATION SERVICES
The Plan can arrange for translation services. Free written materials are available in several different languages
and free oral translation services are available. Call toll-free (800) 499-3416 (toll-free) | TTY/TDD 711 (toll-
free). for help and to access translation services.
Spanish (Español): Para obtener asistencia en Español, llame al (800) 752-5863 (toll-free).
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa (800) 752-5863 (toll-
free).
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 (800) 752-5863 (toll-free).
Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ (800) 752-5863 (toll-free).
SERVICES FOR THE DEAF, HEARING IMPAIRED, and/or VISUALLY IMPAIRED
If you are deaf or hearing impaired and need to speak to the Plan, call TTY/TDD: 711(toll-free). Please contact
the Plan toll-free at (800) 499-3416 if you are in need of a large print copy or cassette/CD of this COI or other
written materials.
In compliance with the Americans with Disabilities Act, this document can be provided in alternate formats. If
you require accommodation or assistance concerning the services or information provided, please contact the
NDPERS ADA Coordinator at (701) 328-3900.
NOTICE REGARDING HIGH DEDUCTIBLE HEALTH PLAN (HDHP) AND A HEALTH
SAVINGS ACCOUNT (HSA)
This Benefit Plan is a high deductible health plan designed to comply with §223 of the U.S. Internal
Revenue Code and is intended for use with a Health Savings Account (HSA).
Sanford Health Plan does not, and is not authorized to, provide legal or tax advice to Members. Sanford
Health Plan expressly disclaims responsibility for, and makes no representation or warranty regarding:
(1) the eligibility of any Member to establish or contribute to an HSA; or (2) the suitability of this
product in all circumstances for use with HSAs.
HEALTH SAVINGS ACCOUNT (HSA) ELIGIBILITY
25
This Benefit Plan is intended to be compatible with Health Savings Accounts (HSAs) as described in §223
of the U.S. Internal Revenue Code, which means the Benefit Plan is designed to comply with federal law
requirements regarding Deductible Amounts and Out-of-Pocket Maximum Amounts.
If a Member desires to establish an HSA, the Member must enter into a separate written agreement with an
HSA trustee or custodian. An HSA will be established for permanent employees of the State by NDPERS
pursuant to the requirements and restrictions of N.D.C.C. §54-52.1-18.
Since HSAs are personal health care savings vehicles, Sanford Health Plan is unable to provide legal or tax
advice as to whether Members are eligible to establish or contribute to an HSA in any tax year. In addition,
although a Member must be covered by a High Deductible Health Plan in order to contribute to an HSA,
additional rules apply:
a. Members may not contribute to an HSA, for example, if:
1. the Member can be claimed as a dependent on someone else’s tax return (this is different from an
Eligible Dependent for purposes of insurance coverage under the Plan); or
2. the Member has other health coverage (other than high deductible coverage), including Medicare,
coverage through a spouse, or coverage under a cafeteria plan that provides reimbursement of
medical expenses.
b. Members are solely responsible for determining the legal and tax implications of:
1. establishing an HSA;
2. eligibility for an HSA;
3. the amount of contributions made to an HSA;
4. the deductibility of contributions made to an HSA; and
5. withdrawals from an HSA and related taxation.
Sanford Health Plan encourages Members to consult with an accountant, lawyer, or other qualified tax
adviser about how HSA and HDHP rules apply to their own individual situations.
FRAUD
Fraud is a crime that can be prosecuted. Any Member who willfully and knowingly engages in an activity
intended to defraud Sanford Health Plan is guilty of fraud.
As a Member, you must:
• File accurate claims. If someone else files claims on your behalf, you should review the form before you sign
it;
• Review the Explanation of Benefits (EOB) form when it is returned to you. Make certain that benefits have
been paid correctly based on your knowledge of the expenses incurred and the services rendered;
• Never allow another person to seek medical treatment under your identity. If your ID card is lost, you should
report the loss to Sanford Health Plan immediately; and
• Provide complete and accurate information on claim forms and any other forms. Answer all questions to the
best of your knowledge.
If you are uncertain or concerned about any information or charge that appears on a bill, form, or Explanation of
Benefits; or if you know of, or suspect, any illegal activity, call Sanford Health Plan at (800) 499-3416 (toll-free)
| TTY/TDD 711 (toll-free). All calls are strictly confidential. In the absence of fraud, all statements made by
applicants, the Group or a Member shall be deemed representations and not warranties, and no statements
made for the purpose of effecting coverage shall avoid such coverage or reduce benefits unless contained
26
in a written instrument signed by the Group or Member, a copy of which has been furnished to such
Group or Member or the Member’s representative.
PHYSICAL EXAMINATION
We may have, at our own expense, a physician examine you when, and as often as we may reasonably require,
during the pendency of a claim under this Policy.
CLERICAL ERROR
Any clerical error by either the Plan or Claims Administrators, or the aforementioned entities’ designees, in
keeping pertinent records or a delay in making any changes will not invalidate coverage otherwise validly in
force or continue coverage validly terminated. An equitable adjustment of contributions will be made when the
error or delay is discovered.
If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount, Sanford Health Plan and
NDPERS retains a contractual right to the overpayment. The person or institution receiving the overpayment will
be required to return the incorrect amount of money.
VALUE-ADDED PROGRAM
Sanford Health Plan may, from time to time, offer health or fitness related programs to our Members through
which Members may receive rewards, access discounted rates from certain vendors for products and services
available to the general public, or other incentives to engage in a healthy lifestyle or to adopt healthy habits.
Products and services available under any such program are not Covered Services. Any such programs are not
guaranteed and could be discontinued at any time. Sanford Health Plan does not endorse any vendor, product or
service associated with such a program and the vendors are solely responsible for the products and services you
receive.
SUMMARY OF THIS PLAN DESCRIPTION
• This Certificate of Insurance serves as your health benefits policy and describes in detail your
Employer’s health care benefit plan and governs the coverage. The Certificate of Insurance, and any
amendments and/or riders, comprise the entire contract between the Employer and Sanford Health Plan.
• A thorough understanding of your coverage will enable you to use your benefits wisely. Please read this
Certificate of Insurance carefully. If you have any questions about the benefits as presented in the
Certificate of Insurance, please contact your Employer or Sanford Health Plan Customer Service.
• This Certificate of Insurance describes in detail the Covered Services provisions and other terms and
conditions of the Plan.
27
NOTICE OF NON-DISCRIMINATION
Sanford Health Plan complies with applicable Federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, sex (including pregnancy, sexual orientation, and
gender identity), or any other classification protected under the law. Sanford Health Plan does not exclude
people or treat them differently because of race, color, national origin, age, disability, sex (including
pregnancy, sexual orientation, and gender identity), or any other classification protected under the law.
Sanford Health Plan shall not, with respect to any person and based upon any health factor or the results
of genetic screening or testing (a) refuse to issue or renew a Certificate of Insurance, (b) terminate
coverage, (c) limit benefits, or (d) charge a different Service Charge.
Sanford Health Plan:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other
formats)
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
• If you need these services, contact Sanford Health Plan at (800) 752-5863.
If you believe that Sanford Health Plan has failed to provide these services or discriminated in another way on
the basis of race, color, national origin, age, disability, or sex, you can file a grievance by contacting the Section
504 Coordinator.
Section 504 Coordinator
2301 E. 60
th
Street
Sioux Falls, SD 57104
Phone: (877) 473-0911 | TTY: 711
Fax: (605) 312-9886
Email: shpcompliance@sanfordhealth.org
You can file a grievance in person or by mail, fax, phone, or email. If you need help filing a grievance, the
Section 504 Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human
Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-
1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
28
SECTION
1.
ENROLLMENT
1.1 ELIGIBILITY AND WHEN TO ENROLL
As provided in N.D.C.C. §54-52.1-01(4) and §54-52.1-18, individuals eligible to receive benefits are every
permanent employee who is employed by the state, and political subdivisions which elect the HDHP option,
whose services are not limited in duration, who is filling an approved and regularly funded position in the state,
and political subdivisions which elect the HDHP option, and who is employed at least seventeen and one-half
hours per week and at least five months each year or for those first employed after August 1, 2003, is employed at
least twenty hours per week and at least twenty weeks each year of employment.
An eligible employee includes members of the Legislative Assembly, judges of the Supreme Court, paid
members of state boards, commissions, or associations, or political subdivision boards, commissions, or
associations which elect the HDHP option, full-time employees of political subdivisions which elect the HDHP
option, elective state officers as defined by N.D.C.C. §54-06-01(2), disabled permanent state employees and
disabled employees of political subdivisions which elect the HDHP option, who are receiving compensation
from the North Dakota workforce safety and insurance.
A temporary employee of a political subdivision which elects the HDHP option, who is employed before August
1, 2007, may elect to participate in the uniform group insurance program by completing the necessary enrollment
forms and qualifying under the medical underwriting requirements of the program if such election is made before
January 1, 2015, and if the temporary employee is participating in the uniform group insurance program on
January 1, 2015.
In order for a temporary employee of a political subdivision which elect the HDHP option, who is employed after
July 31, 2007, to qualify to participate in the uniform group insurance program, the employee must be employed
at least twenty hours per week; must be employed at least twenty weeks each year of employment; must make the
election to participate before January 1, 2015; and must be participating in the uniform group insurance program
as of January 1, 2015. To be eligible to participate in the uniform group insurance program, a temporary
employee of a political subdivision which elects the HDHP option, who is first employed after December 31,
2014, or any temporary employee not participating in the uniform group insurance program as of January 1,
2015, must meet the definition of a full-time employee under §4980H(c)(4) of the Internal Revenue Code [26
U.S.C. 4980H(c)(4)].
Temporary employees employed by the state of North Dakota are not eligible to participate in this Benefit Plan.
An eligible employee is entitled to coverage the first of the month following the month of employment, provided
the employee submits an application for coverage within the first 31 days of employment or eligibility for a
special enrollment period as set forth in N.D.A.C. §71-03-03. Each eligible employee may elect to enroll his/her
Eligible Dependents.
Eligible employees also include non-Medicare eligible retired and terminated employees, and their Eligible
Dependents, who remain eligible to participate in the uniform group insurance program pursuant to applicable
state law, as provided in N.D.C.C. §54-52.1-03 and federal regulations. For a comprehensive description of
eligibility, refer to the NDPERS web site at www.ndpers.nd.gov.
29
Eligibility to receive benefits under the Benefit Plan is initially determined by the Plan Administrator. When an
eligible employee meets the criteria for eligibility, a membership application must be completed. NDPERS has
the ultimate decision making authority regarding eligibility to receive benefits.
A “Late Enrollee” is an Eligible Group Member or Eligible Dependent who declines coverage when he or she is
initially eligible to enroll and later requests to enroll for coverage. A Late Enrollee can only enroll during the next
scheduled Annual Enrollment Period. A Member is not a “Late Enrollee” if any “special enrollment right(s)”
apply, as described later in this section.
1.2 HOW TO ENROLL
Both the Group and Eligible Group Member are involved in the enrollment process.
The Eligible Group Member must:
1. Complete the enrollment process, as designated by NDPERS, for the Group Member and any Eligible
Dependents; and
2. Provide all information needed to determine the eligibility of the Group Member and/or Dependents, if
requested by the Plan.
The Group must:
• Provide all information needed by Sanford Health Plan to determine eligibility; and
• Agree to pay the required premium payments on behalf of the Eligible Group Member.
1.3 WHEN COVERAGE BEGINS
Coverage generally becomes effective on the first day of the month that follows the date of hire, as designated by
NDPERS.
If you are an inpatient in a Hospital or other Facility on the day your coverage begins, we will pay benefits for
Covered Services that you receive beginning on the date your coverage becomes effective, as long as you receive
Covered Services in accordance with the terms of this Certificate. Payment of benefits is subject to any
obligations under a previous plan or coverage arrangement in accordance with state law and applicable
regulations.
For more information, see Section 8, “Continuation of Coverage for Confined Members” and “Extension of
Benefits for Total Disability”.
1.4 ELIGIBILITY REQUIREMENTS FOR DEPENDENTS
The following Dependents are eligible for coverage (“Dependent coverage”):
Spouse - The Subscriber’s spouse under a legally existing marriage. A Spouse is eligible for coverage, subject
to eligibility requirements as designated by NDPERS.
Dependent Child - To be eligible for coverage, a Dependent Child must meet all the following
requirements:
1) Be your natural child, a child placed with you for adoption, a legally adopted child, a child for
whom you have legal guardianship, a stepchild, or foster child; and
30
2) Be one of the following:
• under twenty-six (26) years old; or
• incapable of self-sustaining employment by reason of a disabling condition, and chiefly
dependent upon the Policyholder/Subscriber for support and maintenance. If the Plan so
requests, the Subscriber must provide proof of the Dependent Child’s disability within
thirty-one (31) days of the Plan’s request. Such a request may be no more than annually
following the two year period of the disabled dependent child’s attainment of the limiting age
[N.D.C.C. §26.1-36-22 (4)]; If a person has a disabled dependent that is over the limiting age but
was never previously covered by the Plan, they are eligible for coverage if the disability occurred
prior to reaching the limiting age of 26. If for any reason, Subscriber drops coverage for a
disabled dependent prior to age 26, then wishes to cover the child again, coverage must be
added prior to the child turning age 26. If the disabled child has reached age 26, the child
must be continuously covered under the Plan in order to maintain eligibility.
Dependent of Dependent Child - To be eligible for coverage, a Dependent of the Dependent Child must
be the Subscriber’s grandchild or the grandchild of the Subscriber’s living, covered Spouse if (1) the
parent of the grandchild is a Member and (2) both the parent of the grandchild and the grandchild are
primarily dependent on the Subscriber for financial support. The term grandchild means any of the
following:
• natural child of a Dependent Child;
• child placed with a Dependent Child for adoption;
• child legally adopted by a Dependent Child;
• child for whom a Dependent Child has legal guardianship;
• stepchild of a Dependent Child; or
• foster child of a Dependent Child.
Limitations. A Dependent shall not be covered under this Contract if he or she is eligible to be a Subscriber,
already covered as a Dependent of another Subscriber, or already covered as a Subscriber.
NOTE: Dependent coverage does not include the spouse of an adult Dependent child. Coverage will
continue to the end of the month in which the adult Dependent child reaches the limiting age. Coverage does not
include the adult Dependent child’s spouse or child of such Dependent (dependent of dependent) unless that
Dependent’s child meets other coverage criteria established under state law. Dependent Child’s marital status,
financial status, residency, student status or employment status will not be considered in determining eligibility
for initial or continued coverage.
1.5 NONCUSTODIAL SUBSCRIBERS
Whenever a Dependent Child receives coverage through the noncustodial parent who is the Subscriber,
Sanford Health Plan shall do all of the following:
• Provide necessary information to the custodial parent in order for the Dependent Child to receive benefits
under this Contract;
• Allow the custodial parent or Provider, with the custodial parent’s approval, to submit claims for Covered
Services without approval from the noncustodial parent; and
• Make payment on the submitted claims directly to the custodial parent or Provider.
31
1.6 STATUS OF MEMBER ELIGIBILITY
The Plan Administrator agrees to furnish Sanford Health Plan with any information required by Sanford Health
Plan for the purpose of enrollment. Any changes affecting a Member’s eligibility for coverage must be provided
to Sanford Health Plan by the Plan Administrator and/or the Member immediately, but in any event, the Plan
Administrator and/or the Member shall notify Sanford Health Plan within 31 days of the change.
Statements made on membership applications are deemed representations and not warranties. No statements
made on the membership application may be used in any contest unless a copy has been furnished to that person,
or in the event of the death or incapacity of that person, to the individual’s beneficiary or personal representative.
The Subscriber is provided a copy of the membership application at the time of completion.
A Member making a statement (including the omission of information) on the membership application or in
relation to any of the terms of this Benefit Plan constituting fraud or an intentional misrepresentation of a
material fact will result in the rescission of this Benefit Plan by Sanford Health Plan. A rescission is a
cancellation or discontinuance of coverage, including any benefits paid, that has a retroactive effect of voiding
this Benefit Plan or any benefits paid under the terms of this Benefit Plan.
1.7 WHEN AND HOW TO ENROLL DEPENDENTS
A Subscriber shall apply for coverage for a Dependent during the same periods of time that the Subscriber may
apply for his or her own coverage. However, there is an exception for newborn and adopted children; see
“Coverage from Birth” and “Adoption or Children Placed for Adoption” section below. There is also an
exception for Spouses; see “New Spouses” section below.
How to Enroll Dependents
The Group Member must:
1. Complete the enrollment process, as designated by NDPERS, for the Group Member and any Eligible
Dependents; and
2. Provide all information needed to determine the eligibility of the Group Member and/or Dependents, if
requested by the Plan.
1.8 WHEN DEPENDENT COVERAGE BEGINS
A. General
If a Dependent is enrolled at the same time the Subscriber enrolls for coverage through NDPERS, the
Dependent’s effective date of coverage will be the same as the Subscriber’s effective date as described in
Section “When Coverage Begins” above.
B. Delayed Effective Date of Dependent Coverage
Except for newborns (see “Coverage from Birth” section below), if, on the date Dependent coverage
becomes effective, the Dependent is Hospitalized and covered under an extension of health benefits under
any prior coverage exists, the Plan coordinates benefits. For more details on Coordination of Benefits, see
Section 6.
C. Coverage from Birth
32
If a Subscriber has a child through birth, the child will become a covered Dependent from the date of birth.
Depending on the Class of Coverage the Subscriber is enrolled under, the following provisions apply:
a. Subscribers with Single Coverage: Newborns are covered under a Single Coverage Plan through the
date of mother’s discharge from the hospital in which the child was born. For coverage to extend after
the mother’s hospital discharge, Subscribers must submit application to NDPERS within thirty-one (31)
days of the newborn’s date of birth. Coverage will then be applied retroactively back to the date of birth.
b. Subscribers with Family Coverage: Newborn children will be added to the Certificate automatically if
the Subscriber is enrolled in Family Coverage.
A Dependent of Dependent (Subscriber’s Grandchild), as defined by the eligibility criteria listed above, must
be added to the Subscriber’s policy within thirty-one (31) days of birth to qualify for coverage.
An Eligible Group Member who failed to enroll during a previous enrollment period shall be covered under
this Contract from the date of the child’s birth, provided that coverage is applied for through NDPERS within
thirty-one (31) days of the birth. Pursuant to N.D.A.C. §71-03-03-01, an employee who previously waived
coverage must enroll for coverage at the same time that the Employee’s Eligible Dependent(s) enroll.
Dependent coverage is available for the Spouse. The Spouse may be added if application is made within
thirty-one (31) days of a child’s birth if otherwise eligible for coverage under the Plan, provided that
coverage is applied through NDPERS for the Spouse and, if applicable, the Group Member.
D. Adoption or Children Placed for Adoption
If a Subscriber adopts a child or has a child placed with him or her as a Dependent, that child will become
covered as an Eligible Dependent as of the date specified within a court order or other legal adoption papers.
Regardless of the Class of Coverage the Subscriber is enrolled under, the following provisions apply:
a. Subscribers with either Single or Family Coverage: For coverage to continue beyond thirty-one (31)
days of the date specified within the court order or other legal adoption papers granting an adoption,
placement for adoption, legal guardianship, or order to provide health coverage, the Subscriber must
submit an application for coverage to NDPERS within thirty-one (31) days of the date specified within
the court order or other legal adoption papers that granted initial eligibility.
An Eligible Group Member, and any other Dependents, eligible to be enrolled in the Plan, who failed to
enroll during a previous enrollment period, shall be covered as of the date specified within a court order or
other legal adoption papers, if the Eligible Group Member, and any other Eligible Dependents, submits an
application for coverage to NDPERS within thirty-one (31) days of the date specified within the court order
or in the legal adoption papers granting an adoption, placement for adoption, legal guardianship, or order to
provide health coverage. Pursuant to N.D.A.C. §71-03-03-01, an employee who previously waived coverage
must enroll for coverage at the same time that the Employee’s Eligible Dependent(s) enroll.
Dependent coverage is available for the Spouse, if the Spouse is otherwise eligible for coverage under the
Plan, provided that an application for coverage is submitted to NDPERS for the Spouse and, if applicable,
the Group Member, within thirty-one (31) days of the date specified within the court order or in the legal
adoption papers granting an adoption, placement for adoption, legal guardianship, or order to provide health
coverage.
Coverage at the time of placement for adoption includes the necessary care and treatment of medical
conditions existing prior to the date of placement.
33
E. New Spouses and Dependent Children
If a Subscriber gets married, his or her Spouse, and any of the Spouse’s Dependents who thus become
Eligible Dependents of the Subscriber as a result of the marriage, will become covered as a Member from
the first day of the calendar month beginning after the date of marriage, provided that coverage is applied
for with NDPERS for the Spouse and/or Eligible Dependents within thirty-one (31) days of the date of
marriage. If the Subscriber does not submit an application for coverage to NDPERS for the Spouse and/or
any Eligible Dependent(s) within thirty-one (31) days of the date of marriage, then Late Enrollee provisions
apply and the Late Enrollee can only enroll during the next scheduled Annual Enrollment Period with
coverage effective the following January 1
st
. This includes marriages for which coverage was effective on or
after June 26, 2015, regardless of the Spouses’ gender/sex.
If an Eligible Group Member, who is an Employee eligible to enroll in the Plan, but who did not do so
during a previous enrollment period, gets married, the employee becomes an eligible Subscriber under the
following conditions:
a. The Subscriber, his or her Spouse, and any Dependents who thus become Eligible Dependents of the
Subscriber as a result of the marriage, will become covered as a Member from the first day of the
calendar month beginning after the date of marriage, provided that coverage is applied for within thirty-
one (31) days of the date of marriage or as applicable during the Special Enrollment Period detailed
under notation F in the Special Enrollment Rights section.
b. Pursuant to N.D.A.C. §71-03-03-01, an employee who previously waived coverage must enroll for
coverage at the same time that the Employee’s Eligible Dependent(s) enroll.
** NOTE: Per Federal laws, guidance, and regulations, the sexual orientation and sex/gender of Spouses,
married in a jurisdiction with legal authority to authorize their marriage, is not a factor in the issuance of
coverage or benefit determinations. Sanford Health Plan, in compliance with federal guidance for all states,
offers coverage to all legally married Spouses, and any Eligible Dependents as a result of marriage,
regardless of the jurisdiction in which the marriage occurred. The provisions in this contract regarding
Spousal eligibility and Late Enrollees continue to apply, regardless of Spouses’ sex/gender.
1.9 QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) PROVISION
A QMCSO is an order that creates the right of a Subscriber’s Dependent Child to be enrolled in coverage under
this Contract. If a QMCSO is issued, Sanford Health Plan will provide benefits to the Dependent Child(ren) of a
Subscriber regardless of whether the Dependent Child(ren) reside with the Subscriber. In the event that a
QMCSO is issued, each named Dependent Child(ren) will be covered by this Certificate of Insurance in the same
manner as any other Dependent Child(ren).
When Sanford Health Plan is in receipt of a medical child support order, Sanford Health Plan will notify the
Subscriber and each Dependent Child named in the order, whether or not it is a QMCSO. A QMCSO must
contain the following information:
1. Name and last known address of the Subscriber and the Dependent Child(ren) to be covered by the Plan.
2. A description of the type of coverage to be provided to each Dependent Child.
3. The applicable period determined by the order.
4. The plan determined by the order.
In order for the Dependent Child’s coverage to become effective as of the date of the court order issued, the
Subscriber must apply for coverage as defined previously in this section. Each named Dependent Child may
34
designate another person, such as a custodial guardian, to receive copies of explanation of benefits, checks, and
other materials.
Exceptions
If a court has ordered a Subscriber to provide health coverage for a Dependent Child, the above requirements
under Dependent Child need not be satisfied, but the Subscriber must still request enrollment on behalf of the
Dependent Child as set forth in this Certificate of Insurance. If the Subscriber fails to enroll the Dependent Child,
the other parent may enroll the Dependent Child. A Dependent Child who is provided coverage pursuant to this
exception shall not be terminated unless Sanford Health Plan is provided satisfactory written evidence of any of
the following:
1. The court or administrative order is no longer in effect;
2. The Dependent Child(ren) currently receive(s) or will be enrolled in comparable health coverage through a
health insurance issuer which will take effect not later than the effective date of the termination; or
3. The Group has eliminated family coverage for all of its Eligible Group Members.
1.10 SPECIAL ENROLLMENT PROCEDURES AND RIGHTS
A Special Enrollment Period may apply when an individual becomes an Eligible Dependent through
marriage, birth, adoption, or placement for adoption or when an Eligible Group Member or an Eligible
Dependent involuntarily loses other health coverage.
A. The Subscriber is responsible for notifying the Plan Administrator (NDPERS) of any mailing address change
within thirty-one (31) days of the change.
B. The Subscriber is responsible for notifying the Plan Administrator (NDPERS) of any change in marital status
within thirty-one (31) days of the change or as applicable during the Special Enrollment Period detailed under
notation F in the Special Enrollment Rights section.
1. If the Subscriber marries, Eligible Dependents may be added as a Member if a membership application is
submitted within 31 days of the date of marriage. If the membership application is not submitted within
the 31-day period, and the Eligible Dependent is a Late Enrollee, the effective date of coverage will be the
Group’s anniversary date.
If the membership application is submitted within thirty-one (31) days of the date of marriage, the effective
date of coverage for the Eligible Dependent will be the first of the month immediately following the date
of marriage. If the membership application is not submitted within thirty-one (31) days of the date of
marriage and the Eligible Dependent is a Late Enrollee, the effective date of coverage will be the Group’s
anniversary date.
2. If a Member becomes otherwise ineligible for group membership under this Benefit Plan due to legal
separation, divorce, annulment, or death, coverage for the Subscriber’s Spouse and/or Dependents under
Family Coverage will cease, effective the first of the month immediately following timely notice of the
event causing ineligibility.
If living in the Sanford Health Plan Service Area (see Service Area in Introduction Section), a Member has
the option to continue coverage through one of Sanford Health Plan’s individual plans. For more
information on options available through Sanford Health Plan, visit sanfordhealthplan.com/ndpers or call
Customer Service toll-free at (800) 499-3416 | TTY/TDD: 711 (toll-free).
There may also be other coverage options through the Health Insurance Marketplace, Medicaid, or other
group health plan coverage options (such as another employer’s plan) through what is called a “special
35
enrollment period.” The cost of these options may vary depending on a Subscriber’s individual
circumstances. To learn more about offerings on the Marketplace, and options outside the Sanford Health
Plan Service Area, visit healthcare.gov or call (800) 318-2596 | TTY/TDD: (855) 889-4325.
C. The Subscriber is responsible for notifying the Plan Administrator (NDPERS) and Sanford Health Plan of any
change in family status within thirty-one (31) days of the change. The effective date of coverage for dependents
added to this Benefit Plan within the designated time period will be the date of birth, physical placement, or
the first of the month immediately following the date established by court order. If a membership application
is not submitted within the designated time period and the Eligible Dependent is a Late Enrollee, the effective
date of coverage will be the Group’s anniversary date.
The following provisions will apply:
1. At the time of birth, natural children will automatically be added to the Subscriber’s Benefit Plan if Family
Coverage is in force. If the Subscriber is enrolled under another Class of Coverage, the Subscriber must
submit a membership application for the newborn child within thirty-one (31) days of the date of birth for
coverage to continue beyond the first thirty (30) days beginning with the child’s birth. If the membership
application is not submitted within the designated time period and the child is a Late Enrollee, the effective
date of coverage will be the Group’s anniversary date.
2. Adopted children may be added to this Benefit Plan if a membership application, accompanied by a copy
of the placement agreement or court order, is submitted to NDPERS within thirty-one (31) days of physical
placement of the child. If the membership application is not received in accordance with this provision and
the child is a Late Enrollee, the effective date of coverage will be the Group’s anniversary date.
3. Children who have been placed under the care Subscriber, or the Subscriber’s living, covered spouse due
to the Subscriber, or the Subscriber’s living, covered spouse being appointed legal guardian, may be added
to this Benefit Plan by submitting a membership application within thirty-one (31) days of the date legal
guardianship is established by court order. If the membership application is not received in accordance
with this provision and the child is a Late Enrollee, the effective date of coverage will be the Group’s
anniversary date.
4. Children for whom the Subscriber or the Subscriber’s living, covered spouse are required by court order
to provide health benefits may be added to this Benefit Plan by submitting a membership application within
thirty-one (31) days of the date established by court order. If the membership application is not received in
accordance with this provision and the child is a Late Enrollee, the effective date of coverage will be the
Group’s anniversary date.
5. If any of the Subscriber’s children, or those of the Subscriber’s living, covered spouse, who are Eligible
Dependents under the Plan, beyond the age of 26, incapable of self-sustaining employment by reason of a
disabling condition, and chiefly dependent upon the Certificate holder/Subscriber for support and
maintenance, shall have coverage remain in effect as long as such disabled child remains dependent upon
the Certificate holder/Subscriber or the Subscriber’s spouse for support and maintenance. If the Plan so
requests, the Subscriber must provide proof of the child’s disability within thirty-one (31) days of the Plan’s
request.
6. If a child is no longer an Eligible Dependent under this Benefit Plan, and the child is living in the Sanford
Health Plan Service Area (see Service Area in the above Introduction Section), the Dependent has the
option to continue coverage through one of Sanford Health Plan’s individual plans. For more information
on options available through Sanford Health Plan, visit sanfordhealthplan.com/ndpers or call Customer
Service toll-free at (800) 499-3416 | TTY/TDD: 711 (toll-free). There may also be other coverage options
through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such
as another employer’s plan) through what is called a “special enrollment period.” The cost of these options
may vary depending on a Subscriber’s individual circumstances. To learn more about offerings on the
Marketplace, and options outside the Sanford Health Plan Service Area, visit healthcare.gov or call (800)
318-2596 | TTY/TDD: (855) 889-4325.
36
7. At the time of birth or adoption, other Eligible Dependents may be added to this Benefit Plan if a
membership application is submitted to NDPERS within thirty-one (31 days) of birth or physical
placement of the adopted child. If the membership application is not received in accordance with this
provision, and the Eligible Dependent is a Late Enrollee, the effective date of coverage will be the
Group’s anniversary date. Pursuant to N.D.A.C. §71-03-03-01, an Employee who previously waived
coverage must enroll for coverage at the same time that the Employee’s Eligible Dependent(s) enroll.
D. Employees and/or dependents who previously declined coverage under this Benefit Plan will be able to enroll
under this Benefit Plan if each of the following conditions are met:
1. During the initial enrollment period the employee or dependent states, in writing, that coverage under a
group health plan or health insurance coverage was the reason for declining enrollment at such time.
2. The employee’s or dependent’s coverage under a group health plan or other health insurance coverage:
a. was either terminated as a result of loss of eligibility (Including loss as a result of legal separation,
divorce, death, termination of employment or reduction of hours, loss as a result of having a
subsequent opportunity for late enrollment [including the Annual Enrollment Period] or special
enrollment under the Benefit Plan but again choosing not to enroll, or employer contributions toward
such coverage were terminated; or
b. was under COBRA and the coverage was exhausted.
3. The employee requests such enrollment within thirty-one (31) days after the exhaustion or termination of
coverage.
The effective date of coverage for an employee and/or dependent that previously declined coverage under this
Benefit Plan, and is enrolling pursuant to this provision, will be the first of the month following the exhaustion
or termination of the employee’s and/or dependent’s previous coverage. The employee and/or dependent shall
be responsible for any and all premium payments from the effective date of coverage under this provision
through the date the employee and/or dependent requests enrollment under the terms of this Benefit Plan.
If the membership application is not received in accordance with this provision, and the Employee or
Dependent is a Late Enrollee, the Late Enrollee’s effective date of coverage will be the Group’s anniversary
date.
E. Employees and/or Dependents will be able to enroll under this Benefit Plan if either of the following conditions
is met:
1. The employee or dependent is covered under a Medicaid plan under Title XIX of the Social Security Act,
or under a state child health plan under Title XXI of the Social Security Act, and the employee’s or
dependent’s coverage under such a plan is terminated as a result of loss of eligibility. The employee must
request enrollment within sixty (60) days of the date of termination of coverage; or
2. The employee or dependent becomes eligible for premium assistance under a Medicaid plan under Title
XIX of the Social Security Act or under a state child health plan under Title XXI of the Social Security
Act. The employee must request enrollment within sixty (60) days of the date the employee or dependent
is determined to be eligible for premium assistance.
The effective date of coverage under this Benefit Plan for an employee and/or dependent enrolling pursuant
to this provision will be the first day immediately following the termination of coverage or eligibility for
premium assistance. The employee and/or dependent shall be responsible for any and all premium
payments from the effective date of coverage under this provision through the date the employee and/or
dependent requests enrollment under the terms of this Benefit Plan.
F. In accordance with the decision of the Supreme Court of the United States on June 26, 2015, in Obergefell v.
Hodges, 576 U.S. (2015), regarding same-sex marriage:
37
1. Same-sex marriages that occurred prior to June 26, 2015: NDPERS will have a special enrollment
period from July 1, 2015 through September 30, 2015. Coverage will be effective retroactive to July 1,
2015. If the Subscriber does not enroll during this eligibility period, the Late Enrollee can only enroll
during the next scheduled Annual Enrollment Period with coverage effective the following January 1
st
.
2. Same-sex marriages that occur on or after June 26, 2015: The Subscriber must submit an application
for coverage within the first thirty-one (31) days of the event. If the Subscriber does not enroll when
initially eligible, the Late Enrollee can only enroll during the next scheduled Annual Enrollment Period
with coverage effective the following January 1
st
.
Pursuant to N.D.A.C. §71-03-03-01, an employee who previously waived coverage must enroll for coverage
at the same time that the Employee’s Eligible Dependent is enrolled.
* Loss of coverage due to failure to make premium payment and/or allowable rescissions of coverage does not
qualify for a Special Enrollment Period.
* Voluntarily terminating/dropping COBRA coverage before it runs out outside Annual Enrollment does not
qualify for a Special Enrollment Period.
COBRA coverage must be exhausted (usually 18 or 36 months) or another qualifying life event must occur
before eligible for special enrollment.
1.11 CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT OF 2009
(CHIPRA)
The Children’s Health Insurance Program (CHIP) Reauthorization Act of 2009 grants special enrollment rights
to employees and Dependents who are eligible for, but not enrolled in, a group health plan to enroll in the plan
upon:
• Losing eligibility for coverage under a State Medicaid or CHIP program, or
• Becoming eligible for State premium assistance under Medicaid or CHIP.
In order to qualify for special enrollment, an eligible employee or dependent must request coverage within sixty
(60) days of either being terminated from Medicaid or CHIP coverage, or being determined to be eligible for
federal premium assistance. In either situation, the Plan will also require the eligible employee to enroll in Plan
coverage. Special enrollment rights extend to all benefit packages available under the Plan. If you have
questions about enrolling in your employer plan under CHIPRA special enrollment rights, contact the U.S.
Department of Labor at www.askebsa.dol.gov or call (866) 444-3272 (toll-free).
If you or your Dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
Dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial
(877) KIDS NOW or www.insurekidsnow.gov to find out how to apply.
38
1.12 MICHELLE’S LAW
Federal law requires that we provide the following notice regarding Michelle’s Law [Public Law 110-381].
Please note that changes in federal law may eliminate certain elements of Michelle’s Law, and the Plan intends to
provide continuing coverage of Eligible Dependents up to age twenty-six (26), irrespective of their student status,
for Plan Years beginning on or after September 23, 2010.
A Dependent Child under twenty-five (25) years old and enrolled in and attending an accredited college,
university, or trade or secondary school at least five (5) months each year will remain covered if the Dependent
takes a medically necessary leave of absence from school or changes to part-time status. The leave of absence
must:
1. Be medically necessary;
2. Commence while the child is suffering from a serious illness or injury; and
3. Cause the child to lose coverage under the plan.
Students are only eligible as long as they were covered by their parent’s health insurance Certificate prior to
diagnosis. Coverage will continue until the earlier of one year from the first day of the leave of absence or the
date on which coverage would otherwise terminate because the child no longer meets the requirements to be an
Eligible Dependent (e.g., reaching the plan’s limiting age).
You must provide a written and signed certification from the Dependent Child’s treating Practitioner and/or
Provider stating that the Dependent Child is suffering from a serious illness or injury and that the leave of
absence is medically necessary and the effective date of the leave.
39
SECTION 2
HOW YOU GET CARE
2.1 IDENTIFICATION CARDS
Sanford Health Plan will send you an identification (ID) card when you enroll. Each Subscriber will
receive their own Member ID card after enrollment, which should be used when you receive care. You
must show it whenever you receive services from a Provider, a health care Facility, or fill a prescription at a Plan
pharmacy. If you fail to show your ID card at the time you receive Health Care Services or prescription
medications, you will be responsible for payment of the claim after the Participating Practitioner and/or
Provider’s timely filing period of one-hundred-eighty (180) calendar days has expired. Your coverage
will be terminated if you use your ID card fraudulently or allow another individual to use your ID card to
obtain services.
If you do not receive your ID card within thirty (30) calendar days after the effective date of your
enrollment, you need a temporary card or replacement cards, please call us at (800) 499-3416 | TTY/TDD:
711 (toll-free) or write to us at Sanford Health Plan, ATTN: NDPERS, PO Box 91110 Sioux Falls, SD 57109-
1110. You may also request replacement cards by signing into your account at
sanfordhealthplan.com/memberlogin. Information on creating an account is available at
sanfordhealthplan.com/ndpers.
2.2 CONDITIONS FOR COVERAGE
Members are entitled to coverage for the Health Care Services (listed in the “Covered Services,” in Section
3)that are:
• Medically Necessary and/or Preventive;
• Received from or provided under the orders or direction of a Participating Provider;
• Approved by the Plan, including Preauthorization/Prior Approval where required; and
Within the scope of health care benefits covered by the Plan
However, this specific condition does not apply to Emergency Medical Conditions or urgent care in and out of
the Service Area. In such cases, the services will be covered if they are provided by a Non-Participating or Out-
of-Network Provider.
If during an emergency or Urgent care situation, the Member is in the Service Area and is alert, oriented and
able to communicate (as documented in medical records); the Member must direct the ambulance to the nearest
Participating Practitioner and/or Provider.
Members are not required, but strongly encouraged, to select a Primary Care Physician and use that Physician
to coordinate their Health Care Services.
In addition, all Health Care Services are subject to:
• The exclusions and limitations described in Sections 3 and 4; and
• Any applicable Deductible and Coinsurance amount as stated in this COI, your Summary of Benefits and
Coverage (SBC), and Pharmacy Handbook.
40
2.3 IN-NETWORK COVERAGE
In-Network coverage is provided under two (2) plan levels. For more information, see Selecting a Health
Care Provider in Section 3.7 In-Network benefit payments pay according to coverage under:
1. Basic Plan; or
2. PPO Plan
Note: If you travel out of the Plan’s Service Area for the purpose of seeking medical treatment outside the Plan’s
Service Area, as defined in this COI, without Preauthorization/Prior Approval for a service that requires such
authorization/approval, your claims will be paid according to the Basic Plan benefits and stipulations set forth in
Section 3.7.
Additionally, the Member will receive Basic Plan benefits if: 1) a PPO Health Care Provider is not available in
the Member’s area; or 2) if the Member either chooses or is referred to a Health Care Provider not participating
in the Preferred Provider Organization (PPO).
For Appropriate Access standards, see below.
In the following circumstances, Medically Necessary Health Care Services received from Non-Participating
Providers may be Covered Services subject to In Network Cost Sharing, although Members may be responsible
for the difference between the amount charged by the Non-Participating Provider and Sanford Health Plan’s
payment for Covered Services.
1. Ancillary Health Care Services. Health Care Services received from a Non-Participating Provider that
are ancillary to a Covered Service being provided by In-Network Participating Practitioner and/or
Provider, such as anesthesiology or radiology, if rendered in an In-Network Facility. Any payment by
the Member for the difference between the amount charged by the Non-Participating Provider and
Sanford Health Plan’s payment for Covered Services will count towards the Out-of-Pocket Maximum
Amount applicable to In Network Benefits.
2. Termination of a Participating Provider. Health Care Services received from a Participating Provider
by a Member who is under an Active Course of Treatment and we terminate the Participating Provider’s
status as a Participating Provider without cause. The Member or the terminated Participating Provider
must request and receive written approval from us. Any payment by the Member for the difference
between the amount charged by the Non-Participating Provider and Sanford Health Plan’s payment for
Covered Services will not count towards the Out-of-Pocket Maximum Amount applicable to In Network
Benefits.
2.4 APPROPRIATE ACCESS
Primary Care Physicians and Hospital Providers
Appropriate access for Participating Practitioner and/or Providers who provide primary care services and
Hospital Provider sites is within fifty (50) miles of a Member’s city of legal residence
Specialty Practitioners and Providers
For other Participating Practitioner and/or Providers such as Specialty Physicians, Diagnostic Service Centers,
Nursing Homes, and Rehabilitation Providers, appropriate access is within fifty (50) miles of a Member’s city of
legal residence. If you are traveling within the Service Area where other Participating Practitioner and/or
Providers are available, then you must use Participating Practitioner and/or Providers.
41
Members who live outside of the Plan’s Service Area must use the Plan’s contracted Network of Participating
Practitioners and Providers as indicated in the Plan’s Provider Directory. Members who live outside the Service
Area will receive Identification Cards that display their network logo along with instructions on how to access
this Network. If a Member chooses to go to a Non-Participating Practitioner or Provider when appropriate access
(within fifty (50) miles of a Member’s city of legal residence) is available, claims will be processed at the Basic
Plan (Out-of-Network) level.
Transplant Services
Transplant Services must be performed at designated participating facilities and are not subject to the
appropriate access standards outlined above. Transplant coverage includes related post-surgical treatment,
drugs, eligible travel, and living expenses and shall be subject to and in accordance with the provisions,
limitations and terms of Sanford Health Plan’s transplant policy.
2.5 CASE MANAGEMENT
Case management is a collaborative process that assesses, plans, implements, coordinates, monitors and
evaluates the options and services required to meet an individual’s health needs, using communication and
available resources to promote quality, cost effective outcomes.
Cases are identified for possible case management, based on a request for review or the presence of a number of
parameters, such as:
1. admissions that exceed the recommended or approved length of stay;
2. utilization of health care services that generates ongoing and/or excessively high costs;
3. conditions that are known to require extensive and/or long term follow up care and/or treatment.
Sanford Health Plan’s case management process allows professional case managers to assist Members with
certain complex and/or chronic health issues by coordinating treatment and/or other types of patient care plans.
In consultation with case managers, Sanford Health Plan may approve coverage that extends beyond the limited
time period and/or scope of treatment initially approved. This consultation also includes utilization management
processes as described below.
All decisions made through case management are based on the individual circumstances of a Member’s case.
Each case is reviewed on its own merits by appropriate health plan medical professionals to ensure the best
health outcome(s) of the Member.
NOTE: For certain transplant procedures, case management services will be provided by the Plan’s transplant
vendor, not Sanford Health Plan. For benefit details on transplant services, see Section 3.2.
2.6 BENEFIT DETERMINATION REVIEW PROCESS
Sanford Health Plan Appeals and Grievances Department reviews all non-medical benefit determinations
through review of Certificate of Insurance language, contractual terms, administrative policies related to benefits
42
as defined by this Policy, and benefits requests. All benefit determinations that are Adverse will be made by the
person assigned to coordinate Benefit, Denial, and Appeal processes.
The date of receipt for non-urgent (standard) requests received outside of normal business hours will be the next
business day.
Refer to the Introduction section at the beginning of this document for instructions on how to contact the Appeals
and Grievances department.
2.7 ROUTINE (NON-URGENT) PRE-SERVICE BENEFIT REQUESTS
All pre-service benefit determination (approval) requests will be determined within fifteen (15) business
days of receipt of the request. When a preauthorization (pre-approval) request is received before a service
occurs, the date of receipt for non-urgent (standard) requests is the date the Plan receives the Member’s
request. If the request is made outside of business hours, the date or receipt will be next business day. If
Sanford Health Plan denies a benefit (an Adverse Benefit Determination) the Plan will contact the
Member via mail.
2.8 ROUTINE POST-SERVICE BENEFIT REQUESTS
Retrospective (post-service) requests occur when a Member has already utilized healthcare services and
did not inquire about coverage pre-service. Post-service requests are not related documentation, coding or
reimbursement from the Plan. Sanford Health Plan will review and approve or deny the service based on
Medical Necessity within thirty (30) calendar days of receipt of the request. A letter will be sent to the
Member within those 30 calendar days with the Plan’s determination.
2.9 UTILIZATION MANAGEMENT REVIEW PROCESS
Refer to the Introduction section at the beginning of this document for instructions on how to contact the
Utilization Management department.
The date of receipt for non-urgent requests received outside of normal business hours will be the next business
day. The date of receipt for urgent requests will be the actual date of receipt, whether or not it is during normal
business hours.
All Utilization Review Adverse Determinations will be made by the Sanford Health Plan Chief Medical Officer
or appropriate Practitioner.
Claims for benefits under the Plan can be post-service, pre-service, or concurrent. This part of Section 2 explains
how we process different types of claims.
Designating an Authorized Representative
You may act on your own behalf, or through an Authorized Representative, if you wish to exercise your rights
under this Section. An Authorized Representative is someone you designate in writing to act on your behalf. We
have developed a form that you must complete if you wish to designate an Authorized Representative. You can
get the form by calling Customer Service. You can also log into your account at
www.sanfordhealthplan.com/memberlogin and download a copy of the form. If a person is not properly
43
designated as your Authorized Representative, we will not be able to deal with him or her in connection with
your rights under this Section of your Policy.
For urgent pre-service claims, we will presume that your Provider is your Authorized Representative unless you
tell us otherwise in writing.
Your Right to Information
You have the right, upon request, to receive copies of any documents that we relied on in reaching our decision
and any documents that were submitted, considered, or generated by us in the course of reaching our decision.
You also have the right to receive copies of any internal rules, guidelines, or protocols that we may have relied
upon in reaching our decision. If our decision was based on a medical or scientific determination (such as
Medical Necessity), you may also request that we provide you with a statement explaining our application of
those medical and scientific principles to you. If we obtained advice from a health care professional (regardless
of whether we relied on that advice), you may request that we give you the name of that person. Reasons for any
denial or reimbursement or payment for services with respect to benefits under the Plan will be provided within
30 business days of a request. We will not charge you for any information that you request regarding our
decision.
Your Complaint (Grievance) & Appeal Rights
If you are dissatisfied with our handling of a claim or have any questions or complaints, you may do one or more
of the following:
• You may call or write the Appeals and Grievances Department. We will help you with questions about your
coverage and benefits or investigate any adverse benefit determination you might have received; or
• You may file an Appeal if you have received an Adverse Benefit Determination. Please see Section 10 for
more information on the Appeals Process.
The Plan’s claims procedures are designed to comply with the requirements of ERISA., We will process your
claim according to ERISA standards. In compliance with the Mental Health Parity and Addiction Equity Act of
2008 (MHPAEA), criteria for Medical Necessity determinations is available upon request to any current or
potential Member, beneficiary, or contracting provider. For details on the complaint and appeals process, see
Section 10.
NOTE: If you receive an Adverse Determination, you have the right to request treatment and diagnosis code
information free of charge. Any request for diagnosis and treatment code information may not (and is not)
considered a request for an Internal Appeal and/or External Review.
2.10 PROSPECTIVE (PRE-SERVICE) REVIEW OF SERVICES (CERTIFICATION PRIOR
AUTHORIZATION)
Prior Authorization (also referred to as Certification) is a decision by the Plan that a health care service,
treatment plan, prescription drug or durable medical equipment is medically necessary and appropriate.
Preauthorization is required for services as defined above, except in urgent or emergent situations. Although the
Plan may authorize a health care service as medically necessary, it is not a guarantee the Plan will cover the cost.
44
Determination of the appropriateness of care is based on standard review criteria and assessment of the
following factors:
• The Member’s medical information, including diagnosis, medical history and the presence of complications
and/or comorbidities.
• Consultation with the treating Practitioner and/or Provider, as appropriate.
• Availability of resources and alternate modes of treatment. For admissions to Facilities, other than
Hospitals, additional information may include but is not limited to history of present illness, patient
treatment plan and goals, prognosis, staff qualifications and twenty-four (24) hour availability of qualified
medical staff.
• Sanford Health Plan does not compensate Practitioners, Providers or other individuals conducting
Utilization Review for issuing denials of coverage or service care. Any financial incentives offered to
Utilization Review decision makers do not encourage decisions that result in underutilization and do
not encourage denials of coverage or service.
Prior authorization is required for all inpatient admissions.
This requirement applies, but is not limited to, the following:
1.
Acute care Hospitalizations (including medical, surgical, and non-emergency mental health or substance
use disorder inpatient admissions);
2.
Residential Treatment Facility admissions; and
3.
Rehabilitation center admissions.
Admission before the day of non-Emergency surgery will not be authorized unless the early admission is
Medically Necessary and specifically approved by Sanford Health Plan. Coverage for Hospital expenses
prior to the day of surgery will be denied unless authorized prior to being incurred.
Referrals to Recommended Providers
Referrals to Non-Participating Providers, which are recommended by Participating Providers.
Preauthorization/Prior Approval is required for the purposes of receiving Basic Plan level coverage. If
Preauthorization/Prior Approval is not obtained for referrals to Non-Participating Providers, the services
will be covered at the Basic Plan level. Preauthorization/Prior Approval does not apply to services that are
provided by Non-Participating Providers as a result of a lack of appropriate access to Participating
Providers as described in this section.
Prior Authorization is the responsibility of your Practitioner and/or Provider. For an up to date list or more
information on all things that require prior authorization, please visit:
https://www.sanfordhealthplan.com/members/prior-authorization.
2.11 PHARMACY PRE-APPROVAL (CERTIFICATION) REQUESTS
Certain specialty drugs, or those which require frequent dosing adjustments, close monitoring, special
training, compliance assistance, or need special handling and/or administration, require preauthorization
by the Pharmacy Management Department.
To acquire preauthorization for a medication, ask the prescribing Practitioner and/or Provider to contact us
by phone, complete the Formulary Exception Form found online at sanfordhealthplan.com, or provide a
letter of Medically Necessity. This applies to any request of:
45
1) A non-covered medication or drug; or
2) A medication, or drug not currently listed in the Formulary.
Sanford Health Plan will use appropriate practitioners to consider requests and grant an exceptions to the
Formulary when the prescribing Practitioner and/or Provider of the drug attests the Formulary drug causes an
adverse reaction, is considered contraindicated, or must be dispensed as written to provide maximum medical
benefit to the Member.
The Pharmacy Management department will review the request and make a decision based on:
1. Medical records showing trial and failure of a formulary drug or reasons why a formulary drug trial
should be avoided;
2. Clinical information (such as diagnosis, disease progression and/or medication history); and
3. Medical Necessity.
If the reason for the exception is not clear, the reviewing clinician will contact the prescribing Practitioner
and/or Provider to discuss the request. Additionally, if necessary, a clinical consultant of the appropriate
specialty may be consulted for review.
If a Formulary exception is granted, the Pharmacy Management Department will provide authorization to the
Plan’s Pharmacy Benefit Manager so the Member is able to obtain the requested medication immediately.
Additionally, coverage of the non-Formulary drug will be provided for the duration of the prescription,
including refills.
For more information on drugs that may require prior authorization including oral medications, step therapy and
injectable medications, refer to the formulary and Section 3.5 of this document.
Routine/Standard Pharmacy Pre-Approval Requests
Routine/Standard (non-urgent) pharmacy pre-approval requests will be reviewed within fifteen (15) days after
receipt of the request. If the request is made outside of business hours, the date or receipt will be next business
day.
Urgent Pharmacy Pre-Approval Requests
Urgent pharmacy pre-approval requests be reviewed as soon as possible and no later than twenty-four (24)
hours of receipt of the request. Sanford Health Plan in alignment with the Standard and Expedited Exception
Request requirements. Requests will be considered urgent if the Member’s health is in serious jeopardy, or the
Member’s Practitioner and/or Provider states the Member may experience severe pain that cannot be controlled
while waiting for the Plan’s decision.
How to Request Pre-Approval for a Drug
You or your authorized representative can request a medication pre-approval by:
• Contacting Pharmacy Management
• Complete Formulary Exception Form found online at sanfordhealthplan.com
• Ask the prescribing Practitioner and/or Provider for a letter of medical necessity
• Ask the prescribing Practitioner and/or Provider to contact the Plan by phone
46
What to Include with the Request
Send all information supporting your request to the Plan for review. This may include written comments,
doctor’s notes, documents, or any other information you think would help us approve your request. Your
practitioner and/or provider may be able to help you obtain this information.
Notification of the Decision (Determination)
The Plan will notify the Member, their Authorized Representative, and/or Practitioner and/or Provider
submitting the request of the Plan’s decision.
2.12 ADDITIONAL INFORMATION REGARDING FORMULARY EXCEPTION REQUESTS
1. For contraceptives not in the Formulary, if the prescribing Practitioner and/or Provider determines that a
drug/device is Medically Necessary and an exception to the formulary is granted, the contraceptive
drug/device will be covered at 100% (no charge).
2. If the decision is to approve a standard (routine) Formulary exception request, the Plan will provide
coverage of the non-Formulary drug for the duration of the prescription, including refills. If a request is
granted based on an emergent circumstance, Sanford Health Plan will provide coverage of for the duration
of the incident.
3. In the event that an exception request is granted, Sanford Health Plan will treat the excepted drug(s) as an
essential health benefit, including, if applicable per the Member’s Policy, counting any cost-sharing towards
the Member’s annual limitation on cost-sharing and when calculating the actuarial value.
In determining whether to grant an exception, Sanford Health Plan adheres to, procedures, as outlined above,
allowing Members to request and gain access to clinically appropriate drugs not covered under the Plan’s
Formulary.
2.13 Medical Pre-Approval (Certification) Requests
All requests for Prior Authorization (Certification) are to be made by the Member or
Physician/Practitioner’s office at least three (3) business days prior to the scheduled admission or
requested service. The Utilization Management Department will review the Member’s medical request
against standard criteria.
Determination of the appropriateness of an admission is based on standard review criteria and assessment
of:
1. Member medical information including:
a. diagnosis;
b. medical history;
c. presence of complications and/or co-morbidities;
2. Consultation with the treating Practitioner, as appropriate;
3. Availability of resources and alternate modes of treatment; and
4. For admissions to Facilities other than acute general Hospitals, additional information may
include but is not limited to the following:
a. history of present illness;
b. patient treatment plan and goals;
c. prognosis;
47
d. staff qualifications; and
e. twenty-four (24) hour availability of qualified medical staff.
Routine Pre-Service Pre-Approval Requests
Routine/Standard (non-urgent) pre-service requests for services that require pre-approval from the Plan
will be made within fifteen (15) calendar days from the date the Plan receives the request. If the
request is made outside of business hours, the date or receipt will be next business day. If a request does
not follow the Pre-Approval (Authorization/Certification) Procedure as outlined in this document, we will
notify the Member or Practitioner and/or Provider no later than five (5) calendar days after the date of
the failure. Notification may be oral unless the Member or Practitioner and/or Provider request written
notification.
Urgent Pre-Service Pre-Approval Requests
Urgent pre-service requests for services that require pre-approval from the Plan will be reviewed as soon
as possible and no later than seventy-two (72) hours after receipt of the request. Requests will be
considered urgent if the Member’s health is in serious jeopardy, or the Member’s Practitioner and/or
Provider states the Member may experience severe pain that cannot be controlled while waiting for the
Plan’s decision. If the request does not meet the definition of urgent, or is for a service that has already
occurred, (post-service/retrospective) the request will be processed as a routine/standard request.
If a request does not follow the Pre-Approval (Authorization/Certification) Procedure as outlined in this
document, we will notify the Member or Practitioner and/or Provider no later than twenty-four (24)
hours after the date of the failure. Notification may be oral unless the Member or Practitioner and/or
Provider request written notification.
Emergent Medical Conditions
Pre-approval is not required if a prudent layperson that possesses an average knowledge of health and
medicine determines urgent or emergent care is necessary in a particular situation. Members should
notify Sanford Health Plan as soon as reasonably possible and no later than forty-eight (48) hours after
physically or mentally able to do so. A Member’s Authorized Representative may also notify the Plan on
the Member’s behalf.
How to Request Pre-Approval for a Medical Item or Health Care Service
Refer to the Introduction section at the beginning of this document for instructions on contacting the
Utilization Management department to request a medical pre-approval request.
What to Include with a Pre-Approval Request
Send all information supporting your request to the Plan for review. This may include written comments,
doctor’s notes, documents, or any other information you think would help us approve your request. Your
practitioner and/or provider may be able to help you obtain this information.
Lack of Necessary Information
48
If the Plan is unable to make a decision due to lack of necessary medical information, we will notify the
Member, their Authorized Representative (if applicable) and their Practitioner and/or Provider regarding
what information is necessary to approve the request. If request was received from a Practitioner and/or
Provider, the Plan will communicate solely with the requesting Practitioner and/or Provider regarding
information needed to approve the request. The Plan will notify the appropriate party(ies) regarding the
information needed to make a decision within:
• Twenty-four (24) hours of the receipt of the request if the request meets the definition of Urgent.
The Plan will provide forty-eight (48) hours to supply the requested information. If not received
by the end of the 48-hour extension, the request will be denied.
• Fifteen (15) calendar days of receipt of a routine/standard request. The Plan will provide forty-
five (45) calendar days to supply the requested information. If not received by the end of the
forty-five day extension, the request will be denied.
Notification of the Decision (Determination)
The Plan will notify the Member, their Authorized Representative, and/or Practitioner and/or Provider
submitting the request of the Plan’s decision:
• By phone no later than forty-eight (48) hours after the decision is made for Urgent requests. The
Plan will also provide electronic or written notification of the decision as soon as possible, but no
later than within three (3) calendar days of the phone notification if the request is deemed
urgent.
• By mail within the fifteen (15) calendar days after receipt of the request.
Routine/Standard (Non-Urgent) Post-Service Pre-Approval Request
If a claim is denied for a service that has already occurred or item that has already been received (post-
service or retrospective), the Member may file an appeal as outlined in Section 10 as the denied claim
serves as the initial adverse determination.
2.14 ONGOING (CONCURRENT) PREAUTHORIZATION REQUESTS (CERTIFICATION) OF
HEALTH CARE SERVICES
Concurrent Review is utilized when a request for an extension of an approved ongoing course of treatment for
medical care, including care for behavioral, mental health, and/or substance use disorders, over a period of time
or number of treatments, is warranted. Additional stay days must meet the continued stay review criteria and, if
acute levels of care criteria are not met, a decision to certify further treatment must be made at that time.
Determinations by us to Limit or Reduce Previously Approved Care
If we have previously approved a hospital stay or course of treatment to be provided over a period of time or
number of treatments, and we later decide to limit or reduce the previously approved stay or course of treatment,
we will give you advance written notice to permit you to initiate an appeal and obtain a decision before the date
on which care or treatments are no longer approved. You must follow the rules we establish for the filing of your
appeal, such as the time limits within which the appeal must be filed (See Section 10 for more information on the
49
Appeals Process). Benefits for an ongoing course of treatment cannot be reduced or terminated without providing
advance notice sufficient to allow you to appeal and obtain a review determination before the benefit is reduced
or terminated. In addition, individuals in urgent care situations and those receiving an ongoing course of
treatment may proceed with expedited external review at the same time as the internal appeals process.
Prior Authorization of inpatient care stays will terminate on the date the Member is to be discharged from the
Hospital or other Facility (as ordered by the attending Physician). Hospital/Facility days accumulated beyond
ordered discharge date will not be certified unless the continued stay criteria continue to be met. Charges by
Practitioner and/or Providers associated with these non-certified days are Non-Covered.
Authorization (Certification) of Inpatient health care stays will terminate on the date the Member is to be
discharged from the Hospital or Facility (as ordered by the attending Physician). Hospital/Facility days
accumulated beyond ordered discharge date will not be certified unless the continued stay criteria continue to be
met. Charges by Practitioner and/or Providers associated with these non-certified days will be considered non-
covered.
The health care service or treatment that is the subject of the Adverse Determination shall be continued without
liability to the Member until the Member or the Member’s Authorized Representative has been notified of the
determination with respect to the internal review request made pursuant to the Appeal Procedures.
Any reduction or termination during the course of treatment before the end of the period or number treatments
shall constitute an Adverse Determination.
Requests to Extend Previously Approved Care
A Provider who is requesting an extension of an approved ongoing course of treatment beyond the ordered
period of time or number of treatments must request Prior Authorization from Sanford Health Plan at least
twenty-four (24) hours in advance of the termination of such continuing services. Your Provider may make this
request in writing or orally directly to us. To request a concurrent review determination, call Utilization
Management. Refer to the Introduction section for Utilization Management contact information.
If Utilization Management denies the extension of treatment, it will advise the Member and Practitioners and/or
Providers within twenty-four (24) hours of receiving the request. If the Member decides to appeal this denial, the
health care services or treatment subject to the Adverse Determination shall be continued without cost to the
Member while the determination is under review as specified by the Appeal procedures outlined in Section 10.
If the internal review process results in a denial of the request for an extension, the payment of benefits for such
treatment shall terminate but the Member may pursue the appeal rights described in Section 10.
Any reduction or termination by the Plan during the course of treatment before the end of the period or number
of treatments shall constitute an Adverse Determination.
For requests to extend the course of treatment beyond the initial period of time or the number of treatments, if the
request is made at least twenty-four (24) hours prior to the expiration of the prescribed period of time or number
of treatments, Sanford Health Plan shall make a determination and orally notify the Member, or the Member’s
Authorized Representative, Practitioner and those Providers involved in the provision of the service, of the
determination as soon as possible, taking into account the Member’s medical condition, but in no event more
than seventy-two (72) hours after the date of Sanford Health Plan’s receipt of the request.
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Sanford Health Plan will provide electronic or written notification of an authorization to the Member, Practitioner
and those Providers involved in the provision of the service within three (3) calendar days after the oral
notification.
We shall provide written or electronic notification of the Adverse Determination to the Member and those
Providers involved in the provision of the service sufficiently in advance (but no later than within three (3)
calendar days of the telephone notification) of the reduction or termination to allow the Member or, the
Member’s Authorized Representative to file a Grievance request to review of the Adverse Determination and
obtain a determination with respect to that review before the benefit is reduced or terminated. Sanford Health
Plan will terminate payment of benefits on the date that oral notification of the reduction or termination of
benefits is made. In cases where the Member is not at financial risk, Members will not be notified of an Adverse
Determination unless the decision has the potential to adversely affect the Member, in terms of coverage or
financially, whether immediate or in the future.
Non-Urgent (Standard) Concurrent Reviews
If your request is non-urgent, we will treat it as a new claim for benefits, and will make a determination on your
claim within the pre-service or post-service timeframes as outlined in this Section.
Urgent (Expedited) Concurrent Reviews
If your request for additional care is urgent, and if your Provider submits it no later than twenty-four (24)
hours before the end of your pre-approved stay or course of treatment, Sanford Health Plan will make the
decision as soon as possible (taking into account the medical exigencies) but no later than seventy-two (72)
hours after receiving the request]. For authorizations and denials, we will give telephone notification of the
decision to Members, Practitioners and those Providers involved in the provision of the service within
seventy-two (72) hours of receipt of the request. We will give oral, written or electronic notification of the
decision to the Member, Practitioner and those Providers involved in the provision of the service as soon
as possible but no later than within three (3) calendar days of the oral notification.
If your Provider attempt to file an urgent concurrent review but fails to follow our procedures for doing so, we
will notify you and your Provider of the failure within twenty-four (24) hours. Our notification may be oral,
unless asked for in writing.
Adverse Determinations
If the determination is an Adverse Determination, we shall provide written notice in accordance with the Written
Notification Process for Adverse Determinations procedures outlined below. At this point, the Member can
request an appeal of Adverse Determinations. Refer to the “Appeal Procedures” in Section 10 for details.
Lack of Necessary Information
If we need more information, we will let you know within twenty (24) hours of your claim. Sanford Health Plan
will tell you what further information is needed. You will then have forty-eight (48) hours to provide us with the
additional information. Sanford Health Plan will notify you of our decision within forty-eight (48) hours after we
receive all requested information.
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Our notification may be oral; if it is, we will follow it up in writing within three (3) days. If we do not receive
the information, your claim will be considered denied at the expiration of the forty-eight (48) hours we gave you
for furnishing the information to us.
2.15 WRITTEN NOTIFICATION PROCESS FOR ADVERSE DETERMINATIONS
The written notifications for Adverse Determinations will include the following:
1. The specific reason for the Adverse Determination in easily understandable language;
2. Reference to the specific provision, guideline, or protocol on which the determination was based and
notification that the Member will be provided a copy of the actual provisions, guidelines, and protocols free
of charge upon request. Reasons for any denial or reimbursement or payment for services with respect to
benefits under the plan will be provided within 30 business days of a request;
3. Notice of an Adverse Determination will include information sufficient to identify the claim involved,
including the date of service the Provider, the claim amount (if applicable) and a statement notifying
members of their opportunity to request treatment and diagnosis code information free of charge. Any
request for diagnosis and treatment code information may not be (and is not) considered a request for an
internal appeal or external review;
4. If the Adverse Determination is based in whole or in part upon the Member failing to submit necessary
information, the notice shall include a description of any additional material or information, which the
Member failed to provide to support the request, including an explanation of why the material is necessary;
5. If the Adverse Determination is based on Medical Necessity or an Experimental or Investigational Service or
similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the
determination, applying the terms of the coverage to the Member’s medical circumstances or a statement that
an explanation will be provided to the Member free of charge upon request;
6. For Mental Health and/or Substance Use Disorder (MH/SUD) Adverse Determinations, if information on
any Medical Necessity criteria is requested, documents will be provided for both MH/SUD and
medical/surgical benefits within 30 business days of a Member/Authorized Representative/Provider’s
request. This information will include documentation of processes, strategies, evidentiary standards and other
factors used by the plan, in compliance with MHPAEA;
7. If the Adverse Determination is based on Medical Necessity, a written statement of clinical rationale,
including clinical review criteria used to make the decision if applicable. If the denial is due to a lack of
clinical information, a reference to the clinical criteria that have not been met will be included in the letter. If
there is insufficient clinical information to reference a specific clinical practice guideline or policy, the letter
will state the inability to reference the specific criteria and will describe the information needed to render a
decision;
8. A description of appeal procedures, including how to obtain an expedited review if necessary (and any time
limits applicable to those procedures) including:
• a Member’s right to bring civil action under §502(a) of ERISA
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• the right to submit written comments, documents or other information relevant to the appeal;
• an explanation of the Appeal process including the right to Member representation;
• notification that Expedited External Review can occur concurrently with the internal Appeal process
for urgent care/ongoing treatment; and
• the timeframe the Member has to make an appeal and the amount of time the Plan has to decide it
(including the different timeframes for Expedited Appeals);
9. If the Adverse Determination is based on Medical Necessity, notification and instructions on how the
Practitioner can contact the Practitioner to discuss the determination;
10. You have the right to contact the North Dakota Insurance Commissioner at any time.
(Refer to the Introduction section at the beginning of this document for contact information.)
53
SECTION 3
COVERED SERVICES – OVERVIEW
Subject to the terms and conditions set forth in this Contract, including any exclusions or limitations, this
Contract provides coverage for the following Covered Services. Payment for Covered Services is limited by or
subject to any applicable Coinsurance or Deductible set forth in this Contract including the Summary of Benefits
and Coverage. To receive maximum coverage for Covered Services, the terms of this Contract must be followed,
including receipt of care from In-Network Participating Practitioner and/or Providers as well as obtaining any
required Certification. You are responsible for all expenses incurred for Non-Covered Services. Health Care
Services received from Non-Participating Providers or Out-of-Network Participating Providers are Non-Covered
Services unless otherwise indicated in this Contract.
3.1 HEALTH CARE SERVICES PROVIDED BY PRACTITIONERS AND
PROVIDERS
Here are some important things you should keep in mind about these benefits:
• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this Certificate
of Insurance and are payable only when we determine they are Medically Necessary.
• Be sure to read Section 2, How you get care, for valuable information about conditions for coverage.
• For a list of Limited and Non-Covered Services, see Section 4; Limited and Non-Covered Services___
• Your Practitioner and/or Provider must get Certification of some services in this Section. The benefit
description will say “NOTE: Certification is required for certain services. Failure to get Certification will
result in a reduction or denial of benefits (See Services requiring Certification in Section 2.).”
3.1.1 ARTIFICIAL NUTRITION
NOTE: This requires Certification; failure to get Certification may result in a reduction or denial of
benefits (See Services requiring Certification in Section 2.). Coverage is subject to Sanford Health Plan
Guidelines.
• Parenteral nutrition formula and supplies
• Enteral nutrition formula and supplies
3.1.2 ALLERGY CARE BENEFITS
• Testing and treatment
• Allergy injections
• Allergy serum
54
3.1.3 CHIROPRACTIC SERVICES
Covered when provided on an inpatient or outpatient basis when Medically Necessary as determined by
Sanford Health Plan and within the scope of licensure and practice of a Chiropractor, to the extent
services would be covered if provided by a Physician.
Benefits are not available for Maintenance Care.
3.1.4 CLINICAL TRIALS
NOTE: Certification is required; failure to get Certification may result in a reduction or denial of
benefits if the service would not otherwise be covered.
• Routine Patient Costs when provided as part of an Approved Clinical Trial if the services are
otherwise Covered Services. An In-Network Participating Practitioner and/or Provider must provide
Sanford Health Plan notice of a Member’s participation in an Approved Clinical Trial.
• Routine Patient Costs means the cost of Medically Necessary Health Care Services related to the
care method that is under evaluation in an Approved Clinical Trial. Routine Patient Costs do not
include any of the following.
o The Health Care Service that is the subject of the Approved Clinical Trial.
o Any treatment modality that is not part of the usual and customary standard of care
required to administer or support the Health Care Service that is the subject of the
Approved Clinical Trial.
o Any Health Care Service provided solely to satisfy data collection and analysis
needs that are not used in the direct clinical management of the patient.
o An investigational drug or device that has not been approved for market by the federal
Food and Drug Administration.
o Transportation, lodging, food, or other expenses for the patient or a family
member or companion of the patient that is associated with travel to or from a
facility where an Approved Clinical Trial is conducted.
o A Health Care Service that is provided by the sponsor of the Approved Clinical Trial free
of charge for any new patient.
o A Health Care Service that is eligible for reimbursement from a source other than this
Contract, including the sponsor of the Approved Clinical Trial.
55
3.1.5 DIABETES SUPPLIES, EQUIPMENT AND EDUCATION BENEFITS
NOTE: Indicated Durable Medical Equipment (DME) requires Certification; failure to get Certification may
result in a reduction or denial of benefits.
Item (* Certification Required)
Must be obtained at:
Benefit/Cost Information
•
Blood Glucose test stripes
•
Glucagon
•
Glucometers
•
Glucose Agents
•
Lancets and lancet devices
•
Prescribed oral agents for
controlling blood sugars
•
Syringes
•
Urine testing strips
Pharmacy (prescription
required)
Pharmacy Benefit
• Custom diabetic shoes and
inserts limited to one (1) pair
of depth- inlay shoes and three
(3) pairs of inserts; or one (1)
pair of custom molded shoes
(including inserts) and three
(3) additional pairs of inserts
Durable Medical
Provider
Medical Benefit
• Continuous Glucose Monitor
Receiver*
Durable Medical
Provider and or
Pharmacy (prescription
required)
Pharmacy Benefit (must be on
formulary and available through
a pharmacy)
Medical Benefit (if obtained
through a Durable Medical
Provider)
• Insulin Pump*
Durable Medical
Provider and or
Pharmacy (prescription
required)
Medical Benefit
Coverage for the treatment of diabetes includes:
• Routine foot care, including toenail trimming is covered.
• Diabetes self-management training and education shall only be covered if:
o the service is provided by a Physician, nurse, dietitian, pharmacist or other licensed health care
Practitioner and/or Provider who satisfies the current academic eligibility requirements of the
National Certification Board for Diabetic Educators and has completed a course in diabetes
education and training or has been certified by a diabetes educator; and
o the training and education is based upon a diabetes program recognized by the American Diabetes
Association or a diabetes program with a curriculum approved by the American Diabetes
Association or the North Dakota Department on Health.
56
3.1.6 DIAGNOSTIC AND TREATMENT SERVICES
Professional services from Practitioners, Providers, Physicians, nurse practitioners, and Physician’s assistants
are covered when provided in Practitioner and/or Provider’s offices and urgent care centers. Medical office
consultations and second surgical opinions are also covered per Medical Necessity.
3.1.7 DIALYSIS BENEFIT
• Dialysis for renal disease, unless or until the Member qualifies for federally funded dialysis services under
the End Stage Renal Disease (ESRD) program.
• Services include equipment, training, and medical supplies required for effective dialysis care. See
Outpatient Nutrition Care Services in this Section for additional Chronic Renal Failure benefits.
Coordination of Benefit (COB) Provisions apply. For more information on COB, please see Section 6.
3.1.8 DURABLE MEDICAL EQUIPMENT (DME) BENEFITS
•
Coverage is available for DME equipment prescribed by an attending Practitioner and/or Provider, which
is Medically Necessary, not primarily and customarily used for non-medical purposes, designed for
prolonged use, and for a specific therapeutic purpose in the treatment of an illness or injury. Limitations
per Sanford Health Plan policy guidelines apply.
•
Casts, splints, braces, crutches and dressings for the treatment of fracture, dislocation, torn muscles or
ligaments and other chronic conditions per Sanford Health Plan policy.
•
Prior Approval is required for certain items. For updated information refer to:
https://www.sanfordhealthplan.com/members/prior-authorization
3.1.9 EYE CARE/VISION SERVICES
Eye Care services are as follows:
Exams and Services
Child (age 0-18)
Adult (age 19+)
Routine eye exam
Not covered
Not covered
Dilated eye examination for diabetes-
related diagnosis
Covered with a limit of one
exam per Member per year
Covered with a limit of one
exam per Member per year
Vision therapy
Covered for Members 17
and under; limited to 16
visits per Member per
calendar year
Not covered
Services required because of injury,
accident or cancer that damages the
eye
Covered if the Member was
covered under this Contract
during the time of the injury
or illness causing the
damage
Covered if the Member was
covered under this Contract
during the time of the injury
or illness causing the damage
Cataract surgery
Covered
Covered
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Eye Wear (frames, lenses, contacts)
Child (age 0-18)
Adult (age 19+)
Aphakia patients: Eyeglasses or
contact lenses or soft contact lenses
Up to $200 for eyeglasses,
including lenses and frame
per lifetime; or
Two (2) single clear contact
lenses per Member per
calendar year
Up to $200 for eyeglasses,
including lenses and frame
per lifetime; or
Two (2) single clear contact
lenses per Member per
calendar year
Scleral shells intended for the use in
the treatment of a disease or injury
Soft shells limited to two (2)
per calendar year; Hard
shells limited to one (1) per
lifetime
Soft shells limited to two (2)
per calendar year; Hard shells
limited to one (1) per lifetime
Prescribed lenses and frames, unless
otherwise listed the plan documents
Not covered
Not covered
3.1.10 FAMILY PLANNING BENEFITS
Family Planning Services include consultations, and pre-pregnancy planning. The following medications,
services and devices are covered:
• Barrier methods: diaphragm and cervical cap fitting and purchase.
• Folic acid supplements are covered at 100% (no cost) for women planning to become pregnant or in their
childbearing years if obtained with a written prescription order, per Plan guidelines.
• Generic contraceptives are covered at 100% (no cost). If no generic equivalent exists for a formulary brand-
name contraceptive, then that contraceptive is covered at 100% (no cost) per the Affordable Care Act. (See
your Pharmacy Handbook/Formulary)
• Other contraceptives including injectable medroxyprogesterone acetate and emergency contraception with a
written prescription (generic Plan B) are also covered at 100% (no cost).
• We cover implantable devices; including Mirena and ParaGard intrauterine devices. Placement and removal
is covered once every five (5) years or as medically necessary.
• We cover sterilizations, including voluntary tubal ligations and vasectomies:
o Medical – Occlusion of the fallopian tubes by use of permanent implants (e.g. Essure).
o Surgical – Tubal ligation covered at 100% of allowed only when performed as the primary
procedure. When performed as part of a maternity delivery or for any other medical reason, it will be
covered as a medical benefit with the applicable cost-share applied.
NOTE: For Members enrolled in a High Deductible Health Plan, prescription drugs are subject to
Deductible and Coinsurance amounts, unless the medication or drug dispensed is covered by the Contract
at 100% (no charge).
3.1.11 FOOT CARE SERVICES
Routine foot care covered for Members with diabetes only.
• Non-routine diagnostic testing and treatment of the foot due to illness or injury
NOTE: See Section on Orthotic and prosthetic devices for information on podiatric shoe inserts
58
3.1.12 HEARING SERVICES (TESTING, TREATMENT, AND SUPPLIES)
Coverage is limited to diagnostic testing and treatment related to illness or injury only.
Hearing service coverage is as follows:
Exams and Services
Child
Adult
Routine care
Covered for ages 0-21 as
outlined in Sanford Health
Plan Preventive Health
Guidelines
Not covered
Emergency and acute hearing
services
Covered
Covered
Diagnosis and treatment of sudden
sensorineural hearing loss (SSNHL)
Covered
Covered
Hearing Devices
Child (age 0-18)
Adult (age 19+)
Cochlear implants and bone-
anchored (hearing-aid) implants
Certification required
Certification required
External Hearing Aids or devices
Hearing aids, communication
aids or devices for Members
18 years of age or younger
for hearing loss that is not
correctable by other covered
procedures. Sanford Health
Plan policy guidelines apply.
External hearing aids when
medically necessary for
conditions including, but not
limited to: sudden
sensorineural hearing loss
(SSNHL), accident, injury or
related illness.*
Hearing aid limits
Benefit is limited to one
hearing aid, per ear, per
Member under 19, every
three (3) years, in alignment
with Medical Necessity and
Sanford Health Plan
guidelines
Benefit is limited to one
hearing aid, per ear, per Adult
Member, every three (3)
years, in alignment with
Medical Necessity and
Sanford Health Plan
guidelines. This is a DME
that requires prior approval
(Certification).
* The provision of hearing aids must meet criteria for rehabilitative and/or habilitative services
coverage and either:
• provide significant improvement to the Member within two (2) months, as certified on a
prospective and timely basis by Sanford Health Plan; or
• help maintain or prevent deterioration in physical, cognitive, or behavioral function.
Note: Indicated Durable Medical Equipment (DME) and Implant/Stimulators require Preauthorization/Prior
Approval; failure to get Preauthorization/Prior Approval may result in a reduction or denial of benefits. (See
Services requiring Certification in Section 2.)
59
3.1.13 HOME HEALTH SERVICES
NOTE: This requires Certification; failure to get Certification may result in a reduction or denial of
benefits (See Services requiring Certification in Section 2.).
Member must be home-bound to receive home health services. The following is covered if approved by the Plan
in lieu of Hospital or Skilled Nursing Facility:
• part-time or intermittent care by a RN or LPN/LVN
• part-time or intermittent home health aide services for direct patient care only
• physical, occupational, speech, inhalation, and intravenous therapies up to the maximum benefit allowable
• medical supplies, prescribed medicines, and lab services, to the extent they would be covered if the Member
were Hospitalized
3.1.14 IMPLANTS/STIMULATORS
• Implants and Stimulators prescribed by an attending Practitioner and/or Provider and are Medically
Necessary are covered. Limitations per medical appropriate guidelines apply (available upon request).
• The following Implants/Stimulators may be covered with prior approval (certification);
• Bone Growth (external)
• Cochlear Implant (Device and Procedure)
• Deep Brain Stimulation
• Insertion, Removal, and Revisions of all Implants
• Gastric Stimulator
• Spinal Cord Stimulator (Device and Procedure)
• Vagus Nerve Stimulator
3.1.15 INFERTILITY BENEFITS
Benefits are available for services, supplies and medications related to artificial insemination (AI) and
assisted reproductive technology (ART), includes gamete intrafallopian transfer (GIFT), zygote
intrafallopian transfer (ZIFT), intracytoplasmic sperm injection (ICSI) or in vitro fertilization (IVF).
Preauthorization/Prior Approval is required.
NOTE: Benefits are subject to a $20,000 Lifetime Benefit Maximum Amount per Member. Any Member-paid
coinsurance for infertility services does not apply toward the Out-of-Pocket Maximum Amount.
3.1.16 LAB, X-RAY AND OTHER DIAGNOSTIC TESTS
Coverage includes, but is not limited to, the following
• High End Imaging services
• CT Scans/MRI
• PET Scans
• Blood tests
• DEXA Scans
• Electrocardiogram (EKG)
• Electroencephalography (EEG)Urinalysis
60
• Non-routine mammograms
• Non-routine Pap tests
• Non-routine PSA tests
• Pathology
• Ultrasound
• Urinalysis
NOTE: Some of these services fall under High End Imaging and may require Certification. Failure to get
Certification may result in a reduction or denial of benefits if the service would not otherwise be covered.
3.1.17 ONCOLOGY TREATMENT BENEFITS
NOTE: Certification is required; failure to get Certification may result in a reduction or denial of
benefits if the service would not otherwise be covered.
• Radiation Therapy.
• Chemotherapy, regardless of whether the Member has separate prescription drug benefit coverage.
• The same cost-sharing amounts apply for intravenously administered or injected cancer
chemotherapy agents as for prescribed,
orally-administered, anticancer medications used to kill or
slow the growth of cancerous cells
3.1.18 NEWBORN CARE BENEFITS
A newborn is eligible to be covered from birth. Members must complete NDPERS designated enrollment for
the newborn within thirty-one (31) days of the infant’s birth if enrolled in Single Coverage.
If the Subscriber is already enrolled in Family Coverage, the newborn will automatically be added to the
Certificate if the Plan was aware of the pregnancy. The Subscriber should confirm enrollment of the new child
with the Plan. For further details, see Section 2.
We cover care for the enrolled newborn child from the moment of birth including care and treatment for illness,
injury, premature birth and medically diagnosed congenital defects and birth abnormalities (Please refer to
“Reconstructive Surgery” in Section 3.2 for coverage information on correcting congenital defects).
3.1.19 ORTHOTIC AND PROSTHETIC DEVICES
Note: Select items may require prior approval (certification). For up to date information, please refer to
https://www.sanfordhealthplan.com/members/prior-authorization
•
Adjustments and/or modification to the prosthesis required by wear/tear or due to a change in Member’s
condition or to improve the function are eligible for coverage and do not require Prior Authorization.
•
Cranial Prosthesis, including wigs up to $200 (limited to one per benefit period). .
•
Devices permanently implanted that are not Experimental or Investigational Services such as artificial
joints, pacemakers, and surgically implanted breast implant following mastectomy. This is a DME that
requires Certification
61
•
Externally worn breast prostheses and surgical bras, including necessary replacements following a
mastectomy. Includes two (2) external prosthesis per Calendar Year and four (4) bras per Calendar Year.
For double mastectomy: coverage extends to four (4) external prosthesis per Calendar Year and four (4)
bras per Calendar Year. These do not require prior authorization.
•
Prosthetic limbs, sockets and supplies, and prosthetic eyes. This is a DME that requires Certification
•
Repairs necessary to make the prosthetic functional are covered and do not require authorization. The
expense for repairs is not to exceed the estimated expense of purchasing another prosthesis.
NOTE: Internal prosthetic devices are paid as Hospital benefits; see Section 3.2 for payment information.
Insertion of the device is paid under the surgery benefit.
3.1.20 OTHER TREATMENT THERAPIES NOT SPECIFIED ELSEWHERE
• Inhalation Therapy
• Non-Surgical, medically necessary treatment, of Gender Dysphoria (Gender Identity Disorder), including
hormone therapy, mental/behavioral services, and laboratory testing to monitor the safety of continuous
hormone therapy, per Plan guidelines (available upon request).
• Pheresis Therapy
3.1.21 OUTPATIENT NUTRITIONAL CARE SERVICES
Benefits are available for the following medical conditions:
• Anorexia Nervosa – Maximum Benefit Allowance of four (4) Office Visits per Member per Benefit Period.
• Bulimia – Maximum Benefit Allowance of four (4) Office Visits per Member per Benefit Period.
• Chronic Renal Failure – Maximum Benefit Allowance of four (4) Office Visits per Member per Benefit
Period.
• PKU – Maximum Benefit Allowance of four (4) Office Visits per Member per Benefit Period.
3.1.22 PEDIATRIC (CHILD) HEARING SERVICES
Refer to HEARING SERVICES (TESTING, TREATMENT, AND SUPPLIES)
3.1.23 PEDIATRIC (CHILD) VISION SERVICES
Refer to EYE CARE/VISION SERVICES
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3.1.24 PHENYLKETONURIA (PKU) AND AMINO ACID-BASED ELEMENTAL ORAL FORMULAS
COVERAGE BENEFITS
Phenylketonuria (PKU) Coverage is as follows:
• Testing, diagnosis and treatment of Phenylketonuria including dietary management, formulas, Case
Management, intake and screening, assessment, comprehensive care planning and service referral.
Amino acid-based elemental oral formula coverage is as follows:
• Coverage for medical foods and low-protein modified food products determined by a physician to be
medically necessary for the therapeutic treatment of an inherited metabolic disease of amino acid or
organic acid.
3.1.25 PHYSICAL, CARDIAC SPEECH AND OCCUPATIONAL THERAPIES
Coverage is as follows for outpatient rehabilitative and habilitative therapy services, which include the
management of limitations and disabilities, and services or programs that help maintain or prevent deterioration
in physical, cognitive, or behavioral function:
• Physical Therapy: Benefits are subject to medical necessity and performed by or under the direct
supervision of a licensed Physical Therapist. Services must be provided in accordance with a prescribed plan
of treatment ordered by a Professional Health Care Provider.
▪ Physical therapy and Vitamin D supplements with a prescription order are covered at
100% (no cost) for Members ages 65 and older who are at increased risk for falls.
Benefits are subject to medical necessity.
• Occupational Therapy: Benefits are available for 90 consecutive calendar days per condition, beginning on
the date of the first therapy treatment for the condition. Additional benefits may be allowed after the 90 days
when Medically Necessary. Benefits are available when performed by or under the direct supervision of a
licensed Occupational Therapist. Services must be provided in accordance with a prescribed plan of
treatment ordered by a Professional Health Care Provider.
• Speech Therapy: Benefits are available for 90 consecutive calendar days per condition, beginning on the
date of the first therapy treatment for the condition. Additional benefits may be allowed after the 90 days
when Medically Necessary. Benefits are available when performed by or under the direct supervision of a
certified and licensed Speech Therapist. Services must be provided in accordance with a prescribed plan of
treatment ordered by a Professional Health Care Provider.
• Respiratory/Pulmonary Therapy: Available when services are performed by or under the direct
supervision of a registered respiratory care practitioner for the treatment, management, control and care of
Members with deficiencies and abnormalities of the cardiorespiratory system. Services must be provided in
accordance with an order from a Professional Health Care Provider.
• Cardiac Rehabilitation Services: Cardiac Rehabilitation Services must begin within 2 months following
discharge from the Hospital. Twelve (12) visits per Member per episode, limited to the following diagnosed
medical conditions:
o Myocardial Infarction
o Coronary Artery Bypass Surgery
o Coronary Angioplasty and Stenting
o Heart Valve Surgery
o Heart Transplant Surgery
63
3.1.26 PRENATAL AND MATERNITY SERVICES
NOTE: Due to the inability to predict admission, you or your Practitioner and/or Provider are encouraged to
notify us of your expected due date when the pregnancy is confirmed. You are also encouraged to notify us of
the date of scheduled C-sections when it is confirmed. The minimum inpatient Hospital stay, when
complications are not present, ranges from a minimum of 48 hours for a vaginal delivery or of up to 96 hours
for a cesarean birth, excluding the day of delivery. Such inpatient stays may be shortened if the treating
Practitioner and/or Provider, after consulting with the mother, determines that the mother and child meet certain
criteria and that discharge is medically appropriate. If the inpatient stay is shortened, a post-discharge follow-up
visit shall be provided to the mother and newborn by Participating Practitioners and/or Providers competent in
postpartum care and newborn assessments.
All pre or post-natal care falling outside the routine care limits below will be covered per applicable cost sharing
based on a Member’s Plan. Routine prenatal care (as outlined below) will be covered at 100%:
• Anemia screening
• Bacteruria (bacteria in urine) screening
• Genetic counseling or testing that has in effect a rating of “A” or “B” in the current recommendations of the
United States Preventive Services Task Force. This is considered an Outpatient Service that requires
Preauthorization/Prior Approval.
• Hepatitis B screening
• Outpatient Nutrition Care Services available for gestational diabetes and diabetes mellitus. See Wellness
Nutritional Counseling in this Section.
• Preeclampsia prevention
Prenatal vitamins without Cost Sharing if prescribed by a Practitioner
• Rh (Rhesus) incompatibility screening: first pregnancy visit and 24-28 weeks gestation
• Screening for gestational diabetes mellitus during pregnancy
• Testing includes a screening blood sugar followed by a glucose tolerance test if the sugar is high.
Maternity care includes prenatal through postnatal maternity care and delivery and care for complication of
pregnancy of mother. We cover up to four (4) routine ultrasounds per pregnancy to determine fetal age, size, and
development, per plan guidelines.
Breastfeeding support, supplies and counseling are covered in the following manner:
• Sanford Health Plan will allow one breast pump (electric or manual, non-Hospital grade) per pregnancy.
• Breast pump replacement supplies, including tubing, adapters, locking rings, breast shields, splash
protectors, and breast pump bottles and caps, are covered.
• Breast milk storage bags are covered.
• Bottles which are not specific to breast pump operation and all associated supplies are NOT covered.
• Pumps and supplies are covered only when obtained from a Sanford Health Plan Participating durable
medical equipment Provider. This does NOT include drugstores or department stores.
In addition to pumps, consultation with a lactation (breastfeeding) specialist is also covered.
Healthy Pregnancy Program-Details
The Healthy Pregnancy Program is designed to provide you with the tools and support you need to give your
baby the healthiest start possible. Participation in the Healthy Pregnancy Program is voluntary and free to all Plan
Members.
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As a program participant, you will receive
• Educational information on pregnancy, childbirth and postpartum
• Access to Text4baby, a tool to help remind you of doctor visits, personalized tips on prenatal care, baby’s
growth, signs of labor, nursing, eating habits and more
• Deductible waiver*
• Free prenatal vitamins
• Access to RN case manager to answer questions
After your first prenatal visit, Members may enroll in Sanford Health Plan’s Healthy Pregnancy program starting
their 8
th
week of pregnancy, but no later than the 34
th
week at sanfordhealthplan.com/ndpers/healthy-pregnancy-
program. Members will need their Member number, health care provider name, and expected due date. If you
have questions, please contact our care management team Monday through Friday from 8 a.m. to 5 p.m. CST at
(888) 315-0884 (TTY: 711).
*Note: When a Member is enrolled under the Healthy Pregnancy Program, the deductible Amount is waived for
delivery services received from a PPO Health Care Provider. High Deductible Health Plan members may enroll
in the program but will not receive the deductible waiver benefit.
Newborns’ and Mothers’ Health Protection Act Disclosure
The minimum inpatient Hospital stay, when complications are not present, ranges from a minimum of forty-eight
(48) hours for a vaginal delivery to a minimum of ninety-six (96) hours for a cesarean birth, excluding the day of
delivery. Such inpatient stays may be shortened if the treating Practitioner, after consulting with the mother,
determines that the mother and child meet certain criteria and that discharge is medically appropriate. If the
inpatient stay is shortened, a post-discharge follow-up visit shall be provided to the mother and newborn by a
Participating Practitioner and/or Providers competent in postpartum care and newborn assessments within forty-
eight (48) hours after discharge to verify the condition of the mother and newborn. If such an inpatient stay lasts
longer than the minimum required hours, Sanford Health Plan will not set the level of benefits or out-of-pocket
costs so that the later portion of the stay is treated in a manner less favorable to the mother or newborn than any
earlier portion of the stay.
3.1.27 PREVENTIVE CARE, ADULTS & CHILDREN
The following preventive services, received from In-Network Participating Practitioner and/or Provider are
covered without payment of any deductible or coinsurance requirement that would otherwise apply:
• Evidence-based items or services that have in effect a rating of “A” or “B” in the current
recommendations of the United States Preventive Services Task Force (USPSTF); except for the
recommendations of the USPSTF regarding breast cancer screening, mammography, and prevention
issued in or around November 2009. Which includes;
• One baseline mammogram for women who are at least thirty-five (35) years of age but less than
forty (40) years of age, and one mammogram every year, or more frequently if ordered by a
physician, for women who are at least forty (40) years of age;
• One prostate screening for asymptomatic men aged fifty (50) and over, African American men
aged forty (40) and over, and men aged forty (40) and over with a family history of prostate
cancer.
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• Immunizations for routine use that have in effect a recommendation from the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention with respect to the Member
involved;
• With respect to covered persons who are infants, children, and adolescents, evidence-informed
preventive care and screenings provided for in the comprehensive guidelines supported by the Health
Resources and Services Administration; and
• With respect to covered persons who are women, such additional preventive care and screenings not
described in paragraph (1) above as provided for in comprehensive guidelines supported by the Health
Resources and Services Administration. You do not need prior authorization from Sanford Health Plan
or any other person in order to obtain access to obstetrical and/or gynecological care through an In-
Network Participating Practitioner and/or Provider.
The above is an overview of preventive services covered by Sanford Health Plan. As recommendations change,
your coverage may also change. To view Sanford Health Plan’s Preventive Health Guidelines, visit
www.sanfordhealthplan.com/memberlogin. You may also request a copy by calling Customer Service.
3.1.28 PRIVATE DUTY NURSING
NOTE: Certification is required; failure to get Certification may result in a reduction or denial of benefits
if the service would not otherwise be covered.
• Private Duty Nursing is nursing care that is provided to a Member on a one-to-one basis by licensed
nurse in an inpatient or home setting when any of the following are true:
• No skilled services are already being provided.
• Skilled nursing resources are available in the facility.
• The skilled care can be provided by a Home Health Agency on a per visit basis for a specific
purpose.
• The service is provided to a Covered Person by an independent nurse who is hired directly by the
Covered Person or his/her family. This includes nursing services provided on an inpatient or
home-care basis, whether the service is skilled or non-skilled independent nursing.
3.1.29 TELEHEALTH SERVICES (VIRTUAL VISITS)
Services for telehealth are covered when the following conditions are met:
• The encounter involves a qualifying CPT (Current Procedural Terminology) code that the Health Plan
has approved to be conducted by telehealth.
• The services are medically necessary and meet the definition of Covered Health Services as described
in this Plan document.
• The technology platform used for the encounter is HIPAA (Health Insurance Portability and
Accountability Act) compliant.
• The technology platform used for the encounter allows for fully synchronous, real-time, audio-video
connection between the patient and the provider for the duration of the encounter.
• If the patient is physically present with one provider (host location) and is being connected to a remote
(distant) provider, charges by the host provider as an originating site to facilitate the connection with
the distant provider performing the service are also eligible for coverage, as well as the qualifying
charges from the distant provider for conducting the telehealth encounter.
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These services shall be available only when services are provided by Participating Providers. Cost share may be
subject to applicable Deductible and/or Cost Sharing Amounts and vary based on platform used to complete the
visit. For more information, please refer to the Virtual Care Policy at sanfordhealthplan.com.
3.1.30 TOBACCO CESSATION TREATMENT BENEFITS
Tobacco cessation treatment coverage is as follows:
• Evidence-based items or services that have in effect a rating of “A” or “B” in the current
recommendations of the United States Preventive Services Task Force when received from an In-
Network provider are covered without payment of any Deductible or Coinsurance requirement that
would otherwise apply.
• Tobacco cessation treatment includes:
o Screening for tobacco use; and
o At least two (2) tobacco cessation attempts per year (for Members who use tobacco products).
▪ Covering a cessation attempt is defined to include coverage for:
• Four (4) tobacco cessation counseling sessions of at least ten (10) minutes
each (including telephone counseling, group counseling and individual
counseling) without prior authorization, and
• One ninety (90) day treatment regimen of Food and Drug Administration
(FDA)-approved tobacco cessation medications (including both prescription
and over-the-counter medications) for a 90-day treatment regimen when
prescribed by a Health Care Provider without prior authorization.
3.1.31 WELLNESS NUTRITIONAL COUNSELING SERVICES
Wellness nutritional counseling services coverage is as follows:
Benefits are available for the following medical conditions:
• Diabetes Mellitus – Maximum Benefit Allowance of four (4) Office Visits per Member per Benefit Period.
• Gestational Diabetes – Maximum Benefit Allowance of four (4) Office Visits per Member per Benefit
Period.
• Hyperlipidemia – Maximum Benefit Allowance of four (4) Office Visits per Member per Benefit Period.
• Hypertension – Maximum Benefit Allowance of two (2) Office Visits per Member per Benefit Period.
• Obesity – Maximum Benefit Allowance of four (4) Office Visits per Member per Benefit Period
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3.2 SERVICES PROVIDED BY A HOSPITAL OR OTHER FACILITY
Here are some important things you should keep in mind about these benefits:
• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this Policy and
are payable only when we determine they are Medically Necessary.
• In-Network Participating Practitioner and/or Providers must provide or arrange your care and you must be
hospitalized in a Network Facility.
• Mental Health and Substance Use Disorder benefits provided by a Hospital or other Facility are outlined in
Section 3.4).
• For a list of Limited and Non-Covered Services, see Section 4; Limited and Non-Covered Services
• Be sure to read Section 2, How you get care, for valuable information about conditions for coverage.
• YOUR PRACTITIONER AND/OR PROVIDER MUST GET CERTIFICATION OF SOME OF THESE
SERVICES.
3.2.1 ADMISSIONS
NOTE: Certification is required; failure to get Certification will result in a reduction or denial of
benefits.
The following Hospital Services are covered:
• Room and board
• Critical care services
• Use of the operating room and related facilities
• General Nursing Services, including special duty Nursing Services if approved by the Plan
• The administration of whole blood and blood plasma is a Covered Service. The purchase of whole blood
and blood components is not covered unless such blood components are classified as drugs in the United
States Pharmacopoeia.
• Special diets during Hospitalization, when specifically ordered
• Other services, supplies, biologicals, drugs and medicines prescribed by a Practitioner and/or Provider
during Hospitalization
NOTE: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and
remain in the Hospital up to 48 hours after the procedure.
3.2.2 ANESTHESIA
SHP covers services of an anesthesiologist or other certified anesthesia Provider in connection with an
authorized/approved procedure or treatment.
3.2.3 HOSPICE CARE
• A Member may elect to receive hospice care, instead of the traditional Covered Services provided under the
Plan, when the following circumstances apply:
o The Member has been diagnosed with a terminal disease and has a life expectancy of six (6) months
or less;
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o The Member has chosen a palliative treatment focus (i.e. emphasizing comfort and support services
rather than treatment attempting to cure the disease or condition);and
o The Member continues to meet the terminally ill prognosis as reviewed by the Plan’s Chief Medical
Officer over the course of hospice care.
• The following Hospice Services are Covered Services:
o Admission to a hospice Facility, Hospital, or Skilled Nursing Facility for room and board, supplies
and services for pain management and other acute/chronic symptom management
o In-home hospice care per Plan guidelines (available upon request)
o Part-time or intermittent nursing care by a RN, LPN/LVN, or home health aide for Member care up
to eight (8) hours per day
o Social services under the direction of an In-Network Participating Practitioner and/or Provider
o Psychological and dietary counseling
o Physical or occupational therapy, as described under Section 3.1
o Consultation and Case Management services by an In-Network Participating Practitioner and/or
Provider
o Medical supplies, DME and drugs prescribed by an In-Network Participating Practitioner and/or
Provider Expenses for In-Network Participating Practitioner and/or Providers for consultant or Case
Management services, or for physical or occupational therapists, who are not Group Members of the
hospice, to the extent of coverage for these services as listed in Section 3.1, but only where the
hospice retains responsibility for the care of the Member
3.2.4 ORAL AND MAXILLOFACIAL SURGERY
NOTE: Some services are considered Outpatient Surgery, Services or DME that require Certification;
failure to get Certification will result in a reduction or denial of benefits. (Refer to Services requiring
Certification at https://www.sanfordhealthplan.com/members/prior-authorization)
•
Oral surgical procedures limited to services required because of injury, accident or cancer that
damages Natural Teeth. This is an Outpatient Surgery that requires Certification. .
1.
Care must be received within twelve (12) months of the occurrence
2.
Associated radiology services are included
3.
“Injury” does not include injuries to Natural Teeth caused by biting or chewing
4.
Coverage applies regardless of whether the services are provided in a Hospital or a dental office
•
Orthognathic Surgery per Sanford Health Plan guidelines. This is an Outpatient Surgery that requires
Certification
1.
Associated radiology services are included
2.
“Injury” does not include injuries to Natural Teeth caused by biting or chewing
3.
Coverage applies regardless of whether the services are provided in a Hospital or a dental office
•
Coverage for Temporomandibular Joint (TMJ) Dysfunction and/or Temporomandibular Disorder (TMD)
is as follows:
1.
Services for the Treatment and Diagnosis of TMJ/TMD are covered subject to Medical
Necessity defined by Sanford Health Plan’s Medical coverage guidelines
2.
Manual therapy and osteopathic or chiropractic manipulation treatment if performed by physical
medicine Providers
3.
TMJ Splints and adjustments if your primary diagnosis is TMJ/TMD
▪
Splint limited to one (1) per Member per benefit period.
•
Diagnosis and treatment for craniomandibular disorder are covered subject to Medical Necessity
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defined by Sanford Health Plan’s Medical coverage guidelines
•
Anesthesia and Hospitalization charges for dental care are covered for a Member who: This is
an Outpatient Service requires Certification.
1.
is a child age nine (9) or older- (Certification is not required for children under 9); or
2.
is severely disabled or otherwise suffers from a developmental disability; or
3.
has a high-risk medical condition(s) as determined by a licensed Physician that places the
Member at serious risk.
Note: For more information on Dental Services, see Section 3.
3.2.5 OUTPATIENT HOSPITAL OR AMBULATORY SURGICAL CENTER
NOTE: Some services require Certification; failure to get Certification will result in a reduction or denial
of benefits. (Refer to Services requiring Certification at
https://www.sanfordhealthplan.com/members/prior-authorization)
Health Care Services furnished in connection with a surgical procedure performed at an In-Network Participating
Surgical Center include:
• Outpatient Hospital surgical center
• Outpatient Hospital services such as diagnostic tests
• Ambulatory Surgical Center (same day surgery)
3.2.6 RECONSTRUCTIVE SURGERY
NOTE: Some services require Certification; failure to get Certification will result in a reduction or denial
of benefits. (Refer to Services requiring Certification at
https://www.sanfordhealthplan.com/members/prior-authorization)
•
Surgery to restore bodily function or correct a deformity caused by illness or injury
•
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the
Women’s Health and Cancer Rights Act of 1998 (WHCRA). Coverage for mastectomy related benefits will
be provided in a manner determined in consultation with the attending physician and Member. Coverage
will be provided for reconstructive breast surgery and physical complications at all stages of a mastectomy,
including lymphedema for those Members who had a mastectomy resultant from a disease, illness, or
injury. For single mastectomy: coverage extends to the non-affected side to make it symmetrical with the
affected breast post-surgical reconstruction. Breast prostheses and surgical bras and replacements are also
covered (see Orthotic and Prosthetic devices in this Section). Deductible and Coinsurance applies as
outlined in your Summary of Benefits and Coverage.
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3.2.7 SKILLED NURSING CARE FACILITY BENEFITS
NOTE: Some services require Certification; failure to get Certification will result in a reduction or denial
of benefits. (Refer to Services requiring Certification at
https://www.sanfordhealthplan.com/members/prior-authorization)
• Skilled Nursing Facility Services are covered if approved by the Plan in lieu of continued or anticipated
Hospitalization. The following Skilled Nursing Facility Services are covered when provided through a
state-licensed nursing Facility or program:
1. Skilled nursing care, whether provided in an inpatient skilled nursing unit, a Skilled Nursing
Facility, or a subacute (swing bed) Facility
2. Room and board in a skilled nursing Facility
3. Special diets in a Skilled Nursing Facility, if specifically ordered
Skilled nursing care in a Hospital shall be covered if the level of care needed by a Member has been
reclassified from acute care to skilled nursing care and no designated skilled nursing care beds or swing
beds are available in the Hospital or in another Hospital or Facility within a thirty-mile (30) radius of the
Hospital.
3.2.8 TRANSPLANT SERVICES
NOTE: Certification is required; failure to get Certification will result in a reduction or denial of
benefits. (Refer to Services requiring Certification at https://www.sanfordhealthplan.com/members/prior-
authorization)
To be eligible for coverage, Transplants must meet United Network for Organ Sharing (UNOS) criteria
and/or Sanford Health Plan Medical Criteria. Transplants must be performed at contracted Centers of
Excellence or otherwise identified and accepted by Sanford Health Plan as qualified facilities.
Coverage is provided for transplants according to our medical coverage guidelines (available upon request) for
the following services:
• Bone marrow or stem cell acquisition and short term storage during therapy for a Member with a covered
illness
• Drugs (including immunosuppressive drugs)
• Living donor transplant-related complications for sixty (60) days following the date the organ is removed, if
not otherwise covered by donor’s own health benefit plan, by another group health plan or other coverage
arrangement
• Organ acquisition costs including:
• For cadaver donors: operating room services, intensive care cost, preservation supplies (perfusion
materials and equipment), preservation technician’s services, transportation cost, and tissue typing
of the cadaver organ
• For living donors: organ donor fees, recipient registration fees, laboratory tests (including tissue
typing of recipient and donor), and Hospital services that are directly related to the excision of the
organ
• Post-transplant care and treatment
• Pre-operative care
• Psychological testing
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• Second Opinions
• SHP will notify the Member if a second opinion is required at any time during the determination of
benefits period. If a Member is denied a transplant procedure by the transplant facility, the Plan will
allow them to go to a second transplant facility for evaluation. If the second facility determines, for
any reason, that the Member is an unacceptable candidate for the transplant procedure, benefits will
not be paid for further transplant related services and supplies, even if a third transplant facility
accepts the Member for the procedure.
• Short-term storage of umbilical cord blood for a Member with a malignancy undergoing treatment when
there is a donor match.
• Supplies (must be Prior Authorized)
• Transplant procedure, Facility and professional fees
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3.3 EMERGENCY SERVICES/ACCIDENTS
Here are some important things to keep in mind about these benefits:
• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
Certificate of Insurance and are payable only when we determine they are Medically Necessary.
• Be sure to read Section 2, How you get care, for valuable information about conditions for coverage.
3.3.1 BENEFIT DESCRIPTION
What is an Emergency Medical Condition?
An Emergency Medical Condition is the sudden and unexpected onset of a health condition that requires
immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily
functions or serious dysfunction of a bodily organ or part or would place the person’s health in serious jeopardy.
What is a Prudent Layperson?
A Prudent Layperson is a person who is without medical training and who possess an average knowledge of
health and medicine and who draws on his/her practical experience when making a decision regarding the need
to seek Emergency medical treatment.
What is an urgent care situation?
An urgent care situation is a degree of illness or injury, which is less severe than an Emergency Condition, but
requires prompt medical attention within twenty-four (24) hours, such as stitches for a cut finger.
If an urgent care situation occurs, Members should contact their Primary Care Physician immediately, if one has
been selected, and follows his or her instructions. A Member may always go directly to an urgent care or after-
hours clinic.
We cover worldwide emergency services necessary to screen and stabilize Members without Certification in
cases where a Prudent Layperson reasonably believed that an Emergency Medical Condition existed.
3.3.2 EMERGENCY WITHIN OUR SERVICE AREA
Emergency services from Basic Plan-level Providers will be covered at the same benefit and Cost Sharing level
as services provided by PPO-level Providers both within and outside of the Sanford Health Plan Service Area in
cases where a Prudent Layperson reasonably believed that an Emergency Medical Condition existed. If the Plan
determines the condition did not meet Prudent Layperson definition of an emergency, then the Basic Plan-level
cost-sharing amounts will apply and the Member is responsible for charges above the Maximum Allowed
Amount.
If an Emergency Condition arises, Members should proceed to the nearest emergency Facility that is an In-
Network Participating Practitioner and/or Provider. If the Emergency Condition is such that a Member cannot go
safely to the nearest participating emergency Facility, then the Member should seek care at the nearest emergency
Facility. To find a listing of Participating Providers and Facilities, sign into your account at
sanfordhealthplan.com/memberlogin or call the Plan toll-free at (800) 499-3416 | TTY/TDD: 711 (toll-free).
73
The Practitioner and/or Provider must notify the Plan and the Member’s Primary Care Practitioner and/or
Provider, if one has been selected, as soon as reasonably possible, and no later than forty-eight (48) hours after
physically or mentally able to do so.
3.3.3 PARTICIPATING EMERGENCY PROVIDERS/FACILITIES
The Plan covers Emergency services necessary to screen and stabilize Members without
Preauthorization/Prior Approval in cases where a Prudent Layperson reasonably believed that an
Emergency Medical Condition existed.
NOTE: If the Plan determines the Member’s condition did not meet the Prudent Layperson definition of an
Emergency, then Basic Plan level cost-sharing amounts may apply, subject to whether services were received
from a PPO-level or Basic-level Participating Provider/Facility, as set forth in Section 3.7. See Section 3.7,
“Participating Providers” and “How PPO vs. Basic Plan Determines Benefit Payment” for details.
3.3.4 NON- PARTICIPATING EMERGENCY PROVIDERS/FACILITIES
The Plan covers Emergency services necessary to screen and stabilize a Member and may not require
Prospective (Pre-Service) Review of such services if a Prudent Layperson would have reasonably believed that
use of a Participating Provider would result in a delay that would worsen the Emergency, or if a provision of
federal, state, or local law requires the use of a specific Practitioner and/or Provider. The coverage shall be at the
same benefit level as if the service or treatment had been rendered by a Participating Provider.
NOTE: If the Plan determines the Member’s condition did not meet the Prudent Layperson definition of an
Emergency, then Basic Plan level cost-sharing amounts will apply, subject to the limitations on Non-
Participating Providers set forth in Section 3.7, and whether services were rendered within or outside the state of
North Dakota and its contiguous counties. See Section 3.7, “Non-Participating Health Care Providers”, for
more information.
If a Member is admitted as an inpatient to a Non-Participating Provider Facility, then the Plan will contact the
admitting Practitioner and/or Provider to determine medical necessity and a plan for treatment. In some cases,
where it is medically safe to do so, the Member may be transferred to a Participating Hospital and/or other
appropriate Facility.
3.3.5 EMERGENCY OUTSIDE OUR SERVICE AREA
If an Emergency occurs when traveling outside of the Service Area, Members should go to the nearest
emergency Facility to receive care. The Member or a designated relative or friend must notify us and the
Member’s Primary Care Practitioner and/or Provider, if one has been selected, as soon as reasonably possible,
and no later than forty-eight (48) hours after physically or mentally able to do so.
Coverage will be provided for Emergency Medical Conditions outside of the Service Area unless the Member
has traveled outside the Service Area for the purpose of receiving such treatment.
3.3.6 URGENT CARE SITUATION
Treatment provided in Urgent Care Situations from Basic Plan-level Providers will be covered at the same
benefit and cost sharing level as services provided by PPO-level Providers both within and outside of the
74
Sanford Health Plan Service Area in cases where a Prudent Layperson reasonably believed that an Urgent Care
Situation existed.
NOTE: If the Plan determines the condition did not meet Prudent Layperson definition of an Urgent Care
Situation, then Basic Plan level cost-sharing amounts will apply, and the Member is responsible for charges
above the Maximum Allowed Amount.
If an Urgent Care Situation occurs, Members should contact their Primary Care Practitioner and/or Provider
immediately, if one has been selected, and follow his or her instructions. If a Primary Care Practitioner and/or
Provider has not been selected, the Member should contact the Plan and follow the Plan’s instructions. A
Member may always go directly to a participating urgent care or after-hours clinic. To find a listing of
Participating Providers and Facilities, sign into your account at sanfordhealthplan.com/memberlogin or call the
Plan toll-free at (800) 499-3416 | TTY/TDD: 711 (toll-free).
3.3.7 PARTICIPATING PROVIDERS/FACILITIES
The Plan covers services in an Urgent Care Situation without Preauthorization/Prior Approval in cases where a
Prudent Layperson reasonably believed that an Urgent Care Situation existed.
NOTE: If the Plan determines the Member’s condition did not meet the Prudent Layperson definition of an
Urgent Care Situation, then Basic Plan level cost-sharing amounts may apply, subject to whether services were
received from a PPO-level or Basic-level Participating Provider/Facility, as set forth in Section 3.7. See Section
3.7, “Participating Providers” and “How PPO vs. Basic Plan Determines Benefit Payment” for details.
3.3.8 NON- PARTICIPATING PROVIDERS/FACILITIES
The Plan covers services in an Urgent Care Situation without Preauthorization/Prior Approval requirements if a
Prudent Layperson would have reasonably believed that use of a Participating Provider would result in a delay
that would worsen the Urgent Care Situation, or if a provision of federal, state, or local law requires the use of a
specific Practitioner and/or Provider. The coverage shall be at the same benefit level as if the service or
treatment had been rendered by a Participating Provider.
NOTE: If the Plan determines the Member’s condition did not meet the Prudent Layperson definition of an
Urgent Care Situation, then Basic Plan level cost-sharing amounts will apply, subject to the limitations on Non-
Participating Providers set forth in Section 3.7, and whether services were rendered within or outside the state of
North Dakota and its contiguous counties. See Section 3.7, “Non-Participating Health Care Providers”, for
more information.
3.3.9 AMBULANCE AND TRANSPORTATION SERVICES
NOTE: Certification is required; failure to get Certification will result in a reduction or denial of benefits (Refer to
Services requiring Certification at https://www.sanfordhealthplan.com/members/prior-authorization)
Transportation by professional ground ambulance, air ambulance, or on a regularly scheduled flight on a
commercial airline when transportation is:
1. Medically Necessary; and
2. To the nearest In-Network Participating Practitioner and/or Provider equipped to furnish the
necessary Health Care Services, or as otherwise approved and arranged by the Plan.
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3.4 MENTAL HEALTH AND SUBSTANCE USE DISORDER BENEFITS
Here are some important things to keep in mind about these benefits:
• All benefits are subject to the definitions, limitations, and exclusions in this Certificate of Insurance and are
payable only when we determine they are Medically Necessary.
• Be sure to read Section 2, How you get care, for valuable information about conditions for coverage.
• YOUR PRACTITIONER AND/OR PROVIDER MUST GET CERTIFICATION OF SOME OF THESE
SERVICES. See the benefits description below.
3.4.1 MENTAL HEALTH BENEFITS
In compliance with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the financial
requirements and treatment limitations that apply to Sanford Health Plan’s mental health and/or substance use
disorder benefits are no more restrictive than the predominant financial requirements or treatment limitations that
apply to substantially all medical/surgical benefits. In addition, mental health and substance use disorder benefits
are not subject to separate cost sharing requirements or treatment limitations. Mental health and substance use
disorders are covered consistent with generally recognized independent standards of current medical practice,
which include the current editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the
International Classification of Diseases (ICD).
Coverage is provided for mental health conditions which current prevailing medical consensus affirms
substantially impairs perception, cognitive function, judgment, and/or emotional stability, and limits the life
activities of the person with the condition(s). This includes but is not limited to the following conditions:
schizophrenia; schizoaffective disorders; bipolar disorder; major depressive disorders (single episode or
recurrent); obsessive-compulsive disorders; attention-deficit/hyperactivity disorder; autism spectrum disorders;
post-traumatic stress disorders (acute, chronic, or with delayed onset); and anxiety disorders that cause significant
impairment of function.
Mental health benefits are covered with the same Cost Sharing and restrictions as other medical/surgical benefits
under the Contract. Coverage for mental health conditions includes:
• Diagnostic tests
• Electroconvulsive therapy (ECT)
• Inpatient services, including Hospitalizations
• Intensive Outpatient Programs
• Medication management
• Outpatient Professional services, including therapy by Providers such as psychiatrists, psychologists, clinical
social workers, or other qualified mental health professionals
• Partial Hospitalization
For outpatient treatment services, the first five (5) visits of treatment of any calendar year will be covered
at 100% (no charge). For Members enrolled in a High Deductible Health Plan (HDHP), coverage of the
first five (5) hours will not apply when you elect an HSA.
If you are having difficulty obtaining an appointment with a mental health practitioner and/or Provider, or for
mental health needs or assessment services by phone, call the Sanford USD Medical Center Triage Line toll-free
at (888) 996-4673.
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NOTE: Certification is required for the following; failure to get Certification will result in a reduction or
denial of benefits. (Refer to Services requiring Certification at
https://www.sanfordhealthplan.com/members/prior-authorization)
• All Inpatient services provided by a Hospital, Residential Treatment Facility, or other alternate care
facility
3.4.2 APPLIED BEHAVIOR ANALYSIS FOR TREATMENT OF AUTISM SPECTRUM DISORDER
Applied Behavior Analysis (ABA) is a covered service for the treatment of Members diagnosed with
Autism Spectrum Disorder.
NOTE: Certification is required; failure to get Certification may result in a reduction or denial of benefits.
• Member must be diagnosed with Autism Spectrum Disorder by a Provider and/or Practitioner
qualified to diagnose the condition.
• ABA as behavioral health treatment is expected to result in the achievement of specific improvements
in the Member’s functional capacity of their autism spectrum disorder, subject to Plan medical policy
and medical necessity guidelines
• ABA services are only covered when provided by a licensed or certified practitioner as defined by
law.
• Coverage of ABA is subject to preauthorization, concurrent review, and other care management
requirements.
• Limits are subject to the Plan’s medical management policies and determinations of Medical
Necessity.
3.4.3 SUBSTANCE USE DISORDER BENEFITS
In compliance with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the financial
requirements and treatment limitations that apply to the mental health and/or substance use disorder
benefits are no more restrictive than the predominant financial requirements or treatment limitations that
apply to substantially all medical/surgical benefits. In addition, mental health and substance use disorder
benefits are not subject to separate Cost Sharing requirements or treatment limitations. Mental health and
substance use disorders are covered consistent with generally recognized independent standards of current
medical practice, which include the current editions of the Diagnostic and Statistical Manual of Mental
Disorders (DSM), the American Society of Addiction Medicine Criteria (ASAM Criteria), and the
International Classification of Diseases (ICD).
Substance use disorder benefits are covered with the same Deductibles, Coinsurance factors, and
restrictions as other medical/surgical benefits under the Plan. Coverage for substance use disorders
includes:
1. Addiction treatment, including for alcohol, drug-dependence, and gambling issues
2. Inpatient services, including Hospitalization
3. Outpatient professional services, including therapy by Providers such as psychiatrists,
psychologists, clinical social workers, Licensed Chemical Dependency Counselors, or other
qualified mental health and substance use disorder treatment professionals
4. Partial Hospitalization
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5. Intensive Outpatient Programs
For outpatient treatment services, the first five (5) visits of treatment of any calendar year will be
covered at 100% (no charge). For Members enrolled in a High Deductible Health Plan (HDHP), coverage
of the first five (5) visits will not apply when you elect an HSA.
NOTE: Certification is required for the following; failure to get Certification will result in a reduction or
denial of benefits. (Refer to Services requiring Certification at
https://www.sanfordhealthplan.com/members/prior-authorization)
• All Inpatient services provided by a Hospital, Residential Treatment Facility, or other alternate care
facility
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3.5 OUTPATIENT PRESCRIPTION DRUG BENEFITS
Here are some important things to keep in mind about these benefits:
• Always refer to your Summary of Benefits (SBC), Formulary and other plan documents for specific details
on your coverage.
• SHP covers prescribed drugs and medications, as described in this Section and in your Summary of
Benefits/Formulary documents.
• All benefits are subject to definitions, limitations and exclusions listed in this document and are only payable
when considered Medically Necessary.
• You must receive prior approval (authorization) for some medications. See the Summary of Benefits and
Formulary for information.
Refer to the Introduction section at the beginning of this document for instructions on how to contact Pharmacy
Management.
3.5.1 BENEFIT DESCRIPTION
You must fill the prescription at a Plan Participating pharmacy for Cost Sharing amounts to apply. A Member
may be responsible for payment of the Cost Sharing Amounts at the time the Prescription Medication is
dispensed. A Participating Pharmacy agrees not to charge or collect any amount from the Member that exceeds
the Cost Sharing Amounts. All claims from a Participating Pharmacy must be submitted by the Participating
Pharmacy. A listing of the Plan’s Participating pharmacies is available by contacting the Plan or online at
sanfordhealthplan.com/ndpers. Specialty pharmacy options include any in network pharmacy, there is no
specialty pharmacy requirement. If a Member receives Prescription Medications from a Non-Participating
Pharmacy, the Member is responsible for submitting a Claim for Benefits. Charges in excess of the Allowed
Charge are the Member’s responsibility.
• To fill a prescription, you must present your ID card to your pharmacy, if you do not, you will be
responsible for all (100%) of the costs of the prescription to the pharmacy. Additionally, if you choose
to go to a Non-Participating pharmacy, you must pay 100% of the costs of the medication to the
pharmacy.
NOTE: If a Member receives Prescription Medications from a Non-Participating Pharmacy, the Member
is responsible for payment of the Prescription Order or refill in full at the time it is dispensed and to submit
appropriate reimbursement information to Sanford Health Plan. Payment for covered Prescription
Medications will be sent to the Subscriber. Any charges in excess of the Allowed Charge are the
Subscriber’s responsibility.
• Sanford Health Plan uses a formulary: a list of prescription drug products, which are covered by the
Plan for dispensing to Members when appropriate. The formulary will be reviewed regularly, and
medications may be added or removed from the Formulary throughout the year. The Plan will notify
you of the changes as they occur. For a copy of the Plan Formulary, contact Pharmacy Management or
log in to your Member Portal at www.sanfordhealthplan.com/memberlogin.
• Sanford Health Plan reserves the right to maintain a drug listing of medications that are not
available/excluded for coverage per Plan medical necessity and limitation guidelines. Payment for
excluded medications will be the Member’s responsibility in full. Members may request an appeal
79
(review of an Adverse Determination) based on medical necessity for Non-Covered medications. For
details, refer to the appeals section of this Certificate of Insurance.
• Sanford Health Plan will use appropriate Pharmacists and Practitioner and/or Providers to review
formulary exception requests and promptly grant an exception to the formulary for a Member when
that the prescriber indicates:
o the Formulary drug causes an adverse reaction in the Member;
o the Formulary drug is contraindicated for the Member; or
o the prescription drug must be dispensed as written to provide maximum medical benefit to the
Member.
• NOTE: To request a Formulary exception, please call Pharmacy Management or send a request by
logging into the provider portal at www.sanfordhealthplan.com/memberlogin.
o Members must first try formulary medications before an exception to the formulary will be
made unless the prescriber and the plan determine that use of the formulary drug may cause an
adverse reaction or be contraindicated for the Member. If an exception is granted, coverage of
the non-formulary drug will be provided for the duration of the prescription, including refills.
See Pharmaceutical Review Requests and Exception to the Formulary Process in Section 2 for
details.
• With certain medications, the Plan requires a trial of first-line medications, typically generics, before
more expensive name brand medications are covered. If the desired clinical effect achieved or a side
effect is experienced, then a second line medication may be tried. If a step therapy rule is not met at
the pharmacy, coverage will be determined by Prior Authorization (pre-approval) Review. Request
Prior Authorization by contacting Pharmacy Management. Refer to the Formulary for a complete list
of medications that require step therapy.
• To be covered by the Plan, certain medications require prior authorization (pre-approval) to ensure
medical necessity. This can be in the form of written or verbal certification by a prescriber. To request
certification, contact Pharmacy Management. Refer to the formulary for a complete list of medications
that require Prior Authorization.
• Certain medications have a quantity limit to ensure the medication is being used as prescribed and the
member is receiving the most appropriate treatment based on manufacturer’s safety and dosing
guidelines. Refer to your formulary for a complete list of medications with quantity limits.
There are dispensing limitations.
Prescription Medications and nonprescription diabetes supplies are subject to a dispensing limit of a
100-day supply.
• Prescription refills will be covered when 75% of your prescription has been used up with a surplus
limit of 10 days. The surplus limit is calculated based on the amount of medication obtained over the
previous 180 days and limits you to a maximum of 10 days of additional medication at any given
time.
• If you receive a brand name drug when there is a generic equivalent or biosimilar alternative available,
you will be required to pay a brand penalty. The brand penalty consists of the price difference
between a brand name drug and the generic equivalent or biosimilar alternative, in addition to
applicable cost sharing (deductible and coinsurance) amounts. Brand penalties do not apply to your
deductible or maximum out of pocket.
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• For participants enrolled in a High Deductible Health Plan, the prescription drug benefit is subject to
your deductible and coinsurance amounts.
3.5.2 COVERED MEDICATIONS AND SUPPLIES
To be covered by the Plan, prescriptions must be:
a. Prescribed or approved by a licensed physician, physician assistant, nurse practitioner or dentist;
b. Listed in the Plan Formulary, unless certification (authorization) is given by the Plan;
c. Provided by an In-Network Participating Pharmacy except in the event of urgent or emergent
medical situations (if a prescription is filled at a Non-Participating and/or Out-of-Network Pharmacy
in non-urgent or emergent medication situations, the Member will be responsible for the cost of the
prescription medication in full.);
d. Approved by the Federal Food and Drug Administration (FDA) for use in the United States.
3.5.3 COVERED TYPES OF PRESCRIPTIONS
1. Federal Legend Drugs. Any medicinal substance which bears the legend: “Caution: Federal Law
prohibits dispensing without a prescription,” except for those medicinal substances classified as exempt
narcotics pursuant to applicable laws and regulations.
2. Self-Administered medications- medications such as subcutaneous injections, oral or topical medications,
or nebulized inhalation are to be obtained from a Network Pharmacy
3. Medicinal substances (legally restricted medications) that may only be dispensed by a prescription,
according to applicable laws and regulations
4. Compounded medications are only covered when the medication has at least one ingredient that is a
federal legend or state restricted drug in a therapeutic amount.
5. Diabetic supplies, such as insulin, a blood glucose meter, blood glucose test strips, continuous glucose
monitor receiver, diabetic needles and syringes are covered when medically necessary. (See section 3.1
for Diabetic supplies, equipment, and self-management training benefits.)
6. Generic oral contraceptives, injections and/or devices will be covered by the Plan at 100% (no charge)
7. The following preventive medications/supplies are covered at 100% (no charge) with a written
prescription order:
o Folic Acid Supplements for women planning to become pregnant or in their childbearing years
o Vitamin D Supplements for Members ages 65 and older at risk for falls
o Aspirin to prevent cardiovascular disease for male Members ages 45 through 79 and female
Members ages 55 through 79 who are at risk for developing cardiovascular disease
o Formulary breast cancer preventive medications for women at increased risk for breast cancer
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3.6 DENTAL BENEFITS
Here are some important things to keep in mind about these benefits:
1. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
Certificate of Insurance and are payable only when we determine they are Medically Necessary.
2. We cover Hospitalization for dental procedures only when a non-dental physical impairment exists
which makes Hospitalization necessary to safeguard the health of the Member. See Section 3.2 for
inpatient Hospital benefits. We do not cover the dental procedure unless it is described below.
3. Be sure to read Section 2, How you get care, for valuable information about conditions for coverage.
4. YOU MUST GET CERTIFICATION OF THESE SERVICES.
3.6.1 BENEFIT DESCRIPTION
NOTE: The following benefits are Outpatient Surgeries, Service, of DME that require Certification; failure to
get Certification will result in a reduction or denial of benefits. (See Services that Require Prospective
Review/Prior Authorization (Certification) in Section 2.)
1. Dental services provided by a Dentist (D.D.S.) in an office setting as a result of an accidental injury to the
jaw, sound natural teeth, dentures, mouth or face. This is considered an Outpatient Surgery or Service that
requires Certification.
o Covered Services must be initiated within 12 months of the date of injury and completed within 24
months of the start of treatment or longer if a dental treatment plan approved by Sanford Health Plan is
in place.
o Oral surgical procedures limited to services required because of injury, accident or cancer that damages
Natural Teeth
o Associated radiology services are included
“Injury” does not include injuries to Natural Teeth caused by biting or chewing
2. Coverage for Temporomandibular Joint (TMJ) Dysfunction and/or Temporomandibular Disorder (TMD) is
as follows:
a. Services for the Treatment and Diagnosis of TMJ/TMD subject to Medical Necessity defined by
Sanford Health Plan’s Medical coverage guidelines
b. Manual therapy and osteopathic or chiropractic manipulation treatment if performed by physical
medicine Providers and is Medically Necessary pursuant to Sanford Health Plan’s medical
coverage guidelines.
c. TMJ Splints and adjustments if your primary diagnosis is TMJ/TMD
• Splint limited to one (1) per Member per benefit period.
3. Diagnosis and treatment for craniomandibular disorder are covered subject to Medical Necessity defined
by Sanford Health Plan’s Medical coverage guidelines
4. Anesthesia and Hospitalization charges for dental care are covered for a Member who: This is an Outpatient
Service that requires Certification.
o is a child under age nine (9); or
o is severely disabled or otherwise suffers from a developmental disability as determined by a
licensed Physician; or
o has a medical condition(s) as determined by a licensed Physician that places the Member at
serious risk.
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Coverage applies regardless of whether the services are provided in a Hospital or a dental office
Coverage applies to stabilization related to accident or injury only and not restoration.
3.6.2 PEDIATRIC (CHILD) DENTAL CARE
Not covered
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3.7 SCHEDULE OF BENEFITS
3.7.1 GENERAL
This section outlines the payment provisions for Covered Services described in Sections 3 and 5, subject to the
definitions, exclusions, conditions and limitations of this Benefit Plan.
3.7.2 OVERVIEW OF COST SHARING AMOUNTS AND HOW THEY ACCUMULATE
Cost Sharing Amounts include Coinsurance, Deductibles, Prescription Drug Coinsurance Maximum,
Infertility Services Deductible and Out-of-Pocket Maximum Amounts. See Cost Sharing Amounts – Details &
Definitions later in this Section for more information.
NOTE:
• A Member must meet the annual Deductible Amount before Coinsurance Amounts apply to the cost of
Covered Services, unless otherwise specified in this Certificate of Insurance and/or the Member’s
Summary of Benefits and Coverage (SBC).
• The Deductible Amounts for Covered Services received from a PPO Health Care Provider, or on a Basic
Plan basis, accumulate jointly up to the PPO Deductible Amount.
• The Out-of-Pocket Maximum Amounts for Covered Services received from a PPO Health Care Provider,
or on a Basic Plan basis, accumulate jointly up to the PPO Out-of-Pocket Maximum Amount.
• When the PPO Out-of-Pocket Maximum Amount has been met, all Covered Services received from a
PPO Health Care Provider will be paid at 100% of Allowed Charge
• Covered Services sought on a Basic Plan basis will continue to be paid at 75% of the Allowed Charge
until the Out-of-Pocket Maximum Amount for Basic Plan services is met.
• Prescription Medication/Coinsurance costs accumulate toward a Member’s cumulative annual Out-of-
Pocket Maximum.
A Member is responsible for Cost Sharing Amounts. All Members in the family contribute to Deductible and
Coinsurance Amounts. Health Care Providers may bill you directly or request payment of Coinsurance, and
Deductible Amounts at the time services are provided. For the specific benefits and limitations that apply to
this Plan, please see Section 3.8, Outline of Covered Services; Section 3, Covered Services; Section 4, Limited
and Non-Covered Services; and your Summary of Benefits and Coverage.
If Sanford Health Plan pays amounts to the Health Care Provider that are the Member’s responsibility, such as
Deductibles or Coinsurance Amounts, Sanford Health Plan may collect such amounts directly from the
Member. The Member agrees that Sanford Health Plan has the right to collect such amounts from the Member.
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3.7.3 BENEFIT SCHEDULE
The benefit payment available under this Benefit Plan differs depending on the Subscriber’s choice of a Health
Care Provider. This Benefit Plan recognizes the following categories of Health Care Providers based on the
Health Care Provider’s relationship with Sanford Health Plan. Providers that are contracted with Sanford
Health Plan, and participate in the Plan’s Network, will be paid at either the PPO Plan or Basic Plan level.
Members should refer to the Sanford Health Plan website (sanfordhealthplan.com/ndpers) for the Provider
Directory, which lists Participating Health Care Providers. The Sanford Health Plan website is continuously
updated and has the most up-to-date listing of Health Care Providers. Members may also call Customer
Service to request a provider directory.
3.7.4 HOW PPO VS. BASIC PLAN DETERMINES BENEFIT PAYMENT
PPO Plan
PPO stands for “Preferred Provider Organization” and is a group of Health Care Providers who provide
discounted services to the Members of NDPERS. Because PPO Health Care Providers charge Sanford
Health Plan less for medical care services provided to the Members of NDPERS, cost savings are passed
on to Members by way of reduced Cost Sharing Amounts.
Note: Benefits for Covered Services received by Eligible Dependents, as outlined in Section 2, Eligibility
Requirements for Dependents, who are residing out of the state of North Dakota will be paid at the Basic Plan
level. If the Subscriber, or the Subscriber’s spouse, is required by court order to provide health coverage for
that Eligible Dependent, you may be asked to provide a copy of the court order to the Plan.
Basic Plan
If a PPO Health Care Provider is: 1) not available in the Member’s area; or 2) if the Member either
chooses or is referred to a Health Care Provider not participating in the Preferred Provider Organization
(PPO), the Member will receive the Basic Plan benefits if the Health Care Provider is contracted as part of
the Sanford Health Plan Network.
Benefit Schedule
PPO Plan
Basic Plan
Under this Benefit Plan the Medical Deductible Amounts are:
Single Coverage
$2,000 per Benefit Period
$2,000 per Benefit Period
Family Coverage
$4,000 per Benefit Period
$4,000 per Benefit Period
Under this Benefit Plan the Coinsurance Maximum Amounts are:
Single Coverage
$1,500 per Benefit Period
$2,000 per Benefit Period
Family Coverage
$3,000 per Benefit Period
$4,000 per Benefit Period
Under this Benefit Plan the Out-of-Pocket Maximum Amounts are:
Single Coverage
$3,500 per Benefit Period
$4,000 per Benefit Period
Family Coverage
$7,000 per Benefit Period
$8,000 per Benefit Period
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3.7.5 PARTICIPATING HEALTH CARE PROVIDERS
When Covered Services are received from a Participating Health Care Provider, the Participating Health Care
Provider agrees to submit claims to Sanford Health Plan on behalf of the Member. Reimbursement for
Covered Services will be made directly to the Participating Health Care Provider according to the terms of this
Benefit Plan and the participation agreement between the Health Care Provider and Sanford Health Plan.
When Covered Services are received from a Participating Health Care Provider, a provider discount provision
is in effect. This means the Allowance paid by Sanford Health Plan will be considered by the Participating
Health Care Provider as payment in full, except for Cost Sharing Amounts, or if applicable, Maximum Benefit
Allowances or Lifetime Maximums.
Participating Health Care Providers have also agreed to perform managed benefits requirements on behalf of
the Member. If the Health Care Provider is a Participating Health Care Provider (either at the PPO or Basic
Plan level by contracted “participation agreement” with Sanford Health Plan), the benefit payment will be as
indicated in the Outline of Covered Services and the Member’s Summary of Benefits and Coverage (SBC).
3.7.6 NON-PARTICIPATING HEALTH CARE PROVIDERS
If a Member receives Covered Services from a Non-Participating Health Care Provider (health care providers
who are not contracted with Sanford Health Plan), the Member will be responsible for notifying Sanford
Health Plan of the receipt of services. If Sanford Health Plan needs copies of medical records to process the
Member’s claim, the Member is responsible for obtaining such records from the Non-Participating Health
Care Provider.
3.7.7 NON-PARTICIPATING HEALTH CARE PROVIDERS WITHIN THE STATE OF NORTH
DAKOTA
If a Member receives Covered Services from a Non-Participating Health Care Provider within the state of
North Dakota, benefit payments will be based on the Allowance and reduced by an additional 20%. The 20%
payment reduction does not apply toward the Out-of-Pocket Maximum Amount. The Allowance will not
exceed 80% of the billed charge.
NOTE: The Member is responsible for the 20% payment reduction and any charges in excess of the
Allowance for Covered Services.
Benefit payments will be made directly to the Provider for Covered Services received from a Non-
Participating Health Care Provider. Sanford Health Plan may designate a Health Care Provider as Non-
Payable.
3.7.8 NON-PARTICIPATING HEALTH CARE PROVIDERS OUTSIDE THE STATE OF NORTH
DAKOTA
If a Member receives Covered Services from a Non-Participating Health Care Provider outside the state of
North Dakota, the Allowance for Covered Services will be an amount within a general range of payments
made and judged to be reasonable by Sanford Health Plan.
NOTE: The Member is responsible for any charges in excess of the Allowance for Covered Services.
If a Member receives Covered Services from a Health Care Provider in a county contiguous to North Dakota,
86
the benefit payment will be provided on the same basis as a Health Care Provider located in the state of North
Dakota. If the Health Care Provider is a Participating Health Care Provider, the benefit payment will be as
indicated in the Outline of Covered Services and SBC. If the Health Care Provider is not a Participating Health
Care Provider, benefits will be available at the same level as Non-Participating Health Care Providers within
the state of North Dakota. Sanford Health Plan may designate a Health Care Provider as Non-Payable.
3.7.9 NON-PARTICIPATING PROVIDERS OUTSIDE THE SANFORD HEALTH PLAN SERVICE
AREA
When Covered Services are provided outside of Sanford Health Plan’s Service Area by health care providers
who have not entered into a “participating agreement” with Sanford Health Plan (Non-Participating Health
Care Providers), the amount the Member pays for such services will generally be based on either Sanford
Health Plan’s Non-Participating Health Care Provider local payment or the pricing arrangements required by
applicable state law. In these situations, the Member may be liable for the difference between the amount that
the Non-Participating Health Care Provider bills and the payment Sanford Health Plan will make for the
Covered Services as set forth in this paragraph.
In certain situations, Sanford Health Plan may use other payment bases, such as the payment Sanford Health
Plan would make if the Covered Services had been obtained within the Sanford Health Plan Service Area, or
a special negotiated payment, as permitted, to determine the amount Sanford Health Plan will pay for
Covered Services provided by Non-Participating Health Care Providers. In these situations, a Member may
be liable for the difference between the amount that the Non-Participating Health Care Provider bills and the
payment Sanford Health Plan will make for the Covered Services as set forth in this paragraph.
3.7.10 HEALTH CARE PROVIDERS OUTSIDE THE UNITED STATES
The benefits available under this Benefit Plan are also available to Members traveling or living outside of the
United States. The same Preauthorization/Prior Approval requirements will apply. If the Health Care Provider
is a Participating Provider, the Participating Health Care Provider will submit claims for reimbursement on
behalf of the Member. Reimbursement for Covered Services will be made directly to the Participating Health
Care Provider. If the Health Care Provider is not a Participating Provider, the Member will be responsible for
payment of services and submitting a claim for reimbursement to Sanford Health Plan. Sanford Health Plan
will provide translation and currency conversion services for the Member’s claims outside of the United
States.
Sanford Health Plan will reimburse Prescription Medications purchased outside the United States by
Members who live outside the United States where no suitable alternative exists. Reimbursement will also be
made in instances where Members are traveling and new medication therapy is initiated for acute conditions
or where emergency replacement of medications originally prescribed and purchased in the United States is
necessary. The reimbursable supply of medications in travel situations will be limited to an amount necessary
to assure continuation of therapy during the travel period and for a reasonable period thereafter.
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3.7.11 NON-PAYABLE HEALTH CARE PROVIDERS
If Sanford Health Plan designates a Health Care Provider as Non-Payable, no benefits will be available for
Covered Services prescribed by, performed by or under the direct supervision of the Non-Payable Health Care
Provider. Notice of designation as a Non-Payable Health Care Provider will be provided to Members at least
30 days prior to the effective date of designation as a Non-Payable Health Care Provider.
As of the date of termination, all charges incurred by a Member for services received from the Non-Payable
Health Care Provider will be the Subscriber’s responsibility.
3.7.12 MEDICARE PRIVATE CONTRACTS
A Health Care Provider may ask a Member who is eligible for Medicare to enter into a Medicare private
contract where the Member and the Health Care Provider agree that the Member is to be provided with
services outside of the Medicare program. This Medicare private contract must be entered into between the
Member and the Health Care Provider prior to the receipt of any services, and indicate that 1) neither the
Member nor the Health Care Provider is permitted to file a request for reimbursement with Medicare for any
of the services provided by the Health Care Provider; and 2) the Health Care Provider can charge any amount
agreed to by the Member for services instead of the Medicare limiting charge.
Under a Medicare private contract, the Health Care Provider can set any price for services but Medicare will
not pay anything. If the Member enters into a Medicare private contract, Medicare will not pay any portion of
the services and Sanford Health Plan will limit its payment to the amount Sanford Health Plan would have
paid as though Medicare was paying for such Covered Services. If a Member enters into a Medicare private
contract, the Member is responsible for paying the difference between the amount billed by the Health Care
Provider for Covered Services and the amount paid by Sanford Health Plan.
3.7.13 COST SHARING AMOUNTS-DETAILS & DEFINITIONS
A Cost Sharing Amount is the dollar amount a Member is responsible for paying when Covered Services are
received from a Health Care Provider. Cost Sharing Amounts include Coinsurance and Deductible Amounts.
Applicable Cost Sharing Amounts are identified in Section 2 and the Member’s Summary of Benefits and
Coverage. See the schedule above in Overview of Cost Sharing Amounts and how they accumulate for the
specific Cost Sharing Amounts that apply to this Benefit Plan.
3.7.14 COINSURANCE
Sanford Health Plan shall calculate Coinsurance Amounts on behalf of Members obtaining Covered Services
within the Sanford Health Plan contracted provider network on the lesser of (1) billed charges or (2) provider
negotiated payment rates (Allowed Charge).
If Covered Services are obtained by a Member out of the Sanford Health Plan contracted provider network, the
coinsurance calculation may be based on the Health Care Provider’s billed charges. This may result in a
significantly higher Coinsurance Amount for certain services a Member incurs out of the Sanford Health Plan
contracted provider network. It is not possible to provide specific information for each Health Care Provider
outside of Sanford Health Plan’s Service Area because of the many different arrangements between Health
Care Providers. However, if a Member contacts Sanford Health Plan prior to receiving services from a Health
88
Care Provider outside of Sanford Health Plan’s Service Area, Sanford Health Plan may be able to provide
information regarding specific Health Care Providers.
3.7.15 COINSURANCE MAXIMUM AMOUNTS
The cumulative Coinsurance Amount that is a Member’s responsibility during a Benefit Period. The
Coinsurance Maximum Amounts renew on January 1 of each consecutive Benefit Period.
3.7.16 DEDUCTIBLES
The Deductible Amounts renew on January 1 of each consecutive Benefit Period. A Member must meet the
annual Deductible Amount before Coinsurance Amounts apply to the cost of Covered Services, unless
otherwise specified in this Certificate of Insurance.
NOTE: The deductible amounts for Covered Services received from a PPO Health Care Provider, or on a
Basic Plan basis, cross accumulate jointly up to the PPO Deductible Amount.
3.7.17 OUT OF POCKET MAXIMUM AMOUNTS
When the Out-of-Pocket Maximum Amount is met, this Benefit Plan will pay 100% of the Allowed Charge
for Covered Services. The Out-of-Pocket Maximum Amounts renew on January 1 of each consecutive Benefit
Period.
NOTE: The Out-of-Pocket Maximum Amounts for Covered Services received from a PPO Health Care
Provider, or under the Basic Plan, cross accumulate jointly to the PPO Out-of-Pocket Maximum Amount.
NOTE: When the PPO Out-of-Pocket Maximum Amount has been met, all Covered Services received from a
PPO Health Care Provider will be paid at 100% of Allowed Charge. Covered Services sought on a Basic Plan
basis will continue to be paid at 75% of the Allowed Charge until the Out-of-Pocket Maximum Amount for
Basic Plan services is met.
3.7.18 PRESCRIPTION MEDICATIONS AND COINSURANCE
A Member must meet the Annual Deductible before Coinsurance Amounts will apply to prescription
medications. When the Out-of-Pocket Maximum Amount that is a Member’s responsibility during a Benefit
Period is met, this Benefit Plan will pay 100% of the Allowed Charge for Formulary Prescription
Medications. This Out-of-Pocket Maximum Amount renews on January 1 of each consecutive Benefit
Period.
NOTE: Prescription Medication Coinsurance Amounts accumulate toward a Member’s cumulative annual
Out-of-Pocket Maximum. The Out-of-Pocket Maximum Amount renews on January 1 of each consecutive
Benefit Period.
3.7.19 INFERTILITY SERVICES COINSURANCE/DEDUCTIBLE
Any Member-paid coinsurance costs for infertility services do not apply toward annual Out-of-Pocket
Maximum Amounts. Infertility services are limited to a lifetime benefit maximum, per Member, of $20,000.
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3.8 OUTLINE OF COVERED SERVICES
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
Inpatient Hospital and Medical Services
• Inpatient Hospital Services
80% of Allowed Charge.
75% of Allowed Charge.
• Inpatient Medical
Care Visits
80% of Allowed Charge.
75% of Allowed Charge.
• Ancillary Services
80% of Allowed Charge.
75% of Allowed Charge.
• Inpatient Consultations
80% of Allowed Charge.
75% of Allowed Charge.
• Concurrent Services
80% of Allowed Charge.
75% of Allowed Charge.
• Initial Newborn Care
80% of Allowed Charge.
Deductible Amount is waived.
75% of Allowed Charge.
Deductible Amount is waived.
Inpatient and Outpatient Surgical Services
• Professional Health Care
Provider Services
80% of Allowed Charge.
75% of Allowed Charge.
• Assistant Surgeon Services
80% of Allowed Charge.
75% of Allowed Charge.
• Ambulatory Surgical Facility
Services
80% of Allowed Charge.
75% of Allowed Charge.
• Hospital Ancillary Services
80% of Allowed Charge.
75% of Allowed Charge.
• Anesthesia Services
80% of Allowed Charge.
75% of Allowed Charge.
• Outpatient Sterilization
Procedures for Females
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Transplant Services
• Inpatient and Outpatient
Hospital and Medical Services
80% of Allowed Charge when
Preauthorization/Prior Approval
is received from Sanford Health
Plan.
75% of Allowed Charge when
Preauthorization/Prior Approval
is received from Sanford Health Plan.
• Transportation Services
80% of Allowed Charge.
75% of Allowed Charge.
Maximum Benefit Allowance of $1,000 per transplant procedure.
90
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
Dental Services
• Temporomandibular (TMJ) or
Craniomandibular (CMJ) Joint
Treatment
80% of Allowed Charge.
75% of Allowed Charge.
Benefits are subject to a Maximum Benefit Allowance of 1 splint per Member per
Benefit Period.
• Dental Services Related to
Accidental Injury
80% of Allowed Charge.
75% of Allowed Charge.
• Dental Anesthesia and
Hospitalization
80% of Allowed Charge.
Prior Approval is required for all
Members age 9 and older.
75% of Allowed Charge.
Prior Approval is required for all
Members age 9 and older.
Outpatient Hospital and Medical Services
• Home and Office Visits
80% of Allowed Charge.
75% of Allowed Charge.
• Diagnostic Services
80% of Allowed Charge.
75% of Allowed Charge.
• Emergency Services
80% coinsurance applies for
emergency room facility fee billed
by a Hospital.
80% coinsurance applies for
emergency room facility fee billed by
a Hospital.
80% coinsurance applies for office or
emergency room visit billed by a
Professional Health Care Provider.
80% coinsurance applies for all
Ancillary Services received in an
emergency room or Professional
Health Care Provider’s office.
80% coinsurance applies for office or
emergency room visit billed by a
Professional Health Care Provider.
80% coinsurance applies for all
Ancillary Services received in an
emergency room or Professional
Health Care Provider’s office.
• Ambulance Services
80% of Allowed Charge.
80% of Allowed Charge.
• Radiation Therapy and
Chemotherapy
80% of Allowed Charge.
75% of Allowed Charge.
• Dialysis Treatment
80% of Allowed Charge.
75% of Allowed Charge.
• Home Infusion Therapy Services
80% of Allowed Charge.
75% of Allowed Charge.
91
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
• Allergy Services
80% of Allowed Charge.
75% of Allowed Charge.
• Phenylketonuria (PKU) - Foods
and food products for the dietary
treatment of Members born after
12/31/62 with maple syrup urine
disease or phenylketonuria (PKU)
80% of Allowed Charge.
75% of Allowed Charge.
Wellness Services
Evidence-based items or services that have, in effect, a rating of “A” or “B” in the current recommendations
of the United States Preventive Services Task Force, when received from a Participating Provider, are
covered without payment of any deductible or coinsurance requirement that would otherwise apply. As
these recommendations change, your coverage may also change. Services performed outside of Plan
Preventive Guidelines, and with a medical diagnosis, will be applied to your deductible and coinsurance.
• Well Child Care to the Member’s
18
th
birthday
100% of Allowed Charge. Deductible
Amount is waived.
100% of Allowed Charge. Deductible
Amount is waived.
Benefits are available as follows:
• Pediatric services based on guidelines supported by the HRSA, including
recommendations by the American Academy of Pediatrics Bright Future pediatric
schedule, and newborn metabolic screenings;
• Pediatric services based on evidence-informed preventive care and screening
guidelines supported by the HRSA;
• Medical History for all children throughout development at the following ages: 0 to 11
months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
• Immunizations
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Immunizations are provided and covered as recommended by the Centers for Disease
Control and Prevention Advisory Committee on Immunization Practices (ACIP) and by
the Health Resources and Services Administration (HRSA), with respect to the Member
involved.
92
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
Preventive Screening Services for Members ages 18 and older
• Routine Preventive Wellness
(Physical) Examination
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Preauthorization is not required when
using a participating provider. Your
annual preventive services do not need
to be scheduled 12 months apart You
may have your preventive services one
time per calendar year. For example, if
your services were done July last year, it
is okay to schedule them before July this
year.
Office visit exam includes health advice and counseling on blood pressure, counseling and
interventions on tobacco use, screening and counseling for alcohol use, sun exposure,
screening for depression, obesity screening with referral for behavioral interventions for
patients with a body mass index of 30 or higher and referrals to intensive behavioral
counseling to promote a healthful diet and physical activity to decrease cardiovascular
risk in adults that are overweight or obese and with cardiovascular disease risk factors.
During the visit, you may receive immunizations and screenings based on your
practitioner’s recommendation.
• Routine Diagnostic Screenings
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Screenings include, but are not limited to the following:
• Abdominal Aortic Aneurysm Screening; Lifetime Maximum Benefit Allowance of one
(1) ultrasound screening per male Member ages 65 through 75 with a history of
smoking
• Anemia screening – Hemoglobin or Hematocrit (one or the
other); one (1) per Member per year.
• Basic Metabolic Panel; one (1) per Member per year.
• Cholesterol Screening; coverage for frequency of Lipid Profile is dependent on Member
age. Additional tests, such as comprehensive metabolic panels will be applied to your
deductible/coinsurance.
• Diabetes Screening; benefit allowance of one (1) per Member per year.
• Hepatitis B Virus infection screening.
• Hepatitis C Virus (HCV) infection screening; Lifetime Maximum Benefit Allowance of
either: one (1) screening for Members born between 1945-1965; or one (1) screening
for Members at risk.
• Lung Cancer Screening; benefit allowance of one (1) per Member ages 55 through 80
who: 1) have a 30 pack-year smoking history; 2) currently smoke; or 3) have quit
smoking within the past 15 years.
• Osteoporosis Screening for female Members ages 65 and older, or younger if at
increased risk.
• Sexually Transmitted Disease (STD) Screening; one (1) per Member per year.
• Genetic counseling and evaluation for BRCA Testing and BRCA lab screening for
female members with a family history (breast, ovarian, tubal, or peritoneal cancer)
associated with increased risk for harmful mutation in BRC or BRC. Lifetime Maximum
Benefit Allowance of one (1) screening per Member.
For a complete listing, see the Preventive Health Guidelines for Members by signing
into your account at sanfordhealthplan.com/memberlogin or call (800) 499-3416 to
request a copy. As these recommendations change, your coverage may also change.
93
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
• Mammography Screening
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
• One (1) service for Members between the ages of 35 and 40.
• One (1) service per year for Members age 40 and older.
• Additional mammograms will be covered if recommended by a physician per N.D.C.C.
§26.1-36-09.1.
• Cervical Cancer Screening
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Benefits are subject to a Maximum Benefit Allowance of 1 Pap smear per Benefit Period.
Includes Office Visit.
• Colorectal Cancer Screening for
Members ages 45 and older
Note: Expenses incurred for tissue samples taken during a screening and sent for
evaluation or colonoscopies due to a medical condition will be applied to your
deductible/coinsurance.
➢
Fecal Occult
Blood Test; or
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Maximum Benefit Allowance of one (1) test per Member per year.
➢
Colonoscopy; or
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Maximum Benefit Allowance of one (1) test per Member every 10 years.
➢
Sigmoidoscopy
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Maximum Benefit Allowance of one (1) test per Member every 5 years.
• Prostate Cancer Screening
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Benefits are available for an annual digital rectal examination and an annual prostate-
specific antigen test for the following: an asymptomatic male age 50 and older; a male
age 40 and older of African American descent; and a male age 40 with a family history of
prostate cancer. Includes Office Visit.
94
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
• Nutritional Counseling
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
• Hyperlipidemia – Maximum of four (4) visits per Member per year.
• Gestational Diabetes – Maximum of four (4) visits per Member per year.
• Diabetes Mellitus – Maximum of four (4) visits per Member per year.
• Hypertension – Maximum of two (2) visits per Member per year.
• Obesity – Maximum of four (4) visits per Member per year.
• Aspirin to prevent
cardiovascular disease
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Benefit is available for Male Members ages 45 through 79, and female Members ages 55
through 79 at risk for developing cardiovascular disease.
The preventive care benefits listed above provide a brief overview. For a detailed list of covered services, view the Plan’s Preventive Health
Guidelines by signing into your account at sanfordhealthplan.com/memberlogin.
• Outpatient Nutritional Care
Services
80% of Allowed Charge. Deductible
Amount is waived.
75% of Allowed Charge. Deductible
Amount is waived.
Benefits are available to the Maximum Benefit Allowance for the following diagnosed
medical conditions:
• Chronic Renal Failure – Four (4) Office Visits per Member per year.
• Anorexia Nervosa – Four (4) Office Visits per Member per year.
• Bulimia – Four (4) Office Visits per Member per year.
• PKU – Four (4) Office Visits per Member per year.
• Diabetes Education Services
80% of Allowed Charge.
Deductible Amount is waived.
75% of Allowed Charge.
Deductible Amount is waived.
• Dilated Eye Examination
(for diabetes related diagnosis)
80% of Allowed Charge.
Deductible Amount is waived.
75% of Allowed Charge.
Deductible Amount is waived.
95
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
• Tobacco Cessation Services
Tobacco Cessation services include screening for tobacco use and at least two (2) tobacco
cessation attempts per year (for Members who use tobacco products).
Covering a cessation attempt is defined to include coverage for:
• Four (4) tobacco cessation counseling sessions of at least ten (10) minutes each
(including telephone counseling, group counseling and individual counseling)
without Preauthorization/Prior Approval; and
• All Food and Drug Administration (FDA)-approved tobacco cessation
medications (including both prescription and over-the-counter medications) for
a 90-day treatment regimen when prescribed by a health care provider without
Preauthorization/Prior Approval.
Outpatient Therapy Services
Only the Office Visit Amount will apply if both an Office Visit and Therapy/Manipulation are billed on the same day by the same Health
Care Provider.
• Physical Therapy
80% of Allowed Charge.
75% of Allowed Charge.
Benefits are subject to the medical guidelines established by
Sanford Health Plan.
• Occupational Therapy
80% of Allowed Charge.
75% of Allowed Charge.
Benefits are available for 90 consecutive calendar days
per condition, beginning on the date of the first therapy treatment for the condition.
Additional benefits may be allowed after the 90 days when Medically Appropriate and
Necessary.
• Speech Therapy
80% of Allowed Charge.
75% of Allowed Charge.
Benefits are available for 90 consecutive calendar days
per condition, beginning on the date of the first therapy treatment for the condition.
Additional benefits may be allowed after the 90 days when Medically Appropriate and
Necessary.
• Respiratory Therapy Services
80% of Allowed Charge.
75% of Allowed Charge.
96
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
• Cardiac Rehabilitation Services
80% of Allowed Charge.
Deductible Amount is waived.
75% of Allowed Charge.
Deductible Amount is waived.
Benefits are subject to a Maximum Benefit Allowance of 12 visits per Member per episode
for the following diagnosed medical conditions:
• Myocardial Infarction
• Coronary Artery Bypass Surgery
• Coronary Angioplasty and Stenting
• Heart Valve Surgery
• Heart Transplant Surgery
Cardiac Rehabilitation Services must begin within 2 months following discharge from the
Hospital.
• Pulmonary Rehabilitation
Services
80% of Allowed Charge.
75% of Allowed Charge.
• Physical Therapy for Members
age 65 and older at risk for falls
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
⎯⎯⎯⎯⎯
Benefit subject to Medical Necessity
⎯⎯⎯⎯⎯
Chiropractic Services
Only the Office Visit Amount will apply if both an Office Visit and Therapy/Manipulation are billed
on the same day by the same Health Care Provider.
• Home and Office Visits
80% of Allowed Charge.
75% of Allowed Charge.
• Therapy and Manipulations
80% of Allowed Charge.
75% of Allowed Charge.
• Diagnostic Services
80% of Allowed Charge.
75% of Allowed Charge.
Maternity Services
The Deductible Amount is waived for delivery services received from a PPO Health Care Provider
when the Member is enrolled in the Healthy Pregnancy Program.
• Inpatient Hospital and Medical
Services
80% of Allowed Charge.
75% of Allowed Charge.
• Routine Prenatal and Postnatal
Care
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
• One (1) Prenatal Nutritional
Counseling visit per pregnancy
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
• Lactation Counseling
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
97
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
Infertility Services
• Diagnostics, Treatment, Office
Visits, and Other Services
80% of Allowed Charge.
80% of Allowed Charge.
Benefits are subject to a $20,000 Lifetime Benefit Maximum Amount per Member. Any
Member-paid coinsurance for infertility services do not apply toward the Out-of-Pocket
Maximum Amount.
Contraceptive Services
• Diagnostics, Treatment, Office
Visits, and Other Services
100% of Allowed Charge.
Deductible Amount is waived.
100% of Allowed Charge.
Deductible Amount is waived.
Prescription contraceptive services, obtainable with a Prescription Order, are paid under the
Prescription Drug benefit. See Section 3.5.
Mental Health and Substance Use Disorder Treatment Services
• Mental Health Treatment Services
Inpatient
Includes Acute Inpatient
Admissions and Residential
Treatment
80% of Allowed Charge.
Preauthorization is required.
75% of Allowed Charge.
Preauthorization is required.
Outpatient
For all Outpatient Services, 100% of the Allowed Charge (includes
Deductible/Coinsurance) is waived for the initial 5 visits, per Member per Benefit Period.
Coverage of the first five (5) hours will not apply when you elect an HSA.
Office Visits
80% of Allowed Charge.
75% of Allowed Charge.
All Other Services, Including:
Intensive Outpatient
80% of Allowed Charge.
80% of Allowed Charge.
Partial Hospitalization
80% of Allowed Charge.
80% of Allowed Charge.
Applied Behavioral Analysis
(ABA) for Autism Spectrum
Disorders
80% of Allowed Charge.
Preauthorization/Prior Approval is required.
75% of Allowed Charge.
Preauthorization/Prior Approval is required.
98
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
• Substance Use Disorder Treatment Services
Inpatient
Includes Acute Inpatient
Admissions and Residential
Treatment
80% of Allowed Charge.
Preauthorization is required.
75% of Allowed Charge.
Preauthorization is required.
Outpatient
For all Outpatient Services, 100% of the Allowed Charge (includes
Deductible/Coinsurance) is waived for the initial 5 visits, per Member per Benefit Period.
Coverage of the first five (5) hours will not apply when you elect an HSA.
Office Visits
80% of Allowed Charge.
75% of Allowed Charge.
All Other Services, Including:
Intensive Outpatient
80% of Allowed Charge.
80% of Allowed Charge.
Partial Hospitalization
80% of Allowed Charge.
80% of Allowed Charge.
Other Services Not Previously Listed Above
• Skilled Nursing Facility Services
80% of Allowed Charge.
75% of Allowed Charge.
• Home Health Care Services
80% of Allowed Charge.
75% of Allowed Charge.
• Hospice Services
80% of Allowed Charge.
75% of Allowed Charge.
• Private Duty Nursing Services
80% of Allowed Charge.
75% of Allowed Charge.
• Medical Supplies and Equipment
80% of Allowed Charge.
75% of Allowed Charge.
- Home Medical Equipment
- Prosthetic Appliances and Limbs
- Orthotic Devices
- Supplies for Administration of
Prescription Medications other than the
diabetes supplies specified in Prescription
Drug Benefit (See Section 3.5)
- Oxygen Equipment and Supplies
- Ostomy Supplies
- External Hearing aids
Limited to one hearing aid, per ear, per Member every 3 years in alignment with Medical
Necessity and Sanford Health Plan guidelines..
99
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
• Breast Pumps
100% of Allowed Charge.
Deductible Amount is waived. Benefits
are available for the rental or purchase
of 1 breast pump per pregnancy.
Supplies also covered; see Section 3.
100% of Allowed Charge.
Deductible Amount is waived. Benefits are
available for the rental or purchase of 1
breast pump per pregnancy. Supplies also
covered; see Section 3.
• Eyeglasses or Contact Lenses
(following a covered cataract surgery)
80% of Allowed Charge.
75% of Allowed Charge.
Benefits are subject to a Maximum Benefit Allowance of 1 pair of eyeglasses or contact
lenses per Member when purchased within 6 months following the surgery.
Prescription Drug and Diabetes Supplies Benefits
Retail and Mail Order
Insulin and medical supplies for insulin dosing and administration
• Insulin Formulary and Non-Formulary Insulin only: Deductible amount is waived
1-30 day supply
$25 copayment
$25 copayment
31-60 day supply
$50 copayment
$50 copayment
61-100 day supply
$75 copayment
$75 copayment
• Testing Supplies, Pen Needles and Syringes Formulary and Non-Formulary
1-30 day supply
Deductible then 20% coinsurance
with maximum of $25
Deductible then 20% coinsurance
with maximum of $25
31-60 day supply
Deductible then 20% coinsurance
with maximum of $50
Deductible then 20% coinsurance
with maximum of $50
61-100 day supply
Deductible then 20% coinsurance
with maximum of $75
Deductible then 20% coinsurance
with maximum of $75
Formulary Prescription Medication
80% of Allowed Charge
80% of Allowed Charge
Non-Formulary Prescription
Medication
50% of Allowed Charge
50% of Allowed Charge
100
Covered Services
PROVIDER OF SERVICE
PPO Plan
After Deductible Amount
Basic Plan
After Deductible Amount
Formulary contraceptive medications obtainable with a Prescription Order are paid at 100% of Allowed Charge; this includes
over-the-counter Plan-B, if obtained with a Prescription Order. Deductible Amount is waived.
If a Generic Prescription Medication is the therapeutic equivalent for a Brand Name Prescription Medication, and is authorized
by a Member’s Professional Health Care Provider, benefits will be based on the Allowance for the Generic equivalent. If the
Member does not accept the Generic equivalent, the Member is responsible for the cost difference between the Generic and the
Brand Name Prescription Medication and applicable Cost Sharing Amounts.
Prescription Medications and nonprescription diabetes supplies are subject to a dispensing limit of a 100-day supply.
Cost Sharing Amounts are waived for generic federal legend prenatal vitamins when the member is enrolled in the Healthy
Pregnancy program. Member will be responsible for copayment plus co-insurance for all brand name federal legend prenatal
vitamins and generic federal legend vitamins, if not enrolled in the Healthy Pregnancy Program. For details, see Section 3.
Folic Acid Supplements are covered at 100% (no charge) for women planning to become pregnant or in their childbearing
years, if obtained with a Prescription Order. Deductible Amount is waived. For details, see Section 3.
Vitamin D supplements are covered at 100% (no charge) for Members ages 65 and older at risk for falls, if obtained with a
Prescription Order. Deductible Amount is waived. For details, see Section 3.
Formulary breast cancer preventive medications obtainable with a Prescription Order are covered at 100% (no charge) for
women at increased risk for breast cancer. Deductible Amount is waived. For details, see Section 3.
101
SECTION 4
LIMITED AND NON-COVERED SERVICES
This section describes services that are subject to limitations or NOT covered under this Contract. The Plan is not
responsible for payment of non-covered or excluded benefits.
4.1 GENERAL MEDICAL EXCLUSIONS
1. Acupuncture
2. Additional refractive procedure (including lens) after coverage of initial lens at time of cataract
correction.)
3. Admissions to Hospitals performed only for the convenience of the Member, the Member’s family or
the Member’s Practitioner and/or Provider
4. Adult vision exams (routine)
5. Air conditioners, air filters, or other products to eradicate dust mites
6. All other hearing related supplies, purchases, examinations, testing or fittings not covered under this
policy
7. Alternative treatment therapies including, but not limited to: acupressure, massage therapy unless
covered per plan guidelines under WHCRA for mastectomy/lymphedema treatment, naturopathy,
homeopathy, holistic medicine, hypnotism, hypnotherapy, hypnotic anesthesia, sleep therapy (except for
treatment of obstructive apnea), or therapeutic touch
8. Amniocentesis or chorionic villi sampling (CVS) solely for sex determination
9. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole,
probation or custody or visitation evaluations unless medically necessary and otherwise covered under
this Certificate of Insurance
10. Any expenses related to surrogate parenting, except if Surrogate is a covered Member under this
Certificate of Insurance and seeking otherwise Covered Services
11. Any form of allergy testing and immunotherapy that is considered experimental or not FDA approved
12. Any fraudulently billed charges or services received under fraudulent circumstances
13. Any other equipment and/or supplies which the Plan determines not eligible for coverage
14. Any services or supplies for the treatment of obesity that do not meet Sanford Health Plan’s coverage
guidelines, including but not limited to: dietary regimen (except as related to covered nutritional
counseling); nutritional supplements or food supplements; and weight loss or exercise programs
15. Appetite suppressants and supplies of a similar nature
16. Appointment scheduling
17. Artificial organs, any transplant or transplant services not listed above
18. Autopsies, unless the autopsy is at the request of The Plan in order to settle a dispute concerning
provision or payment of benefits. The autopsy will be at the Plan’s expense.
19. Blood and blood derivatives replaced by the Member
20. Bifocal contact lenses
21. Charges for duplicating and obtaining medical records from Non-Participating Providers unless
requested by the Plan.
22. Charges for professional sign language and foreign language interpreter services unless required by state
or federal law
23. Charges for sales tax, mailing, interest and delivery
102
24. Charges for services determined to be duplicate services
25. Charges for telephone calls to or from a Physician, Hospital or other medical Practitioner and/or
Provider or electronic consultations, unless otherwise stated in this Certificate of Insurance
26. Charges that exceed the Maximum Allowed Amount for Non-Participating Providers
27. Chemical peel for acne
28. Chiropractic manipulations for allergies
29. Clarification of simple instructions
30. Cleaning and polishing of prosthetic eye(s)
31. Clinical ecology, orthomolecular therapy, vitamins (unless listed as covered elsewhere in this COI) or
dietary nutritional supplements, or related testing provided on an inpatient or outpatient basis.
32. Commodes and/or similar convenience items
33. Complications resulting from non-covered or denied Health Care Services.
34. Confinement Services to hold or confine a Member under chemical influence when no Medically
Necessary services are provided, regardless of where the services are received (e.g. detoxification
centers)
35. Consultative message exchanges with an individual who is seen in the provider’s office following a
video visit for the same condition, per Sanford Health Plan guidelines
36. Convalescent care
37. Cosmetic Services and/or supplies to repair or reshape a body structure not Medically Necessary and/or
primarily for the improvement of a Member’s appearance or psychological well-being or self-esteem,
including but not limited to, breast augmentation, treatment of gynecomastia and any related reduction
services, skin disorders, rhinoplasty, liposuction, scar revisions, and cosmetic dental services
38. Costs related to locating organ donors
39. Coverage beyond one (1) piece of same-use equipment (e.g. mobilization, suction), unless replacement
is covered under the replacement guidelines in this policy. Duplicate or back up equipment is not a
covered benefit.
40. Cryogenic or other preservation techniques used in such or similar procedures;
41. Custodial care
42. Custodial or convalescent care
43. Cutting, removal, or treatment of corns, calluses, or nails for reasons other than authorized corrective
surgery (except as stated above and in Section 3 “Diabetes supplies, equipment, and education”)
44. Daycare, Attendant, or Homemaker Services
45. Deluxe equipment
46. Dental appliances of any sort, including but not limited to those related to Sleep Apnea, bridges, braces,
and retainers that are for cosmetic reasons and/or medically unnecessary
47. Dental care and treatment (routine or non-routine) for Members ages nineteen (19) and older including
but not limited to:
a. natural Teeth replacements including crowns, bridges, braces or implants;
b. extraction of wisdom teeth;
c. hospitalization for extraction of teeth;
d. dental x-rays or dental appliances;
e. shortening of the mandible or maxillae for cosmetic purposes;
f. services and supplies related to ridge augmentation, implantology, and preventive
vestibuloplasty; and
g. dental appliances of any sort, including but not limited to bridges, braces, and retainers, other
than for treatment of TMJ/TMD
h. Osseointegrated implant surgery (dental implants)
103
48. Dental services not specifically listed as Covered by the Policy
49. Dental x-rays
50. Dialysis services received by Non-Participating Providers when traveling out of the service area
51. Diet therapy (specialty foods) for allergies
52. Dietary desserts and snack items
53. Dietary surveillance and counseling
54. Disposable supplies (including diapers) or non-durable supplies and appliances, including those
associated with equipment determined not to be eligible for coverage
55. Domiciliary care or Long-Term Residential Care
56. Donor eggs including any donor treatment and retrieval costs, donor sperm, cryopreservation or storage
of embryos, sperm, or eggs; Surrogate pregnancy and delivery; Gestational Carrier pregnancy and
delivery; and preimplantation genetic diagnosis testing
57. Donor expenses for complications of transplants that occur after sixty (60) days from the date the an
organ is removed, regardless if the donor is covered as a Member under this Plan or not
58. Duplicate or similar items
59. Duplicate services, including allergy testing for percutaneous scratch tests, intradermal tests, and patch
tests
60. Education and training for patient self-management by a qualified, non-physician health care
professional using a standardized curriculum, face-to-face with the patient (could include
caregiver/family)
61. Education Programs or Tutoring Services (not specifically defined elsewhere) including, but not limited
to,
a. Education on self-care or home management
b. Educational or non-medical services for learning disabilities
c. Educational or non-medical services for learning disabilities and/or behavioral problems,
including those educational or non-medical services as provided under the Individuals with
Disabilities Education Act (IDEA)
d. Educational or non-medical services for learning disabilities or behavioral problems
62. Elective abortion services
63. Elective health services received outside of the United States
64. Expenses incurred by a Member as a donor, unless the recipient is also a Member
65. Experimental and Investigational Services not part of an Approved Clinical Trial unless certain criteria
are met pursuant to Sanford Health Plan’s medical coverage policies
66. Extra care costs related to taking part in an Approved Clinical Trial such as additional tests that a
Member may need as part of the trial, but not Routine Patient Costs.
67. Extraction of wisdom teeth
68. Eyeglasses or contact lenses and the vision examination for prescribing or fitting eyeglasses or contact
lenses, unless specified as Covered elsewhere in this Certificate of Insurance
69. Fees associated with Room and Board, unless Prior Authorization is received pursuant to Medical
Necessity guidelines
70. First aid or precautionary equipment such as standby portable oxygen units
71. Food items for medical nutrition therapy
72. Food items for medical nutrition therapy (except as specifically allowed in the Covered Benefits Section
of this Certificate of Insurance).
73. Formula and supplements available Over the Counter
74. Genetic counseling or testing except for services that have a rating of “A” or “B” in the current
recommendations of the United States Preventive Services Task Force; Preauthorization/Prior Approval
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is required)
75. Hair transplants or hair plugs
76. Health Care Services covered by any governmental agency/unit for military service-related
injuries/diseases, unless applicable law requires primary coverage for the same
77. Health Care Services for injury or disease due to voluntary participation in a riot, unless source of injury
is a result of domestic violence or a medical condition
78. Health Care Services for sickness or injury sustained in the commission of a felony, unless source of
injury is a result of domestic violence or a medical condition
79. Health Care Services ordered by a court or as a condition of parole or probation, unless applicable law
requires the Plan to provide coverage for the same
80. Health Care Services performed by any Provider who is a Member of the Member’s immediate family,
including any person normally residing in the Member’s home. This exclusion does not apply in those
areas in which the immediate family member is the only Provider in the area. If the immediate family
member is the only In-Network Participating Practitioner and/or Provider in the area, the Member may
be treated by that Provider provided they are acting within the scope of their practice. The Member may
also go to a Non-Participating Provider and receive In-Network coverage (Section 2). If the immediate
family member is not the only In-Network Participating Practitioner and/or Provider in the area, the
Member must go to another In-Network Participating Practitioner and/or Provider in order to receive
coverage at the In-Network level.
81. Health Care Services prohibited state or federal rule, law, or regulation
82. Health Care Services provided either before the effective date of the Member’s coverage or after the
Member’s coverage is terminated.
83. Health Care Services received from a Non-Participating Provider, unless otherwise specified in this
Contract.
84. Health Care Services required while incarcerated in a federal, state or local penal institution or required
while in custody of federal, state or local law enforcement authorities, including work release programs,
unless otherwise required by law or regulation
85. Health Care Services that are the responsibility of a Third-Party Payor
86. Health Care Services that we determine are not Medically Necessary
87. Health services received outside of the United States that are not Medically Necessary emergency or
urgent care services.
88. Home birth settings, related equipment and fees
89. Home delivered meals or laundry services
90. Home modifications including, but not limited to, its wiring, plumbing or changes for installation of
equipment
91. Home Traction Units
92. Homeopathic treatment of allergies
93. Hospitalization for extraction of teeth that is not Medically Necessary
94. Hot/cold pack therapy including polar ice therapy and water circulating devices
95. Household equipment which primarily has customary uses other than medical, such as, but not limited
to, air purifiers, central or unit air conditioners, water purifiers, non-allergic pillows, mattresses or
waterbeds, physical fitness equipment, hot tubs, or whirlpools
96. Household fixtures including, but not limited to, escalators or elevators, ramps, swimming pools and
saunas
97. Hypnotism
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98. Iatrogenic condition illness or injury as a result of mistakes made in medical treatment, such as surgical
mistakes, prescribing or dispensing the wrong medication or poor hand writing resulting in a treatment
error. Charges related to Iatrogenic illness or injury are not the responsibility of the Member.
99. Independent nursing, homemaker services, respite care
100. Inpatient services provided at a Residential Treatment Facility if treatment is not provided at an acute
level of care with 24-hour registered nursing care under the supervision of a Chief Medical Officer.
101. Installation or maintenance of any telecommunication devices or systems
102. Intermediate level or domiciliary care
103. Items which are primarily non-medical and educational in nature or for vocation, comfort, convenience
or recreation
104. LASIK eye surgery
105. Lifestyle Improvement Services, such as physical fitness programs, health or weight loss clubs or clinics
106. Liposuction, gastric balloons, or wiring of the jaw (unless otherwise related to a covered injury or
illness)
107. Long-Term Residential Care
108. Low protein modified food products or medical food for PKU to the extent those benefits are available
under a Department of Health program or other state agency
109. Maintenance and service fee for capped-rental items
110. Maintenance Care that is typically long-term and by definition not therapeutically necessary but is
provided at regular intervals to promote health and enhance the quality of life; this includes care
provided after maximum therapeutic improvement, without a trial of withdrawal of treatment, to
prevent symptomatic deterioration or initiated by Members without symptoms in order to promote
health and to prevent further problems, unless specifically stated as covered elsewhere in this
Certificate of Insurance
111. Maintenance Therapy
112. Marriage counseling; pastoral counseling; financial or legal counseling; and custodial care counseling
113. Maternity classes and/or education programs
114. Meals, custodial care or housekeeping
115. Methods of desensitization treatment: provocation/neutralization therapy for food/chemical or inhalant
allergies by sublingual, intradermal and subcutaneous routes, Urine Autoinjections, Repository Emulsion
Therapy, Candidiasis Hypersensitivity Syndrome Treatment or IV Vitamin C Therapy.
116. Milieu therapy
117. Never Events, Avoidable Hospital Conditions, or Serious Reportable Events. Participating Providers are
not permitted to bill Members for services related to such events.
118. Newborn delivery and nursery charges for adopted Dependents prior to the adoption-bonding period
(See Section 1.8 “When Dependent Coverage Begins.”)
119. Non-licensed birthing assistance, such as doulas
120. Non-surgical treatments that do not meet the Plan’s Medically Necessary guidelines (available upon
request)
121. Nursing care requested by, or for the convenience of the Member or the Member’s family (rest cures)
122. Nutritional or food supplements (services supplies and/or nutritional sustenance products or food
related to enteral feeding, except when it’s the sole means of nutrition)
123. Online assessment and management service provided by a qualified non-physician health care
professional, internet or electronic communications.
124. Orthopedic shoes; custom made orthotics; over-the-counter orthotics and appliances
125. Panniculectomy that does not meet Plan guidelines
126. Personal comfort items (telephone, television, guest meals and beds)
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127. PKU dietary desserts and snack items
128. Pre-employment and employment physicals, insurance physicals, or government licensing physicals
(including, but not limited to, physicals and eye exams for driver’s licenses)
129. Purchase, examination, or fitting of eyeglasses or contact lenses, except as specifically covered
elsewhere
130. Provider-initiated e-mail
131. Provocative food testing
132. Radial Keratotomy, Myopic Keratomileusis, and any surgery involving corneal tissue for the purpose of
altering, modifying, or correcting myopia, hyperopia, or stigmatic error
133. Refractive errors of the eye
134. Refractive eye surgery when used in otherwise healthy eyes to replace eyeglasses or contact lenses
135. Reimbursement for personal transportation costs incurred while traveling to/from Practitioner and/or
Provider visits or other Health Care Services
136. Reminders of scheduled office visits
137. Remote control devices as optional accessories
138. Removal of skin tags
139. Removal, revision or re-implantation of saline or silicone implants for: breast implant malposition;
unsatisfactory aesthetic outcome; Member desire for change of implant; Member fear of possible
negative health effects; or removal of ruptured saline implants that do not meet Medical Necessity
criteria. Fees for room and board unless Prior Authorized
140. Replacement of lost, stolen, broken, or damaged lenses or glasses
141. Replacement or repair of equipment if items are damaged or destroyed by Member misuse, abuse, or
carelessness; or if lost or stolen
142. Replacement or repair of items, if the items are damaged or destroyed by the Member’s misuse, abuse
or carelessness; or if lost or stolen
143. Reproductive Health Care Services prohibited by the laws of This State
144. Requests for a referral
145. Research costs related to conducting the Approved Clinical Trial such as research physician and nurse
time, analysis of results, and clinical tests performed only for research purposes. These costs are
generally covered by the clinical trials; Sanford Health Plan does not cover these costs.
146. Rest cures
147. Restorative replacements including crowns, bridges, braces or implants
148. Reversal of voluntary sterilization
149. Reversals of prior sterilization procedures
150. Revision of durable medical equipment, except when made necessary by normal wear or use
151. Revision/replacement of prosthetics (except as noted per Plan policy)
152. Routine cleaning of Scleral Shells
153. Sales tax, mailing, delivery charges, service call charges, or charges for repair estimates
154. Self-help and adaptive aids are not a covered benefit, including assistive communication devices and
training aids.
155. Sensitivity training
156. Sequela, which are primarily cosmetic that occur secondary to a weight loss procedure (e.g.,
Panniculectomy, breast reduction or reconstruction)
157. Service call charges and charges for repair estimates
158. Services and supplies related to ridge augmentation, implantology, and preventive vestibuloplasty
159. Services and/or travel expenses relating to a Non-Emergency Medical Condition
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160. Services by a vocational residential rehabilitation center, a community reentry program, halfway house
or group home that are not Medically Necessary
161. Services determined to be cosmetic by the Plan
162. Services for excluded benefits
163. Services for which the Member has no legal obligation to pay or for which no charge would be made if
the Member did not have health plan or insurance coverage.
164. Services not medically appropriate or necessary
165. Services not medically appropriate to do via telehealth
166. Services not performed in the most cost-efficient setting appropriate for the condition based on medical
standards and accepted practice parameters of the community, or provided at a frequency other than that
accepted by the medical community as medically appropriate
167. Services or supplies determined by the Plan to be special or unusual, including orthoptics, and vision aids
168. Services provided in the Member’s home for convenience
169. Services related to environmental change
170. Services that are not Health Care Services
171. Services that are the responsibility of a Third Party Payor or are not billable to health insurance
172. Services that can be provided safely and effectively by a non-clinically trained person
173. Services that involve payment of family members or nonprofessional care givers for services
performed for the member
174. Service(s) that would similarly not be charged for in regular office visit
175. Services to assist in activities of daily living
176. Services, chemotherapy, radiation therapy (or any therapy that damaged the bone marrow), supplies
drugs and aftercare for or related to artificial or non-human organ transplants
177. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not
specifically approved by the Plan’s Chief Medical Officer or its designee
178. Services, chemotherapy, supplies, drugs and aftercare for or related to transplants performed at a non-
Plan Participating Center of Excellence
179. Shortening of the mandible or maxillae for cosmetic purposes
180. Special education, including lessons in sign language to instruct a Member, whose ability to speak has
been lost or impaired, to function without that ability, is not covered
181. Special lens coating or lens treatments for prosthetic eyewear
182. Sports physicals, pre-employment and employment physicals, insurance physicals, or government
licensing physicals (including, but not limited to, physicals and eye exams for driver’s licenses)
183. Storage of stem cells including storing umbilical cord blood of non-diseased persons for possible future
use
184. Sublingual allergy desensitization
185. Subsequent surgeries when no tangible evidence of Medical Necessity or improved quality of life exists.
186. Surgical procedures that can be done in a Practitioner office setting (i.e. vasectomy, toe nail removal)
187. Take-home drugs (Prescription medications provided to a Member at discharge are paid under the
Prescription Drug benefit. See Sections 3.5, 3.7, and 3.8 for benefit details.)
188. Telecommunication Devices
189. Telephone assessment and management services
190. Tests considered experimental or investigational for the treatment of autism spectrum disorder,
including but not limited to: allergy testing, celiac antibody testing, hair analysis, testing for
mitochondrial disorders, and micronutrient testing.
191. The following allergy testing modalities: nasal challenge testing, provocative/neutralization testing for
food and food additive allergies, leukocyte histamine release, Rebuck skin window test, passive transfer
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or Prausnitz-Kustner test, cytotoxic food testing, metabisulfite testing, candidiasis hypersensitivity
syndrome testing, IgG level testing for food allergies, general volatile organic screening test and mauve
urine test.
192. Therabands and cervical pillows
193. Therapies considered experimental or investigational for the treatment of autism spectrum disorder,
including but not limited to: auditory integration therapy, biofeedback, chelation therapy, hippotherapy,
and hyperbaric oxygen therapy.
194. Therapy and service animals, including those used for emotional or anxiety support
195. Thermograms or thermography
196. Tinnitus Maskers
197. Transfers performed only for the convenience of the Member, the Member’s family, or the Member’s
Practitioner and/or Provider
198. Transmission fees
199. Transplant evaluations with no end organ complications
200. Transplants and transplant evaluations that do not meet the United Network for Organ Sharing (UNOS)
criteria
201. Transportation costs for non-emergency services and/or travel
202. Treatment of weak, strained, or flat feet
203. Treatment received outside of the United States
204. Upgrades of equipment for outdoor use, or equipment needed for use outside of the home that is not
needed for in-home use, are not covered.
205. Vehicle modifications including, but not limited to, hand brakes, hydraulic lifts, and car carrier
206. Vitamins and minerals (unless otherwise specified as covered in this Policy)
207. Voluntary or involuntary drug testing unless a part of a Plan approved treatment plan
208. Wearable artificial kidney, each
209. Weight loss or exercise programs that do not meet the Plan’s Medical Necessity coverage guidelines
4.2 GENERAL PHARMACY EXCLUSIONS
1. Any medication equivalent to an OTC medication except for drugs that have a rating of “A” or “B” in
the current recommendations of the United States Preventive Services Task Force and only when
prescribed by a health care Practitioner and/or Provider
2. B-12 injection (except for pernicious anemia)
3. Compound medications containing any combination of the following: Baclofen, Bromfenac,
Bupivicaine, Cyclobenzaprine, Gabapentin, Ketamine, Ketoprofen or Orphenadrine
4. Compound medications with no legend (prescription) medication
5. Drug Efficacy Study Implementation (“DESI”) drugs
6. Experimental or Investigational medications or medication usage pursuant to the Plan’s medical
coverage policies
7. Excluded medications from coverage that provide little or no evidence of therapeutic advantage over other
products available.
8. Food supplements and baby formula (except to treat phenylketonuria (PKU) or otherwise required to
sustain life), nutritional and electrolyte substances
9. Medical Cannabis and/or its equivalents
10. Medications and associated expenses and devices not approved by the FDA for a particular use except
as required by law (unless Provider certifies off-label use with a letter of Medical Necessity)
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11. Medications for cosmetic purposes, including baldness, removal of facial hair, or pigmenting or anti-
pigmenting of the skin
12. Medications not listed in the Plans Formulary
13. Medications obtained at a Non-Participating and/or Out-of-Network Pharmacy;
14. Medications that are obtained without Prior Authorization or a Formulary exception from the Plan
15. Medications that may be received without charge under a government program, unless coverage is
required for the medication
16. Medications that provide little or no evidence of therapeutic advantage over other products available
17. Medications that require professional administration (may include: intravenous (IV) infusion or
injection, intramuscular (IM) injections, intravitreal (ocular) injection, intra-articular (joint) injection,
intrathecal (spinal) injections) will apply to the Member’s medical benefit;
18. Orthomolecular therapy, including nutrients or vitamins unless otherwise specified as covered in this
document, food supplements and baby formula (except to treat PKU or otherwise required to sustain life or
amino acid-based elemental oral formulas), nutritional and electrolyte substances
19. Over-the-counter (OTC) medications vitamins and/or supplements, equipment or supplies (except for
Plan B and its generic equivalents; insulin and select diabetic supplies, e.g., insulin syringes, needles,
test strips and lancets, or aspirin to prevent cardiovascular disease when prescribed by a Healthcare
Practitioner and/or Provider) that by Federal or State law do not require a prescription order
20. Outpatient medications dispensed in a Provider’s office or non-retail pharmacy location
21. Refills of any prescription older than one (1) year
22. Repackaged medications
23. Replacement of a prescription medication due to loss, damage, or theft
24. Self-administered medications dispensed in a Provider’s office or non-retail pharmacy location
25. Unit dose packaging
26. Whole Blood and Blood Components Not Classified as Drugs in the United States Pharmacopoeia
4.3 SPECIAL SITUATIONS AFFECTING COVERAGE
Neither Sanford Health, nor any Participating Provider, shall have any liability or obligation because of a delay or
a Participating Provider’s inability to provide services as a result of the following circumstances:
• Complete or partial destruction of the Provider’s facilities;
• Declared or undeclared acts of War or Terrorism;
• Riot;
• Civil insurrection;
• Major disaster;
• Disability of a significant portion of the Participating Providers;
• Epidemic; or
• A labor dispute not involving Participating Providers, we will use our best efforts to arrange for the provision
of Covered Services within the limitations of available facilities and personnel. If provision or approval of
Covered Services is delayed due to a labor dispute involving Participating Providers, Non-Emergency Care
may be deferred until after resolution of the labor dispute.
Additionally, non-Emergency care may be deferred until after resolution of the above circumstances.
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4.4 SERVICES COVERED BY OTHER PAYORS
The following are excluded from coverage:
• Health Care Services for which other coverage is either (1) required by federal, state or local law to be
purchased or provided through other arrangements or (2) has been made available to and was purchased by
the Covered Person. Examples include coverage required by Worker’s compensation, no-fault auto
insurance, medical payments coverage or similar legislation.
• The Plan is not issued in lieu of nor does it affect any requirements for coverage by Worker’s Compensation.
This Plan contains a limitation, which states that health services for injuries or sickness, which are job,
employment or work, related for which benefits are paid under any Worker’s Compensation or Occupational
Disease Act or Law, are excluded from coverage by the Plan. However, if benefits are paid under the Plan,
and it is determined that Member is eligible to receive Worker’s Compensation for the same incident;
Sanford Health Plan has the right to recover any amounts paid. As a condition of receiving benefits on a
contested work or occupational claim, Member will consent to reimburse Sanford Health Plan the full
amount of the Reasonable Costs when entering into any settlement and compromise agreement, or at any
Worker’s Compensation Division Hearing. Sanford Health Plan reserves its right to recover against Member
even though:
• The Worker’s Compensation benefits are in dispute or are made by means of settlement or
compromise; or
• No final determination is made that the injury or sickness was sustained in the course of or resulted
from employment;
• The amount of Worker’s Compensation for medical or health care is not agreed upon or defined by
Member or the Worker’s Compensation carrier; or
• The medical or health care benefits are specifically excluded from the Worker’s Compensation
settlement or compromise.
• Member will not enter into a compromise or hold harmless agreement relating to any work related claims
paid by the Plan, whether or not such claims are disputed by the Worker’s Compensation insurer, without the
express written agreement of Sanford Health Plan.
• Health Care Services received directly from Providers employed by or directly under contract with the
Member’s employer, mutual benefit association, labor union, trust, or any similar person or Group.
• Health Care Services for injury or sickness for which there is other non-Group insurance providing medical
payments or medical expense coverage, regardless of whether the other coverage is primary, excess, or
contingent to the Plan. If the benefits subject to this provision are paid for or provided by the Plan, the Plan
may exercise its Rights of Subrogation.
• Health Care Services for conditions that under the laws of This State must be provided in a governmental
institution.
• Health Care Services covered by any governmental health benefit program such as Medicare, Medicaid,
ESRD and TRICARE, unless applicable law requires the Plan to provide primary coverage for the same.
4.5 SERVICES AND PAYMENTS THAT ARE THE RESPONSIBILITY OF MEMBER
• Out-of-pocket costs, including Deductibles and Coinsurance are the responsibility of the Member in
accordance with the attached Summary of Benefits and Coverage and Summary of Pharmacy Benefits.
Additionally, the Member is responsible to a Provider for payment for Non-Covered Services;
• Finance charges, late fees, charges for missed appointments and other administrative charges; and
• Services for which a Member is neither legally, nor as customary practice, is required to pay in the absence
of a group health plan or other coverage arrangement.
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SECTION 5
HOW SERVICES ARE PAID FOR UNDER THE CERTIFICATE OF
INSURANCE
5.1 REIMBURSEMENT OF CHARGES BY PARTICIPATING PROVIDERS
• When you see Participating Practitioner and/or Providers, receive services at Participating Practitioner
and/or Provider Providers and facilities, or obtain your prescription drugs at Network Pharmacies, you
will not have to file claims. You must present your current identification card and pay any
deductible/coinsurance amount due.
• When a Member receives Covered Services from a Participating Practitioner and/or Provider, Sanford
Health Plan will pay the Participating Practitioner and/or Provider directly, and the Member will not
have to submit claims for payment. The Member’s only payment responsibility, in this case, is to pay the
Participating Practitioner and/or Provider, at the time of service, any Deductible or Coinsurance amount
that is required for that service. Participating Practitioner and/or Providers agree to accept either Sanford
Health Plan’s payment arrangements or the negotiated contract amounts.
Time Limits. Participating Practitioner and/or Providers must file claims to Sanford Health Plan within one
hundred eighty (180) days after the date that the cost was incurred. If the Member fails to show his/her ID card at
the time of service, then the Member may be responsible for payment of claim after Practitioner and/or
Provider’s timely filing period of one hundred eighty (180) days has expired.
In any event, the claim must be submitted to Sanford Health Plan no later than one hundred eighty (180) days
after the date that the cost was incurred, unless the claimant was legally incapacitated.
5.2 REIMBURSEMENT OF CHARGES BY NON-PARTICIPATING PROVIDERS
Sanford Health Plan does not have contractual relationships with Non-Participating Providers and they may not
accept the Sanford Health Plan’s payment arrangements. In addition to any Deductible or Coinsurance amount
that is required for that service, Members are responsible for any difference between the amount charges and
Sanford Health Plan’s payment for Covered Services. Non-Participating Providers are reimbursed the Maximum
Allowed Amount, which is the lesser of:
• the amount charged for a Covered Service or supply; or
• inside Sanford Health Plan’s service area, negotiated schedules of payment developed by Sanford Health
Plan which are accepted by Participating Practitioners and/or Providers, or
• outside of Sanford Health Plan’s service area, using current publicly available data adjusted for
geographical differences where applicable:
• Fees typically reimbursed to providers for same or similar professionals; or
• Costs for facilities providing the same or similar services, plus a margin factor.
You may need to file a claim when you receive services from Non-Participating Providers. Sometimes these
Practitioners and/or Providers submit a claim to us directly. Check with the Practitioner and/or Provider to make
sure they are submitting the claim. You are responsible for making sure claim is submitted to Sanford Health Plan
within one-hundred-eighty (180) days after the date that the cost was incurred.
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If you, or the Non-Participating Provider, does not file the claim within 180 days after the date that the cost
was incurred you will be responsible for payment of the claim.
If you need to file the claim, here is the process:
The Member must give Sanford Health Plan written notice of the costs to be reimbursed. Claim forms are
available from the Customer Service Department to aid in this process. Bills and receipts should be itemized and
show:
• Covered Member’s name and ID number;
• Name and address of the Physician or Facility that provided the service or supply;
• Dates Member received the services or supplies;
• Diagnosis;
• Type of each service or supply;
• The charge for each service or supply;
• A copy of the explanation of benefits, payments, or denial from any primary payer – such as the
Medicare Summary Notice (MSN); and
• Receipts, if you paid for your services.
Time Limits: Claims must be submitted to Sanford Health Plan within one hundred eighty (180) days after the
date that the cost was incurred. If you, or the Non-Participating Provider, file the claim after the one-hundred-
eighty (180) timely filing limit has expired, you will be responsible for payment of the claim.
Submit your claims to: Sanford Health Plan, ATTN: NDPERS, PO Box 91110, Sioux Falls, SD 57109-1110
5.3 PAYMENTS FOR AIR AMBULANCE CHARGES
As a safeguard for Members, the reimbursement rate for Out-of-Network air ambulance services is equal
to the average of Sanford Health Plan’s In-Network rates for air ambulance providers licensed by the
North Dakota Department of Health.
A claim made by the Member for Out-of-Network air ambulance services provided by an air ambulance
provider licensed by the North Dakota Health Department will be paid in accordance with Sanford Health
Plan’s above mentioned policy. A payment made in accordance with this policy is the same as an In-
Network payment for services.
If you have questions, please call our Customer Service Department.
5.4 BALANCE BILLING FROM NON-PARTICIPATING PROVIDERS
Balance billing, sometimes referred to as surprised billing, is the practice of a medical provider charging a
patient for the difference between the total cost of services being billed and the amount the insurance
pays. When a Member receives Covered Services from an In-Network Participating Practitioner and/or
Provider, the Member is protected from balance billing because the provider cannot attempt to collect
charges above what Sanford Health Plan reimburses. When Sanford Health Plan does not have a
contractual relationship in place and the provider is a Non-Participating Provider, they may not accept
Sanford Health Plan’s payment arrangements and members may be balanced billed for services received.
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Members may be balance billed in emergency situations even when Sanford Health Plan covers all of the
charges at an In-Network Level if the provider is a Non-Participating Provider who will not accept our
payment as full and final. In such circumstances, the Non-Participating Provider must satisfy the Notice
and Consent Process and Requirements before sending surprise bills. Out-of-Network facilities and
providers are prohibited from sending surprise bills for out-of-network cost sharing without signed
consent from the Member. Please check the Sanford Health Plan provider directory before receiving
services to make sure you are seeing an In-Network Participating Practitioner and/or Provider.
If you think you’ve been wrongly billed, contact the No Surprises Help Desk (NSHD) at 1-800-985-3059
or visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal
law. For Minnesota residents, you may also contact the Minnesota Department of Commerce at (651)
539-1600 or 1-800-657-3602 for more information about your rights under Minnesota law.
5.5 HEALTH CARE SERVICES RECEIVED OUTSIDE OF THE UNITED STATES
Covered services for Medically Necessary emergency and urgent care services received in a foreign country are
covered at the In-Network level. There is no coverage for elective Health Care Services if a Member travels to
another country for the purpose of seeking medical treatment outside the United States.
5.6 TIMEFRAME FOR PAYMENT OF CLAIMS
• The payment for reimbursement of the Member’s costs will be made within fifteen (15) days of when
Sanford Health Plan receives a complete written claim with all required supporting information.
• When a Member receives Covered Services from a Non-Participating Provider and payment is to be made
according to our guidelines, Sanford Health Plan will arrange for direct payment to either the Non-
Participating Provider or the Member. If the Provider refuses direct payment, the Member will be reimbursed
for the Maximum Allowed Amount of the services in accordance with the terms of This Contract. The
Member will be responsible for any expenses that exceed Maximum Allowed Amount, as well as any
Deductible or Coinsurance required for the Covered Service.
5.7 WHEN WE NEED ADDITIONAL INFORMATION
Please reply promptly when we ask for additional information. We may delay processing or deny your claim if
you do not respond
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5.8 MEMBER BILL AUDIT PROGRAM
Upon receiving notice of a claims payment, or Explanation of Benefits (EOB), from Sanford Health Plan,
Members are encouraged to audit their medical bills and notify the Plan of any services which are improperly
billed or of services that the Member did not receive. If, upon audit of a bill, an error of $40 or more is found, the
Member will receive a minimum payment of $20 or 50% of the resulting savings for paid Covered Services up to
a maximum payment of $500.
To obtain payment through the Member Bill Audit Program, the Member must complete a Member Bill Audit
Refund Request Form. To obtain a form, sign into your account at www.sanfordhealthplan.com/memberlogin or
call Sanford Health Plan Customer Service toll-free at (800) 499-3416 | TTY/TDD: 711 (toll-free) and request a
form be mailed to you.
Note: This program does not apply when the NDPERS Benefit Plan is the secondary payor on a claim. For
more information on claims with more than one payor, see Section 6, Coordination of Benefits.
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SECTION 6
COORDINATION OF BENEFITS
NOTE: Sanford Health Plan follows North Dakota Administrative Code §45-08-01.2-03 regarding Coordination
of Benefits (COB). The COB provision applies when a person has health care coverage under more than one
“plan” as defined for COB purposes.
If a Member is covered by another health plan, insurance, or other coverage arrangement, the plans and/or
insurance companies will share or allocate the costs of the Member’s health care by a process called
“Coordination of Benefits” so that the same care is not paid for twice.
The Member has two obligations concerning Coordination of Benefits (“COB”):
• The Member must tell Sanford Health Plan about any other plans or insurance that cover health care for the
Member, and
• The Member must cooperate with Sanford Health Plan by providing any information requested by Sanford
Health Plan.
The rest of the provisions under this section explain how COB works.
6.1 APPLICABILITY
This Coordination of Benefits (COB) provision applies to Sanford Health Plan when a Member has health care
coverage under more than one Plan. “Plan” and “this Plan” are defined below.
If this COB provision applies, the order of benefit determination rules should be looked at first. Those rules
determine whether the benefits of this Plan are determined before or after those of another plan.
The benefits of this Plan:
• shall not be reduced when, under the order of benefit determination rules, this Plan determines its benefits
before another plan; but
• may be reduced when, under the order of benefits determination rules, another plan determines its benefits
first. The above reduction is described in the section below entitled: “Effect of COB on the Benefits of this
Plan.”
6.2 DEFINITIONS (FOR COB PURPOSES ONLY)
“Plan” is any of the following which provides benefits or services for, or because of, medical or dental care or
treatment:
a) Group and non-group insurance contracts, health maintenance organization (HMO) contracts, closed panel
plans or other forms of Group-type coverage, whether insured or uninsured. This includes prepayment,
group practice or individual practice coverage. It also includes medical care components of long-term care
contracts, such as skilled nursing care; medical benefits coverage in Group, Group-type, and individual
automobile “no-fault” and traditional automobile “fault” type contracts; and Medicare or any other federal
governmental plan, as permitted by law.
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b) “Plan” may include coverage under a governmental plan, or coverage required or provided by law. This does
not include a state plan under Medicaid (Title MX, Grants to States for Medical Assistance Programs, of the
United States Social Security Act (42 U.S.C.A. 301, et seq.), as amended from time to time). Plan does not
include: Hospital indemnity coverage or other fixed indemnity coverage; accident-only coverage; specified
disease or specified accident coverage; limited benefit health coverage, as defined by state law; school
accident-type coverage; benefits for nonmedical components of long-term care policies; Medicare
supplement policies; Medicaid policies; or coverage under other federal governmental plans, unless
permitted by law.
Each contract or other arrangement for coverage under (a) or (b) is a separate plan. Also, if an arrangement has
two (2) parts and COB rules apply only to one of the two, each of the parts is a separate plan.
“This Plan” refers to this certificate, which provides benefits for health care expenses and means, in a COB
provision, the part of the contract providing the health care benefits to which the COB provision applies and
which may be reduced because of the benefits of other plans. Any other part of the contract providing health care
benefits is separate from this Plan. A contract may apply one COB provision to certain benefits, such as dental
benefits, coordinating only with similar benefits, and may apply another COB provision to coordinate other
benefits.
“Primary Plan/Secondary Plan”: The order of benefit determination rules state whether this Plan is a Primary
Plan or Secondary Plan as to another plan covering the Member and covered Dependents.
a) When this Plan is a Primary Plan, its benefits are determined before those of the other plan and without
considering the other plan’s benefits.
b) When this Plan is a Secondary Plan, its benefits are determined after those of the other plan and may be
reduced because of the other plan’s benefits.
c) When there are more than two (2) plans covering the Member, this Plan may be a Primary Plan as to one or
more other plans, and may be a Secondary Plan as to a different plan or plans.
“Allowable Expense” means a necessary, reasonable and customary health care service or expense including
Deductibles, Coinsurance that is covered in full or in part by one or more plans covering the person for whom the
claim is made. If a plan provides benefits in the form of services, the reasonable cash value of each service is
considered an allowable expense and a benefit paid. An expense or service or a portion of an expense or service
that is not covered by any of the plans is not an allowable expense. Expenses that are not allowable include the
following:
a) The difference between the cost of a private Hospital room and the cost of a semi-private Hospital room
(unless the Member’s stay in a private Hospital room is Medically Necessary either in terms of generally
accepted medical practice, or as specifically defined by the Plan) is not an allowable expense;
b) If a person is covered by two or more plans (excluding Medicare, see “Coordination of Benefits with
Medicare” Section below) that compute the benefit payments on the basis of reasonable costs, any amount in
excess of the highest of the reasonable costs for a specified benefit is not an allowable expense;
c) If a person is covered by two or more plans (excluding Medicare, see “Coordination of Benefits with
Medicare” Section below) that provide benefits or services on the basis of negotiated fees, any amount in
excess of the highest of the negotiated fees is not an allowable expense;
d) If a person is covered by one plan that calculates its benefits or services on the basis of reasonable costs and
another plan that provides its benefits or services on the basis of negotiated fees, the primary plan’s payment
arrangement shall be allowable expense for all plans; or
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e) When benefits are reduced under a Primary Plan because a Member does not comply with The Plan
provisions, the amount of such reduction will not be considered an allowable expense. Examples of such
provisions are those related to second surgical opinions, Certification of admissions or because the person
has a lower benefit because the person did not use a preferred Practitioner and/or Provider.
“Claim” means a request that benefits of a plan be provided or paid in the form of services (including supplies),
payment for all or portion of the expenses incurred, or an indemnification.
“Claim Determination Period” means a Calendar Year over which allowable expenses are compared with total
benefits payable in the absence of COB to determine if over-insurance exists. However, it does not include any
part of a year during which a person has no coverage under this Plan, or any part of a year before the date this
COB provision or similar provision takes effect.
“Closed Panel Plan” is a plan that provides health benefits to Members primarily in the form of services through
a panel of Practitioner and/or Providers that have contracted with or are employed by The Plan, and that limits or
excludes benefits for services provided by other Practitioner and/or Providers, except in cases of emergency or
Plan authorized referral by an In-Network Participating Practitioner and/or Provider.
“Custodial Parent” means a parent awarded custody by a court decree. In the absence of a court decree, it is the
parent with whom the child resides more than one half of the Calendar Year without regard to any temporary
visitation.
6.3 ORDER OF BENEFIT DETERMINATION RULES
General. When two or more plans pay benefits, the rules for determining the order of payment is as follows:
a) The primary plan pays or provides benefits as if the secondary plan or plans did not exist.
b) If the primary plan is a closed panel plan and the secondary plan is not a closed panel plan, the secondary
plan shall pay or provide benefits as if it were the primary plan when a covered person uses a non-panel
provider, except for emergency services or authorized referrals that are paid or provided by the primary plan;
c) If multiple contracts providing coordinated coverage are treated as a single plan under North Dakota State
law, inclusive, this section applies only to the plan as a whole, and coordination among the component
contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits under
the plan, the carrier designated as primary within the plan shall be responsible for the plan’s compliance with
this law;
d) If a person is covered by more than one secondary plan, this order of benefit determination provisions decide
the order in which secondary plans benefits are determined in relation to each other. Each secondary plan
shall take into consideration the benefits of any primary plan and the benefits of any other plan, which has its
benefits determined before those of that secondary plan;
e) Except as provided in subdivision (b) of this section, a plan that does not contain order of benefit
determination provisions that are consistent with North Dakota State law, inclusive, is always the primary
plan unless the provisions of both plans, regardless of the provisions of this section, state that the complying
plan is primary;
f) Coverage that is obtained by virtue of membership in a group and designed to supplement a part of a basic
package of benefits may provide that the supplementary coverage shall be excess to any other parts of the
plan provided by the contract holder. Examples of these types of situations are major medical coverages that
are superimposed over base plan Hospital and surgical benefits, and insurance type coverages that are written
in connection with a closed panel plan to provide out-of-network benefits.
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Rules. This Plan determines its order of benefits using the first of the following rules which applies:
Non-Dependent/Dependent. The plan which covers the person as a Group Member, Member, or Subscriber
(that is, other than as a Dependent) are determined before those of the plan which covers the person as a
Dependent. However, if the person is also a Medicare beneficiary, Medicare is:
• secondary to the Plan covering the person as a Dependent; and
• primary to the Plan covering the person as other than a Dependent, for example a retired Group Member;
then the order of benefits between the two plans is reversed so that the plan covering the person as a Group
Member, Member, or Subscriber is secondary and the other plan is primary.
Child Covered Under More Than One Plan. The order of benefits when a child is covered by more than one
plan is:
• The primary plan is the plan of the parent whose birthday is earlier in the year if:
• The parents are married;
• The parents are not separated (whether or not they even have been married); or
• A court decree awards joint custody without specifying that one party has the responsibility to provide health
care coverage.
If both parents have the same birthday, the plan that covered either of the parents longer is primary.
If the specific terms of a court decree state that one of the parents is responsible for the child’s health care
expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is
primary. This rule applies to claim determination periods or plan years commencing after The Plan is given
notice of the court decree.
If the parents are not married, or are separated (whether or not they ever have been married) or are divorced, the
order of benefits is:
• The plan of the custodial parent;
• The plan of the Spouse of the custodial parent;
• The plan of the noncustodial parent; and then
• The plan of the Spouse of the noncustodial parent.
Active/Inactive Group Member. The benefit of a plan, which covers a person as a Group Member who is
neither laid off nor retired (or as that Group Member’s Dependent), is primary. If the other plan does not have this
rule, and if as a result the Plans do not agree on the order of benefits, this rule is ignored. Coverage provided to an
individual as a retired worker and as a Dependent of an actively working Spouse will be determined under Rule
“Child Covered Under More Than One Plan” above.
Continuation Coverage. If a person whose coverage is provided under a right of continuation pursuant to a
federal or state law also is covered under another plan, the following shall be the order of benefit determination:
• primary, the benefits of a plan covering the person as a Group Member, Member or Subscriber (or as that
person’s Dependent);
• secondary, the benefits under the continuation coverage. If none of the above rules determines the order of
benefits, the benefits of the plan that covered a Group Member, Member or Subscriber longer is primary.
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If the preceding rules do not determine the primary plan, the allowable expenses shall be shared equally between
the plans meeting the definition of plan under this regulation. In addition, this plan will not pay more than it
would have paid had it been primary.
6.4 EFFECT OF COB ON THE BENEFITS OF THIS PLAN
When This Section Applies. This section applies when, in accordance with the “Order of Benefit Determination
Rules,” section above, this Plan is a Secondary Plan as to one or more other plans. In that event, the benefits of
this Plan may be reduced under this section. Such other plan or plans are referred to as “the other plans” in
paragraph “b(ii)” immediately below.
Reduction in this Plan’s Benefits. The benefits of this Plan will be reduced when the sum of:
• the benefits that would be payable for the Allowable Expense under this Plan in the absence of this COB
provision; and
• the benefits that would be payable for the Allowable Expenses under the other plans, in the absence of
provisions with a purpose like that of this COB provision, whether or not claim is made, exceeds those
Allowable Expenses in a Claim Determination Period. In that case, the benefits of this Plan will be reduced
so that they and the benefits payable under the other plans do not total more than 100% of those Allowable
Expenses.
If a Member is enrolled in two or more closed panel plans and if, for any reason, including the provision of
services by a Non-Participating Provider, benefits are not payable by one closed panel plan, COB shall not apply
between this plan and any other closed panel plans.
When the benefits of this Plan are reduced as described above, each benefit is reduced in proportion. It is then
charged against any applicable benefit limit of this Plan.
Plan’s Right to Receive and Release Needed Information. Certain facts are needed to apply these COB rules.
The Plan has the right to decide which facts it needs. It may get needed facts from or give them to any other
organization or person. The Plan need not tell, or get the consent of any person to do this. Each person claiming
benefits under this Plan must give the Plan any facts it needs to pay the claim.
Facility of Payment. A payment made under another plan may include an amount that should have been paid
under this Plan. If it does, the Plan may pay that amount to the organization that made that payment. That amount
will then be treated as though it was a benefit paid under this Plan. The Plan will not have to pay that amount
again. The term “payment made” includes providing benefits in the form of services, in which case “payment
made” means reasonable cash value of the benefits provided in the form of services.
Right of Recovery. If the amount of the payments made by the Plan is more than it should have paid under this
COB provision, it may recover the excess from one or more of:
• the persons it has paid or for whom it has paid;
• insurance companies; or
• other organizations.
The “amount of the payments made” includes the reasonable cash value of any benefits provided in the form of
services.
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6.5 CALCULATION OF BENEFITS, SECONDARY PLAN
If Sanford Health Plan is secondary, it shall reduce its benefits so that the total benefits paid or provided by all
plans for any claim or claims are not more than one hundred percent of total allowable expenses. In determining
the amount of a claim to be paid by Sanford Health Plan, should The Plan wish to coordinate benefits, it shall
calculate the benefits it would have paid in the absence of other insurance and apply that calculated amount to
any allowable expense under The Plan that is unpaid by the primary plan. Sanford Health Plan may reduce its
payment by any amount that, when combined with the amount paid by the primary plan, exceeds the total
allowable expense for that claim.
6.6 COORDINATION OF BENEFITS WITH GOVERNMENT PLANS AND BENEFITS
After Sanford Health Plan, Medicare (if applicable), and/or any Medicare Supplementary Insurance (Medigap)
have paid claims, then Medicaid and/or TRICARE pay last. Sanford Health Plan will pay primary to TRICARE
and a State Child Health Insurance Plan (SCHIP) to the extent required by federal law.
IMPORTANT NOTICE TO PERSONS ON MEDICARE:
THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS
This is NOT a Medicare Supplement Insurance.
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your
Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance
duplicates Medicare benefits when it pays:
• the benefits stated in the policy and coverage for the same event is provided by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them.
These include:
• hospitalization
• physician services
• hospice
• [outpatient prescription drugs if you are enrolled in Medicare Part D]
• other approved items and services
6.7 COORDINATION OF BENEFITS WITH MEDICARE
The federal “Medicare Secondary Payer” (MSP) rules require that, for persons covered under both Medicare and
a group health plan, Medicare must be the secondary payer in certain situations. This means that the group health
plan must not take Medicare entitlement into account when:
• determining whether these individuals are eligible to participate in the Plan; or
• providing benefits under the Plan.
Medicare will pay primary, secondary, or last to the extent stated in federal law. When Medicare is to be the
primary payer, Sanford Health Plan will base its payment upon benefits that would have been paid by Medicare
under Parts A and B regardless of whether the person was enrolled under any of these parts. Sanford Health Plan
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reserves the right to coordinate benefits with respect to Medicare Part D. Sanford Health Plan will make this
determination based on the information available through CMS.
When MSP Rules Apply to COB
Medicare Coordination of Benefits provisions apply when a Member has health coverage under this Certificate
of Insurance and is eligible for insurance under Medicare, Parts A and B, (whether or not the Member has applied
or is enrolled in Medicare). This provision applies before any other Coordination of Benefits Provision of this
Certificate of Insurance.
Coordination with Medicare Part D
This Certificate of Insurance shall coordinate information relating to prescription drug coverage, the payment of
premiums for the coverage, and the payment for supplemental prescription drug benefits for Part D eligible
individuals enrolled in a Medicare Part D plan or any other prescription drug coverage.
The following provisions apply to Sanford Health Plan’s COB with Medicare:
When Medicare is the primary payer for a Member’s claims:
• If you’re 65, or older, and have group health plan coverage based on your or your spouse’s current
employment
• If you have retiree insurance (insurance from former employment)
NOTE: The hospital or doctor will first file claims with Medicare. Once Medicare processes the claim, an
Explanation Of Medicare Benefits (EOMB) form will be mailed to the Member explaining what charges were
covered by Medicare. Then the health care professional will generally file the claim with us. If a professional
does not do so, the Member may file the claim by sending a copy of the EOMB, together with his or her member
identification number, to the address shown on his or her member ID card.
When Medicare is primary despite the MSP rules:
• A Medicare-entitled person refuses coverage under the Plan;*
• Medical services or supplies are covered by Medicare but are excluded under the group health plan;
• A Medicare-entitled person has exhausted his or her benefits under the group health plan;
• A person entitled to Medicare for any reason other than ESRD, experiences a COBRA qualifying event, and
elects COBRA continuation;
• A person who was on COBRA becomes entitled to Medicare for a reason other than ESRD, and his or her
COBRA coverage ends.
* NOTE: Despite the MSP rules, the law does not force an Eligible Employee to accept coverage under this
Plan. If an Eligible Employee, who is entitled to Medicare, refuses coverage under this Plan, Medicare will
be the primary payer. In this situation, the Plan does not (and is not allowed to) provide coverage for any
benefits to supplement the individual’s Medicare benefits.
When this Certificate of Insurance is the primary payer for a Member’s claims:
• If you’re under 65 and disabled, and have coverage based on your or a family member’s current employment
• When coverage is provided through the Consolidated Omnibus Budget Reconciliation Act (COBRA)
• The Member (actively-working Employee) is enrolled in Medicare because they are age 65 or older.
• A Covered Spouse, who is enrolled in Medicare because they are age 65 or older, regardless of the age of the
Member/Employee.
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NOTE: The Member’s claim is filed with us by Practitioner or Provider. After the claim is processed, we send
the Member an Explanation of Benefits (EOB) outlining the charges that were covered. We also notify the
Practitioner or Provider of the covered charges. If there are remaining charges covered by Medicare, the
Practitioner or Provider may file a claim with Medicare. If the Practitioner or Provider will not do so, the
Member can file the claim with Medicare. Members may contact their local Social Security office to find out
where and how to file claims with the appropriate “Medicare intermediary” (a private insurance company that
processes Medicare claims).
If a Practitioner and/or Provider has accepted assignment of Medicare, Sanford Health Plan determines allowable
expenses based upon the amount allowed by Medicare. Sanford Health Plan’s allowable expense is the Medicare
allowable amount. Sanford Health Plan pays the difference between what Medicare pays and Sanford Health
Plan’s allowable expense.
6.8 MEMBERS WITH END STAGE RENAL DISEASE (ESRD)
End-Stage Renal Disease (ESRD) is a medical condition in which a person’s kidneys cease functioning on a
permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain
life. Beneficiaries may become entitled to Medicare based on ESRD. Benefits covered by Medicare, because of
ESRD, are for all Covered Services, not only those related to the kidney failure condition.
Sanford Health Plan does not differentiate in the benefits it provides to individuals who have ESRD, e.g.
terminating coverage, imposing benefit limitations, or charging higher premiums.
How Primary vs. Secondary is Determined:
When coverage under this Certificate of Insurance is the primary payer for a Member’s claims under ESRD:
• Sanford Health Plan will pay first for the first 30 months after you become eligible to join Medicare.
• During the Medicare coordination period of thirty (30) months, which begins with the earlier of:
• The month in which a regular course of renal dialysis is initiated; or
• In the case of an individual who receives a kidney transplant, the first month in which the individual
became entitled to Medicare.
• The Medicare COB period applies regardless of whether coverage is based on current employment
status.
After the 30-month period, if a Member does not enroll in, or is no longer eligible for, Medicare.
When coverage is provided through the Consolidated Omnibus Budget Reconciliation Act (COBRA), or a
retirement plan.
When Medicare is the primary payer for a Member’s claims under ESRD:
• If the Member is eligible and enrolled in Medicare, Medicare will pay first after the coordination period for
ESRD (30-months) has ended period.
6.9 COORDINATION OF BENEFITS WITH MEDICAID
• A Covered Individual’s eligibility for any State Medicaid benefits will not be taken into account in
determining or making any payments for benefits to or on behalf of such Covered Individual. Any such
benefit payments will be subject to the applicable State’s right to reimbursement for benefits it has paid on
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behalf of the Covered Individual, as required by such state’s Medicaid program; and Sanford Health Plan
will honor any subrogation rights the State may have with respect to benefits that are payable under this
Certificate of Insurance.
• When an individual covered by Medicaid also has coverage under this Certificate of Insurance, Medicaid is
the payer of last resort. If also covered under Medicare, Sanford Health Plan pays primary, then Medicare,
and Medicaid is tertiary.
See provisions below on Coordination of Benefits with TRICARE, if a Member is covered by both Medicaid and
TRICARE.
6.10 COORDINATION OF BENEFITS WITH TRICARE
Generally, TRICARE is the secondary payer if the TRICARE beneficiary is enrolled in, or covered by, any other
health plan to the extent that the service provided is also covered under the other plan.
• Sanford Health Plan pays first if an individual is covered by both TRICARE and Sanford Health Plan, as
either the Member or Member’s Dependent; and a particular treatment or procedure is covered under both
benefit plans.
• TRICARE will pay last; TRICARE benefits may not be extended until all other double coverage plans have
adjudicated the claim.
• When a TRICARE beneficiary is covered under Sanford Health Plan, and also entitled to either Medicare or
Medicaid, Sanford Health Plan will be the primary payer, Medicare/Medicaid will be secondary, and
TRICARE will be tertiary (last).
• TRICARE-eligible employees and beneficiaries receive primary coverage under this Certificate of Insurance
in the same manner, and to the same extent, as similarly situated employees of the Plan Sponsor (Employer)
who are not TRICARE eligible.
The Plan does not:
• Provide financial or other incentives for a TRICARE-eligible employee not to enroll (or to terminate
enrollment) under the Plan, which would (in the case of such enrollment) be a primary plan (the incentive
prohibition); and
• Deprive a TRICARE-eligible employee of the opportunity to elect to participate in this health benefit plan.
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SECTION 7
SUBROGATION AND RIGHT OF REIMBURSEMENT
Sanford Health Plan will provide Health Care Services to the Member for the illness or injury, just as it would in
any other case. However, if the Member accepts the services from Sanford Health Plan, this acceptance
constitutes the Member’s consent to the provisions discussed below.
Subrogation Defined
If a Member is injured or becomes ill because of an action or omission of a third party who is or may be liable to
the Member for the injury or illness, Sanford Health Plan may be able to “step into the shoes” of the Member to
recover health care costs from the party responsible for the injury or illness. This is called “Subrogation.”
Reimbursement Defined
Sanford Health Plan has a right to reduce benefits, or to be reimbursed for that which it has provided to the
Member. This is called “Reimbursement.”
Covered Individuals
Each and every Covered Individual hereby authorizes Sanford Health Plan to give or obtain any medical or other
personal information reasonably necessary to apply the provisions of Sections 6 and 7.
A Covered Individual will give this Plan the information it asks for about other plans and their payment of
Allowable Charges. This Plan may give or obtain needed information from another insurer or any other
organization or person.
7.1 SANFORD HEALTH PLAN’S RIGHTS OF SUBROGATION
In the event of any payments for benefits provided to a Member under this Plan, Sanford Health Plan, to the
extent of such payment, shall be subrogated to all rights of recovery such Member, Member’s parents, heirs,
guardians, executors, or other representatives may have against any person or organization. These subrogation
and reimbursement rights also include the right to recover from uninsured motorist insurance, underinsured
motorist insurance, no-fault insurance, automobile medical payments coverage, premises medical expense
coverage, and Workers’ Compensation insurance or substitute coverage.
Sanford Health Plan shall be entitled to receive from any such recovery an amount up to the Maximum Allowed
Amount for the services provided by Sanford Health Plan. In providing benefits to a Member, Sanford Health
Plan may obtain discounts from its health care Providers, compensate Providers on a capitated basis or enter into
other arrangements under which it pays to another less than the reasonable costs of the benefits provided to the
Member. Regardless of any such arrangement, when a Member receives a benefit under this Certificate of
Insurance for an illness or injury, Sanford Health Plan is subrogated to the Member’s right to recover the
reasonable costs of the benefits it provides on account of such illness or injury, even if those reasonable costs
exceed the amount paid by Sanford Health Plan.
Sanford Health Plan is granted a first priority right to subrogation or reimbursement from any source of recovery.
Sanford Health Plan’s first priority right applies whether or not the Member has been made whole by any
recovery. Sanford Health Plan shall have a lien on all funds received by the Member, Member’s parents, heirs,
guardians, executors, or other representatives up to the Reasonable Costs Charge for any past, present, or future
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Health Care Services provided to the Member. Sanford Health Plan may give notice of that lien to any party who
may have contributed to the loss.
If Sanford Health Plan so decides, it may be subrogated to the Member’s rights to the extent of the benefits
provided or to be provided under this Plan. This includes Sanford Health Plan’s right to bring suit against the
third party in the Member’s name.
7.2 SANFORD HEALTH PLAN’S RIGHT TO REDUCTION AND REIMBURSEMENT
Sanford Health Plan shall have the right to reduce or deny benefits otherwise payable by Sanford Health Plan, or
to recover benefits previously paid by Sanford Health Plan, to the extent of any and all payments made to or for a
Member by or on behalf of a third party who is or may be liable to the Member, regardless of whether such
payments are designated as payment for, but not limited to, pain and suffering, loss of income, medical benefits
or expenses, or other specified damages.
To the extent that federal or state statutes or courts, eliminate or restrict any such right of reduction or
reimbursement provided to Sanford Health Plan under this Policy; such rights shall thus either be limited or no
longer apply, or be limited by the extent of federal and state actions.
Sanford Health Plan shall have a lien on all funds received by the Member, Member’s parents, heirs, guardians,
executors, or other representatives up to the Maximum Allowed Amount for the Health Care Services provided to
the Member.
7.3 ERRONEOUS PAYMENTS
To the extent payments made by Sanford Health Plan with respect to a Covered Individual are in excess of the
Maximum Amount of payment necessary under the terms of this Certificate of Insurance, Sanford Health Plan
shall have the right to recover such payments, to the extent of such excess, from any one or more of the following
sources, as this Plan shall determine any person to or with respect to whom such payments were made, or such
person’s legal representative, any insurance companies, or any other individuals or organizations which Sanford
Health Plan determines are either responsible for payment or received payment in error, and any future benefits
payable to the Covered Individual.
7.4 MEMBER’S RESPONSIBILITIES
The Member, Member’s parents, heirs, guardians, executors, or other representatives must take such action,
furnish such information and assistance, and execute such instruments as Sanford Health Plan requires to
facilitate enforcement of its rights under this Certificate of Insurance. The Member shall take no action
prejudicing the rights and interests of Sanford Health Plan under this provision.
Neither a Member nor Member’s attorney or other representative is authorized to accept subrogation or
reimbursement payments on behalf of Sanford Health Plan, to negotiate or compromise Sanford Health Plan’s
subrogation or reimbursement claim, or to release any right of recovery or reimbursement without Sanford
Health Plan’s express written consent.
Any Member who fails to cooperate in Sanford Health Plan’s administration of this Part shall be responsible for
the reasonable cost for services subject to this section and any legal costs incurred by Sanford Health Plan to
enforce its rights under this section. Sanford Health Plan shall have no obligation whatsoever to pay medical
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benefits to a Covered Individual if a Covered Individual refuses to cooperate with Sanford Health Plan’s
Subrogation and Refund rights or refuses to execute and deliver such papers as Sanford Health Plan may require
in furtherance of its Subrogation and Refund rights. Further, in the event the Covered Individual is a minor,
Sanford Health Plan shall have no obligation to pay any medical benefits incurred on account of injury or illness
caused by a third-party until after the Covered Individual or his or her authorized legal representative obtains
valid court recognition and approval of Sanford Health Plan’s 100%, first-dollar Subrogation and refund rights on
all recoveries, as well as approval for the execution of any papers necessary for the enforcement thereof, as
described herein.
Members must also report any recoveries from insurance companies or other persons or organizations arising
form or relating to an act or omission that caused or contributed to an injury or illness to the Member paid for by
Sanford Health Plan. Failure to comply will entitle Sanford Health Plan to withhold benefits, services, payments,
or credits due under Sanford Health Plan.
7.5 SEPARATION OF FUNDS
Benefits paid by Sanford Health Plan, funds recovered by the Covered Individual(s), and funds held in trust over
which Sanford Health Plan has an equitable lien exist separately from the property and estate of the Covered
Individual(s), such that the death of the Covered Individual(s), or filing of bankruptcy by the Covered
Individual(s), will not affect Sanford Health Plan’s equitable lien, the funds over which Sanford Health Plan has a
lien, or Sanford Health Plan’s right to subrogation and reimbursement.
7.6 PAYMENT IN ERROR
If for any reason we make payment under this Policy in error, we may recover the amount we paid.
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SECTION 8
HOW COVERAGE ENDS
8.1 TERMINATION BY THE SUBSCRIBER
Upon a qualifying event, you may be allowed to terminate coverage for you and/or any Dependent(s) at any time.
Sanford Health Plan must receive a written request from the Group to end coverage. The Subscriber will be
responsible for any Service Charges through the date of termination or the end of the calendar month in which
termination occurs, whichever is later.
8.2 TERMINATION, NONRENEWAL, OR MODIFICATION OF MEMBER COVERAGE
A Member or Dependent’s coverage will automatically terminate at the earliest of the following events below.
Such action by Sanford Health Plan is called “Termination” of the Member.
• Failure to Pay Service Charge Payments. Failure to make any required Service Charge payments
when due. A grace period of thirty-one (31) days, following the due date will be allowed for the payment
of any Service Charge after the first fee is paid. During this time, coverage will remain in force. If the
Service Charge is not paid on or before the end of the grace period, coverage will terminate at the end of
the grace period.
• Termination of Employment. The last day of the month in which date the Member’s active
employment with the Group is terminated is the date benefits will cease for the Member(s).
• Termination of this Contract. In the event this Contract terminates, the last day of the month for
which Service Charge Payments were made is the date benefits will cease for the Member(s).
• Loss of Eligibility. The last day of the month in which the Member is no longer an Eligible Group
Member is the date benefits will cease for the Member(s).
• Movement Outside the Service Area. The last day of the month in which the Member no longer
resides in the Service Area is the date benefits will cease for the Member(s).
• Death. The date the Member dies is the date benefits will cease for the Member(s).
• Fraudulent Information. An act, practice, or omission that constitutes fraud or intentional
misrepresentations of material fact, may be used to rescind this application or Certificate of Insurance,
terminate coverage and deny claims. The date identified on the notice of termination is the date benefits
will cease for the Member(s).
• Use of ID Card by Another. The use of a Member’s ID Card by someone other than the Member is
considered fraud. The date a Member allows another individual to use his or her ID card to obtain
services is the date benefits will cease for the Member(s).
• Product Discontinuance. Sanford Health Plan discontinues a particular product provided that Sanford
Health Plan provides the Group and all Group Members with written notice at least 90 days before the
date the product will be discontinued, Sanford Health Plan offers the Group and all Group Members the
option to purchase any other coverage currently being offered by Sanford Health Plan to group health
plans, and Sanford Health Plan acts uniformly without regard to claims experience of the Group or any
health status-related factor relating to particular Group Members covered or who may be eligible for
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coverage. The date identified in the notice of discontinuance is the date benefits will cease for the
Member(s)
• Discontinuance of All Coverage in Group Market or All Markets. Sanford Health Plan discontinues
offering all coverage in the group market or in all markets in Minnesota provided that Sanford Health
Plan provides the Group and all Group Members and the Minnesota Department of Insurance with
written notice of the discontinuance at least 180 calendar days prior to the date the coverage will be
discontinued and all coverage issued or delivered by Sanford Health Plan in the group market in
Minnesota are discontinued and not renewed. The date identified in the notice of discontinuance is the
date benefits will cease for the Member(s).
• Any other reason permitted by State or federal law.
Notification
Sanford Health Plan must notify all covered persons of the termination at least 30 days before the
effective termination date for the termination to be effective
Uniform Modification of Coverage
Sanford Health Plan may, at the time of renewal and with 60 days prior written notice, modify the Contract if the
modification is consistent with State law and is effective uniformly for all persons who have coverage under this
type of contract.
8.3 MEMBER APPEAL OF TERMINATION
A Member may Appeal Sanford Health Plan’s decision to terminate, cancel, or refuse to renew the Member’s
coverage. The Appeal will be considered a Member Grievance and the Sanford Health Plan’s Policy on Member
Grievances and Appeals will govern the process.
Pending the Appeal decision, coverage will terminate on the date that was set by Sanford Health Plan. However,
the Member may continue coverage, if entitled to do so, by complying with the “Continuation of Coverage”
provisions in Section 9. If the Appeal is decided in favor of the Member, coverage will be reinstated, retroactive
to the effective date of termination, as if there had been no lapse in coverage.
NOTE: A Member may not be terminated due to the status of the Member’s health or because the Member has
exercised his or her rights to file a complaint or appeal.
8.4 TERMINATION OF MEMBER COVERAGE
For the purposes of this Benefit Plan, upon termination of Member Coverage, the following provisions
control:
1. Determining Ineligibility. Eligibility for benefits subsequent to retirement or termination will be determined
pursuant to N.D.C.C. §54-52.1-03.
2. Continuation of health, dental, vision, or prescription drug coverage after termination. An employee
who terminates employment and is not receiving a monthly retirement benefit from one of the eligible
retirement systems, and applies for continued coverage with the health, dental, vision, or prescription drug
plan may continue such coverage for a maximum of eighteen (18) months by remitting timely payments to
the Board. The employee desiring coverage shall notify the Board within sixty (60) days of the termination.
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Coverage will become effective on the first day of the month following the last day of coverage by the
employing agency, if an application is submitted within sixty (60) days. An individual who fails to timely
notify the board is not eligible for coverage. [N.D.A.C. §71-03-03-06]
3. Continuation of health, dental, vision, or prescription drug coverage for dependents. Dependents of
employees with family coverage may continue coverage with the group after their eligibility would ordinarily
cease. This provision includes divorced or widowed spouses and children when they are no longer dependent
on the employee. Coverage is contingent on the prompt payment of the premium, and in no case will
coverage continue for more than thirty-six (36) months. Dependents desiring coverage shall notify the board
within sixty (60) days of the qualifying event and must submit an application in a timely manner. An
individual who fails to notify the Board within the sixty (60) days, and who desires subsequent coverage, will
not be eligible for coverage. [N.D.A.C. §71-03-03-07]
4. Leave without pay. An employee on an approved leave without pay may elect to continue coverage for the
periods specified in the plans for life insurance, health, dental, vision, or prescription drug coverages by
paying the full premium to the agency. An eligible employee electing not to continue coverage during a leave
of absence is entitled to renew coverage for the first of the month following the month that the employee has
returned to work if the employee submits an application for coverage within the first thirty-one (31) days of
returning to work. An eligible employee failing to submit an application for coverage within the first thirty-
one (31) days of returning to work or eligibility for a special enrollment period, may enroll during the annual
open enrollment. Upon a showing of good cause, the executive director may waive the thirty-one day
application requirement. [N.D.A.C. §71-03-03-09]
a. In the event an enrolled eligible employee is not entitled to receive salary, wages, or other compensation
for a particular calendar month, that employee may make direct payment of the required premium to the
board to continue the employee’s coverage, and the employing department, board, or agency shall
provide for the giving of a timely notice to the employee of that person’s right to make such payment at
the time the right arises. [N.D.C.C. §54-52.1-06]
NOTE: A Member’s coverage may not be terminated due to the status of the Member’s health, or
because the Member has exercised his or her rights, under the Plan’s policy on member complaints,
or the policy on appeal procedures for medical review determinations.
8.5 CONTINUATION
1. If the Subscriber becomes ineligible for group membership under this Benefit Plan due to an inability to meet
NDPERS requirements and enrollment regulations, coverage will be canceled at the end of the last month
that premium was received from the Plan Administrator. Exceptions may be made if:
a. The Plan Administrator cancels coverage. Conversion coverage will not be offered to a Subscriber, if on
the date of conversion, the Plan Administrator through which the Subscriber is eligible has terminated
coverage with Sanford Health Plan, and the Plan Administrator has enrolled with another insurance
carrier.
b. The Plan Administrator no longer meets Sanford Health Plan’s group coverage requirements. The
Subscriber will be given the right to convert to a nongroup benefit plan, subject to premiums and benefit
plan provisions in effect, if application for such coverage is made within 31 days after the termination
date of the previous benefit plan.
c. Ineligibility occurs because the Subscriber elects to discontinue employment, is terminated or is
otherwise no longer covered under the group health plan. The Subscriber may elect continuation
coverage through the Plan Administrator in accordance with state and federal law.
d. Ineligibility occurs because the Subscriber is no longer eligible to continue coverage under the group
(NDPERS). The Subscriber may elect conversion (individual) coverage on a nongroup basis, subject to
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premiums and benefit plan provisions for nongroup coverage then in effect, if the Subscriber applies for
nongroup coverage within 31 days after the termination date of the previous group health plan coverage.
If a Member becomes otherwise ineligible for group membership under this Benefit Plan, Sanford Health Plan
must at least offer the Subscriber its conversion (individual) benefit plan, if the Member lives in the Sanford
Health Plan Service Area. There may be other coverage options for the Subscriber and/or Eligible Dependents
through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a
spouse’s plan) through what is called a “special enrollment period.” The cost of these options may vary
depending on a Subscriber’s individual circumstances. To learn more, visit healthcare.gov or call (800) 318-
2596 | TTY/TDD: (855) 889-4325.
8.6 Continuation of Coverage for Confined Members
Any Member who is an inpatient in a Hospital or other Facility on the date of coverage termination under
this Benefit Plan will be covered in accordance with the terms of this Certificate until they are discharged
from such Hospital or other Facility. Applicable charges for coverage that was in effect prior to
termination of this Certificate will apply.
8.7 Extension of Benefits for Total Disability
An extension of benefits is provided Covered Members/Subscribers who become totally disabled while enrolled
under this Benefit Plan and whom continue to be totally disabled at the date of termination of this Certificate.
Upon payment applicable premium charges at the current Group rate, coverage will remain in full force and
effect until the first of the following occurs:
• The end of a period of twelve (12) months starting with the date of termination of the Group contract;
• The date the Member is no longer totally disabled; or
• The date a succeeding plan provides replacement coverage to that Member without limitation as to the
disabling condition.
Upon termination of the extension of benefits, the Member/Subscriber will have continuation and conversion
rights as stated in Sections 9 and 10.
8.8 CANCELLATION OF THIS OR PREVIOUS BENEFIT PLANS
If the Benefit Plan is terminated, modified or amended, coverage is automatically terminated, modified or
amended for all enrolled Members of the NDPERS Dakota Plan. It is the Plan Administrator’s responsibility to
notify Members of the termination of coverage.
8.9 NOTICE OF CREDITABLE COVERAGE
You may request a Certificate of Creditable Coverage for you and your covered family Members upon your
voluntary or involuntary termination from the Plan. You may also request a Certificate of Creditable Coverage at
any time by calling Customer Service.
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8.10 NOTICE OF GROUP TERMINATION OF COVERAGE
• Termination due to Non-Renewal
The Group will give thirty (30) days written notice of the termination to the Members. For purposes of This
Contract, “give written notice” means to present the notice to the Member or mail it to the Member’s last known
address.
This notice will set forth at least the following:
• The effective date and hour of termination or of the decision to not renew coverage;
• The reason(s) for the termination or nonrenewal; and
• The Member’s options listed below, including requirements for qualification and how to exercise the
Member’s rights:
• the availability of Continuation of Coverage, if any; and
• the fact that the Member may have rights under federal COBRA provisions, independent from any
provisions of This Contract, and should contact the Group for information on the COBRA
provisions.
• Termination due to Non-Payment of Premiums
If an employer fails to submit Premium payment to Sanford Health Plan resulting in loss of coverage to the
Members, switches plans or cancels the coverage, The Group is required to give written notice of the termination
to the Members as soon as reasonably possible but no later than ten (10) days after the date of termination.
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SECTION 9
OPTIONS AFTER COVERAGE ENDS
9.1 FEDERAL CONTINUATION OF COVERAGE PROVISIONS (“COBRA”)
Notice of Continuation Coverage Rights Under COBRA for employer groups with twenty (20) or more
employees
Introduction
You are getting this notice because you recently gained coverage under an employer sponsored group health plan
(the Plan). This notice has important information about your right to COBRA continuation coverage, which is a
temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it
may become available to you and your family, and what you need to do to protect your right to get it. When you
become eligible for COBRA, you may also become eligible for other coverage options that may cost less than
COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other
members of your family when employer sponsored group health coverage would otherwise end. For more
information about your rights and obligations under the Plan and under federal law, you should review your Plan
Document (Policy) or contact the Plan Administrator (your Employer).
You may have other options available to you when you lose group health coverage. For example, you may be
eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through
the Health Insurance Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-
pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan
for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept “Late Entrants”.
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of coverage when it would otherwise end because of a life
event. This is also called a “qualifying event.” Specific qualifying events are listed below. After a qualifying
event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.”
You, your Spouse, and your Dependent Children could become qualified beneficiaries if coverage is lost because
of the qualifying event. Qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA
continuation coverage.
If you are an employee and the Plan is subject to COBRA, you will become a qualified beneficiary if you lose
your coverage under the Plan because of the following qualifying events:
• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.
If you are the Spouse and the Plan is subject to COBRA, you will become a qualified beneficiary if you lose your
coverage under the Plan because of the following qualifying events:
• Your spouse dies;
• Your spouse’s hours of employment are reduced;
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• Your spouse’s employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
• You become divorced or legally separated from your spouse.
If the Plan is subject to COBRA, your Dependent Children will become qualified beneficiaries if they lose
coverage under the Plan because of the following qualifying events:
• The parent-employee dies;
• The parent-employee’s hours of employment are reduced;
• The parent-employee’s employment ends for any reason other than his or her gross misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage as a “Dependent Child.”
Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event.
If a proceeding in bankruptcy is filed with respect to the employer sponsoring coverage under the Plan, and that
bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee
will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and Dependent Children
will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.
When is COBRA Coverage Available?
The employer is responsible for the timely mailing of applicable COBRA notices to Members (the “COBRA
Notification Letter”). The employer must notify Sanford Health Plan when qualifying events occur. Sanford
Health Plan will offer COBRA continuation coverage to qualified beneficiaries only after being notified by the
employer that a qualifying event has occurred. The employer must notify the Plan of the following qualifying
events:
• The end of employment or reduction of hours of employment;
• Death of the employee;
• Commencement of a proceeding in bankruptcy with respect to the employer; or
• The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
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For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent
child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator
within 31 days after the qualifying event occurs. You must provide this notice to:
North Dakota Public Employees Retirement System
PO Box 1657
Bismarck, ND 58502
(701) 328-3900
How is COBRA Coverage Provided?
Upon notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the
qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation
coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses and
Dependent Children.
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to
employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event
during the initial period of coverage, may permit a qualified beneficiary to receive a maximum of 36 months of
coverage.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
Disability extension of 18-month period of COBRA continuation coverage
• If you or a covered Dependent is determined by Social Security to be disabled and you notify the Plan
Administrator in a timely fashion, you and your covered Dependents may be entitled to get up to an
additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would
have to have started at some time before the 60th day of COBRA continuation coverage and must last at
least until the end of the 18-month period of COBRA continuation coverage.
Second qualifying event extension of 18-month period of continuation coverage
• If you or your covered Dependents experience another qualifying event during the 18 months of COBRA
continuation coverage, the Spouse and Dependent Children in your family can get up to 18 additional
months of COBRA continuation coverage, for a maximum of 36 months, if your employer is properly
notified about the second qualifying event.
• This extension may be available to your Spouse and any Dependent Children getting COBRA continuation
coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part
B, or both); gets divorced or legally separated; or if the Dependent Child stops being eligible under the Plan
as a Dependent Child. This extension is only available if the second qualifying event would have caused the
Spouse or Dependent Child to lose coverage under the Plan had the first qualifying event not occurred.
Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and
your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options
(such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost
less than COBRA continuation coverage. You can learn more about many of these options at
www.healthcare.gov.
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THE UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA)
The Uniformed Services Employment and Reemployment Rights Act (USERRA) requires employers to offer
employees and their Spouse and/or Dependent Children the opportunity to pay for a temporary extension of
health coverage (called continuation coverage) at group rates in certain instances where the employee leaves the
position of employment due to service in the military. The Member or the Member’s Authorized Representative
may elect to continue the employee’s coverage by making an election of a form provided by Sanford Health
Plan. The Member has sixty (60) days to elect continuation coverage measured from the later of (1) the date the
employee left the position of employment, or (2) the date notice of election rights is received. If continuation
coverage is elected within this period, the coverage will be retroactive to the date the employee left the position
of employment.
The Member may elect continuation coverage on behalf of a covered Dependent; however, there is no
independent right of each covered Dependent to elect continuation of coverage. If the Member does not elect
coverage, there is no USERRA continuation available for the Spouse or Dependent Children. In addition, even if
the Member does not elect USERRA coverage or continuation coverage, the Member has the right to have
coverage reinstated upon reemployment. Continuation coverage continues for up to twenty-four (24) months.
This section is to inform covered individuals, in summary fashion, of their rights and obligations under the
continuation of coverage provisions of USERRA. It is intended that no greater rights be provided than those
required by federal law.
IF YOU HAVE QUESTIONS
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact
or contacts identified below. For more information about your rights under the Employee Retirement Income
Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws
affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s
Employee Benefits Security Administration (EBSA) in your area or visit dol.gov/ebsa. (Addresses and phone
numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information
about the Marketplace, visit healthcare.gov.
Keep Sanford Health Plan Informed of Address Changes
To protect your family’s rights, let Sanford Health Plan know about any changes in the addresses of covered
Dependents. You should also keep a copy, for your records, of any notices you send to Sanford Health Plan.
Plan Contact Information
Mail: Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110.
Phone: (800) 752-5863 (toll-free) | TTY/TDD: 711 (toll-free)
For free help in a language other than English: (800) 752-5863 (toll-free)
Fax: (605) 328-6812
Online: www.sanfordhealthplan.com/memberlogin
Or contact your employer.
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SECTION 10
PROBLEM RESOLUTION
10.1 MEMBER APPEAL PROCEDURES - OVERVIEW
Sanford Health Plan makes decisions in a timely manner to accommodate the clinical urgency of the situation
and to minimize any disruption in the provision of health care. Benefits under this Certificate of Insurance
will be paid only if Sanford Health Plan decides, at Sanford Health Plan’s discretion, that the applicant is
entitled to them.
Claims for benefits under this Certificate of Insurance can be post-service, pre-service, or concurrent. This
Section of your Summary Plan Description explains how you can file a complaint regarding services provided
by Sanford Health Plan; or appeal a partial or complete denial of a claim. The appeal procedures outlined
below are designed to comply with the requirements of the Employee Retirement Income Security Act of
1974 (ERISA).
For information on medication/drug Formulary exception requests, see Section 2, Pharmaceutical Review
Requests and Exception to the Formulary Process.
The following parties may request a review of any Adverse Determination by Sanford Health Plan: the
Member and/or legal guardian; a health care Practitioner and/or Provider with knowledge of the Member’s
medical condition; an Authorized Representative of the Member; and/or an attorney representing the Member
or the Member’s estate.
NOTE: The Member or his/her legal guardian may designate in writing to Sanford Health Plan an
Authorized Representative to act on his/her behalf. In cases where the Member wishes to exercise this right, a
written designation of representation from the Member should accompany a Member’s complaint or request
to Appeal an Adverse Determination. See Designating an Authorized Representative below for further details.
For urgent (expedited) appeals, written designation of an Authorized Representative is not required.
Special Communication and Language Access Services
For Members who request language services, Sanford Health Plan will provide services at no charge in the
requested language through an interpreter. Translated documents are also available at no charge to help
Members submit a complaint or appeal, and Sanford Health Plan will communicate with Members free of
charge about their complaint or appeal in the Member’s preferred language, upon request. To get help in a
language other than English, call (800) 892-0625.
For Members who are deaf, hard of hearing, or speech-impaired
To contact Sanford Health Plan, a TTY/TDD line is available free of charge by calling toll-free 711.
Please contact the Plan toll-free at (800) 499-3416 if you are in need of a large print copy or cassette/CD of this
COI or other written materials.
Help to understand this policy and your rights is free.
If you would like it in a different format (for example, in a larger font size),
please call us at (800) 499-3416 (toll-free).
If you are deaf, hard of hearing, or speech-impaired,
reach us at TTY/TDD: 711(toll-free).
Help in a language other than English is also free.
Please call (800) 752-5863 (toll-free) to connect with us using free translation services.
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Maximum Appeal Timelines
Type of Notice
Emergency
Pre-Service
Post-Service
Initial Determinations
72 Hours
15 days
30 Days
Extension for Initial Plan
Determinations
NONE
15 days
15 Days
Additional Information
Request (Plan)
24 Hours
15 days
15 Days
Response to Request For
Additional Information
(Member)
48 Hours
45 Days
45 Days
Request for Internal Appeal
(Member)
180 Days
180 Days
180 Days
Internal Appeal
Determinations
72 Hours
30 Days
60 Days
Request for External
Appeal (Member)
N/A
4 months
4 Months
External Appeal
Determinations
72 Hours
45 Days
45 Days
10.2 DESIGNATING AN AUTHORIZED REPRESENTATIVE
You must act on your own behalf, or through an Authorized Representative, if you wish to exercise your rights
under this Section. If you wish to designate an Authorized Representative, you must do so in writing. You can get
a form by calling Customer Service toll-free at (800) 499-3416; or logging into your account at
www.sanfordhealthplan.com/memberlogin. If a person is not properly designated in writing as your Authorized
Representative, we will not be able to deal with him or her in connection with your rights under this Section of
your Policy.
For urgent pre-service claims, we will presume that your provider is your Authorized Representative
unless you tell us otherwise, in writing.
10.3 AUDIT TRAILS
Audit trails for Complaints, Adverse Determinations and Appeals are provided by Sanford Health Plan’s
Information System and an Access database which includes documentation of the Complaints, Adverse
Determination and/or Appeals by date, service, procedure, substance of the Complaint/Appeal (including any
clinical aspects/details, and reason for the Complaint, Adverse Determination and/or Appeal.
The Appeal file includes telephone notification, and documentation indicating the date; the name of the person
spoken to; the Member; the service, procedure, or admission certified; and the date of the service, procedure, or
Adverse Determination and reason for determination. If Sanford Health Plan indicates authorization
(Certification) by use of a number, the number will be called the “authorization number.”
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10.4 DEFINITIONS
Adverse Determination: A denial, reduction or termination of, or a failure to provide or make payment (in
whole or in part) for a benefit, including any such denial, reduction, termination, or failure to provide or make
payment (for pre-service or post-service claims) based on:
• A determination of an individual’s eligibility to participate in a plan;
• A determination that a benefit is not a Covered Benefit;
• The imposition of a source-of-injury exclusion, network exclusion, application of any Utilization Review,
or other limitation on otherwise covered benefits;
• A determination that a benefit is Experimental, Investigational or not Medically Necessary or appropriate;
or
• A rescission of coverage. Only an act, practice, or omission that constitutes fraud or intentional
misrepresentations of material fact, made by an applicant for health insurance coverage may be used to
void application or policy and deny claims.
Appeal: A request to change a previous Adverse Determination made by Sanford Health Plan.
Inquiry: A telephone call regarding eligibility, plan interpretation, plan policies and procedures, or plan design.
It is the policy of Sanford Health Plan to address Member and Practitioner and/or Provider inquiries through
informal resolution over the telephone whenever possible. If the resolution is not satisfactory to the inquirer, he or
she will be instructed of his or her rights to file a verbal or written Complaint.
Complaint: An oral or written expression of dissatisfaction. It is the policy of Sanford Health Plan to make
reasonable efforts to resolve Member and Practitioner and/or Provider Complaints. A process has been
established for Members (or their designees) and Practitioners and/or Providers to use when they are dissatisfied
with Sanford Health Plan, its Practitioners and/or Providers, or processes. Examples of Complaints are eligibility
issues; coverage denials, cancellations, or non-renewals of coverage; administrative operations; discrimination
based on race, color, national origin, sex, age, or disability; and the quality, timeliness, and appropriateness of
health care services provided.
Complainant: This is a Member, applicant, or former Member or anyone acting on behalf of a Member,
applicant, or former Member, who submits a Complaint. The Member and his/her legal guardian may designate
in writing to Sanford Health Plan an Authorized Representative to act on his/her behalf. This written designation
of representation from the Member should accompany the Complaint.
External Review: An External Review is a request for an Independent, External Review of a medical necessity
final determination made by Sanford Health Plan through its External Appeals process.
Urgent Care Situation: A degree of illness or injury that is less severe than an Emergency Condition, but
requires prompt medical attention within twenty-four (24) hours. An Urgent Care Request means a request for a
health care service or course of treatment with respect to which the time periods for making a non-Urgent Care
Request determination could:
• Seriously jeopardize the life or health of the Member or the ability of the Member to regain maximum
function, based on a prudent layperson’s judgment; or
• In the opinion of a Practitioner with knowledge of the Member’s medical condition, would subject the
Member to severe pain that cannot be adequately managed without the health care service or treatment that
is the subject of the request.
In determining whether a request is “Urgent,” Sanford Health Plan shall apply the judgment of a Prudent
Layperson as defined in Section 8. A Practitioner, with knowledge of the Member’s medical condition, who
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determines a request to be “Urgent,” as defined in Section 8, shall have such a request treated as an Urgent Care
Request by Sanford Health Plan.
10.5 COMPLAINT (GRIEVANCE) PROCEDURES
A Member has the right to file a Complaint either by telephone or in writing to The Appeals and Grievances
Department. The Appeals and Grievances Department will make every effort to investigate and resolve all
Complaints. Refer to the Introduction section at the beginning of this document for instructions on how to contact
the Appeals and Grievances Department.
10.6 ORAL COMPLAINTS
A complainant may orally submit a Complaint to Customer Service. If the oral Complaint is not resolved to the
complainant’s satisfaction within ten (10) business days of receipt of the Complaint, Sanford Health Plan will
provide a Complaint form to the complainant, which must be completed and returned to the Appeals and
Grievances Department for further consideration. Upon request, Customer Service will provide assistance in
submitting the Complaint form.
10.7 WRITTEN COMPLAINTS
A complainant can seek further review of a Complaint not resolved by phone by submitting a written Complaint
form. A Member, or his/her Authorized Representative may send the completed Complaint form, including
comments, documents, records and other information relating to the Complaint, the reasons they believe they are
entitled to benefits and any other supporting documents. Refer to the Introduction section at the beginning of this
document for instructions on how to contact the Appeals and Grievances Department.
Complaints based on discrimination must be sent to the attention of the Civil Rights Coordinator.
The Appeals and Grievances Department will notify the complainant within ten (10) business days upon receipt
of the Complaint form, unless the Complaint has been resolved to the complainant’s satisfaction within those ten
(10) business days.
Upon request and at no charge, the complainant will be given reasonable access to and copies of all documents,
records and other information relevant to the Complaint.
10.8 COMPLAINT INVESTIGATIONS
The Appeals and Grievances Department will investigate and review the Complaint and notify the complainant
of Sanford Health Plan’s decision in accordance with the following timelines:
• A decision and written notification on the Complaint will be made to the complainant, his or her Practitioners
and/or Providers involved in the provision of the service within thirty (30) calendar days from the date
Sanford Health Plan receives your request.
• In certain circumstances, the time period may be extended by up to fourteen (14) days upon agreement. In
such cases, Sanford Health Plan will notify the complainant in advance, of the reasons for the extension.
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Any complaints related to the quality of care received are subject to practitioner review. If the complaint is related
to an urgent clinical matter, it will be handled in an expedited manner, and a response will be provided within
twenty-four (24) hours.
If the complaint is not resolved to the Member’s satisfaction, the Member, or his/her Authorized Representative,
has the right to Appeal any Adverse Determination made by Sanford Health Plan. Appeal Rights may be
requested by calling the Appeals and Grievances Department.
Sanford Health Plan will make appropriate arrangements to ensure that individuals with disabilities and
individuals with limited English proficiency are provided auxiliary aids and services or language assistance
services, respectively, if needed to participate in the complaint or appeals process.
All notifications described above will comply with applicable law. A complete description of your Appeal rights
and the Appeal process will be included in your written response.
10.9 APPEAL PROCEDURES
Types of Appeals
Types of appeals include:
• A Pre-service Appeal is a request to change an Adverse Determination that Sanford Health Plan
approved in whole or in part in advance of the Member obtaining care or services.
• A Post-service Appeal is a request to change an Adverse Determination for care or services already
received by the Member.
• An Expedited Appeal for Urgent Care is a request to change a previous Adverse Determination made
by Sanford Health Plan for an Urgent Care Request. If the Member’s situation meets the definition of
urgent, their review will generally be conducted within 24 hours.
10.10 CONTINUED COVERAGE FOR CONCURRENT CARE
A Member is entitled to continued coverage for concurrent care pending the outcome of the appeals process;
benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice
sufficient to allow the claimant to Appeal and obtain a review determination before the benefit is reduced or
terminated. Review determinations would be made within twenty-four (24) hours.
10.11 INTERNAL APPEALS OF ADVERSE DETERMINATION (DENIAL)
Appeals can be made for up to 180 days from notification of the Adverse Determination.
Within one-hundred-eighty (180) days after the date of receipt of a notice of an Adverse Determination sent to a
Member or the Member’s Authorized Representative (as designated in writing by the Member), the Member or
their Authorized Representative may file an Appeal with Sanford Health Plan requesting a review of the Adverse
Determination. To Appeal, the Member may sign into their account at sanfordhealthplan.com/memberlogin and
complete the “Appeal Filing Form” under the Forms tab. The Member or their Authorized Representative may
also contact the Plan by sending a written Appeal to the Plan.
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If the Member, Authorized Representative, Practitioner/Provider, and/or attorney, has questions, they are
encouraged to contact the Plan. Customer Service is available to help with understanding information and
processes. Alternate formats are also available and translation is available free of charge for written materials and
Member communication with the Plan.
Refer to the Introduction section at the beginning of this document for instructions on how to contact the
Customer Service Department.
10.12 APPEAL RIGHTS AND PROCEDURES
If the Member or their Authorized Representative (as designated in writing by the Member) files an Appeal for
an Adverse Determination, the following Appeal Rights apply:
• The Member shall have the opportunity to submit written comments, documents, records and other
information relating to the claim for benefits. Members do not have the right to attend or have a
representative attend the review.
• The Member shall be provided, free of charge, with any new or additional evidence considered, relied upon,
or generated by, or at the direction of, Sanford Health Plan in connection with the claim; and such evidence
shall be provided as soon as possible and sufficiently in advance of the date on which the notice of final
internal Adverse Determination is required to be provided to give the Member a reasonable opportunity to
respond prior to that date.
• Confirm with the Member whether additional information will be provided for appeal review. Sanford
Health Plan will document if additional information is provided or no new information is provided for appeal
review.
• Before Sanford Health Plan can issue a final Adverse Determination based on a new or additional rationale,
the Member will be provided, free of charge, with the rationale; the rationale will be provided as soon as
possible and sufficiently in advance of the date on which the notice of Adverse Determination is required to
be provided and give the Member a reasonable opportunity to respond prior to the date. Members shall have
the right to review all evidence and present evidence and testimony.
• The Member shall be provided, upon request and free of charge, reasonable access to, and copies of, all
documents, records and other information relevant to the Member’s initial request.
• The review shall take into account all comments, documents, records, and other information submitted by
the Member relating to the claim, without regard to whether such information was submitted or considered
in the initial benefit determination.
• Full and thorough investigation of the substance of the Appeal, including any aspects of clinical care
involved, will be coordinated by the Appeals and Grievances Department.
• Sanford Health Plan will document the substance of the Appeal, including but not limited to, the Member’s
reason for appealing the previous decision and additional clinical or other information provided with the
appeal request. Sanford Health Plan will also document any actions taken, including but not limited to,
previous denial or appeal history and follow-up activities associated with the denial and conducted before the
current appeal.
• The review shall not afford deference to the initial Adverse Determination and shall be conducted by a
Sanford Health Plan representative who is neither the individual who made the Adverse Determination that
is the subject of the appeal, nor the subordinate of such individual.
• In deciding an appeal of any Adverse Determination that is based in whole or in part on a medical judgment,
including determinations with regard to whether a particular treatment, drug or other item is Experimental,
Investigational, or not Medically Necessary or appropriate, Sanford Health Plan shall consult with a health
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care professional (same-or-similar specialist) who has appropriate training and experience in the field of
medicine involved in the medical judgment. The health care Practitioner and/or Provider engaged for
purposes of a consultation under this paragraph shall be an individual who is neither an individual who was
consulted in connection with the Adverse Determination that is the subject of the appeal, nor the subordinate
of any such individual.
• Sanford Health Plan shall identify the medical or vocational experts whose advice was obtained on behalf of
Sanford Health Plan in connection with a Member’s Adverse Determination, without regard to whether the
advice was relied upon in making the benefit request determination.
• In order to ensure the independence and impartiality of the persons involved in making claims
determinations and appeals decisions, all decisions regarding hiring, compensation, termination, promotion,
or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) shall
not be made based upon the likelihood that the individual will support the denial of benefits.
• The attending Practitioner and/or Provider and the Member will be made aware of their responsibility for
submitting the documentation required for resolution of the Appeal within three (3) working days of receipt
of the Appeal.
• Sanford Health Plan will provide notice of any Adverse Determination in a manner consistent with
applicable federal regulations.
10.13 APPEAL NOTIFICATION TIMELINES
For Prospective (Pre-service) Appeals: for decisions not regarding pharmacy service, certification of non-
covered medication, or Formulary design issues, Sanford Health Plan will notify the Member or their Authorized
Representative and any Practitioner and/or Providers involved in the Appeal in writing or electronically within
thirty (30) calendar days of receipt of the Appeal.
For Retrospective (Post-service) Appeals: for decisions not regarding pharmacy service, certification of non-
covered medication, or Formulary design issues, Sanford Health Plan will notify the Member or their Authorized
Representative and any Practitioner and/or Providers involved in the Appeal in writing or electronically within
sixty (60) calendar days of receipt of the Appeal.
For Appeals Based on Discrimination: Sanford Health Plan will notify the Member or their Authorized
Representative and any Practitioner and/or Providers involved in the Appeal in writing within thirty (30)
calendar days of receipt of the Appeal.
If the Member does not receive the decision within the time periods stated above, the Member may be entitled to
file a request for External Review.
10.14 EXPEDITED INTERNAL APPEAL PROCEDURE
An Expedited Appeal procedure is used when the Member’s condition is emergent or urgent in nature, as defined
in this Certificate. An Expedited Appeal of a Prior Authorization (Pre-service) Denial must be utilized if the
Practitioner acting on behalf of the Member believes that the request is warranted. This can be done by oral or
written notification to Sanford Health Plan. We will accept all necessary information (electronic or by telephone)
for review from the Practitioner of care. A designated Physician advisor will conduct the review and will be
available to discuss the case with the attending Practitioner on request. For Medical Necessity reviews only, a
Practitioner in the same or similar specialty that typically treats the medical condition, performs the procedure, or
provides the treatment will review the request.
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The determination will be made and provided to the Member and those Practitioners and/or Providers involved in
the Appeal via telephone by the Utilization Management Department as expeditiously as the Member’s medical
condition requires but no later than within seventy-two (72) hours of receipt of the request. The Member and
those Practitioners and/or Providers involved in the Appeal will receive written notification within three (3)
calendar days of the telephone notification.
If the Expedited Review is a Concurrent Review determination, the service will be continued without liability to
the Member until the Member or the Representative has been notified of the determination.
NOTE: For procedures, rights, and notification timelines related to an Appeal of Adverse Determination
regarding pharmacy services, certification of a non-covered medication, or Formulary design issues, see External
Procedures for Adverse Determinations of Pharmaceutical Exception Requests in this Section.
10.15 WRITTEN NOTIFICATION PROCESS FOR INTERNAL APPEALS
The written decision for the Appeal reviews will contain the following information:
• The results and date of the Appeal Determination;
• The specific reason for the Adverse Determination in easily understandable language;
• The titles and qualifications, including specialty, of the person or persons participating in the first level
review process (Reviewer names are available upon request);
• Reference to the evidence, benefit provision, guideline, protocol and/or other similar criterion on which
the determination was based and notification that the Member on request can have a copy of the actual
benefit provisions, guidelines, protocols and other similar criterion free of charge;
• Notification the Member can receive, upon request and free of charge, reasonable access and copies of
all documents, records and other information relevant to the Member’s benefit request;
• Statement of the reviewer’s understanding of the Member’s Appeal;
• The Reviewer’s decision in clear terms and The Contract basis or medical rationale in sufficient detail
for the Member to respond further;
• Notification and instructions on how the Practitioner and/or Provider can contact the Physician or
appropriate specialist to discuss the determination;
• If the Adverse Determination is based on Medical Necessity or Experimental or Investigational Service
or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the
determination, applying the terms of the Certificate of Insurance to the Member’s medical
circumstances or a statement that an explanation will be provided to the Member free of charge upon
request;
• If applicable, instructions for requesting:
a. A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the
Adverse Determination; or
b. The written statement of the scientific or clinical rationale for the determination;
• For Adverse Determinations of Prospective (Pre-service) or Retrospective (Post-service) Review a
statement indicating:
1. The written procedures governing the standard internal review, including any required
timeframe for the review; and
2. The Member’s right to bring a civil action in a court of competent jurisdiction;
3. Notice of the Member’s right to contact the Division of Insurance for assistance at any time.
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4. Notice of the right to initiate the External Review process for Adverse Determinations based on
Medical Necessity. Refer to “Independent, External Review of Final Determinations” in this
Section for details on this process. Final Adverse Determination letters will contain
information on the circumstances under which Appeals are eligible for External Review and
information on how the Member can seek further information about these rights.
5. If the Adverse Determination is completely overturned, the decision notice will state the
decision and the date.
10.16 EXTERNAL PROCEDURES FOR ADVERSE DETERMINATIONS OF PHARMACEUTICAL
EXCEPTION REQUESTS
Sanford Health Plan follows all requirements for denials and appeals as it relates to any Adverse Determination
when there has been a Medical Necessity determination based on pharmacy service, certification of non-covered
medication or Formulary design issue. This applies to requests for coverage of non-covered medications, generic
substitution, therapeutic interchanges and step-therapy protocols.
External Exception Review (Appeal) of a Standard Exception Request:
• If we deny a request for a Standard Exception, the Member may request that the original exception request
and subsequent denial of such request be reviewed by an Independent Review Organization.
• The Plan will make its determination on the External Exception Request and notify the Member or the
Member’s Authorized Representative, and the prescribing physician (or other prescriber, as appropriate) of
its coverage determination no later than 72 hours following the Plan’s receipt of the request if the original
request was a Standard Exception Request.
• If the Plan grants an External Exception Review of a Standard Exception Request, the Plan will provide
coverage of the non-Formulary drug for the duration of the prescription.
External Exception Review (Appeal) of an Expedited (Urgent) Exception Request:
• If Sanford Health Plan denies a request for an Expedited Exception, the Member may request that the
original exception request and subsequent denial of such request be reviewed by an Independent
Review Organization.
• Sanford Health Plan will make its determination on the External Exception Request and notify the
Member or the Member’s Authorized Representative, and the prescribing physician (or other
prescriber, as appropriate) of its coverage determination no later than 24 hours following our receipt
of the request if the original request as an expedited exception.
• If Sanford Health Plan grants an External Exception Review of an Expedited Exception Request, we
will provide coverage of the non- Formulary drug for the duration of the exigency.
10.17 STANDARD EXTERNAL REVIEW REQUEST PROCESSES & PROCEDURES
1.
The Plan will follow the procedure for providing independent, external review of final determinations as
outlined by federal ERISA regulations and rules governing the Plan in the Patient Protection and
Affordable Care Act. Accordingly, an Independent External Review is not available for a Benefit Denial
when it does not involve medical judgment.
NOTE: Adverse Benefit Determinations, e.g. denials that do not involve medical/clinical review, are not eligible
for an External Review. The Plan’s decision on Benefit Determinations is final and binding.
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External Appeal Review Program – OVERVIEW
Members may file a request for External Review with Sanford Health Plan or with the North Dakota
Insurance Commissioner. Refer to the Introduction section at the beginning of this document for
contact information.
An expedited Appeal procedure is used when the condition is an Urgent Care Situation, as defined
previously in this Certificate of Insurance.
An expedited review involving Urgent Care Requests for Adverse Determinations of Pre-service or
Concurrent claims must be utilized if the Member or Practitioner and/or Provider acting on behalf of
the Member believe that an expedited determination is warranted. All of the procedures of a
standard review described apply. In addition, for an Expedited Appeal, the request for an expedited
review may be submitted. This can be done orally or in writing and the Plan will accept all
necessary information by telephone or electronically. In such situations, the Practitioner who made
the initial Adverse Determination may review the appeal and overturn the previous decision.
The determination will be made and provided to the Member and those Practitioners and/or
Providers involved in the appeal via oral notification by the Utilization Management Department as
expeditiously as the Member’s medical condition requires but no later than twenty-four (24) hours
of receipt of the request. Sanford Health Plan will notify you orally by telephone or in writing by
facsimile or via other expedient means. The Member and those Practitioners and/or Providers
involved in the appeal will receive written notification within three (3) calendar days of the oral
notification. If your claim is no longer considered urgent, it will be handled in the same manner as a
Non-urgent Pre-service or a Non-urgent post-service appeal, depending upon the circumstances.
If the expedited review is a Concurrent Review determination, the service must be continued
without liability to the Member until the Member or the representative has been notified of the
determination.
10.18 EXTERNAL APPEAL REVIEW PROGRAM PROCEDURES
For independent, External Review of a final Adverse Determination, Sanford Health Plan will
provide:
• Members the right to an independent, third party, binding review whenever they meet the following
eligibility criteria:
• The Member is Appealing an Adverse Determination that is based on Medical Necessity (benefits
Adverse Determinations are not eligible);
• Sanford Health Plan has completed the internal Appeal review and its decision is unfavorable to the
Member, or has exceeded the time limit for making a decision, or Sanford Health Plan has elected to
bypass the available internal level of Appeal with the Member’s permission;
• The request for independent, External Review is filed within four (4) months of the date that
Sanford Health Plan’s Adverse Determination was made.
• Notification to Members about the independent, External Review program and decision are as follows:
• General communications to Members, at least annually, to announce the availability of the right to
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independent, External Review.
• Letters informing Members and Practitioners of the upholding of an Adverse Determination covered
by this standard including notice of the independent, External Appeal rights, directions on how to
use the process, contact information for the independent, External Review organization, and a
statement that the Member does not bear any costs of the independent, External Review
organization, unless otherwise required by state law.
• The External Review organization will communicate its decision in clear terms in writing to the Member
and Sanford Health Plan. The decision will include:
• a general description of the reason for the request for external review;
• the date the independent review organization received the assignment from Sanford Health Plan to
conduct the external review;
• the date the external review was conducted;
• the date of its decision;
• the principal reason(s) for the decision, including any, Medical Necessity rationale or evidence-
based standards that were a basis for its decision; and
• the list of titles and qualifications, including specialty, of individuals participating in the appeal
review, statement of the reviewer’s understanding of the pertinent facts of the appeal and reference
to evidence or documentation used as a basis for the decision.
• The External Review organization must also notify the Member how and when Members receive
any payment or service in the case of overturned Adverse Determinations.
• Conduct of the External Appeal Review program as follows:
• A Member will contact Sanford Health Plan with an external review request.
• Within five (5) business days following the date of receipt of the external review request, Sanford
Health Plan shall complete a preliminary review of the request to determine whether:
• The Member is or was a covered person at the time the health care service was requested or, in the
case of a Retrospective Review, was a covered person in the Plan at the time the health care service
was provided;
• The health care service that is the subject of the Adverse Determination is a covered service under
the Member’s health benefit plan, but for a determination by the health carrier that the health care
service is not covered because it does not meet the Plan’s requirements for medical necessity,
appropriateness, health care setting, or level of care or effectiveness;
• The Member has exhausted Sanford Health Plan’s internal Appeal process unless the Member is not
required to exhaust Sanford Health Plan’s internal Appeal process as defined above; and
• The Member has provided all the information and forms required to process an external review.
• Within one (1) business day after completion of the preliminary review, Sanford Health Plan shall notify
the Member and, if applicable, the Member’s authorized representative in writing whether the request is
complete and eligible for external review.
• If the request is not complete, the NDID shall inform the Member and, if applicable, the Member’s
Authorized Representative in writing and include in the notice what information or materials are needed to
make the request complete; or if the request is not eligible for external review, the NDID shall inform the
Member and, if applicable, the Member’s Authorized Representative in writing and include the reasons for
its ineligibility. If the Independent Review Organization upheld the denial, there is no further review
available under this appeals process. However, you may have other remedies available under State or
Federal law, such as filing a lawsuit.
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• If the request is complete, within one (1) business day after verifying eligibility, the NDID shall assign an
independent review organization and notify in writing the Member, and, if applicable, the Member’s
Authorized Representative of the request’s eligibility and acceptance for external review. The Member
may submit in writing to the assigned Independent Review Organization within five (5) business days
following the date of receipt of the notice provided by the NDID any additional information that the
independent review organization shall consider when conducting the external review. The independent
review organization is not required to, but may, accept and consider additional information submitted after
ten (10) business days.
• Within five (5) business days after the date the NDID determines the request is eligible for external review,
of receipt, the NDID shall provide to the assigned independent review organization the documents and any
information considered in making the adverse determination or final Adverse Determination.
• The North Dakota Insurance Department contracts with the independent, external review organization that:
• is accredited by a nationally recognized private accrediting entity;
• conducts a thorough review, in which it considers all previously determined facts; allows the
introduction of new information; considers and assesses sound medical evidence; and makes a
decision that is not bound by the decisions or conclusions of Sanford Health Plan or determinations
made in any prior appeal.
• completes their review and issues a written final decision for non-urgent appeals within forty-five
(45) calendar days of the request. For clinically Urgent Care appeals, the review and decision will be
made and orally communicated as expeditiously as the Member’s medical condition or
circumstances requires, but in no event more than seventy-two (72) hours after the date of receipt of
the request for an expedited external review. Within forty-eight (48) hours after the date of providing
the oral notification, the assigned independent review organization will provide written confirmation
of the decision to the Member, or if applicable, the Member’s Authorized Representative, and their
treating Practitioner and/or Provider.
• has no material professional, familial or financial conflict of interest with Sanford Health Plan.
• With the exception of exercising its rights as party to the appeal, Sanford Health Plan must not attempt to
interfere with the Independent Review Organization’s proceeding or appeal decision.
• Sanford Health Plan will provide the Independent Review Organization with all relevant medical records
as permitted by state law, supporting documentation used to render the decision pertaining to the
Member’s case (summary description of applicable issues including Sanford Health Plan’s decision,
criteria used and clinical reasons, utilization management criteria, communication from the Member to
Sanford Health Plan regarding the appeal), and any new information related to the case that has become
available since the internal appeal decision.
• The Member is not required to bear costs of the Independent Review Organization’s review, including any
filing fees. However, Sanford Health Plan is not responsible for costs associated with an attorney,
physician or other expert, or the costs of travel to an independent, External Review hearing.
• The Member or his/her legal guardian may designate in writing a representative to act on his/her behalf. A
Practitioner and/or Provider may not file an Appeal without explicit, written designation by the Member.
• The Independent Review Organization’s decision is final and binding to Sanford Health Plan and Sanford
Health Plan implements the Independent Review Organization’s decision within the timeframe specified
by the Independent Review Organization. The decision is not binding to the Member, because the Member
has legal rights to pursue further appeals in court if they are dissatisfied with the outcome. However, a
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Member may not file a subsequent request for external review involving the same Adverse Determination
for which the Member has already received an external review decision.
• Sanford Health Plan maintains and tracks data on each appeal case, including descriptions of the denied
item(s), reasons for denial, Independent, External Review organization decisions and reasons for decisions.
Sanford Health Plan uses this information in tracking and evaluating its Medical Necessity decision-
making process and improving the quality of its clinical decision making procedures. This information is
reported to the Medical Management Quality Committee when a case is resolved for discussion and plan
of care or action.
NOTE: ALL NOTIFICATIONS AND PROCEDURES DESCRIBED IN THIS SECTION, IN
ADDITION TO THOSE RELATED TO BOTH BENEFIT AND MEDICAL CARE
DETERMINATIONS IN SECTION 2, WILL COMPLY WITH APPLICABLE LAW. SHOULD A
CONFLICT EXIST BETWEEN PLAN PROCEDURES AND FEDERAL REGULATIONS,
FEDERAL REGULATIONS SHALL CONTROL.
A COMPLETE DESCRIPTION OF YOUR COMPLAINT (GRIEVANCE) AND APPEAL RIGHTS
AND THE APPEAL PROCESS WILL BE INCLUDED IN DETERMINATION RESPONSES AND
DECISIONS MADE BY SANFORD HEALTH PLAN. ADDITIONALLY, AN OVERVIEW OF
YOUR COMPLAINT (GRIEVANCE) AND APPEAL RIGHTS, ALONG WITH AN APPEAL
FILING FORM, IS INCLUDED IN ALL EXPLANATION OF BENEFITS (EOBS) GENERATED
BY SANFORD HEALTH PLAN.
10.19 EXPEDITED EXTERNAL REVIEW REQUESTS
• A Member or the Member’s Authorized Representative may request an expedited external review
of an Adverse Determination if the Adverse Determination involves an Urgent Care requests for
Prospective (pre-service) or Concurrent Review request for which
• the timeframe for completion of a standard internal review would seriously jeopardize the life
or health of the Member; or would jeopardize the Member’s ability to regain maximum
function; or
• in the case of a request for Experimental or Investigational Services, the treating Provider
certifies, in writing, that the requested Health Care Services or treatment would be significantly
less effective if not promptly initiated.
• The Member has the right to contact the North Dakota Insurance Commissioner for assistance at
any time.
• Immediately upon receipt of the request from the Member or the Member’s Representative, the
NDID shall determine whether the request is eligible for Expedited External Review. If the request
is ineligible for an Expedited External Review as described in (1) above, the NDID will give
notification to the Member or the Member’s Representative that they may appeal to the state
insurance department.
• Upon determination that the Expedited External Review request meets the reviewability
requirements, the NDID shall assign a contracted, independent review organization to conduct the
expedited external review. The assigned independent review organization is not bound by any
decisions or conclusions reached during Sanford Health Plan’s utilization review or internal appeal
process.
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• Sanford Health Plan will send all necessary documents and information considered in making the
Adverse Determination to the assigned independent review organization electronically, by
telephone, or facsimile or any other available expeditious method.
• The independent review organization will make a decision to uphold or reverse the adverse
determination and provide oral notification to the Member, and, if applicable, the Member’s
Authorized Representative, and the treating Practitioners and/or Providers as expeditiously as the
Member’s medical condition or circumstances requires but in no event more than seventy-two (72)
hours after the date of receipt of the request for an expedited external review. The Member and
those Practitioners and/or Providers involved in the appeal will receive written notification within
forty-eight (48) hours of the oral notification.
• At the same time a Member, or the Member’s Authorized Representative, files a request for an
internal Expedited Review of an Appeal involving an Adverse Determination, the Member, or the
Member’s Authorized Representative, may also file a request for an external Expedited External
Review if the Member has a medical condition where the timeframe for completion of an expedited
review would seriously jeopardize the life or health of the Member or would jeopardize their ability
to regain maximum function; or if the requested health care service or treatment is an Experimental
or Investigational Service and the Member’s treating Practitioner and/or Provider certifies in
writing that the recommended or requested health care service or treatment that is the subject of the
Adverse Determination would be significantly less effective if not promptly initiated.
• Upon Sanford Health Plan’s receipt of the independent review organization’s decision to reverse
the Adverse Determination, Sanford Health Plan shall immediately approve the coverage that was
the subject of the Adverse Determination
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SECTION 11
DEFINITIONS OF TERMS WE USE IN THIS CERTIFICATE OF
INSURANCE
Adverse
Determination
Any of the following determinations:
The denial, reduction, termination, or failure to provide or make payment in whole or in part, for
a benefit based on a determination of a Member’s eligibility to participate in the Plan;
Any prospective review or retrospective Utilization Review determination that denies, reduces,
terminates, or fails to provide or make payment, in whole or in part, for a benefit; or
A rescission of coverage determination.
Affordable Care Act or
ACA
The Patient Protection and Affordable Care Act, Public Law 111-148, as amended by the
Healthcare and Education Reconciliation Act, Public Law 111-152, collectively referred to as the
Affordable Care Act or ACA.
Admission
Entry into a facility as an Inpatient for treatment and care when ordered by a Health Care
Provider with admitting privileges. An Admission ends when a Member is discharged or released
from the facility and is no longer registered as a patient. Also known as Hospitalization.
Allowance or Allowed
Charge
The maximum dollar amount that payment for a procedure or service is based on as determined
by Sanford Health Plan.
Ambulatory Surgical
Center
A lawfully operated, public or private establishment that:
1. Has an organized staff of Practitioners;
2. Has permanent facilities that are equipped and operated mostly for performing surgery;
3. Has continuous Practitioner services and Nursing Services when a patient is in the Facility;
and
Does not have services for an overnight stay.
Annual Enrollment
A period of time at least once a year when Eligible Group Members may enroll themselves and
their Dependents in the Plan. Annual Enrollment does not pertain to non-Medicare retirees.
Approved Clinical Trial
A phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the
prevention, detection, or treatment of cancer or other life-threatening disease or condition and is
one of the following:
1. A federally funded or approved trial;
2. A clinical trial conducted under an FDA investigational new medication application; or
A medication trial that is exempt from the requirement of an FDA investigational new medication
application.
151
Authorized
Representative
A person to whom a covered person has given express written consent to represent the Member, a
person authorized by law to provide substituted consent for a Member, a family member of the
Member or the Member’s treating health care professional if the Member is unable to provide
consent, or a health care professional if the Member’s Plan requires that a request for a benefit
under the plan be initiated by the health care professional. For any Urgent Care Request, the term
includes a health care professional with knowledge of the Member’s medical condition.
Avoidable Hospital
Conditions
Conditions that could reasonably have been prevented through application of evidence-based
guidelines. These conditions are not present on admission, but present during the course of the
stay. Participating Providers are not permitted to bill the Plan or Members for services related to
Avoidable Hospital Conditions.
Basic Plan
The Member elects to access the health care system through a Health Care Provider that is not a
part of the Preferred Provider Organization. Benefit payment will be at the Basic Plan level.
Health Care Providers accessed at the Basic Plan level are also Participating Providers.
152
Benefit Period
A specified period of time when benefits are available for Covered Services under this Benefit
Plan. A Claim for Benefits will be considered for payment only if the date of service or supply
was within the Benefit Period. All benefits are determined on a Calendar Year (January 1
st
through
December 31
st
) Benefit Period.
Benefit Plan
The agreement with Sanford Health Plan, including the Subscriber’s membership application,
Identification Card, the Benefit Plan Agreement, this Certificate of Insurance, the Benefit Plan
Attachment and any supplements, endorsements, attachments, addenda or amendments
[The] Board
Means the North Dakota Public Employees Retirement System (NDPERS) board.
Calendar Year
A period of one year which starts on January 1
st
and ends December 31
st
.
Case Management
A coordinated set of activities conducted for individual patient management of chronic, serious,
complicated, protracted, or other health conditions.
Certification
Certification is a determination by Sanford Health Plan that a request for a benefit has
been reviewed and, based on the information provided, satisfies Sanford Health Plan’s
requirements for Medical Necessity, appropriateness, health care setting, level of care,
and effectiveness.
Claims Administrator or
Claims Payor
Sanford Health Plan
Class of Coverage
The type of coverage the Subscriber is enrolled under, identifying who is eligible to receive
benefits for Covered Services under this Benefit Plan. Classes of Coverage under this Benefit
Plan are Single Coverage and Family Coverage.
Coinsurance Amount
A percentage of the Allowed Charge for Covered Services that is a Member’s responsibility.
Coinsurance Maximum
Amount
The total Coinsurance Amount that is a Member’s responsibility during a Benefit Period. The
Coinsurance Maximum Amount renews on January 1 of each consecutive Benefit Period
Concurrent Review
Concurrent Review is Utilization Review for an extension of previously approved, ongoing
course of treatment over a period of time or number of treatments typically associated with
Hospital inpatient care including care received at a Residential Treatment Facility and ongoing
outpatient services, including ongoing ambulatory care.
[This] Contract or [The]
Contract
This Certificate of Insurance, which is a statement of the essential features and services given to
the Subscriber by the Plan, including all attachments, the Group’s application, the applications of
the Subscribers and the Health Maintenance Contract.
153
Cosmetic
Surgery, medication, or other services performed for the primary purpose of enhancing or altering
physical appearance without correcting, restoring or improving physiological function, or
improving an underlying condition or disease.
Cost Sharing
The share of costs covered by your insurance that you pay out of your own pocket. This term
generally includes coinsurance, copayments, or similar charges, but it doesn’t include premiums,
balance-billing amounts for non-network providers, or the cost of non-covered services.
Covered Services
Those Health Care Services to which a Member is entitled under the terms of This Contract.
Creditable Coverage
Benefits or coverage provided under:
1. A group health benefit plan (as such term is defined under North Dakota law);
2. A health benefit plan (as such term is defined under North Dakota law);
3. Medicare;
4. Medicaid;
5. Civilian health and medical program for uniformed services;
6. A health plan offered under 5 U.S.C. 89;
7. A medical care program of the Indian Health Service or of a tribal organization;
8. A state health benefits risk pool, including coverage issued under N.D.C.C. Chapter 26.1-08;
9. A public health plan as defined in federal regulations, including a plan maintained by a state
government, the United States government, or a foreign government;
10. A health benefit plan under Section 5(e) of the Peace Corps Act [Pub. L. 87-293; 75 Stat.
612; 22 U.S.C. 2504(e)]; and
11. A state’s children’s health insurance program funded through Title XXI of the federal Social
Security Act [42 U.S.C. 1397aa et seq.].
Custodial Care
Care designed to assist the patient in meeting the activities of daily living and not primarily
provided for its therapeutic value in the treatment of an illness, disease, injury or condition.
Deductible Amount
A specified dollar amount payable by the Member for certain Covered Services received during
the Benefit Period.
Dependent
The Spouse and any Dependent Child of a Subscriber.
Dependent Child
The definition of a Dependent Child of a Subscriber includes a child who is related to the
Subscriber as a natural child, a child placed for adoption, a legally adopted child, a child for
whom the Subscriber has legal guardianship, a stepchild, or a foster child; and is one of the
following: (a) under the age of twenty-six (26), (b) incapable of self-sustaining employment by
reason of a disabling condition and chiefly dependent upon the Certificate holder/Subscriber for
support and maintenance. If the Plan so requests, the Subscriber must provide proof of the child’s
disability within thirty-one (31) days of the Plan’s request. If a person has a disabled dependent
that is over the limiting age but was never previously covered by the Plan, they are eligible for
coverage if the disability occurred prior to reaching the limiting age of 26. If for any reason,
Subscriber drops coverage for a disabled dependent prior to age 26, then wishes to cover the
child again, coverage must be added prior to the child turning age 26. If the disabled child
has reached age 26, the child must be continuously covered under the Plan in order to
maintain eligibility.
154
Dependent of Dependent
To be eligible for coverage, a dependent of the Subscriber’s Dependent child, as defined above,
must meet all the following requirements:
1. Be the natural child of the Subscriber’s Dependent Child, a child placed with the
Subscriber’s Dependent Child for adoption, a legally adopted child by the
Subscriber’s Dependent Child, a child for whom the Subscriber’s Dependent Child
has legal guardianship, a stepchild of the Subscriber’s Dependent Child, or foster
child of the Subscriber’s Dependent Child. These same definitions apply to
dependents of the Dependent Child(ren) of the Subscriber’s living, covered Spouse;
and
2. The Subscriber’s Dependent Child must be a Covered Dependent under this
Certificate of Insurance for the Dependent of the Dependent Child to be eligible; and
The Dependent Child must be chiefly dependent on the Subscriber for support [N.D.C.C. §26.1-
36-22 (3)(4)] .
Domiciliary Care
Domiciliary Care consists of a protected situation in a community or Facility, which includes
room, board, and personal services for individuals who cannot live independently yet do not
require a 24-hour Facility or nursing care.
Eligible Dependent
An Eligible Dependent includes: (1) The Spouse of the Subscriber; (2) A Dependent child who is
related to the Subscriber as a natural child, a child placed for adoption, a legally adopted child, a
child for whom the Subscriber has legal guardianship, a stepchild, or a foster child; and is one of
the following: (a) under the age of twenty-six (26), (b) incapable of self-sustaining employment
by reason of a disabling condition and chiefly dependent upon the Certificate holder/Subscriber
for support and maintenance. If the Plan so requests, the Subscriber must provide proof of the
child’s disability within thirty-one (31) days of the Plan’s request. If a person has a disabled
dependent that is over the limiting age but was never previously covered by the Plan, they are
eligible for coverage if the disability occurred prior to reaching the limiting age of 26. If for any
reason, Subscriber drops coverage for a disabled dependent prior to age 26, then wishes to
cover the child again, coverage must be added prior to the child turning age 26. If the
disabled child has reached age 26, the child must be continuously covered under the Plan in
order to maintain eligibility; and (3) a Dependent of Dependent (a) Is the natural child of the
Subscriber’s Dependent child, a child placed with the Subscriber’s Dependent child for adoption,
a legally adopted child by the Subscriber’s Dependent child, a child for whom the Subscriber’s
Dependent child has legal guardianship, a stepchild of the Subscriber’s Dependent child, or foster
child of the Subscriber’s Dependent child. These same definitions apply to dependents of the
Dependent child(ren) of the Subscriber’s living, covered Spouse; and (b) the Subscriber’s
Eligible Dependent
(CONTINUED)
Dependent child must be a Covered Dependent under this Certificate of Coverage for the
dependent of the Dependent child to be eligible; and (c) The Dependent Child must be chiefly
dependent on the Subscriber for support. [N.D.C.C. §26.1-36-22 (3)(4)].
Eligible Group Member
Any Group Member who meets the specific eligibility requirements of NDPERS.
155
Emergency Care
Services
Emergency Care Services means: (1) Within the Service Area: covered health care services
rendered by Participating or Non-Participating Providers under unforeseen conditions that require
immediate medical attention. Emergency care services within the Service Area include covered
health care services from Non-Participating Providers only when delay in receiving care from
Participating Providers could reasonably be expected to cause severe jeopardy to the Member’s
condition or (2) Outside the Service Area: medically necessary health care services that are
immediately required because of unforeseen illness or injury while the enrollee is outside the
geographical limits of the Plan’s Service Area.
Emergency Medical
Condition
A medical condition of recent onset and severity, including severe pain, that would lead a prudent
layperson acting reasonably and possessing an average knowledge of health and medicine to
believe that the absence of immediate medical attention could reasonably be expected to result in
serious impairment to bodily function, serious dysfunction of any bodily organ or part, or would
place the person’s health, or with respect to a pregnant woman, the health of the woman or her
unborn child, in serious jeopardy.
Encounter
Any type of initiated contact between a member and provider via a qualified telehealth
technology platform.
Enrollee
An individual who is covered by this Plan.
ESRD
The federal End Stage Renal Disease program.
Expedited Appeal
An expedited review involving Urgent Care Requests for Adverse Determinations of Prospective
(Pre-service) or Concurrent Reviews must be utilized if the Member, or Practitioner and/or
Provider acting on behalf of the Member, believes that an expedited determination is warranted.
Experimental or
Investigational Services
Health Care Services where the Health Care Service in question either:
1. is not recognized in accordance with generally accepted medical standards as being safe and
effective for treatment of the condition in question, regardless of whether the service is
authorized by law or used in testing or other studies; or
2. requires approval by any governmental authority and such approval has not been granted
prior to the service being rendered.
Facility
An institution providing Health Care Services or a health care setting, including Hospitals and
other licensed inpatient centers, ambulatory surgical or treatment centers, Skilled Nursing
Facilities, Residential Treatment Facilities, diagnostic, laboratory, and imaging centers, and
rehabilitation, and other therapeutic health settings.
Family Coverage
The Class Of Coverage identifying that the Subscriber and Eligible Dependents are enrolled to
received benefits for Covered Services under this Plan.
Formulary
A list of prescription medication products, which are preferred by the Plan for dispensing to
Members when appropriate. This list is subject to periodic review and modifications. Additional
medications may be added or removed from the Formulary throughout the year.
Gestational Carrier
An adult woman who enters into an agreement to have a fertilized egg, gamete, zygote or embryo
implanted in her and bear the resulting child for intended parents, where the embryo is conceived
by using the egg and sperm of the intended parents.
156
Grievance
A written complaint submitted in accordance with the Plan’s formal grievance procedure by or on
behalf of the enrollee regarding any aspect of the Plan relative to the Member.
[The] Group or [This]
Group
NDPERS has signed an agreement with Sanford Health Plan to provide health care benefits for its
eligible employees, retirees, and Eligible Dependents.
Group Contract Holder
The individual to whom a Group Contract has been issued.
Group Member
Any employee, sole proprietor, partner, director, officer or Member of the Group.
Health Care Services
Services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness,
injury or disease.
Health Savings Account
(HSA)
A medical savings account available to taxpayers who are enrolled in a High Deductible Health
Plan. The funds contributed to the account aren’t subject to federal income tax at the time of
deposit. Funds must be used to pay for qualified medical expenses, and roll over year to year, if
you don’t spend them.
High Deductible Health
Plan (HDHP)
A plan that features higher deductibles than traditional insurance plans. High Deductible Health
Plans can be combined with a health savings account or a health reimbursement arrangement to
allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.
Hospital
A short-term, acute care, duly licensed institution that is primarily engaged in providing inpatient
diagnostic and therapeutic services for the diagnosis, treatment, and care of injured and sick
persons by or under the supervision of Physicians. It has organized departments of medicine
and/or major surgery and provides 24-hour nursing service by or under the supervision of
registered nurses. The term “Hospital” specifically excludes rest homes, places that are primarily
for the care of convalescents, nursing homes, skilled nursing facilities, Residential Care Facilities,
custodial care homes, intermediate care facilities, health resorts, clinics, Practitioner and/or
Provider’s offices, private homes, Ambulatory Surgical Centers, residential or transitional living
centers, or similar facilities.
157
Hospitalization
A stay as an inpatient in a Hospital. Each “day” of Hospitalization includes an overnight stay for
which a charge is customarily made. Benefits may not be restricted in a way that is based upon the
number of hours that the Member stays in the Hospital.
Iatrogenic Condition
Illness or injury because of mistakes made in medical treatment, such as surgical mistakes, prescribing or
dispensing the wrong medication or poor hand writing resulting in a treatment error.
Infertility Services
Deductible Amount
A specified dollar amount payable by the Member during their lifetime for infertility services. The
Infertility Services Deductible Amount does not apply toward the Out-of-Pocket Maximum
Amount.
In-Network Benefit
Level
The PPO Plan level of benefits when a Member seeks services from a Participating Practitioner
and/or Provider.
Intensive Outpatient
Program (IOP)
Provides mental health and/or substance use disorder outpatient treatment services during which a
Member remains in the program a minimum of three (3) continuous hours per day and does not
remain in the program overnight. Programs may be available in the evenings or weekends.
Intermediate Care
Intermediate Care means care in a Facility, corporation or association licensed or regulated by the
State for the accommodation of persons, who, because of incapacitating infirmities, require
minimum but continuous care but are not in need of continuous medical or nursing services. The
term also includes facilities for the nonresident care of elderly individuals and others who are
able to live independently but who require care during the day.
Late Enrollee
An individual who enrolls in a group health plan on a date other than either the earliest date on
which coverage can begin under the plan terms or on a special enrollment date.
Maintenance Care
Treatment provided to a Member whose condition/progress has ceased improvement or could reasonably be
expected to be managed without the skills of a Health Care Provider. Exception: periodic reassessments are
not considered Maintenance Care.
Maximum Allowed
Amount
The amount established by Sanford Health Plan using various methodologies for covered services
and supplies. Sanford Health Plan’s Maximum Allowable Amount is the lesser of
(a)the amount charged for a covered service or supply; or
(b) inside Sanford Health Plan’s service area, negotiated schedules of payment developed by
Sanford Health Plan which are accepted by Participating Practitioners and/or Providers, or
(c) outside of Sanford Health Plan’s service area, using current publicly available data
adjusted for geographical differences where applicable:
i. Fees typically reimbursed to providers for same or similar
professionals; or
Costs for facilities providing the same or similar services, plus a margin factor.
158
Medically Necessary or
Medical Necessity
Health Care Services that are appropriate and necessary as determined by any Participating
Provider, in terms or type, frequency, level, setting, and duration, according to the Member’s
diagnosis or condition, and diagnostic testing and Preventive services. Medically Necessary care
must be consistent with generally accepted standards of medical practice as recognized by the
Plan, as determined by health care Practitioner and/or Providers in the same or similar general
specialty as typically manages the condition, procedure, or treatment at issue; and
A. help restore or maintain the Members health; or
B. prevent deterioration of the Member’s condition; or
C. prevent the reasonably likely onset of a health problem or detect an incipient problem; or
D. not considered Experimental or Investigative
Member
The Subscriber and, if another Class of Coverage is in force, the Subscriber’s Eligible Dependents
Mental Health and/or
Substance Use Disorder
Services
Health Care Services for disorders specified in the Diagnostic and Statistical Manual of Mental
Disorders (DSM), the American Society of Addiction Medicine Criteria (ASAM Criteria), and the
International Classification of Diseases (ICD), current editions. Also referred to as behavioral
health, psychiatric, chemical dependency, substance abuse, and/or addiction services.
Natural Teeth
Teeth, which are whole and without impairment or periodontal disease, and are not in need of the
treatment provided for reasons other than dental injury.
NDPERS
The North Dakota Public Employees Retirement System.
Never Event
Errors in medical care that are clearly identifiable, preventable, and serious in their consequences
for patients, and indicate a problem in the safety and credibility of a health care Facility.
Participating Providers are not permitted to bill the Plan or Members for services related to Never
Events.
Non-Covered Services
Those Health Care Services to which a Member is not entitled and are not part of the benefits paid
under the terms of This Contract.
Non-Participating
Provider
A Practitioner and/or Provider who does not have a contractual relationship with Sanford Health
Plan, directly or indirectly, and not approved by Sanford Health Plan to provide Health Care
Services to Members with an expectation of receiving payment, other than Coinsurance, Copays,
or Deductibles, from Sanford Health Plan.
Non-Payable Health
Care Provider
A Health Care Provider that is not reimbursable by the Plan. No benefits will be available for
Covered Services prescribed by, performed by or under the direct supervision of a Non-Payable
Health Care Provider.
Nursing Services
Health Care Services which are provided by a registered nurse (RN), licensed practical nurse
(LPN), or other licensed nurse who is: (1) acting within the scope of that person’s license, (2)
authorized by a Provider, and (3) not a Member of the Member’s immediate family.
Open Enrollment or
Open Enrollment Period
A period of time at least once a year when Eligible Group Members may enroll themselves and
their Dependents in the Plan
159
Out-of-Network Benefit
Level
The Basic Plan level of benefits provided when a Member seeks services from a Non-
Participating Practitioner and/or Provider. This is most often referred to as benefits received under
the Basic Plan level but may include services received from Practitioners and/or Providers that
have not signed a contract with the Plan.
Out-of-Pocket
Maximum Amount
The total Deductible and Coinsurance Amounts for certain Covered Services that are a
Member’s responsibility during a Benefit Period. The Out-of-Pocket Maximum Amount renews
on January 1 of each consecutive Benefit Period.
Partial Hospitalization
Also known as day treatment; A licensed or approved day or evening outpatient treatment
program that includes the major diagnostic, medical, psychiatric and psychosocial rehabilitation
treatment modalities designed for individuals with mental health and/or substance use disorders
who require coordinated, intensive, comprehensive and multi-disciplinary treatment.
Participating [Health
Care] Provider
A Provider who, under a contract with the Plan, or with its contractor or subcontractor, has agreed
to provide Health Care Services to Members with an expectation of receiving payment, other than
Coinsurance, Copays, or Deductibles, directly or indirectly, from the Plan. A Participating
Provider includes Providers at either the Basic or PPO Plan level.
Physician
An individual licensed to practice medicine or osteopathy.
[The] Plan or [This] Plan
Sanford Health Plan.
Plan Administrator
North Dakota Public Employees Retirement System (NDPERS)
PPO (Preferred Provider
Organization) Plan
A group of Health Care Providers who provide discounted services to the Members of NDPERS.
Because PPO Health Care Providers charge Sanford Health Plan less for medical care services
provided to the Members of NDPERS, cost savings are passed on to Members by way of
reduced Cost Sharing Amounts. To receive a higher payment level, Covered Services must be
received from an NDPERS PPO Health Care Provider. Health Care Providers accessed at the
PPO level are also Participating Providers.
Practitioner
A professional who provides health care services. Practitioners are usually required to be licensed
as required by law. Practitioners are also Physicians.
Preauthorization
The process of the Member or the Member’s representative notifying Sanford Health Plan to
request approval for specified services. Eligibility for benefits for services requiring
Preauthorization is contingent upon compliance with the provisions in Sections 2, 4 and 5.
Preauthorization does not guarantee payment of benefits.
Preventive
Health Care Services that are medically accepted methods of prophylaxis or diagnosis which
prevent disease or provide early diagnosis of illness and/or which are otherwise recognized by the
Plan.
Primary Care
Practitioner and/or
Provider (PCP)
A Participating Practitioner and/or Provider who is an internist, family practice Physician,
pediatrician, or obstetrician/gynecologist, who is a Participating Practitioner, and who has been
chosen to be designated as a Primary Care Practitioner and/or Provider as indicated in the
Provider Directory and may be responsible for providing, prescribing, directing, referring, and/or
authorizing all care and treatment of a Member.
160
Prior Approval
The process of the Member or Member’s representative providing information to Sanford Health
Plan substantiating the medical appropriateness of specified services in order to receive benefits
for such service. This information must be submitted in writing from the Member’s Health Care
Provider. Sanford Health Plan reserves the right to deny benefits if Preauthorization/Prior
Approval is not obtained.
Prospective
(Pre-service) Review
Means Urgent and non-Urgent Utilization Review conducted prior to an admission or the
provision of a Health Care Service or a course of treatment.
[Health Care] Provider
An individual, institution or organization that provides services for Plan Members. Examples of
Providers include but are not limited to Hospitals, Physicians, Practitioners and/or Providers, and
home health agencies.
Prudent Layperson
A person who is without medical training and who possess an average knowledge of health and
medicine and who draws on his/her practical experience when making a decision regarding the
need to seek Emergency medical treatment.
Qualifying Event
A change in your life that can make you eligible for a Special Enrollment Period to enroll in
health coverage. Examples of qualifying life events are moving to a new state, certain changes in
your income, and changes in your family size (for example, if you marry, divorce, or have a baby)
and gaining membership in a federally recognized tribe or status as an Alaska Native Claims
Settlement Act (ANCSA) Corporation shareholder.
Qualified Mental Health
Professional
A licensed Physician who is a psychiatrist; a licensed clinical psychologist who is qualified for
listing on the national register of health service providers in psychology; a licensed certified social
worker who is a board-certified in clinical social work; or a nurse who holds advanced licensure
in psychiatric nursing
Reduced Payment Level
The lower level of benefits provided by The Plan, as defined in the Summary of Benefits and
Coverage, when a Member seeks services from a Participating or Non-Participating Provider
without certification or prior-authorization when certification/prior-authorization is required.
Residential Treatment
Facility
An inpatient mental health or substance use disorder treatment Facility that provides twenty-four
(24) hour availability of qualified medical staff for psychiatric, substance abuse, and other
therapeutic and clinically informed services to individuals whose immediate treatment needs
require a structured twenty-four (24) hour residential setting that provides all required services on
site. Services provided include, but are not limited to, multi-disciplinary evaluation, medication
management, individual, family and group therapy, substance abuse education/counseling.
Facilities must be under the direction of a board-eligible or certified psychiatrist, with appropriate
staffing on-site at all times. If the Facility provides services to children and adolescents, it must be
under the direction of a board-eligible or certified child psychiatrist or general psychiatrist with
experience in the treatment of children. Hospital licensure is required if the treatment is Hospital-
based. The treatment Facility must be licensed by the state in which it operates.
Retrospective (Post-
service) Review
Means any review of a request for a benefit that is not a Prospective (Pre-service) Review request,
which does not include the review of a claim that is limited to veracity of documentation, or
accuracy of coding, or adjudication of payment. Retrospective (Post-service) Review will be
utilized by Sanford Health Plan to review services that have already been utilized.
161
Serious Reportable
Event
An event that results in a physical or mental impairment that substantially limits one or more
major life activities of a Member or a loss of bodily function, if the impairment or loss lasts more
than seven (7) days or is still present at the time of discharge from an inpatient health care
Facility. Serious events also include loss of a body part and death. Participating Providers are not
permitted to bill Members or the Plan for services related to Serious Reportable Events.
[NDPERS] Service
Agreement and/or
[Group] Contract
The Service Agreement between NDPERS and Sanford Health Plan that is a contract for Health
Care Services, which by its terms limits eligibility to enrollees of a specified group. The Group
Contract may include coverage for Dependents.
Service Area
The geographic Service Area approved by the State’s Insurance Department.
Single Coverage
The Class Of Coverage identifying that only the Subscriber is enrolled to received benefits for
Covered Services under this Plan.
Skilled Nursing Facility
A Facility that is operated pursuant to the presiding state law and is primarily engaged in
providing room and board accommodations and skilled nursing care under the supervision of a
duly-licensed Physician.
Spouse
The Subscriber’s spouse, under a legally existing marriage, is eligible for coverage, subject to the
eligibility requirements as designated by NDPERS.
[This] State
The State of North Dakota.
Subscriber
An Eligible Group Member who is enrolled in the Plan whose employment or other status (except
family dependency) is the basis for eligibility for enrollment in the Plan. A Subscriber is also a
Member and Enrollee.
Surrogate
An adult woman who enters into an agreement to bear a child conceived through assisted
conception for intended parents.
Summary of Benefits
and Coverage or SBC
Attachment I of this Contract that sets forth important information on coverage and Cost Sharing.
Urgent Care Request
Means a request for a Health Care Service or course of treatment with respect to which the time
periods for making a non-Urgent Care Request determination which:
A. Could seriously jeopardize the life or health of the Member or the ability of the Member to
regain maximum function, based on a Prudent Layperson’s judgment; or
B. In the opinion of a Practitioner and/or Provider with knowledge of the Member’s medical
condition, would subject the Member to severe pain that cannot be adequately managed
without the health care service or treatment that is the subject of the request.
162
Urgent Care Situation
An Urgent Care Situation is a degree of illness or injury, which is less severe than an Emergency
Condition, but requires prompt medical attention within twenty-four (24) hours, such as stitches
for a cut finger. Urgent care means a request for a health care service or course of treatment with
respect to which the time periods for making a non-Urgent Care Request determination:
A. Could seriously jeopardize the life or health of the Member or the ability of the Member to
regain maximum function, based on a Prudent Layperson’s judgment; or
B. In the opinion of a Practitioner and/or Provider with knowledge of the Member’s medical
condition, would subject the Member to severe pain that cannot be adequately managed
without the health care service or treatment that is the subject of the request.
Us/We/Our
Refers to Sanford Health Plan
Utilization Review
A set of formal techniques used by the Plan to monitor and evaluate the medical necessity,
appropriateness, and efficiency of Health Care Services and procedures including techniques such
as ambulatory review, Prospective (pre-service) Review, second opinion, Preauthorization/Prior
Approval, Concurrent Review, Case Management, discharge planning, and retrospective (post-
service) review.
You
Refers to the Subscriber or Member, as applicable.
163
ATTACHMENT I. SUMMARY OF BENEFITS AND COVERAGE
This page is intentionally left blank. Your Summary of Benefits and Coverage is an attachment to this
Certificate of Coverage.
164
NOTICE OF PROTECTION PROVIDED BY THE
NORTH DAKOTA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION
This notice provides a brief summary of the North Dakota Life and Health Insurance Guaranty Association (“the
Association”) and the protection it provides for policyholders. This safety net was created under North Dakota law,
which determines who and what is covered and the amounts of coverage.
The Association was established to provide protection in the unlikely event that your life, annuity or health insurance
company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this
should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with North
Dakota law, with funding from assessments paid by other insurance companies.
The protections provided by the Association are based on contract obligations up to the following amounts:
• Life Insurance
o $300,000 in death benefits
o $100,000 in cash surrender or withdrawal values
• Health Insurance
o $500,000 in hospital, medical and surgical insurance benefits
o $300,000 in disability income insurance benefits
o $300,000 in long-term care insurance benefits
o $100,000 in other types of health insurance benefits
• Annuities
o $250,000 in withdrawal and cash values
The maximum amount of protection for each individual, regardless of type of coverage is $300,000; however,
may be up to $500,000 with regard to hospital, medical and surgical insurance benefits.
Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not
extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment
additions to the account value of a variable life insurance policy or a variable annuity contract. If coverage is
available, it will be subject to substantial limitations. There are also various residency requirements and other
limitations under North Dakota law. To learn more about the above protections, as well as protections relating to
group contracts or retirement plans, please visit the Association’s website at www.ndlifega.org or contact:
North Dakota Life and Health Insurance North Dakota Insurance Department
Guaranty Association 600 East Boulevard Avenue, Dept. 401
P.O. Box 2422 Bismarck, ND 58505
Fargo, North Dakota 58108
COMPLAINTS AND COMPANY FINANCIAL INFORMATION
A written complaint to allege a violation of any provision of the Life and Health Insurance Guaranty Association Act
must be filed with the North Dakota Insurance Department, 600 East Boulevard Avenue, Dept. 401, Bismarck,
North Dakota 58505; telephone (701) 328-2440. Financial information for an insurance company, if the information
is not proprietary, is available at the same address and telephone number and on the Insurance Department
website at www.nd.gov/ndins.
Insurance companies and agents are not allowed by North Dakota law to use the existence of the Association or its
coverage to sell, solicit or induce you to purchase any form of insurance. When selecting an insurance company,
you should not rely on Association coverage. If there is any inconsistency between this notice and North Dakota law,
then North Dakota law will control.
HP-3203 6-19
