Health Insurance Definitions
Find definitions to common health insurance terms below or visit our Health Insurance FAQ's to learn more.
To ensure you are receiving in-network benefit coverage, you are required to use the Sanford Health Plan network. The network consists of nearly 15,000 providers in SD, MN, IA, NE and ND. NOTE: If you choose to go to a non-participating provider when in network access is available, your claims will be paid according to your out-of-network benefits.
What if there aren’t participating Sanford Health Plan providers in my residential area?
Sanford Health Plan has contracted with other networks for those members who reside, travel or attend school outside the Sanford Health Plan service area. If you have an additional network listed on your identification card, you may seek medical care from a provider that is participating with the additional network. If these additional networks do not provide you with access to a needed provider, the Sanford Health Plan Access and Availability rules will apply. Please refer to your Policy for details.
An Ancillary fee is an extra fee often associated with obtaining prescription drugs which are not listed on your health insurance plan’s formulary.
The total amount of your deductible plus coinsurance and copayment amounts is how you accumulate to reach your maximum out-of-pocket. However, there are differences in this based on the current status of your plan:
If your plan is grandfathered or non-grandfathered transitional, then the office visit, emergency room, and pharmacy copays do NOT apply towards your out-of-pocket maximum
If your plan is an ACA-compliant plan, in-network office visit, emergency room and pharmacy copays DO apply towards your out-of-pocket maximum.
• $1,000 = deductible paid by you
• $1,600 = paid by health insurance plan (80% of the remaining $2,000)
• $400 = paid by you (20% of the remaining $2,000)
Your responsibility = $1,400
Health insurance plan responsibility = $1,600.
Copayments do not apply towards the deductible.