Q. What is a plan provider?
A. A plan, or in-plan, provider is a doctor, hospital, pharmacy or other medical provider who has contracted with Dean Health Plan to provide services through our network and is listed in our provider directory. Nonplan providers are providers who do not participate in our network and are therefore not listed in the directory. Members who see plan providers will receive the highest benefit level available at the lowest out-of-pocket cost.
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Q. Must I choose a physician at the time of enrollment?
A. No, you are not required to select a Primary Care Physician. You simply choose the provider you wish to see at the time you seek services. However, you are encouraged to choose a physician that you feel comfortable seeing on a continuing basis.
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Q. I am currently seeing a provider who is not in the Dean Health Plan network. Will you pay for this service?
A. Yes. Any member can see plan providers for some services and nonplan providers for others. Covered benefits, deductibles, co-insurance and co-payment costs are calculated for each person, for each visit or treatment, depending on the provider chosen for that service. If you see a nonplan provider, services would be paid according to the out-of-network benefit level. Payment for charges submitted by nonplan providers are limited to the maximum allowable fee (after the deductible and co-insurance are applied).
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Q. My plan includes co-payments. What does this mean?
A. A co-payment is a fixed dollar amount that must be paid each time services are received. There is no annual limit, and they do not apply to the maximum out of pocket amount or the deductible. You should be prepared to pay your co-payment to the provider at the time of your visit.
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Q. What does it mean when my co-payment amounts do not apply to the maximum out-of-pocket?
A. This means that you will always pay the co-payment each time you receive the service. The co-payment amounts you pay do not accumulate to fulfill the maximum out-of-pocket amount stated in the brochure. Services in which a co-payment does not apply to the out-of-pocket maximum are indicated by an asterisk(*). Deductible amounts do apply to maximum out-of-pocket expense.
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Q. How are deductibles accumulated?
A. The deductible is the amount that you must pay before your insurance begins to cover expenses. For families, each member must meet the “single” amount to begin receiving benefits, but once the “family” amount has been met, no more deductibles will be collected for any family member. Deductible amounts are combined between plan and nonplan providers. Co-payments do not apply toward the deductible.
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Q. What if there are charges from a nonplan provider that are greater than the maximum allowable fee?
A. Payments for charges submitted by nonplan providers will be limited to the maximum allowable fee. Any amount that exceeds this is your responsibility and does not apply to the maximum out-of-pocket.
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Q. What about referrals and approvals?
A. Point members are not required to obtain referrals to see their physician of choice, even if that physician is a nonplan provider. However, some services of these providers do require prior authorization. If you use plan providers, the prior approval requirements are lessened. Please see your Member Certificate for more detailed information.
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Q. What should I do for a hospital admission?
A. For a planned hospital admission, you must call our Customer Care Center at (800) 279-1301 at least 10 business days before admission to obtain certification approval. For an emergency admission, you must call our Customer Care Center by the next business day for certification approval.
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Q. What is prior authorization?
A. Prior authorization is approval for certain prescription drugs, medical equipment purchase or rental and certain services. Some services require prior authorization only if received from a nonplan provider. It is the member’s responsibility to obtain prior authorization from Dean Health Plan before services are received and charges are incurred. If prior authorization is not obtained when required, benefits will be paid as follows:
- A benefit reduction amount (50% of the maximum allowable amount, up to $500 maximum per occurance) will be applied to other covered services. Any applicable deductible, co-insurance or co-payments will apply to the reduced amount.
- The benefit reduction amount will not apply to satisfaction of the out-of-pocket maximums.
To request prior authorization, or inquire whether or not you need prior authorization, please call our Customer Care Center at (800) 279-1301. A representative will make the necessary arrangements for your request to be filed.
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Q. Why are prior authorizations important?
A. When you call our Customer Care Center for prior authorization, we will verify coverage of the service or drug in question, notify you of co-insurance or deductibles that may apply, and provide information that may help you minimize your out-of-pocket costs. If you are receiving long-term treatment, we may assign a case manager who can help you understand your coverage for different provider and treatment options. In some cases, prior authorization helps us ensure that the health care services that you receive are coordinated between providers, and consistent with the guidelines for most effective care that have been written by our physicians. The prior authorization process benefits both of us!
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Q. What is a precertification?
A. Precertification is approval of an admission to a facility and/or the approval of a specified number of days for a facility confinement prior to the services being received. If possible, you must request precertification at least 10 days prior to the planned admission to allow time for us to review your needs and estimate the number of days of inpatient treatment required.
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Q.What if prior authorization or pre-admission certification is needed after hours?
A. You can call our Customer Care Center at (800) 279-1301 after hours and leave a message for prior authorization or admission certification. A representative will return your call the next business day.
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Q. Who is a qualified dependent?
A. A qualified dependent may be:
- a legally married spouse;
- an unmarried biological child from birth, adopted child, child placed for adoption, or stepchild to the maximum dependent age limitation selected by your employer;
- an unmarried legal ward residing with you in a parent-child relationship who is dependent on you for at least 50 percent of support and maintenance; or
- a grandchild, until the eligible parent dependent child reaches age 18.
Disabled children may also be covered after the limiting age. Please call our Customer Care Center for more information.
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Q. How are qualified dependents living outside the service area covered?
A. Qualified dependents who are currently living outside the service area may take advantage of the option to use nonplan providers and receive benefits at the reduced, nonplan level. To receive the higher plan provider benefit level, they must use plan providers.
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Q. What benefit level would apply if a plan provider advises me to see a nonplan provider?
A. The deductible, co-insurance or co-payment amount for a nonplan provider would apply. Please note whether prior authorization is necessary before receiving services.
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Q. How are prescription drugs covered?
A. If you fill your prescription at a plan pharmacy, you pay the appropriate plan provider co-payment. If you go to a nonplan pharmacy, you must pay for the full amount of the prescription, then submit a claim to Dean Health Plan to receive reimbursement at the reduced level. If you are out of the service area, you can receive plan provider benefits by utilizing one of the national pharmacies listed in the provider directory. Note that some prescription drugs require prior authorization. A list of these drugs can be obtained by calling our Customer Care Center.
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Q. What if I need to see a specialist?
A. You may choose to see either plan or nonplan specialists at any time without a referral. However, many services provided by specialists require approval prior to being received (see your Member Certificate). There are numerous area medical specialists affiliated with Dean Health Plan, including but not limited to Dean Medical Center, one of the largest multi-specialty clinics in the nation.
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Q. Is there an overall maximum benefit?
A. There is a lifetime benefit limit per member, combined between plan and nonplan providers. Please refer to your Member Certificate for the lifetime benefit maximum.
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