A Guide to North Dakota Medicaid and Sanford Health Plan

Residents of North Dakota can enroll for medical care with Sanford Health Plan. It is the largest rural health system in the country, dedicated to providing free or low-cost healthcare in the heartland of America. Sanford Health Plan provides medical coverage for those who qualify, as well as perks like discounts on apparel, electronics, and entertainment. Sanford Health Plan knows that overall wellness encompasses more than just medical treatment. As of July 2023, North Dakota’s Medicaid program supported 124,926 eligible people. To prevent shouldering the debt of unexpected medical expenses, many North Dakotans extend their Medicaid coverage to include a more comprehensive range of benefits and services by way of private health insurance.

    What Is the Sanford Health Plan?

    Sanford Health Plan provides low-cost health coverage to people in Minnesota, Iowa, and North and South Dakota. The goal is to provide affordable medical care to residents in the upper Midwest.

    Sanford Health believes everyone should have access to healthcare no matter where they live. The program aims to serve diverse communities through a healthcare system that reaches far into rural areas.

    Members receive access to services like doctor’s appointments, home health care, and transportation to medical visits.

    The basic Sanford Health Plan enrollment covers common medical procedures, but it does not cover everything. Before choosing a health plan, assess your expected medical needs, including prescription medications, doctor’s visits, and yearly exams. If you aren’t sure what procedures and treatments are covered, review the information provided in this article and always reach out to a Sanford Health Professional at 1-888-315-0886.

    How Much Does the Sanford Health Plan Cost?

    The cost for Sanford Health Plan depends on your quoted premium in the Healthcare Marketplace. If you want to determine how much a procedure or medical visit will cost, you can log into your My Sanford Chart account. Under the Billing menu, select “Estimates” to determine the costs of common medical treatments under your plan.

    You can pay your monthly premium from your phone or computer through your MyChart account. You also have the option to set up autopay to withdraw your monthly premium automatically on a set date.

    What Is a Sanford Health Plan Card?

    North Dakota Medicaid

    Your Sanford Health Plan card contains important information about your health plan. You must show it to each healthcare provider and your pharmacy to receive benefits. Failure to do so could result in denial of care or a hefty bill you cannot afford.

    The card shows your name, insurance plan, and your network information. It also lists your copay information so that if you get charged a different amount, you have proof of what you owe.

    The card includes your policyholder ID number and group ID number if you have one.

    On the back, you will find contact information if you need to speak with a customer service representative or request prior authorization for a medical service.

    How To Apply for Sanford Health Plan

    If you are not eligible for North Dakota Medicaid, or if you currently have Medicaid but are losing your benefits in the near future, you may qualify for the Sanford Health Plan.

    Prospective members can contact the sales team during regular business hours by calling 888-535-4831 or sending the main office an email at sales@sanfordhealth.org. You can also choose your health plan online.

    Note that regardless of how you choose to apply, before submitting the application, you’ll need to provide the right documentation. A few documents you may need include the following:

    • Proof of name, birth date, and Social Security Number
    • Rent or mortgage payment history
    • Recent utility bills
    • Recent medical bills
    • Bank statements
    • Pay stubs
    • Medical records that prove your disability or non-healing condition
    • Proof of North Dakota citizenship

    Eligibility Requirements

    To enroll in Sanford Health Plan, you should go through the Healthcare Marketplace. There, you can shop for a plan that fits your budget and the medical needs of you and your family.

    When you access the Healthcare Marketplace website, you will answer a few questions to determine your eligibility. The questions include things like:

    • Household size
    • Level of medical needs
    • Annual gross income

    Once you fill out the eligibility portion, you will see a range of plans with different premiums, deductibles, and copays. The out-of-pocket costs vary depending on your expected healthcare needs.

    The income limits to qualify for the program are as follows:

    Household Size Maximum Income Level (Per Year)
    1 $19,392
    2 $26,228
    3 $33,064
    4 $39,900
    5 $46,737
    6 $53,573
    7 $60,409
    8 $67,245

    Getting a Sanford Health Plan Card

    When you enroll in Sanford Health Plan, you will receive an Explanation of Benefits handbook in the mail, along with a member card. The card contains your personal member number. Your physician, pharmacy, and any other healthcare provider will need your member number to bill your insurance.

    Keep your member card with you at all times so you can receive medical care in the event of an emergency if you are unable to communicate.

    Renewing or Replacing Your Sanford Health Plan Card

    If you lose your Sanford Health Plan card, you should request another one as soon as possible. It may take some time to receive your new card, and you could end up having to postpone medical care without proof of enrollment.

    Renewing or replacing your card is easy. All you have to do is log into the Sanford Health Plan website and follow the prompts to request a card. You will need your login ID and password to access the website.

    Sanford Health Plan Coverage

    With North Dakota Medicaid, you can get access to top-quality healthcare services without the financial burden. The state’s Medicaid program comes with a wide variety of coverage options, ensuring that people in need receive the same level of treatment as their more fortunate neighbors.


    Sanford Health Plan provides dental care for members aged 19 and 20 specifically. That includes a routine exam twice per year along with the following:

    • Cleaning
    • Extraction
    • Fillings and crowns
    • Root canals
    • Exams and X-rays
    • Screenings
    • Sedation

    Prescription Drugs

    The North Dakota Department of Human Services administers prescription drug benefits. If you need prescription drug coverage, you will receive a separate membership card in the mail. A list of the North Dakota drug formulary can be found here. North Dakota has an assistance program available called Prescription Connection for citizens who need financial help to get their prescription medications. To qualify for Prescription Connection, you must meet certain criteria:

    • You must reside in North Dakota
    • You must fall within the income restrictions that designate you as a low-income household
    • You must not qualify for any other state programs for financial help obtaining prescription medication

    Professional Prescription Advice

    If you need help navigating the process of finding prescription drug coverage, reach out to Professional Prescription Advice. Their mission is to help everyone get the medications they need at little or no cost. A representative will ask you questions about which medications you need and then guide you through the list of low- or no-cost clinics and various programs to help you receive the medications you need.


    NeedyMeds provides online assistance to people who need help with healthcare costs and prescription medication coverage. They do not require you to submit any personal information, and their services are always free. They guide you through the available Patient Assistance Programs to help you find free or low-cost prescription medications.

    The digital NeedyMeds drug discount card helps alleviate some of the financial burden for prescription medications by providing up to an 80% discount. There is no cost for the card, and you can use the discount for your entire family. All you need to do is download the digital card to utilize the discount.

    Extended Health Care

    Sanford Health Plan does not generally cover long-term care. If you or a member of your household needs an assisted living facility or other long-term care options, there may be some coverage available through North Dakota Medicaid. While routine checkups and basic medical treatments will only get you so far, many patients require additional care, but they go without because of financial concerns, lack of coverage, and restricted access. Investing in quality disability insurance is an excellent way to assist with some of the costs incurred with not being able to work either temporarily or permanently, and to help with the cost of medical needs.

    Travel and Out-of-State Coverage

    If you travel out of state and need medical care, you may end up with a huge bill. Sanford Health Plan does not pay for care from an out-of-network physician or hospital unless no in-network provider offers the care you need.

    If you have a medical emergency, Sanford Health Plan may cover your emergency care outside your network. If you receive emergency care while traveling, notify your primary care provider as soon as possible to schedule a follow-up visit. If you are traveling outside of North Dakota for leisure, invest in proper travelers insurance.

    Students and Seniors

    College students who attend schools outside of the coverage area can receive emergency care while at school. Any non-emergency medical care should occur within the covered network to avoid paying for the service out of pocket. Students can enroll in the Signature Series Plan if they need non-emergency doctor visits and coverage while at school.

    Sanford Health Plan continues to provide coverage to members as they enter their senior years with the goal of helping people maintain their independence as long as possible before entering into a long-term care facility. Each medical team works to create an individualized treatment plan tailored to the needs of each patient. Some of the available services are:

    • Geriatric medical appointments with a physician who specializes in treating people in their advanced years
    • Nutrition assistance to help seniors eat healthy and balanced meals
    • Short-term care where patients can rest and recover after getting discharged from the hospital
    • Assisted living access that helps patients find a facility that can offer each patient the kind of care they need
    • Memory care services that allow for diagnosis and treatment of chronic diseases like Alzheimer’s and dementia

    Coverage for Subgroups

    If you fall under one of the following subgroups, you could be eligible to receive specialized care under Sanford Health Plan.


    Sanford Health Plan provides comprehensive medical care to members of the military who currently serve or have served previously. They offer programs and opportunities created for members of the military and their families.

    Some of the available programs are as follows:

    • Veteran Ambassador Program: This program relies on volunteers with past military experience to visit hospitalized veterans.
    • Sanford Veterans Clubs: There are currently two clubs: one in Fargo, North Dakota, and one in Sioux Falls, South Dakota. Each club gives veterans a place to relax and enjoy coffee, internet access, and games. It provides a space to talk with other veterans or wait to receive medical treatment.
    • Veteran Information Hotline: Veterans enrolled in Sanford Health can call 800-949-1848 with any questions regarding their plan.

    Native Groups

    Sanford Health works to provide Native Americans with access to healthcare through the Native American Community Outreach initiative. One of the goals of NACO is to provide nearby access to healthcare, including spiritual services while in the hospital.

    What Sanford Health Plan Does Not Cover

    Sanford Health Plan does not cover every medical treatment and procedure. The Explanation of Benefits you receive in the mail will go into further detail.

    Sanford Health Plan does not cover treatment from providers outside of your network unless you get prior approval or you have a medical emergency.

    Any care you receive before enrolling in Sanford Health Plan or after your membership ends is not covered.

    Other areas Sanford Health Plan does not cover include:

    Elective or cosmetic procedures
    Workers’ compensation treatment or care
    Allergy testing for non-fatal allergies
    Infertility treatment

    It is also important to note that North Dakota Medicaid will allow the allocation of some funds to be set aside for the costs related to funerals and burials, however they must be designated before the person's death. The policy surrounding this part of the program can be read here. While a small amount of assistance is available, medicaid certainly won’t cover the whole cost. Securing yourself and your family with comprehensive funeral insurance is advisable.

    If you have questions about what procedures are included in your health plan, consult your North Dakota Medicaid policy manual.

    Getting Prior Approval for Care or Prescription Medications

    Some medications and treatments require prior approval. If you don’t get prior approval, you could end up paying for the medication or medical care you receive.

    Services that require prior approval with Sanford Health Plan include:

    • Outpatient surgery
    • In-home healthcare
    • Bariatric surgery
    • Cochlear implants
    • Prosthetics and orthotics

    Prior approval doesn’t mean your service won’t be covered; it just means you need to get approval before you move forward. If you aren’t sure a service or medication has prior approval, call the Sanford Health Plan help desk at 855-276-7214 and also refer to this pre-authorization document.

    You should try to get approval as far in advance as possible. Sanford Health Plan reviews each request individually, and it can take up to 14 days to receive a response of approval or denial. If Sanford Health needs to contact your doctor or medical team, it could take longer to get a response. You will receive a letter in the mail if the process takes longer than 14 days.

    There are some terms that allow you to request expedited approval. Those conditions include:

    • If you are in physical pain and waiting for approval for a procedure that will provide you with relief
    • Waiting the 14 days for approval will put your life in danger
    • In these cases, Sanford Health Plan will process your pre-approval request within 72 hours

    24/7 Virtual Care With Sanford Health Plan

    Anyone who enrolls in Sanford Health Plan receives access to 24/7 virtual care. The virtual option makes health care more accessible by allowing patients to meet with their doctor without taking time away from work or family responsibilities to drive to an office or clinic.

    Virtual care includes:

    • E-visits with a Sanford Health Plan provider. Patients can fill out a questionnaire for non-emergent problems and receive a response within the same day.
    • Telehealth visits allow patients to see their doctor for an appointment via a video call. This arrangement is ideal for doctor’s visits that don’t require a physical exam, like cold and flu visits.
    • Diagnostic exams use a special device you receive in the mail to help your physician administer an exam virtually. A virtual diagnostic exam helps patients form a treatment plan and allows doctors to prescribe medicine without an in-office visit.

    Some virtual care is included with the basic Sanford Health Plan, while some requires an additional fee or enrollment in a different branch of the plan. Consult your explanation of benefits or reach out to customer service to determine the cost of your virtual care.

    Common Procedures and Sanford Health Plan Eligibility

    If you're not acquainted with North Dakota Medicaid, navigating its details might be perplexing and daunting. Below, we've outlined typical procedures and eligibility criteria to provide clarity, ensuring you're well-informed and prepared for potential costs without unexpected surprises.

    Your plan includes routine dental care for members aged 19 and 20 only. For members over age 21, coverage includes treatment for damage to your natural teeth, assuming the damage is not due to biting or chewing. Services must be performed by a dentist who has enrolled in the North Dakota Medicaid program. More covered services are:
    X-Rays Yes
    Sealants Yes
    Fillings Yes
    Teeth cleaning Yes
    Dental exams Yes, twice per year
    Adult vision care is not covered. Members aged 19 and 20 can receive routine eye exams at no cost. For those eligible, the following vision services are covered and must be performed by an eye doctor who is enrolled in the program:
    Eye Exams Yes, once per year
    Lenses Certain lenses only are covered
    Contact lenses Only with prior approval and with a medical necessity
    Rhinoplasty Covered only if they are deemed medically necessary and not cosmetic or elective. They may require pre-authorization.
    Breast Reduction Covered only if they are deemed medically necessary and not cosmetic or elective. They may require pre-authorization.
    Hospital stays Hospital stays require prior authorization, and you will owe 20% coinsurance after you meet your deductible. You do not have to pay any physician or surgeon fees.
    Ambulance transportation You will pay 20% coinsurance for emergency transport and 20% for emergency room care.
    Giving birth You won’t owe any payment for office visits. For the birth, you will owe 20% coinsurance after meeting your deductible.
    Therapy and Counselling
    The plan covers office visits related to mental health or substance abuse, including physicians, counselors, and outpatient treatment. There is no cost for mental health or substance abuse treatment.
    Mental Health
    Physical and mental health are closely related. Sanford Health Plan covers various tests and treatments to improve and maintain mental and emotional well-being.
    Depression screening Members aged 12 and up can receive a depression screening.
    Sexual Health
    Sanford Health Plan provides wellness exams to diagnose diseases and illnesses in their early stages.
    Breast exams Patients between the ages of 35 and 39 receive one baseline mammogram. After age 40, they can receive one mammogram per calendar year.
    Birth control Contraception coverage varies according to plan. Birth control pills are generally covered, as are counseling and education on available products and services.
    Cervical cancer Those with a cervix can receive a Pap smear once every three years. Those aged 30-65 can receive an HPV DNA test every five years.
    Chlamydia screening Adolescents and women can receive one chlamydia screening per calendar year.
    Human immunodeficiency virus (HIV) Anyone age 11 and up can receive one HIV test per calendar year.
    HIV treatment Anyone who tests positive can receive medication with prior authorization. Those who test negative can receive preexposure prophylaxis, or PrEP.

    Immunizations are a vital part of medical care. They help prevent the spread of disease in children and adults. Sanford Health Plan covers immunizations, but they must be administered according to the CDC vaccine schedule.

    Some of the covered vaccines include:

    • Flu
    • Chickenpox (varicella)
    • MMR (measles, mumps, and rubella)
    • DTaP (diphtheria, tetanus toxoids, and acellular pertussis)
    • COVID-19
    • HPV (human papillomavirus), according to gender and age
    Specialist Services
    The following are covered, but there may be some limitations. Always refer to the explanation of benefits for your specific plan.
    Dermatology Yes, limitations may apply
    Physiotherapy Yes, limitations may apply
    Massage Therapy Yes, limitations may apply
    Podiatry and Foot Care Yes, limitations may apply
    Allergy Testing Yes, limitations may apply
    Sleep Physician Services and CPAP Machines Yes, limitations may apply

    Extending Sanford Health Plan Coverage

    The North Dakota Medicaid expansion broadens the scope of who can qualify for Medicaid and receive medical benefits that could improve their quality of life. North Dakota wants to make healthcare accessible for as many of its residents as possible.

    The sooner you start the process of obtaining medical coverage, the sooner you can receive the care you need. Starting the process before your current coverage ends can help avoid a lapse in coverage that could cost you thousands of dollars if you have a medical emergency or need treatment right away.

    Insurdinary helps people through the confusing process of finding adequate insurance for medical treatment and prescription medication costs in the United States and Canada. You can find help with all types of insurance, including disability, life, and travel insurance, at the best possible rates.


    How long does it take to get approved for North Dakota Medicaid?

    The approval timeline for North Dakota Medicaid varies based on individual circumstances, with an average processing time of approximately 45 days. Urgent cases may undergo expedited processing for quicker approval.

    What are the methods to apply for North Dakota Medicaid?

    You can apply for North Dakota Medicaid through several channels: online, in person, by mail, or at a local Department of Human Services office. Ensure that you submit necessary documents, including proof of income, household size, and residency, along with your application.

    Does North Dakota Medicaid cover the expenses of funerals?

    No, North Dakota Medicaid primarily provides healthcare coverage and does not include benefits for funeral expenses. If you require assistance with funeral costs, consider exploring alternatives such as funeral insurance.

    Who is eligible for North Dakota Medicaid?

    Eligibility for North Dakota Medicaid is determined by factors such as income, household composition, and other considerations. Typically, the program extends coverage to low-income individuals, families, pregnant women, children, elderly individuals, and those with disabilities.

    What is North Dakota Medicaid?

    North Dakota Medicaid is a program designed to provide medical coverage to eligible low-income residents of the state. Funded jointly by federal and state resources, its purpose is to ensure access to essential healthcare services for those who meet the qualifying criteria.

    What other types of insurance does Insurdinary offer?

    Insurdinary, and its network of partners offer many different types of insurance. In addition to health, dental, disability, life, funeral and travel insurance as discussed on this page, you may also be interested to explore the following:


    1. https://www.sanfordhealth.org/medical-services/internal-medicine/geriatric-medicine
    2. https://www.sanfordhealthplan.com/-/media/files/documents/employer-resources-toolkit/853-778-762-booklet-shp-large-group-new-employer-guide.pdf
    3. https://www.sanfordhealth.org/patients-and-visitors/patient-information/veteran-and-military-services
    4. https://www.aha.org/role-hospitals-sanford-health
    5. https://www.sanfordhealthplan.com/-/media/plan-documents/2022/hp_2801_2022_sg_nd_simplicity_500.pdf
    6. https://www.sanfordhealth.org/patients-and-visitors/billing-and-insurance/price-estimates
    7. https://www.insurance.nd.gov/consumers/prescription-connection#:~:text=For%20more%20information%20or%20to,Intake%20Application%20(SFN%2058370)
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