Close

Sanford Health Plan

Sanford Heart of America Health Plan, a Medicare Cost Plan (HMO)

Sanford Heart of America Health Plan, a Medicare Cost Plan (HMO) is a Medicare approved Cost Plan. Many Medicare beneficiaries find that managed care cost plans are a good way to get more health care for their dollar. Sanford Heart of America Health Plans (Cost) will provide or arrange for all Medicare covered services. This means if you join a managed care cost plan and get all of your services through the Sanford Heart of America Health Plan (Cost) your out-of-pocket costs are usually more predictable. Also, depending on your health needs, those costs may be less than you would pay if you were liable for the regular Medicare deductibles and co-insurance amounts.

What are the advantages of managed care cost plans?

  • No Medicare deductibles - only monthly premiums
  • No claim forms and virtually no paperwork for you
  • Local administration
  • Predictable expenses - so you can easily budget your health care dollars
  • No health screening, waiting periods or pre-existing condition clauses

Obtaining membership:

To join the Sanford Heart of America Health Plan (Cost), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the counties and zip codes in North Dakota listed here. You may not enroll in Sanford Heart of America Health Plan (Cost) if you currently have End-Stage Renal Disease (ESRD) unless:
a. You are a member of Heart of America Group/Commercial grandfathered plan in good standing and have been diagnosed with ESRD during your current membership, or
b. You do not need regular dialysis anymore.

How to enroll:

  • Call Sanford Heart of America Health Plan (Cost) and request an enrollment form:
    Sales: (701) 776-5848
    Customer Service: (877) 652-1845
    TTY/TDD: (877) 652-1844
  • For coverage terms, exclusions, contract termination, members rights and responsibilities, and other information, please refer to the 2017 Evidence of Coverage.
  • Please review the Summary of Benefits before enrolling.
  • Or download the Cost Plan Enrollment form on this site, complete it and mail or fax it to SHAHP.

Receiving care once you are enrolled:

The Sanford Heart of America Health Plan (Cost) coordinates its benefits with traditional Medicare coverage. As a member of the Sanford Heart of America Health Plan (Cost) you must receive all of your primary medical care through one of the SHAHPs' (Cost) Plan Physicians, except in the case of an emergency or urgent care out of the service area. Plan physicians can be found under the Provider Directory link or by searching our Online Provider Directory. The provider network may change at any time. You will receive notice when necessary.

If as a member of SHAHP (Cost) you need specialty care, you must obtain a referral from your primary care physician prior to receiving the specialty care. You can click the Referral Form link to see a sample of a referral form. (see below)

Premium and Cost Sharing

Monthly Plan Premium

You pay $140.00. This information is not a complete description of benefits. Contact the plan for more information. Benefits, premiums and/or cost sharing may change on January 1 of each year.

What you should know:

You must continue to pay your Medicare Part B premium. This Premium only includes your Part C Premium. It does not include Part D outpatient prescription drug supplemental coverage you may choose to buy separately from this plan.

Deductible

You pay nothing. This plan does not have a deductible.

Inpatient Hospital Coverage (includes Substance Abuse and Rehabilitation Services)
  • You pay nothing for each Medicare-covered stay in a network hospital up to 150 days per benefit period.
  • You pay 100% per day for each additional day beyond 150 days for each benefit period in a network hospital.
  • Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. Lifetime reserve days can only be used once.

What you should know:

  • You pay nothing for each Medicare-covered stay in a network hospital up to 150 days per benefit period.
  • You pay 100% per day for each additional day beyond 150 days for each benefit period in a network hospital.
  • Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. Lifetime reserve days can only be used once.
Doctor Visits
  • Primary Care (PCP): You pay nothing.
  • Specialist: You pay nothing. Referral from a PCP is required.

What you should know:

  • In most cases, you must go to network doctors, specialists, and hospitals. You will need a referral to go to a specialist or any provider out of the plan’s network. If you go to a provider without a referral and the provider accepts Medicare patients, you’re covered under Original Medicare.
  • You may go to any doctor, specialist or hospital that accepts Medicare. If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you pay more.
Preventive Care

You pay nothing. Any additional preventive services approved by Medicare during the contract year will be covered. There are some items not covered at $0 cost.

Emergency Care

You pay nothing.

What you should know:

  • If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care.
  • If the Plan authorizes your inpatient care at an out-of-network hospital after your emergency condition is stabilized, your cost is the cost sharing you would pay at a network hospital.
  • NOT covered outside the U.S. except under limited circumstances.
Urgently Needed Services (This is NOT emergency care, and in most cases, is out of the Service Area.)

You pay nothing. 

What you should know:

NOT covered outside the U.S. except under limited circumstances.

Diagnostic Services/ Labs/ Imaging
  • Diagnostic radiology service (e.g., MRI); You pay nothing.
  • Lab services: You pay nothing.
  • Diagnostic tests and procedures: You pay nothing.
  • Outpatient x-rays: You pay nothing.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Hearing Services
  • Hearing exam: You pay nothing for diagnostic hearing exam.
  • Hearing aids: Not covered.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information. Supplemental routine hearing exams and hearing aids not covered.

Dental Services

Preventive dental benefits (such as cleaning) not covered.

Vision Services

Not Covered.

Vision Services
  • Diagnosis & treatment of diseases and conditions of the eye: You pay nothing. One pair of eyeglasses or contact lenses covered after cataract surgery.
  • Supplemental routine eye exams and glasses: Not covered.
  • Annual glaucoma screenings: You pay nothing. Covered for people at risk.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Mental Health Services
  • Inpatient stays: You pay nothing for each Medicare-covered hospital stay for days 1-190. You pay 100% for each day beyond the 190-day limit. There is a 190-day lifetime limit in a psychiatric hospital.
  • Outpatient group / individual therapy visit: You pay nothing per outpatient group/individual therapy visit.
  • All other outpatient services: You pay nothing for Medicare-covered services, e.g. “Partial Hospitalization” or “Intensive Outpatient’ treatment programs.

What you should know: 

  • A referral may be required by your PCP for some services. Please contact the plan for more information.
  • Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
  • "Partial hospitalization program" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization.
Skilled Nursing Facility (in a Medicare-certified skilled nursing facility)
  • You pay nothing each day for days 1-20 each benefit period.
  • You pay nothing each day for days 21-100 each benefit period for Medicare-covered services.
  • You pay 100% for each additional day beyond 100 days each benefit period.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information. There is a limit of 100 days for each benefit period.

Rehabilitation Services
  • Occupational therapy visit: You pay nothing.
  • Physical therapy, and speech and language therapy visit: You pay nothing.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Ambulance

You pay nothing.

Non-Emergency Transportation

Not covered.

Foot Care (podiatry services)
  • Foot exams and treatment: You pay nothing.
  • Routine foot care: You pay nothing for medically necessary foot care. Supplemental routine care not covered.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Medical Equipment / Supplies
  • Durable Medical Equipment (e.g., wheelchairs, oxygen): You pay nothing.
  • Prosthetics (e.g., braces, artificial limbs): You pay nothing.
  • Diabetes supplies: You pay nothing.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Wellness Programs (e.g., fitness)

Not covered.

Medicare Part B Drugs

You pay nothing.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.)
  • You pay nothing for Medicare-covered home health visits.
  • You pay 100% for custodial care and respite care.
  • You pay 100% for homemaker services.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Hospice

When you enroll in a Medicare-certified hospice program, your hospice services and your Part A and Part B services related to your terminal condition are not paid for by Sanford Heart of America Health Plan, but instead by Original Medicare.

What you should know:

You must get care from a Medicare-certified hospice.

Chiropractic Services

You pay nothing for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

What you should know:

Supplemental routine care not covered. A referral may be required by your PCP for some services. Please contact the plan for more information.

Outpatient Substance Abuse Care

You pay nothing for each individual visit for Medicare-covered benefits. You pay nothing for each group visit for Medicare-covered benefits.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Outpatient Services/Surgery

You pay nothing for each Medicare-covered visit to an ambulatory surgical center. You pay nothing for each Medicare-covered visit to an outpatient hospital facility.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Diabetes Programs and Supplies

You pay nothing. 

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Cardiac and Pulmonary Rehabilitation Services

You pay nothing.

What you should know:

A referral may be required by your PCP for some services. Please contact the plan for more information.

Outpatient (Part D) Prescription Drugs

Not covered.

Member Rights
  1. You have the right to receive information in a way that works for you. This includes getting the information in languages other than English and in large print or other alternate formats
  2. You have the right to be treated with fairness and respect at all times.
  3. You have the legal right to be protected from discrimination and/or unfair treatment. Sanford Heart of America Health Plan does do not discriminate based on a person’s race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area.
  4. You have the right to get timely access to your covered services. This means that as a plan member, you have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care.
  5. As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services
  6. You have the right to go to a women’s health specialist (such as a gynecologist) without a referral.
  7. You have the right to have the privacy of your personal health information protected.
  8. You have the right to look at your medical records held at the plan, and to get a copy of your records.
  9. You have the right to ask us to make additions or corrections to your medical records
  10. You have the right to know how your health information has been shared with others for any purposes that are not routine.
  11. You have the right to know about the plan, its network of providers, and your covered services
  12. You have the right to get several kinds of information from us – information about our plan; information about our network providers; information about your coverage and the rules you must follow when using your coverage; and information about why something is not covered, and what you can do about it.
  13. If you are not happy, or if you disagree with a decision we make about what medical care is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal.
  14. You have the right to have the plan support your decisions about your care.
  15. You have the right to know your treatment options and participate in decisions about your health care.
  16. You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand.
  17. You have the right to participate fully in decisions about your health care.
  18. You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself.
  19. You have the right to make complaints and to ask us to reconsider decisions we have made.
  20. You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past.
Member Responsibilities
  1. You must be familiar with your covered services and the rules you must follow to get these covered services.
  2. If you have any other health insurance coverage in addition to our plan, you are required to tell us.
  3. You must tell your doctor and other health care providers that you are enrolled in our plan.
  4. You must show your plan membership card whenever you get your medical care.
  5. You must help your doctors and other providers help you by giving them information, asking questions, and following through on your care
  6. Be considerate
  7. Pay what you owe
  8. Tell us if you move. If you move outside of our plan service area, you cannot remain a member of our plan. If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you
  9. Call Member Services for help if you have questions or concerns.

 


Contact Information:

 

Mailing Address Sanford Heart of America Health Plan (Cost)
PO Box 1999
Fargo, ND 58107
   
Phone Numbers  
Sales: (701) 776-5848
Customer Service: (877) 652-1845
TTY/TDD:  TTY/TDD: (877) 652-1844
Fax:  (605) 328-6811
LanguageLine Solutions: (800) 892-0675
   
Hours of Operation Monday through Friday, 8:00 am to 8:00 pm

 


 

For calendar year 2016, this Medicare Cost Plan has received 0 appeals and/or grievances.

Sanford Heart of America Health Plan, a Medicare Cost Plan (HMO) is a Medicare Cost Plan with a Medicare contract. Enrollment in the Plan depends on contract renewal.


H3503_201605 Pending CMS Approval 
© 2010-2016 Sanford Heart of America Health Plan, a Medicare Cost Plan (HMO)

Last updated: 5/10/2017

happy mother and baby laying in meadow

Tell Us About Yourself

Insurance terms are confusing. Let us help make sense of it all.

Purchasing through Sanford Health Plan or the Marketplace, let us explain the differences

+ Add Another
thumbnial graphic for step 2

Tell Us About Yourself

Insurance terms are confusing. Let us help make sense of it all.

Purchasing through Sanford Health Plan or the Marketplace, let us explain the differences

thumbnail graphic for step 3

Tell Us About Yourself

Insurance terms are confusing. Let us help make sense of it all.

Purchasing through Sanford Health Plan or the Marketplace, let us explain the differences

Sanford Health Plan offers two different provider network products in your area. Select what option that best fits your needs.

Click here to search our provider directory. If your doctor does not display, they most likely are not a participating provider with Sanford Health Plan. Feel free to continue the Plan Picker tool if you are still interested in what options Sanford Health Plan has to offer. If not, we appreciate you using our Plan Picker!

Please complete all steps in the questionnaire to see your results.