Newsroom · Sioux Falls

Sanford vs. Avera: How Sioux Falls' Two Health Systems Shape Your 2026 Medicare Plan Choice

Your hospital network question comes before your premium question — and the data tells you exactly where the lines fall.

Big Sioux Benefits Data Desk

Published July 4, 2026 · 9 min read · Sourced from CMS.gov & CDC

In Sioux Falls, your Medicare plan choice is really a hospital network choice first, and a premium choice second. The city's care landscape runs through two competing health systems — Sanford Health and Avera Health — and each of the five standard Medicare Advantage PPOs available to Minnehaha County beneficiaries has a different relationship with those systems. Two are run by Sanford itself. Three are regional or national carriers whose networks include both. Before you look at premiums, look at where your doctors practice.

Every figure in this article comes from public federal data: the CMS PY2026 Medicare Advantage landscape, CMS Hospital Compare star ratings, CMS county enrollment, and CDC PLACES local health data. No invented numbers, no "call for pricing."

The Sioux Falls healthcare duopoly — and why it's your first Medicare question

Sioux Falls is a mid-sized city with a disproportionately large healthcare footprint. Sanford Health and Avera Health each operate full-service acute-care hospitals in the metro, along with extensive clinic networks, specialty practices, and long-term care facilities throughout eastern South Dakota. For most Sioux Falls residents, every meaningful healthcare relationship runs through one of these two systems — primary care, specialists, labs, imaging, pharmacy partnerships, and hospital stays.

That concentration means your Medicare plan's network is effectively a choice between two health systems — and switching plans can mean switching health systems, which can mean switching doctors. That's a real disruption, especially for the roughly 31.7% of Minnehaha County adults managing high blood pressure or the 10% managing diabetes, who may have established long-term relationships with specific specialists. The plan-choice question is therefore not abstract: which system do your current doctors practice in?

A third option exists for veterans. The Sioux Falls VA Medical Center — also a 5-star rated facility — operates as an entirely separate network. Dual VA + Medicare beneficiaries face their own coordination picture, covered in our Veterans & Medicare guide.

Hospital quality by the numbers: what CMS star ratings tell you

CMS publishes an Overall Hospital Quality Star Rating for every Medicare-participating hospital in the country, scoring each facility on five domains: mortality, safety of care, readmission, patient experience, and timely and effective care. The rating runs from 1 to 5 stars; both Sioux Falls flagship hospitals land in the strong tier:

Source: CMS Hospital Compare — Overall Star Ratings.

The one-star gap between Sanford (5★) and Avera McKennan (4★) reflects relative performance across these five quality domains — both are above-average facilities by national standards. For most Medicare beneficiaries, the practical implication is not "one hospital is risky" but rather "both are strong, so the network question comes down to your specific doctors, not a quality gap large enough to override other factors."

What the star ratings do tell you: if you're choosing between two plans of equivalent premium and your physicians are split between systems, the 5-star Sanford rating is a mild tiebreaker in favor of the Sanford-primary plan. But "mild" is the operative word — a 4-star hospital is still in the top tier nationally.

Which plans align with which network in 2026

Here's where the premium table becomes a network-alignment table. Two of the five PPOs are operated directly by Sanford Health under the Align brand — making Sanford USD Medical Center and Sanford's clinic network the natural preferred-network anchor for those plans. The other three plans (two Aetna variants and the Wellmark plan) are operated by regional or national carriers whose PPO networks include both Sanford and Avera providers, typically at the same in-network tier.

Source: CMS Medicare Advantage / Part D Landscape (PY2026) & CMS Medicare Advantage & Part D Star Ratings (2026), Minnehaha County 2026. Network-alignment notes based on carrier contract (H8385 = Sanford Align; H1608 = Aetna; H5900 = Wellmark/BCBS).

Notice that the $0-premium plans are split: one is Sanford-backed (Align ChoicePlus) and one is Aetna (Medicare Signature), which includes both systems. So even beneficiaries on a tight premium budget have both network options available at $0 per month. The drug deductible difference — $350 for Align ChoicePlus vs. $615 for Aetna Medicare Signature — is where the two $0-premium plans diverge meaningfully.

The PPO safety net — out-of-network access is built in

One of the most important things to understand about the Sioux Falls Medicare Advantage market: there are no HMO plans here. Every standard Medicare Advantage plan available in Minnehaha County for 2026 is a PPO — a Preferred Provider Organization. That distinction matters enormously for the network question.

In an HMO, out-of-network care is generally not covered at all (except in emergencies). In a PPO, out-of-network care is always allowed — you pay a higher cost-sharing rate, but the door is not closed. So even if you enroll in an Align plan and need to see an Avera specialist, you're not locked out. You just pay at the out-of-network tier rather than the in-network tier. The same logic applies in reverse: an Aetna or Wellmark enrollee who needs to use Sanford's specialty services can do so.

This PPO flexibility is the reason the Sioux Falls network question is a cost question, not a coverage question. The 2026 Part D out-of-pocket cap of $2,100 applies to your drug spending regardless of network. And while the drug deductible varies ($300–$615 depending on plan), it's the same for in-network and out-of-network drug coverage at most local plans. The financial exposure from a network mismatch is in cost-sharing for medical services — specialist visits, diagnostic tests, outpatient procedures — not in coverage denials.

The practical implication: if you're 90% Sanford but occasionally see one Avera specialist, an Align plan with that specialist used at the out-of-network PPO tier may still pencil out — especially given Align's lower drug deductible. Run the math with your actual specialist visit frequency, not just the plan premium.

What your health profile says about which network you need

The chronic-condition profile of Minnehaha County tells a clear story about why network depth matters for the local Medicare population. CDC PLACES 2023 model-based estimates for adult residents show:

Source: CDC PLACES: Local Data for Better Health, County 2023 (2023 release), Minnehaha County adult prevalence estimates.

High blood pressure (31.7%) and diabetes (10%) are the two conditions most likely to drive regular specialist visits — cardiologists, endocrinologists, nephrologists, and podiatrists. Both Sanford and Avera maintain strong specialty programs in these areas, but individual specialists at each system may have different wait times, referral pathways, and availability. If you've been managing a chronic condition with a specific physician for years, confirming that physician's in-network status on any plan you're considering is the non-negotiable step.

Arthritis (22.9%) and depression (22.3%) add orthopedic and behavioral-health network depth to the mix. Both systems offer these services; the question is whether your current orthopedic surgeon or therapist is in-network on a given plan. For mental health, note that Medicare Advantage plans are federally required to cover behavioral health at parity with medical benefits — the network check matters here too, since "covered" and "your specific provider is in-network" are different things.

COPD (5.6%) and coronary heart disease (5.5%) point toward pulmonology and cardiology access. For beneficiaries managing these conditions, hospital proximity and emergency network status matter more than for routine conditions — confirming which system your pulmonologist or cardiologist practices in, and which emergency department you'd be transported to in a crisis, is especially important.

The D-SNP and Medicaid dual-eligible network picture

For the 122,936 South Dakotans enrolled in Medicaid as of February 2026 — including those who are dual-eligible for Medicare and Medicaid — the network picture has an additional layer. Minnehaha County offers four Dual-Eligible Special Needs Plans (D-SNPs):

Source: CMS Medicare Advantage / Part D Landscape (PY2026) & CMS Medicare Advantage & Part D Star Ratings (2026).

UnitedHealthcare's two D-SNP plans carry a 4.5-star CMS rating — the highest of any plan in the county — and are operated independently of either local health system. Aetna's two D-SNP plans carry the same 3.5-star rating as the standard PPOs. All four D-SNPs are "coordination-only" plans, meaning they coordinate Medicare and Medicaid benefits but Medicaid coverage is administered separately through South Dakota's Medicaid program. For dual eligibles, Medicaid-contracted providers may determine care access as much as the Medicare plan network does — both need to be verified before enrolling.

Statewide carrier presence: how the networks reach beyond Sioux Falls

If you travel, spend winters elsewhere in South Dakota, or split time between Sioux Falls and another SD county, statewide carrier reach matters. Here's how the organizations serving Sioux Falls compare in their statewide footprint:

Source: CMS Medicare Advantage / Part D Landscape (PY2026), statewide (all plan types).

Sanford Health's Align plans serve 30 counties — concentrated in eastern South Dakota where Sanford Health systems operate. If you plan to spend extended time in Rapid City, Pierre, or western SD counties, confirm that your Align plan's in-network footprint reaches those areas, or verify that the PPO's out-of-network coverage will be sufficient. UHC (48 counties), Medica (all 66 counties), and Wellmark (43 counties) have broader statewide reach — an advantage for beneficiaries who are mobile across the state. Aetna's 35-county footprint is solid but not statewide; verify your western-SD location if applicable.

What to watch through the rest of 2026

1. Verify your 2026 in-network status now, not at AEP. Networks can change mid-year if a provider leaves a plan's roster. If you're already enrolled, call your plan or use its provider directory to confirm your Sanford or Avera physicians are still in-network today.
2. Watch for Annual Notice of Change (ANOC) letters in September. Arriving by September 30, your ANOC will show any 2027 network, premium, or formulary changes. A network contraction that affects your system access is a valid reason to switch during AEP (Oct 15–Dec 7).
3. Track CMS star-rating updates in October. CMS typically releases the following plan year's star ratings in the fall. A plan jumping to 4+ stars would unlock the 5-star Special Enrollment Period (year-round switching); a drop below 3 stars is a warning signal. The current 3.5-star rating for all five standard PPOs means no year-round switching is available for 2026.
4. If you're turning 65 this year, use your Medigap guaranteed-issue window. The one-time guaranteed-issue right — no medical underwriting — only applies during your Initial Enrollment Period and a short window after. Medigap supplements work with any Medicare-accepting provider nationwide, making the Sanford-vs-Avera question moot. But once the window closes, underwriting applies in South Dakota.
5. Review your Part D deductible against the $2,100 cap. If you're on multiple brand-name medications, the gap between a $300 and $615 drug deductible matters more than the plan's monthly premium. Model your expected annual drug spend against the cap — a licensed agent can run this with your actual formulary.

How we know all this: Big Sioux Benefits runs every article through a data desk that cross-references the CMS PY2026 Medicare Advantage landscape file, CMS Hospital Compare overall star ratings, CMS county enrollment data, CMS 2026 plan-level star ratings, and CDC PLACES local health data — built and maintained by Strategic AI Architects. Every figure is traceable to a public federal dataset. This is education, not advice; confirm your plan, network status, and costs with a licensed agent or Medicare.gov before enrolling. We receive no payment from any carrier to feature a plan.