North Dakota

Individual TRUE

Certificate of Coverage

Help understanding this document is free. If you would like this Certificate of Coverage in another format (for example, a larger font size or a file for use with assistive technology, like a screen reader), please call us at (800) 752-5863 (toll- free) | TTY/TDD: (877) 652-1844 (toll-free). Help in a language other than English is also free. Please call (855) 857-4426 (toll-free) to connect with us using free translation services.

Sanford Health Plan HP-1601 1-18 ND Individual TRUE

Welcome to Sanford Health Plan

Welcome to Sanford Health Plan. We are pleased to have you as a Member and look forward to providing you and your enrolled Dependents with Services.

In exchange for your completed application, and payment of the Premium as shown on your application, we will pay benefits of this Certificate of Coverage according to its provisions.

PLEASE NOTE: This Contract has no Out-of-Network coverage except when Urgent or Emergent Care is Medically Necessary. Please read this Certificate of Coverage carefully and pay close attention that you are receiving care from In-Network Participating Practitioner and/or Providers.

This is your Certificate of Coverage, which explains each feature of your coverage. This Certificate replaces any prior policies you may have had. We hope you find your Certificate easy to read and helpful in answering your health coverage questions. Your Certificate is the legal document representing your coverage so please keep it in a safe place where you can easily find it.

Individual Certificate of Coverage Renewal Provision Coverage under this Contract is guaranteed renewable at the discretion of the Subscriber except as permitted to be canceled, rescinded, or not renewed under applicable Law and as described in Section 2 How Coverage Ends. To keep the Certificate of Coverage in force, you must pay each Premium on its due date or within the grace period. We may change the Premium annually, but only if we change the Premium for all contracts of this product type. Right to Cancel and Return Your Contract We want you to be satisfied with this Contract. If you are not satisfied, you may cancel it within ten (10) calendar days after receiving it by mail or delivering it to us. If returned, the Contract will be considered void from the original effective date and we will refund any Premiums paid. If we have paid claims for you during this inspection period, we have the right to recover any amounts we paid.

Disclaimer The ACA includes provisions to lower Premiums and reduce Cost Sharing for individuals with low to modest incomes through advance payment of premium tax credits and Cost Sharing reductions. Such affordability programs are available only for qualifying individuals who purchase health insurance coverage through the Federal Marketplace. Please be advised that this Contract will only qualify for these affordability programs if it is obtained and issued through the Federal Marketplace. How to Contact Us If you have any questions about provisions of this Certificate of Coverage, please write or call: Sanford Health Plan 300 Cherapa Place, Suite 201 PO Box 91110 Sioux Falls, SD 57103 Phone: (877) 305-5463 (toll-free) | TTY/TDD: (877) 652-1844 (toll-free)

Sanford Health Plan HP-0346 1-17 ND Non-GF Individual/TRUE

Certificate of Coverage Table of Contents Free Help in Other Languages ...... a Notice of Privacy Practices ...... 3 Introduction ...... 5 How to Contact Sanford Health Plan ...... 5 Member Rights ...... 5 Member Responsibilities ...... 6 Authorized Certificate of Coverage Changes ...... 6 Governing Law ...... 6 Incontestability ...... 6 Physical Examination ...... 6 Legal Action ...... 6 Premium Refund in the Event of Death ...... 7 Disclosure Statement ...... 7 Service Area ...... 7 Medical Terminology ...... 7 Definitions ...... 7 Conformity with State and Federal Laws ...... 7 Special Communicat