• No pre-existing condition limitation

We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

• Minimum essential coverage (MEC)

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

• Minimum value standard

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits.  The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

• Where you can get information about enrolling in the FEHB Program

See www.opm.gov/healthcare-insurance for enrollment information as well as:

Information on the FEHB Program and plans available to you

• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We don’t determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

• Types of coverage available for you and your family

Self Only coverage is for you alone.  Self Plus One coverage is for you and one eligible family member. Self and Family coverage is for you, and one eligible family member, or your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event.  

The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members are enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at  www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

• Family member coverage

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

• Children’s Equity Act

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM;
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children. 

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

• When benefits and premiums start

The benefits in this brochure are effective January 1.  If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1.  If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2021 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2020 benefits until the effective date of your coverage with your new plan.  Annuitants’ coverage and premiums begin on January 1.  If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

• When you retire

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

• When FEHB coverage ends

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy.)

• Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). 

If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-insurance/healthcare/plan-information. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

• Temporary Continuation of Coverage (TCC)

If you leave Federal service or Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, regardless of marital status, etc. 

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums.  Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHBP coverage.

• Converting to individual coverage

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-279-1301 or visit our website at www.deancare.com.

• Health Insurance Marketplace

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-279-1301 or write to us at:

P.O. Box 56099, Madison WI 53705

You may also request replacement cards through our online member portal DeanConnect at www.deancare.com/deanconnect.

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance, and you will not have to file claims. You can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network.

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to NCQA and Dean Health Plan standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website at www.deancare.com.

Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update daily. The provider directory can be found on our website at www.deancare.com/find-a-doc.

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. When you enroll, you (and your family members) must choose a primary care physician. Each member of your family may select a different primary care physician. A physician who specializes in only one area of medicine would not be able to treat all of your basic health care needs.

Primary care physicians specialize in different areas, and each specialty has its own benefits. A basic summary might help you narrow your search:

• Family Medicine (with or without Obstetrics) focuses on health care for individuals and families of all ages.  This includes routine and preventive care, treatment of acute and chronic illness, and coordination of your overall care. Some Family Medicine physicians also include Obstetrics (the care of women during pregnancy and childbirth).
• Internal Medicine focuses on adult patients and the aging process. Internists generally see patients over 18 years old. They also frequently care for patients with multiple ongoing health conditions. They provide preventative care, age-related screenings and health guidance.
• Pediatrics is a specialty which treats children from birth to their late teens. While pediatricians see healthy children for primary care, they also help children who have special or difficult health conditions. Pediatricians provide ongoing screenings, immunizations and preventative care throughout childhood.

Dean Health Plan members are free to switch to a different primary care provider (PCP) at any time. If you are changing to another PCP within the same clinic, you may ask that clinic’s staff for assistance. Otherwise you may call the Customer Care Center at 800-279-1301.

Specialty care

Written referrals are not required when seeing a Dean Health Plan provider.

Here are some other things you should know about specialty care:

• Your primary care physician will create your treatment plan. The physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. If he or she decides to refer you to a specialist, ask if you can see your current specialist.

If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause; 
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our service area and you enroll in another FEHB plan;
• If you receive care from an Out-of-Network Provider that is not available from a Network Provider and have an approved Prior Authorization to see this Out-of-Network Provider, payment for covered charges will be based on the actual charges, and not the Maximum Allowable Fee. We have no liability or responsibility for the quality of care provided by an Out-of-Network Provider. Prior Authorization is required both to determine medical appropriateness and whether services can be provided by Network Providers.

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.  Services provided by an Out-of-Network Provider require Prior Authorization.

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our Customer Care Center immediately at 800-279-1301.  If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first

These provisions apply only to the benefits of the hospitalized person.  If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply.  In such cases, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment.

You need prior Plan approval for certain services

Since your primary care physician arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

If you choose an out-of-network provider, it is up to you to secure a prior authorization.  Failure to do so may result in a penalty of 100% of cost. Your out-of-network provider must contact our Customer Care Center to submit a prior authorization request. Dean Health Plan will then review the request and provide a written decision to both you and your provider within 15 business days. Make sure you wait until you receive this approval before receiving the recommended services to avoid penalty.

A good rule to remember is that any time you seek services with an out-of-network or non-participating provider, you will need to obtain a prior authorization from an in-plan provider.

If you fail to obtain a Prior Authorization for any Medically Necessary covered service which requires an authorization, you, the Member, will be responsible for 100% of the total cost of services. It is the responsibility of the Member to ensure that Prior Authorization has been obtained for all services, including facility Confinements and/or surgery.

Other services

Your health care provider must get prior authorization from us before we will cover certain procedures or services. Examples of procedures and services that need prior authorization are listed below. This is not an all-inclusive list. You should contact the Customer Care Center at 800-279-1301 or TTY 711 to verify whether a procedure or service needs prior authorization.

Examples of Procedures/Services Requiring Prior Authorization:

• All Out-of-Network Provider services, except for emergency and urgent care services
• Certain medical injectables
• Certain prescription drugs
• Certain radiology services
• Clinical trials
• Communication devices
• Non-emergency ambulance transport
• Habilitative Services
• Select services provided in a home setting
  • Physical and Occupational Therapy
  • Skilled Nursing
  • Home Infusion
  • Home Hospice
• Dental services required to treat accidental injury to teeth
• Medically necessary hospitalization for dental services
• Durable medical equipment (DME) as stated in Our medical policies
• Therapies (e.g. physical therapy, occupational therapy)
• Select Pain management
  • Epidural steroid injections
  • Facet joint injections and radio-frequency ablation
  • Intrathecal pump implantation
  • Sacroiliac injections
  • Spinal cord or dorsal column stimulation and dorsal ganglion stimulation
• New technologies not commonly accepted as standard of care
• Hospice
• Transplants (except cornea)
• Elective inpatient admissions and services
• Select diagnostic testing
  • Genetic Testing
  • Lumbar discography
  • Neuropsychological testing
• Skilled nursing facility/swing beds (SNF)
• Surgical procedures related to obesity
• Orthopedic and Prosthetic Devices
• Sleep studies

The Process for Obtaining Prior Authorization:

If your health care provider recommends that you have a service or procedure that needs prior authorization, your health care provider should submit a prior authorization request form to Us. It is the member’s responsibility to make sure that your health care provider requests prior authorization. We must receive the prior authorization request at least 15 business days before the date of your service or procedure. We will notify you in writing of our decision.

Your health care provider may decide that it is medically necessary for you to 1) get additional services beyond what we originally authorized, or 2) receive care for longer than the length of time we originally authorized. If this happens, your health care provider must contact Us to request an extension of the original authorization. You and your health care provider will be notified of whether we approve or deny your extension request.

Prior authorization does not guarantee coverage and/or payment if you have already reached a benefit maximum or your coverage has been terminated.

First, your physician, your hospital, you, or your representative, must call us at 800-279-1301 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

Non-urgent care claims

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

Urgent care claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-279-1301. You may also call OPM's FEHB 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-279-1301. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

Concurrent care claims

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

The Federal Flexible Spending Account Program - FSAFEDS

Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).

FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Emergency inpatient admission

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

Maternity care

Your Plan primary care physician will make the necessary arrangements. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

If your treatment needs to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

What happens when you do not follow the precertification rules when using non-network facilities

Failure to Obtain Authorization for Non-Plan Providers:  If you fail to obtain Prior Authorization for any service requiring such an authorization, you, the Member, will be responsible for 100% of the total cost of services received from any Non-Plan Provider. It is the responsibility of the Member to ensure that Prior Authorization has been obtained for all services.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.

To reconsider a non-urgent care claim

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
   • You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.
   • If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.
3. Write to you and maintain our denial.

To reconsider an urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

To file an appeal with OPM

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

Coinsurance

Coinsurance is the percentage of covered expenses that a member is required to pay each time covered services are provided, subject to any maximums specified in this brochure.  Coinsurance amounts are applied toward the catastrophic protection out-of-pocket maximum expense in most circumstances.  Coinsurance does not begin until you have met your calendar year deductible.

This Basic Option does not have coinsurance amounts.

Copayments

A copayment is a specified dollar amount that you may be required to pay each time covered services are provided, subject to any maximums specified in this policy. 

Copayment amounts are applied to our contracted fee or Maximum Allowable Fee, and apply at the benefit level.

Copayment amounts are applied toward the out-of-pocket expense maximum.

Example:

Primary Care Provider copayment:  When you see your primary care physician or chiropractor you pay a copayment of $40 per office visit.

Specialist Provider copayment:  When you see a specialty provider you pay a copayment of $80 per office visit.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

This Basic Option does not have a deductible.

Differences between our Plan allowance and the bill

The maximum amount payable based upon the average charge for the same service provided.

Your catastrophic protection out-of-pocket maximum

After your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $6,000 for Self Only, or $12,000 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $6,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario:  Your plan has a $6,000 Self Only maximum out-of-pocket limit and a $12,000 Self Plus One or Self and Family maximum out-of-pocket limit.   If you or one of your eligible family members has out-of-pocket qualified medical expenses of $6,000 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family enrollment out-of-pocket maximum of $12,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $6,000 for the calendar year before their qualified medical expenses will begin to be covered in full. 

However, copayments and coinsurance, if applicable for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

• Premiums
• Non-Covered Services
• Benefit Reduction Amounts
• Services provided by out-of-network providers that have not been prior authorized

Be sure to keep accurate records and receipts of your copayments and coinsurance to ensure the plan’s calculation of your out-of-pocket maximum is reflected accurately.

Carryover

If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan.  If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan.  Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

Individual and Family Health Insurance Plans

If you or a family member is not eligible under the FEHB Plan benefits, Dean Health Plan offers a variety of individual and family health insurance plans.

For more information, visit our website at deancare.com/shop-plans/individual-family-plans.

New to Medicare?

Whether you are eligible for Medicare coverage now, or will be soon, Dean Health Plan is here to help you understand more about Medicare. For more information, visit our website at deancare.com/medicare/medicare-plans.

Classes

www.deancare.com/Calendar/

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, call us at 800-279-1301, or at our website at www.deancare.com.

When you must file a claim – such as for services you receive outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. 

Submit your claims to: Dean Health Plan, P.O. Box 56099, Madison WI 53705

If you receive services from a Health Care Provider that require you to submit the claim to us for reimbursement, you must obtain an itemized bill and submit it to:

Dean Health Plan
Attention: Claims Department
P.O. Box 56099
Madison, WI 53705

Send us all of the documents for your claim as soon as possible.  You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Notice Requirements 

If you live in a country where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

1

Ask us in writing to reconsider our initial decision.  You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: P.O. Box 56099, Madison, WI  53705 ; and

c) Include a statement about why you believe our initial decision was wrong, based on specific
    benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative
    reports, bills, medical records, and explanation of benefits (EOB) forms.

e) Include your email address (optional for member), if you would like to receive our decision
    via email.  Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision.  We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date.  However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration.  You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or  

b) Write to you and maintain our denial or.

c) Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

3

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.
• Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

4

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to file a lawsuit. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

When you have other health coverage

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays health care expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines.  For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.deancare.com/health-insurance/federal-employee-members/

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

• TRICARE and CHAMPVA

TRICARE is the health care program for eligible dependents of military persons, and retirees of the military.  TRICARE includes the CHAMPUS program.  CHAMPVA provides health coverage to disabled Veterans and their eligible dependents.  IF TRICARE or CHAMPVA and this Plan cover you, we pay first.  See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

• Workers’ Compensation

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

• Medicaid

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium.  For information on suspending your FEHB enrollment, contact your retirement office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

When other Government agencies are responsible for your care

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

When others are responsible for injuries

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment.  Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness.  However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned.  Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

Some FEHB plans already cover some dental and vision services.  When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage.  FEDVIP coverage pays secondary to that coverage.  When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits.  Providing your FEHB information may reduce your out-of-pocket cost.

Clinical trials

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. 

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs (as mandated by state) – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.
• Extra care costs – This plan does not cover these costs.
• Research costs – This plan does not cover these costs.

When you have Medicare

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

• The Original Medicare Plan (Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States.  It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now.  You may go to any doctor, specialist, or hospital that accepts Medicare.  The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary.  This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. 

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first.  In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges.  To find out if you need to do something to file your claim, call us at 800-279-1301 or see our website at www.deancare.com.

We waive some costs if the Original Medicare Plan is your primary payor.  We will waive some out-of-pocket costs as follows:

• Medical services and supplies provided by physicians and other health care professionals.
• Standard member cost-share will apply for services not covered by Medicare (i.e. oral surgery).

Please review the following table it illustrates your cost share if you are enrolled in Medicare Part B.  If you purchase Medicare Part B, your provider is in our network and participates in Medicare, Medicare will be the primary payor. 

Basic Option

Benefit Description: Deductible
Basic Option You pay without Medicare: N/A
Basic Option You pay with Medicare Part B: N/A

Benefit Description: Coinsurance
Basic Option You pay without Medicare: N/A
Basic Option You pay with Medicare Part B: N/A

Benefit Description: Coinsurance Limit
Basic Option You pay without Medicare: N/A
Basic Option You pay with Medicare Part B: N/A

Benefit Description: Out-of-Pocket Maximum
Basic Option You pay without Medicare: $6,000 (Self Only), $12,000 (Self + 1), $12,000 (Self + Family)
Basic Option You pay with Medicare Part B: $6,000 (Self Only), $12,000 (Self + 1), $12,000 (Self + Family)

Benefit Description: Primary Care Physician
Basic Option You pay without Medicare: $40 copayment per visit
Basic Option You pay with Medicare Part B: Nothing

Benefit Description: Specialist
Basic Option You pay without Medicare: $80 copayment per visit
Basic Option You pay with Medicare Part B: Nothing

Benefit Description: Inpatient Hospital
Basic Option You pay without Medicare: $1,000 copayment per day up to a maximum of $3,000 per contract year
Basic Option You pay with Medicare Part B: Nothing

Benefit Description: Outpatient Hospital
Basic Option You pay without Medicare: $1,000 copayment per occurrence up to a maximum of $3,000 per contract year
Basic Option You pay with Medicare Part B: Nothing

You can find more information on how our plan coordinates benefits with Medicare by calling our Customer Care Center at 800-279-1301.

https://www.deancare.com/employers/resources/medicare

https://www.deancare.com/employers/resources/claims

• Tell us about your Medicare coverage

• Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan.  These are private health care choices (like HMOs and regional PPOs) in some areas of the country. 

To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan:  You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan.  We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers).  

However, we will not waive any of our copayments, coinsurance, or deductibles.  If you enroll in a Medicare Advantage plan, tell us.  We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium.  (OPM does not contribute to your Medicare Advantage plan premium.)  For information on suspending your FEHB enrollment, contact your retirement office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

• Medicare prescription drug coverage (Part D)

Calendar Year

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Clinical Trials Cost Categories

An approved clinical trail includes a phase I, phase II, phase III, or phase IV clinical trail that is considered in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded, conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trail, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trail or is receiving standard therapy.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
• Research costs - costs related to conducting the clinical trail such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trails. This plan does not cover these costs.

Coinsurance

See Section 4, page (Applies to printed brochure only).

Coinsurance Limit

Includes Coinsurance amounts for certain medical expenses that a Member is required to pay when a covered service is provided. Pharmacy expenses and certain medical expenses are not included in the Coinsurance Limit. The Coinsurance amounts also apply toward the Out-of-Pocket Expense Maximum. No other out-of-pocket expenses apply toward the Coinsurance Limit.

Confinement/Confined

a) The period of time between admission to and discharge from an inpatient or outpatient hospital, AODA residential center, skilled nursing facility, or licensed ambulatory surgical center on the advice of your physician, and discharge there from; or b) the time spent in a hospital receiving emergency care for illness or injury. Hospital swing bed Confinement is considered the same as Confinement in a skilled nursing facility. If the Member is transferred to another facility for continued treatment of the same or related condition, it is one Confinement.

Specific to a skilled nursing facility (SNF), an inpatient stay begins on the day of admission into a skilled nursing facility.  The 120 day SNF benefit renews when you haven't received any inpatient hospital care or skilled care in a skilled nursing facility for the same or a similar diagnosis for 60 days in a row.  If you go into a hospital or a skilled nursing facility after one SNF benefit period has ended, a new benefit period begins. There is no limit to the number of SNF Inpatient benefit periods.  However, an additional 120 days is not available until skilled care has not been required for at least 60 consecutive days. 

Copayment

See Section 4, page (Applies to printed brochure only).

Cost-sharing

See Section 4, page (Applies to printed brochure only).

Covered Services

Care we provide benefits for, as described in this brochure.

Custodial Care

The type of care given when the basic goal is to help a person in the activities of daily life. This includes help in walking, getting in and out of bed, bathing, dressing, eating, using the toilet, preparing special diets, taking medications properly and 24 hour supervision for potentially unsafe behavior. Such care is custodial when it does not require continued attention by trained medical personnel. Such care is custodial even if provided by registered nurses, licensed practical nurses, or other trained medical personnel. Custodial care that lasts 90 days or more is sometimes known as Long Term Care.

Deductible

See Section 4, page (Applies to printed brochure only).

Experimental or Investigational Service

We regularly evaluate new medical devices, new techniques, and new uses for older existing procedures. This process is both proactive and reactive. Health care experts in the Dean organization, including physician, and specialty providers, review and evaluate all pertinent information. If new technology is approved, procedures and policies are revised or established to implement this decision.

Group Health Coverage

Health Care Professional

A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

Maximum Allowable Fee

Maximum Allowable Fee is the maximum amount We allow for a given service/procedure with an Out-of-Network Provider.

This amount may be based on:

• Geographic location;
• Provider specialty;
• Training and experience of provider;
• Date of service;
• Complexity of treatment; or
• Degree of skill required of provider.

If there is a difference between the Maximum Allowable Fee and the amount billed by an Out-of-Network Provider, the Member will be responsible for the difference.

When you are seeking care with an Out-of-Network Provider, you can obtain information about Maximum Allowable Fees prior to receiving care. You need to contact your Out-of-Network Provider for the procedure code(s) and the amount(s) the provider intends to charge. Then provide this information to Our Customer Care Center in order for Us to determine the Maximum Allowable Fee for the service(s) in question. Within 5 business days of receiving your request for Maximum Allowable Fee details, We will notify you as to whether the service is covered and if it is subject to the Maximum Allowable Fee or any other Policy provisions (e.g. Deductibles or Copayments).

Medical Necessity

The services or supplies provided by a hospital, or plan provider (or a non-plan provider if there is an authorized referral requested or in an emergency or urgent care situation) that are required to identify or treat a member’s illness or injury as which, as determined by the Utilization Management Department, are: (a) consistent with the illness or injury; (b) in accordance with generally accepted standards of acceptable medical practice; (c) not solely for the convenience of a member, hospital, plan provider, or other provider; and (d) the most appropriate supply or level of services that can be safely provided to the member.

Plan Allowance

Plan allowance is the amount we use to determine our payment and your co-insurance for covered services.

We determine our Plan allowance as follows: Covered charges will be paid based on the contract agreement between the plan and the plan provider (subject to any coinsurance and copayment provisions outlined in this Certificate). If there is a difference between our contracted amount and the amount that the provider bills us, you will not be responsible for that amount.

Post-Service Claims

Any claims that are not pre-service claims.  In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

We use providers in a specific geographic area. Being a Member of Dean Health Plan means you agree to use providers who are part of our provider network (Network Providers). Any care you need should be provided by Network Providers, including doctors and hospitals.

When you enroll as a Member you will choose a physician or clinic from our network of providers to be responsible for managing your health care.  This is your primary care provider (PCP) and is the provider you contact first whenever you need health care services. Your PCP evaluates your total health needs and provides personal medical care in one or more medical fields. If you choose a clinic rather than a physician, you may see any PCP in that clinic. When medically needed, your PCP preserves the continuity of care.  Your PCP is also in charge of coordinating other provider health services.

Pre-Service Claims

Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.

Reimbursement

Subrogation

Urgent Care Claims

A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve pre-service claims and not Post-service claims.  We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Care Center at 800-279-1301. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

• Deductible

Nothing (this plan does not have a deductible)

(Applies to printed brochure only)

• Coinsurance

Nothing (this plan does not have coinsurance)

(Applies to printed brochure only)

• Maximum Out-of-Pocket (coinsurance, medical and pharmacy drug copayments)
  

$6,000 Self Only enrollment or $12,000 Self Plus One and Self and Family enrollment

(Applies to printed brochure only)

Medical services provided by physicians: Treatment services provided in the office

$40 office visit copayment (Primary Care Provider)
$80 office visit copayment (Specialist)

(Applies to printed brochure only)

Medical services provided by physicians: Diagnostic services provided in the office

Nothing

(Applies to printed brochure only)

Services provided by a hospital and emergency services: Inpatient/Outpatient Hospital Services

$1,000 copayment per day up to a maximum of $3,000 per contract year (Inpatient)

$1,000 copayment per occurrence up to a maximum of $3,000 per contract year (Outpatient)

(Applies to printed brochure only), (Applies to printed brochure only)

Services provided by a hospital and emergency services: Emergency In-area

$300 copayment per emergency room visit (waived if direct admit to inpatient)

$40 copayment per urgent care visit

(Applies to printed brochure only)

Services provided by a hospital and emergency services: Emergency Out-of-Area

$300 copayment per emergency room visit (waived if direct admit to inpatient)

$40 copayment per urgent care visit

(Applies to printed brochure only)

Behavioral health and substance use disorder treatment:

$40 copayment per visit (outpatient)

$1,000 copayment per day up to a maximum of $3,000 per contract year (inpatient)

(Applies to printed brochure only)

Prescription drugs: Retail pharmacy

Tier 1 (Generics) $20 copayment

Tier 2 (Preferred Brands and select Generics) $45 copayment

Tier 3 (Non-Preferred Brands and select Generics) $70 copayment

Tier 4 (Specialty Drugs) $150 copayment

(Applies to printed brochure only)

Prescription drugs: Mail order

90-day supply (maintenance medications)

• Tier 1 - $40 copayment (90-day supply)
• Tier 2 - $90 copayment (90-day supply)
• Tier 3 - $210 copayment (90-day supply)
• Tier 4 - Not available

(Applies to printed brochure only)