Q. How can I change my Primary Care Provider (PCP)?
A. Please call Customer Care Center at (800) 279-1301 to change your PCP. Please remember to file a Health Insurance Information Change form (found at your payroll/personnel office) displaying the effective date of the change as indicated from Dean Health Plan, and submit it to your payroll office.
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Q. Do I need a separate ID card specifically noting that I have Ameritas Group Dental insurance?
A. Yes. There will be a separate ID card issued for your dental coverage.
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Q. I am a current Dean Health Plan member, what should I do to continue my coverage with Dean Health Plan?
A. You do not have to do anything to continue your coverage with Dean Health Plan.
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Q. How do I get a provider directory?
A.You may use our provider directory on this web site and search by name or location. You may also call us at (800) 279-1301 or and use our automated system to have a provider directory sent to you. Please choose menu options 3, 1, 2, 4 on your telephone keypad and answer the questions. A provider directory will be mailed to you immediately.
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Q. Can I still see the doctor I am currently seeing?
A. If your doctor is a Dean Health Plan provider, you may continue to receive services from this doctor. If this is your Primary Care Provider you can select this doctor as your PCP when you complete an enrollment application. Search the provider directory.
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Q. If my current physician is not part of the Dean Health Plan network; can I get a referral so I can continue to see this doctor?
A. If your doctor is not a Dean Health Plan doctor, you do need to choose a plan doctor. You may check the provider directory on our website to locate a plan doctor.
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Q. Can family members have different PCPs?
A. Yes, each family member may choose a different PCP.
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Q. What is a referral and when do I need one?
A. A referral request is a form sent to Dean Health Plan by your PCP or specialty physician requesting permission for you to receive outpatient treatment by another provider outside of the Dean Health Plan network. Services by out-of-plan providers are approved if the requested service is not available in plan.
Your referring physician may request a referral for up to one year. However, your physician or Dean Health Plan may limit the number of visits, type of service, or length of time. An approved referral expires when one of these limits is reached. For example, you may receive a referral to see an out-of-network specialist for three visits over the next three months. If you used only two visits and three months have elapsed, the third visit is not authorized. Or, if you used three visits in two months’ time, the referral is not valid for the remaining month. Before receiving additional care, you must contact your referring physician for another referral request. As a DHP member, it is your responsibility to obtain a valid referral request for out-of-network care. Please keep in mind—a referral request does not authorize payment of non-covered or exhausted benefits. Services are subject to all benefit maximums, policy limitations, and eligibility requirements. Please refer to the “It’s Your Choice” book for benefit limitations.
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Q. In what way does Medicare Eligibility affect my DHP insurance coverage?
A. You should contact your payroll office, if “active at work” or the ETF, if retired/on COBRA. You can also contact the DHP Medicare COB Analyst through our Customer Care Center for eligibility questions.
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Q. If I am an active employee, how may I expect my claims to process?
A. It is important to understand that many factors influence treatment costs, such as the intensity of the condition and individual physician rates. We encourage you to verify that the price estimate you request accurately reflects the services you will receive.
Please note copay and co‐insurance amounts apply, as outlined in your It’s Your Choice Decision Guide.
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Q. What if I am a retiree who is a Medicare Prime member?
A. If you are a Medicare Prime member, your benefits remain under the full‐pay plan (just as in 2011). However, your non‐Medicare covered dependents will have coverage under the new co‐insurance plan.
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Q. What is co‐insurance?
A. Co‐insurance is a percentage of the claim that an individual is required to pay for services. In 2012, your health plan has a 10 percent co‐insurance for most covered services.
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Q. What is an out‐of‐pocket maximum?
A. The out‐of‐pocket maximum is the limit you pay during a policy year before your health plan begins to pay 100 percent of the covered service. The out‐of‐pocket maximum will never include your monthly premium, non‐covered services or certain copayments. You will need to refer to your 2012 It’s Your Choice Decision Guide for details on what services apply and don’t apply to the out‐of‐pocket maximum.
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Q. What is my health plan’s annual out‐of‐pocket maximum?
A. Your health plan has a $500 single and a $1,000 family out‐of‐pocket maximum; the single out‐of‐pocket maximum is met by one individual while the family out‐of‐pocket maximum can be met by two or more family members. Your 10 percent co‐insurance portion (the amount you’ve paid) is what accumulates towards the annual out‐of‐pocket maximum. For example, you’d need to incur $5,000 of allowed charges in a given year of which you paid 10 percent to meet the $500 out‐of‐pocket maximum on an individual level. And a family would need to collectively incur $10,000 of allowable charges with no one individual contributing more than $5,000 of incurred allowable charges.
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Q. How can I determine how likely it is that I (or my family) will hit the out‐of‐pocket maximum in 2012?
A. The best way to approach this is to take a look at what services you and/or your family incurred in 2011 and determine if this was a typical year and likely to be similar to 2012. You can do this in two ways: 1) by going into DeanConnect (register by going to deancare.com and clicking on the DeanConnect icon) or 2) by contacting a Customer Care Specialist via the online request form at deancare.com/contact‐us and request a claims itemization for 2011. Please note that you will have access to claims information for yourself and for any child dependents, but you will not be able to access claims information for your spouse or adult children without their prior authorization due to privacy laws. When looking at claims itemization details, you should focus on the allowed amount and paid amount. In situations where the allowed amount and paid amount were equal, this means that the insurance covered 100 percent of the service. In 2012, your insurance would now cover that service at 90 percent and you would be responsible for 10 percent.
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Q. If I have a planned medical service in 2012, how can I determine my out‐of‐pocket expense?
A. Dean Health Plan is dedicated to helping you access information about the cost of your healthcare. We believe providing you with the financial information required will assist you in making informed healthcare choices every day. To get an estimate, call the Customer Care Center with the following information: name of your provider, current procedural Terminology (CPT) code, date or approximate date of service or procedure and the amount your provider is billing. The information you provide will help our Customer Care Specialists give you an approximate cost and your financial responsibility. Once an estimate has been formed, you will be sent a written estimate of costs within five business days of the request.
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Q. What if I do not have a procedure code?
To get a general estimate of what you can expect to pay for standard services log into DeanConnect [link to DeanConnect] and look at your specific claims utilization over the past 18 months. Although your plan did not include any cost-sharing (co-insurance) at the time you incurred theses charges, it will help give you an idea of what some of your services may cost. Since you have a 10% coinsurance figure 10% of the allowed amount of the claim to get the best estimate of the amount of the claim you would be responsible for. In order for you to reach your $500 out-of-pocket maximum, you would need to incur $5,000 in allowed services.
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Q. How can I benefit from using DeanConnect?
A. If you have not used DeanConnect in the past, we encourage you to start using it in 2012. DeanConnect will allow you to check on claims after you’ve had a service and to view details on what your insurance coverage has paid at any given time and what you are responsible to pay. Please note that DeanConnect is tracking your insurance coverage, but does not track any payments you have made to the clinics or providers as this is handled separately through the clinic or provider billing systems.
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Q. Will I be required to make the co‐insurance payments at the time of service or will I be billed later?
A. You will not be required to make the co‐insurance payment at the time of the service. The clinic’s billing office will submit the claim to Dean Health Plan; we will process it using the contracted amount, and then apply co‐insurance, copayments or other cost sharing to the service, and then we’ll make a payment to the provider and send you a document explaining what we have paid and what you owe. At that point, the clinic will be ready to reach out to you via a billing invoice for the amount remaining that you owe to them. You will always pay the clinic (or provider office or hospital) directly for the co‐insurance; you will not pay the health plan.
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Q. What is an Explanation of Benefits and what do I do if I get one from Dean?
A. An Explanation of Benefits (EOB) is the summary document that you receive from us when we make a payment on your behalf to a provider and there is a remaining amount that you still owe. You should keep the EOB (or summary document) for a service, and then compare it to the bill you receive later from the provider. Occasionally, there are timing issues or billing errors and it’s important for you to pay attention to what has been paid on your behalf by insurance and what you actually owe or expect to owe. Please carefully watch for “date of service” and provider name as this will help you pinpoint which service the document refers to. The last page in the document is a sample EOB that will help you better understand the document.
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Q. What may I expect to pay out‐of‐pocket with an emergency room visit?
A. If you do go to the emergency room you may be required to pay a copay plus co‐insurance. These expenses can vary greatly and depend on where you go and what treatment you require. Your primary care physician team is a great source to help you choose what is right for your medical situation—you can describe your symptoms, ask questions and get information that can help you decide whether you should go to the emergency room, urgent care or if your problem can be handled with self‐care or a visit to your PCP’s office. Dean On Call is another great resource to determine the type of care you need. Call a registered nurse at (800) 57‐NURSE 24 hours a day, seven days a week. Making informed choices when you are experiencing a medical issue will result in better care. Of course, sometimes a trip to the emergency room is necessary, so if you have a medical emergency please seek immediate care.
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Q. What services are considered preventive care? Is this different than routine care?
A. Preventive care refers to services such as physical exams, mammograms, well‐baby care and immunizations (excluding immunizations required for travel). You are not required to pay co‐insurance for a preventive care appointment or service. Preventive care and routine care are often used interchangeably; however routine care may imply care for a chronic condition such as diabetes and congestive heart failure; as such, co‐insurance would apply. For example, if you routinely see your physician for diagnostic procedures due to a chronic condition, such as diabetes, these office visits and services would be subject to co‐insurance.
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Q. How long may my eligible dependent remain insured under my policy?
A. State law will align with federal law to allow for coverage of an adult child until the end of the month in which the adult child turns 26 years of age or otherwise loses eligibility, whichever occurs first. The previous age limit was 27.
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Q. If I suffer from an accidental injury to my mouth and need dental implants, what kind of a provider should I see?
A. You should see a plan oral surgeon. We encourage you to first have a consultation and ask the provider to submit a pretreatment estimate to Dean Health Plan. The pre‐treatment estimate will be reviewed and notification will be sent to both you and your provider about what services are covered and/or not covered prior to your having the services done. Don’t forget that your 10 percent co‐insurance will apply and that co‐insurance does apply to your out‐of‐pocket maximum. There is also a maximum benefit limit of $1,000 per tooth.
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If you have any other questions about your health care coverage, please call the Dean Health Plan Customer Care Center at (800) 279‐1301.
