EMPLOYER-PROVIDED INSURANCE
2024 Dean Health Plan by Medica New Member Guide
Welcome to Dean Health You now have resources to manage your health and take control of your care. That means benefits you can understand, tools that save you time, and support from our friendly staff whenever you need us.
Getting started
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I have an insurance question or concern
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What should I do as a new member?
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I have a medical question or concern
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I want wellness rewards
We’re here to support you.
The basics
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I need to pay my premium or bill
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I need to find a doctor or a primary care provider
Questions?
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Where should I go for care?
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I’m not sick but I need preventive care
Contact Member Services to turn health insurance confusion into clarity. • Get answers to benefit and coverage questions • Figure out what your financial responsibility is for a bill • Learn the details about a provider 1 (800) 279-1301 (TTY: 711 ) Monday – Thursday, 7:30 am – 5 pm Friday, 8 am – 4:30 pm
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What should I know about traveling?
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I need to see a specialist
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I take medication or was recently prescribed some
Plan details
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What should I do if I’ve had big changes in my life?
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I’m eligible for medicare or have another insurance policy
Support is just a click away. Visit DeanCare.com/Contact
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I’d like to file a grievance or appeal
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What should I know about privacy?
Stop by our Insurance Desk, Monday – Friday, 8 am – 4:30 pm, or one of the SSM Health Dean Medical Group locations listed here: Madison Health Plan Business Office: 1277 Deming Way
Network: Dean Group Number: XXXXXXXXXXXX Product Type: HMO deancare.com
Member Number
Member Name TEST TEST TEST TEST 1
012345678901 012345678902 012345678903 012345678904
If you haven’t yet received your Member ID Card , it should be on the way. > See page 4 for a digital option.
TEST TEST 2 TEST TEST 3 Deductible*: Individual $XXXXX Family $XXXXX
Ded/Coinsurance Max*: Individual $XXXXX Family $XXXXX Out of Pocket Max*: Individual $XXXXX Family $XXXXX
South Madison Campus: 1211 Fish Hatchery Road
PCN: 5 104 • BIN: 610602
Customer Care: 800-279-1301(TTY: 711) • Nurse Advice Line: 800-576-8773
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YOUR PLAN RESOURCES What you need to know
Important member documents and helpful terms to know • Your Member Certificate (sometimes called a “Member Policy”) has information about your insurance benefits and coverage, and it lists general limitations and exclusions to your plan • Your Summary of Benefits and Coverage (SBC) is an easy-to-read grid that lists the details of plan coverage, along with a basic cost estimate of your financial responsibilities for common medical services** • Common health insurance terms are listed on page 8. Find member documents and more at Deancare.com/Login . † • The Pharmacy Drug Formulary is a list of prescription drugs that help you understand what is and isn’t covered by your insurance If you have other health care coverage • Your Dean Health Plan policy has a Coordination of Benefits (COB) provision – a fancy way of saying we’ll need to sort through situations where you’re covered by another health insurance company (such as through an employer or Medicare) • Please contact Member Services to inform us of any additional coverage. See page 3 for contact details • If you have any questions about Medicare enrollment or eligibility, or need to report that you have Medicare, please contact the Medicare Coordination of Benefits Specialist at 1 (608) 827-4189 . If you have a chronic condition or a health concern • We’re here to support you if you have a serious condition or have a complex health care need • Visit Deancare.com/CareManagement and click on “ Complex Case Management ” to learn how we can help, or contact Member Services ** Your financial responsibilities may come in the form of a copay, coinsurance, or deductible. The terms stated in these documents may change at your annual policy renewal, and we will send you an outline of any changes at that time. † These documents are also available by contacting Member Services to request copies be mailed to you. See page 3 for contact details.
Get started with your new health plan in two easy steps
Activate your accounts You'll find most of the information you need in your member, MyChart and Living Healthy accounts. Manage your health insurance information with your secure and convenient member account by visiting Deancare.com/Login . Your member account lets you: • Download your ID card to your mobile wallet • View your insurance plan details • Find an in-network doctor, hospital, or clinic close to you • Check the status of claims Your MyChart account lets you: • Schedule appointments, send secure messages to your provider and more through your MyChart account* Your Living Healthy account lets you: • Explore your wellness benefits* to achieve your goals for a healthy lifestyle and earn rewards along the way * See pages 6-7 for details Decide where to receive primary care Contact our Welcome Center at (608) 250-1134 ( TTY : 711) or visit Deancare.com/Locations to find a primary care clinic near you. Before your first visit, contact your previous clinic to complete an Authorization to Release Protected Health Information Form. The form allows your previous clinic to send your medical records to your new clinic so your medical team can best continue your care.
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YOUR CARE NETWORK Here for you
YOUR WELLNESS BENEFIT Earn up to $ 150
Welcome Center * A team of customer care professionals and registered nurses help ease your transition by: • Helping to establish a primary care provider that fits your needs • Facilitating the transfer of medical records • Activating and linking MyChart to your past MyChart account • Reviewing any upcoming appointments that need to be scheduled and any preventive services needed Contact the Welcome Center at (608) 250-1134 ( TTY : 711) . SSM Health Express Virtual Care When you can’t meet with your regular provider or need after-hours care, SSM Health Express Virtual Care (E-visit and Video Visit) can help from the comfort of your home. Only certain conditions qualify. Visit Deancare.com/Evisit . MyChart † Manage your health care – all from a computer or smart phone. • Send and receive secure messages with your primary care provider • Schedule appointments • Get lab results • Request prescription refills and more • View and pay your medical bill Visit Deancare.com/MyChart to activate your account. Health pandemics If and when pandemics happen, Dean Health Plan will make every effort to provide up-to-date information. For Coronavirus (Covid-19) updates, please visit Deancare.com/Wellness/Coronavirus . * Service only available when selecting an SSM Health primary care provider. ASO and Federal employees should contact Member Services at 1 (800) 279-1301 ( TTY : 711) for member onboarding assistance. † Some features of MyChart may not be available at all primary care clinics.
With the right tools, information, and motivation, you can achieve your goals for a healthier lifestyle. That’s what Living Healthy is all about. Visit Deancare.com/LivingHealthy to create your account today. **
Living Healthy Rewards ** Prevention or early detection of common diseases is the best way to be the healthiest you. The list below includes common preventive and screening services, but it’s important to check with your primary care provider to determine which tests are appropriate for your medical history and family history. Plus you can earn points for taking care of yourself. • Immunizations: Influenza, Varicella, Tetanus, Meningococcal and Pneumococcal • Cancer screenings: Mammogram, Colon Cancer (FIT testing, Cologuard, Colonoscopy) and PAP smear • Other screenings: Chlamydia, Gonorrhea, HIV, Hepatitis C, Diabetes, and Depression Here’s how it works: • Choose a healthy activity, complete it, and earn points • Get your reward in the form of gift cards to your choice of many national retailers, restaurants, and other popular merchants • All rewards must be redeemed before December 31, 2024
For more information visit Deancare.com/Wellness .
** Only Dean Health Plan members, ages 18 and older, are eligible for Living Healthy rewards.
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YOUR PAYMENTS AND CLAIMS How insurance works
It’s our goal to make it as easy as possible for you to understand your financial responsibilities.* Your policy may use a system of cost sharing that can include a copay, coinsurance, deductible, or any combination of the three.
Estimate the cost for a service Check your Member Policy document for details about common medical services. You may also visit Deancare.com/Cost-Estimator for three tools that estimate physician, facility and pharmacy costs. Explanation of benefits (EOB) The EOB is not a bill. The EOB lists the services used, amount charged by the provider, and your financial responsibility to pay toward deductibles or coinsurance. Sign in to your secure member website to see your past EOBs at Deancare.com/Login . Submit a claim Claims are usually sent directly to Dean Health Plan by providers or clinics. Sometimes – if you’re traveling out of the area or have a college-age dependent, for example — it may be necessary for you to submit a claim for reimbursement. Visit Deancare.com and search the phrase: “member paid claim reimbursement form.” Be sure to follow these guidelines: • Send an itemized bill from the provider of service. If services were received outside of the U.S., you’ll need to submit the original bill along with an itemized bill and indicate the appropriate currency exchange rate at the time the services were received • Send the bill within 60 days (up to 12 months are allowed) after the services are received to:
Deductible Each time you receive medical services, you’ll pay the bill for services up to a certain amount. This amount is your deductible, which is your responsibility to pay for covered health care services each year before we begin to pay. Coinsurance † Once you’ve paid the deductible amount, we will then start splitting the cost of additional medical services with you. This is known as coinsurance, meaning you only pay a percentage or part of the total cost of services and we’ll pay the rest. Deductible and coinsurance limit There is a dollar limit to the amount you’ll pay toward your deductible and coinsurance. Copays A copay is a fixed dollar amount, which you pay at the time you receive medical services (for things like an office visit) and prescriptions. All your copays add up toward your maximum out-of-pocket total. Maximum out-of-pocket There’s a dollar limit to all your cost sharing. You reach this amount by means of your deductible, plus your coinsurance, and your copays. Once this limit is reached, you’ll pay nothing on subsequent covered medical charges for the remainder of your policy year. Premium – the amount you pay each month to access your health insurance.
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Dean Health Plan, Attn: Claims Department PO Box 56099 • Madison, WI 53705-9399
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• If you have another insurance company that is the primary payer, you’ll need to send the Explanation of Benefits to Dean Health Plan or your health care provider
* Not all of the cost-sharing terms listed here apply to all members. Refer to your Member Policy document to understand which apply to you. † Coinsurance is your share of the costs of a covered health care service. It’s calculated as a percent of the allowed amount for the service. For members with PPO and POS Smart Plans and POS Smart Value Choice Plans, coinsurance and copays apply.
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WHERE TO GO FOR CARE Know the right care for your needs
Too sick or unable to drive to the doctor? Fill out an online questionnaire, receive a written diagnosis, treatment, and a prescription. Lowest cost option: $ Prefer a face-to-face conversation? Start a video visit and quickly connect with an SSM Health provider. No appointment necessary. Learn more about SSM Express virtual care options at DeanCare.com/VirtualCare . Abnormal headaches, earaches, chronic conditions, etc. Wish to see your provider for care? Schedule an appointment at your primary care clinic. Same-day appointments are usually available. In-person treatments and annual checkups.
Primary Care Provider (PCP) Health care is a personal experience. Your care team is committed to working with you to build a relationship of trust. Trust combined with their training and experience means you have true health advocates who care. Your care team: • Consists of your primary care providers • Provides care for a wide range of preventive and long-term health care • Helps you stay healthier with regular visits, immunizations and screenings
• Handles your immediate care needs • Coordinates needed specialist care • Coordinates your health care with other medical experts
Visit Deancare.com/Doctors to search our online provider directory for an available primary care provider. Filter your search to only see providers in your network. Then select a provider to learn about his or her education, specialty, certification and more. Coordinated care We are part of an Integrated Delivery Network (IDN) with SSM Health. That means physicians, hospitals, a health plan, and pharmacy care work together to reduce health care costs, improve quality and deliver a better member and patient experience. In-network provider Access a network of facilities, providers, and suppliers that provide health care services at negotiated rates. By staying in your plan’s network for your care, you’ll likely pay less in overall costs. Out-of-network provider A provider or facility with no contract with your health plan can charge you full price for any health care services received.
Primary care clinic full or closed? Visit your nearest Urgent Care facility.
Life-threatening illness or injury? Go to the nearest emergency room or call 911. Heart attack, stroke, head injury, severe pain. Greatest cost option: $$$
Unsure of the type of care you need? Call the Nurse Advice Line at 1 (800) 576-8773 ( TTY : 711) for support.
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YOUR PREVENTIVE CARE
YOUR NETWORK
Care to keep you healthy
Coverage that travels with you
Traveling services You don’t need to take insurance coverage worries with you on your vacation. We have you covered for urgent and emergency care worldwide. We’ll cover services provided in an urgent care facility and/or emergency room while you’re out of the Dean Health Plan service area, subject to policy copayments, coinsurance, deductibles and maximum allowable fees. No referral or prior authorization needed. If you’re unable to get to an in-network plan provider, please go to the nearest urgent care or emergency center for treatment. Please notify us as soon as possible by calling Member Services at 1 (800) 279-1301 ( TTY :711) . An in-network provider should resume all follow-up care. If you’re out of the area and not able to see an in-network plan provider, call your primary care provider to discuss the urgent/emergent services you received and any follow-up services that were recommended by your out-of-network provider. You must have an approved prior authorization for services to be covered. Your primary care provider can submit a request for medically necessary services with the out-of- network provider. Out-of-area dependents † Your kids may be out of sight, but we know they are never out of mind. You have coverage for your dependent children (up to age 26) who are living in another community. • Away at college • Traveling adventures • Internships • Living out-of-state Complete and submit an out-of-area dependent form and access our out-of-area provider search at Deancare.com/OutofArea . † Out-of-area dependent coverage for non-urgent and non-emergency care applies to large group employer (51+ employees) plans only; please check with your employer’s benefits administrator if you have questions.
We do more than pay the medical bill. At the heart of our preventive care philosophy is a promise that you’ll get the support you need to remain as healthy as possible and help prevent disease. Annual preventive visit This type of visit can bring to light health concerns so they can be addressed before they get worse. That’s what preventive care is all about. • Allows your primary care provider to get to know you and your health care needs • Helps you prevent or manage illnesses, diseases or other health problems • Includes important preventive services, such as patient counseling, referrals to specialists and recommendations for other preventive care to get Preventive care * In addition to an annual preventive visit for all ages, we encourage and cover: • Immunizations - doses and age-specific vaccines vary • Screenings for breast, cervical and colon cancer • Annual sexually transmitted infection (STI) counseling for adults and adolescents • Cholesterol screening for all ages and more Visit Deancare.com/PreventiveCare for a complete list of covered preventive services. * Information presented here is meant to supplement – not replace – the advice and care of health care professionals. To see your specific preventive care coverage details, please review your Member Certificate (sometimes called a “Member Policy”) and Summary of Benefits and Coverage documents. Details for covered preventive services may change. For coverage questions, contact Member Services. See page 2 for contact details.
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YOUR SPECIALTY CARE Coverage that’s focused on you
Do you need prior authorization? My PCP (or other in-network provider) recommended I visit a specialist. In-network provider With a Dean Health HMO or Focus Plan, in-network provider — you don’t need to do anything. Although the service may require a prior authorization, it’s up to your in-network provider to get prior authorization for you. Out-of-network provider With a Dean Health HMO or Focus Plan, out-of-network provider prior authorization is needed to see an out-of-network provider. Discuss this with your plan physician and they will submit an authorization to the health plan if the services are not available with plan providers. We’ll then review the request and provide a written decision to both you and the referring provider within 15 calendar days from receipt. Make sure you wait until you receive this approval before receiving the recommended services to avoid any unnecessary fees. PPO or POS plan Because each POS and PPO plan is different, we recommend you check if a prior authorization is required for any services outside of a normal office visit. For a plan-specific list of these services, refer to the “Prior Authorization” section of your Member Certificate (sometimes called “Member Policy”) available at MemberBenefits. Deancare.com . You may also call 1 (800) 279-1301 ( TTY : 711) for help. † If Member Services is unable to address your authorization concerns, you’ll be connected to the Care Management Department. If you have an urgent need outside of business hours, leave a message with Member Services and your call will be returned within one business day.
In addition to primary care providers, our network includes a variety of medical specialties. Your primary care provider can help you find the specialist who is right for you. Specialty care 101 If you’re ever unsure, you can talk to your primary care provider about when a specialist is needed. • Examples of specialty care include physical therapy, podiatry, chiropractic services and dermatology • There are many specialists affiliated with Dean Health Plan, including but not limited to SSM Health • You should be seen by a specialist within the Dean Health Plan network of providers Visit Deancare.com/Doctors for a comprehensive list of our specialty providers, behavioral health services and hospitals. Prior authorization Certain medical services or specialty care services might require you to get prior authorization.* • Anytime you seek services with an out-of-network provider, you need prior authorization unless your benefit plan includes an out-of-network option • Prior authorization allows our medical management team to review the medical necessity of the recommended service or visit and make sure you’re getting appropriate care. * A prior authorization can only be obtained for services that are covered under your plan benefits. For example, if bariatric surgery isn’t covered in your policy, prior authorization will not change the policy to cover it. If the services are covered under your plan, they remain subject to a decision regarding medical necessity and any applicable cost sharing (e.g., copays, coinsurance or deductibles).
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YOUR DRUG BENEFITS Pharmacy services
Specialty pharmacy Medications for many chronic and complex health conditions can be hard to manage. Lumicera , our specialty pharmacy, works with you and your provider to help manage your condition and to make sure you receive the best care possible. We offer free delivery, same-day service, refill reminders, financial assistance and more. Have questions? Call 1 (255) 847-3553 . Drug formulary & management procedures We use a drug formulary, which is a list of prescription drugs that helps you understand what is and isn’t covered. Our drug formulary breaks the list into different tiers. The tiers are organized by the level of cost sharing between you and the health plan. The drug formulary is reviewed every month and updated on a regular basis. For example, we update the drug formulary when a new generic drug is approved. There are restrictions to and procedures for your coverage in order to help keep plan costs down. Restrictions to and procedures for your prescription coverage mean you may only receive drugs listed on our drug formulary (closed formulary). Certain drugs may have specialist restrictions or require you to visit a specialty pharmacy. You may also be required to have prior authorization, mandatory generic substitution, step therapy and quantity level limits for certain drugs. Be familiar with your plan’s specific coverage details and visit Deancare.com/Pharmacy to review our drug formulary, along with general limitations and procedures. Vaccine coverage Vaccines are covered and recommended for people of all ages. Doses and age-specific vaccines vary. Check with your doctor to ensure you and your family receive vaccines – including the flu vaccine – on time. As a health plan member with pharmacy benefits, you and your family can receive essential immunizations from your provider at your annual preventive care visits. Health plan members, ages six and older, can also get vaccines at in-network pharmacy locations. To find a pharmacy near you, visit Deancare.com/Pharmacy.
Convenience and member affordability are the name of the game when it comes to Dean Health Plan pharmacy services. We’re here to help you manage your prescriptions and lower your expenses.
SSM Health pharmacies + no-cost delivery Our friendly and professional staff are available at eight convenient locations. • Get answers to your questions and make sure your medications are right
• Refill prescriptions by phone or online • Get prescriptions filled for 90 days
Costco pharmacy Our preferred mail order pharmacy.
Interested in having your prescriptions delivered? You can order all your prescriptions through the Costco Pharmacy. A Costco membership is not needed to use their mail order pharmacy. To switch to Costco, members will need to register with Costco Mail Order Pharmacy. They can register by visiting Pharmacy.Costco.com and clicking “ Sign in/Register. ” You’ll also need your prescriber to submit new prescriptions to Costco. For more information about our Mail Order Pharmacy program, contact Member Services at 1 (800) 279-1301 ( TTY : 711) .
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YOUR DRUG BENEFITS Pharmacy services
$0 Preferred diabetic supplies ** Cost should not be a barrier to controlling your diabetes. That’s why all formularies include preferred diabetic supplies such as syringes, lancets, and pen needles at $0 for large and small group members. This way you can focus on staying healthy, not the cost of getting there. Visit MemberBenefits.Deancare.com to view your drug formulary, find nearby pharmacies and learn more about mail-order delivery, immunizations and other pharmacy services.
Pharmacy Concierge Services Understanding what medications are covered or when you need a prior authorization can feel overwhelming without expert help. Just like a concierge helps find the best local places to explore, our pharmacy concierge helps you navigate your benefits, helps onboard new members, and tackles more complex pharmacy-related needs. Find the answers you need to feel confident using your pharmacy benefits to their fullest. A better pharmacy experience starts at DeanCare.com/PharmacyBenefits . Preventive drug list † Many medications are covered at $0 for large group members which helps you manage drug costs. Medications on the preventive drug list include but are not limited to:
• Preferred mental health medications • Preferred brand diabetes medications • Preferred Insulin • Preferred inhalers and nebulizer solutions
To see the most up-to-date list of $0 preventive drugs, visit DeanCare.com/PharmacyBenefits or review the Member Document Center on DeanCare.com . $6 for 6-month supply Remembering to order the prescriptions you need each month is a hassle. Our $6 for a 6-month supply program helps members with conditions like diabetes, high blood pressure, mood disorders, and bone health get a 6-month supply of certain generic medications for $6 when they use Costco (retail — Costco membership not needed) and SSM retail pharmacies. See the list of medications at DeanCare.com/PharmacySavings .
† Benefits are available only for large group (51+ employees) plans.
** Benefit is available for both large group plans (51+ employees) and ACA-compliant small group plans (2–50 employees).
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YOUR COVERAGE
YOUR MEMBERSHIP
Making changes to your plan
Member information
Member rights & responsibilities You deserve the best service and health care possible. Rights and responsibilities help foster cooperation among members, providers and Dean Health Plan. Visit Deancare.com/Member-Rights to view all of your member rights and responsibilities. Grievance & external independent review rights We know that at times you may have questions and concerns about benefits, claims or services you’ve received from Dean Health Plan. When a question or concern arises, we encourage you to reach out to Member Services. We’ll make every effort to resolve your concern promptly and completely. Your input matters, and we encourage you to call with any concerns you may have regarding your health care coverage. If after contacting us, you continue to feel a decision has adversely affected your coverage, benefits or relationship with Dean Health Plan, you may file a grievance or appeal. Visit Deancare.com/Appeals for details on how to file or for more information about these procedures. You may also find information in your Member Certificate or Summary. Contact the Customer Care Center with any questions about the process. See page 3 for contact details. How to submit a complaint If you have a complaint, please contact Member Services at 1 (800) 279-1301 ( TTY : 711) . We will document and investigate your complaint and notify you of the outcome. For more information, visit Deancare.com/Appeals. Terms & conditions All your benefits are subject to terms and conditions as described in your Schedule of Benefits and in your “Member Policy.” Please refer to these important documents for complete details. Drugs and new medical technology Each year, we evaluate new and existing medical technology to determine if any updates to medical policies are needed. Drugs covered under your pharmacy benefit are also reviewed by a Dean Health Plan medical director and pharmacists from SSM Health System and Navitus Health Solutions. Dean Health Plan follows the review process set forth by the National Committee for Quality Assurance (NCQA) any time there is a new product or process. Based upon the results of the technology assessment, Dean Health Plan will revise its medical policies if necessary.
We understand that sometimes big events happen in your life and it means you need to make a change to your coverage with Dean Health Plan. You can make changes to our plan outside of the designated open enrollment period, but only if you have a qualifying event that would
trigger a special enrollment period. Special Enrollment
You can make changes to your plan outside of the designated open enrollment period but only if you have a qualifying event that would trigger a special enrollment period.* Visit Deancare.com/SpecialEnrollment for more information on qualifying event requirements. Let us know if you have other coverage or Medicare Do you have health insurance coverage in addition to your coverage through Dean Health Plan? When you have coverage through more than one source, we have to determine in what order claims will be paid, referred to as coordination of benefits. It is especially important that you notify us when you are eligible for or are enrolled in Medicare. In situations when Medicare is or will be the primary payer, we strongly suggest that you enroll in both Medicare Part A and Part B. † We’re here to help you sort it all out. If you are enrolled in Medicare or have questions about Medicare, please contact the Medicare Coordination of Benefits Specialist at 1 (608) 827-4189 ( TTY : 711) . To report additional coverage other than Medicare, please call Member Services at 1 (800) 279-1301 ( TTY : 711). † You are Medicare-eligible if you are a legal U.S. resident and one of the following applies to you: • You are age 65 or older • You are any age and have a qualifying permanent disability • You are any age and have been diagnosed with end-stage renal disease (ESRD)
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YOUR NOTICES Privacy & Confidentiality
Notice of privacy practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Review it carefully. Protecting the privacy of your personal health information This notice describes how we protect the privacy of our members’ (and former members’) nonpublic personal information. It also explains your rights and how we obtain, use, and protect your nonpublic personal information. Dean is required by law to maintain the privacy and security of your personal health and financial information (i.e., nonpublic personal information). We will notify you right away if a breach occurs that may have compromised the privacy or security of your nonpublic personal information. Dean understands the importance of keeping your nonpublic personal information safe. Dean is required to provide you with a written notice of our legal duties and privacy practices about that information. NOTE: This notice applies to the Medica/Dean Health Affiliated Covered Entities (ACE). The combined entities are designated as a single HIPAA covered entity as permitted by HIPAA. This designation may be amended from time to time to add new covered entities that are under common control or ownership. The current list of the participant members of the Medica/Dean Health ACE include: Medica Health Plans, Medica Insurance Company, Medica Community Health Plan, Medica Regional Insurance Company, Medica Central Health Plan, Medica Central Insurance Company, Dean Health Plan, Inc., and Dean Health Insurance, Inc. Dean Health Insurance, Inc., along with Dean Health Plan, Medica Central Health Plan, and Medica Central Insurance Company may take part in Organized Health Care Arrangements (OHCAs), including an OHCA with SSM Health and Dean Health System. As part of an OHCA, we may from time to time share your information with other members of the OHCA in order to perform joint health care activities as permitted by HIPAA. Types of information Dean collects about you We collect different types of nonpublic personal information to help us manage your health insurance coverage and benefits. We collect nonpublic personal information about you from some of the following sources.
• Information we get directly or indirectly from you or your employer or benefit plan sponsor through applications, surveys or other forms. This may include information received in writing, in person, by telephone or electronically. Examples include name, address, social security number, date of birth, marital status and medical history. • Information about your business with us, our affiliates, providers, agents, and others. This includes information from health care claims, medical history, eligibility information, payment information, service requests and appeals and grievance information. • Information you allow us to get from others. Choices about your health information We will not use or release your health information without your written permission, except as described in this Notice. In some cases, you may be able to ask us to disclose your health information to the third-party application of your choosing. For the most part, you have the right and choice to tell us to: • Share information with your family, close friends or others involved in payment for your care. • Share information in a disaster relief situation. If you are not able to share your preference, such as if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In the following cases we never share your information unless you give us written permission: • Most uses and releases of psychotherapy notes. • Marketing purposes. • Sale of your information. If you do give us written authorization to use or release your health information for a particular purpose, you may change your mind at any time. You must let us know in writing if you change your mind.
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How Dean may use or release your health information We will not release your nonpublic personal information unless we are allowed or required by law to do so. The following describes the ways that Dean may use and release your nonpublic personal information. For each way we might use or release your information, we will explain what we mean and give some examples. Not every use or release we might make will be listed. However, all the ways we are allowed to use or release information will fall within one of these items. Note: Some of the uses and releases described in this notice may be limited in certain cases by laws that are stricter than Federal Privacy laws, including releases related to mental health and substance abuse, developmental disability, alcohol and other drug abuse (AODA), and HIV testing. We are allowed to use and release information for one of the following reasons: Make or collect payments. We may use and release your information to make and collect payment for premiums, or treatment and services you receive. For example, we may share information with your dental plan to arrange payment for covered dental work. This could include, but is not limited to: • Collecting premiums, • Collecting payment for your health services, • Determining your eligibility for plan benefits, and • Determining your health plan’s responsibility for benefits. Run our organization. We may use and release your health information to run our organization and contact you when necessary. For example, we use medical information about you to develop better services for your health. However, we are not allowed to use genetic information to decide whether we will give you coverage or the price of that coverage. We also will not use cultural information, such as race, ethnicity, language, gender identity, and sexual orientation for purposes of underwriting, rate setting, or denial of coverage. Help manage the treatment you receive. We may share your health information with your treatment team. For example, a doctor sends us information about your diagnosis and treatment plan so we can set up additional services. We may also contact you with information on treatment choices and other information that may be of interest to you. Offering Health-related Benefits and Services. We may use and release your health information to give you information on health-related benefits and services that may be of interest to you. For example, we may share your health information with a care partner company to offer you additional services to help you manage your health. Manage your plan. If applicable, we may share your health information with the sponsor of your group health plan for purposes of managing benefits under the plan. If you have a group health plan, your employer is the plan sponsor.
Public Safety. We can share health information about you for certain situations such as the following. • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence • Stopping or lowering a serious and immediate threat to the health or safety of a certain person or the public Research. Sometimes, and only after a special approval process, we may use and release your health information to help conduct research. Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations, a coroner, medical examiner, or a funeral director when someone dies. Required by law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services to see that we are following federal privacy laws. Workers’ compensation, law enforcement, and other government requests. We can use and share health information about you in the following situations. • Workers’ compensation claims • Law enforcement purposes or with a law enforcement official • Health oversight agencies for activities we must do under the law • Special government roles such as military, national security, and presidential protective services Respond to lawsuits and legal actions. We may share your health information in response to a court or administrative order, or in response to a subpoena. How Dean protects this information We limit the gathering of your nonpublic personal information to only what we need to run our business, provide quality service, and meet regulatory requirements. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to safeguard your nonpublic personal information. We limit the internal use of oral, written, and electronic use of this information about you and ensure that only staff and business associates with the need to know have access to it. We have safeguards for your nonpublic personal information and review them regularly to protect your privacy. We protect cultural information such as race, ethnicity, language, gender identity, and sexual orientation, the same as all other nonpublic personal information.
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Your rights Request restrictions on your health records. You have the right to ask us to not use or share certain health information. We may not agree to this request, but we will follow any request we agree to. Request confidential communications. You have the right to ask us to contact you in a specific way (for example a home phone or office phone) or to send mail to a different address. We will consider all reasonable requests and we must agree if you tell us you would be in danger if we do not. Receive a copy of your health records. You have the right to see or get a copy of your health and claims information. We may charge you for the cost of copying the records. Ask us to correct your health records. You have a right to request that Dean correct certain health information held by Dean if you think it is incorrect or incomplete. We may not agree to your request, but we’ll tell you why in writing. Receive an accounting of disclosures. You have the right to receive a list (accounting) of the times we have shared your health information for the six years prior to your request. The list will not include releases made for purposes of treatment, payment, health care operations, or certain other releases (such as those you asked us to make). If you ask for more than one list per year, we may charge you for the cost of providing it. Receive a copy of this notice. You have a right to ask for a paper copy of this Notice at any time. We will provide you with a paper copy promptly. Notification of a breach. You will be notified in the event of a breach of your unsecured protected health information. Right to a representative. If you have chosen a medical power of attorney or have a legal guardian, that person can exercise your rights and make choices about your health information. We will make sure that the person has this authority and can act for you before we take any action. Changes to this notice of privacy practices Dean may change this Notice from time to time and make the new notice effective for all nonpublic personal information we maintain, including information we created or collected before the change. Dean will always follow the current version of this notice. The new notice will be available upon request and on our website.
Complaints Submit complaints about this Notice or how we handle your health information, in writing, to our Privacy Officer. Dean will not hold any complaint you submit against you in any way. In addition, if you believe your privacy rights have been violated, you may file a complaint with the Secretary of the U.S. Department of Health and Human Services. To do so, write to the Office for Civil Rights, U.S. Department of Health & Human Services, 233 N. Michigan Ave., Ste 240, Chicago, IL 60601. If you have questions, complaints, or want to exercise any of your health information rights, call the Customer Care Center at 800-279-1301 (or, if you purchased coverage on the Health Insurance Marketplace, at 877-394-9080) or contact us at the following address:
Privacy Officer PO Box 56099 Madison, WI 53705
The effective date of this notice is October 15, 2023.
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The law recognizes advance directives as they relate to health care that’s provided to a patient who is unable to make decisions because of illness or injury. Examples include someone who has suffered brain damage and is in a coma; a patient with advanced Alzheimer’s disease; or a person in the final stages of cancer. Creating an advance directive helps protect your right to make choices about your medical care. It also helps your physician and family by providing guidelines for care. Your health care coverage from Dean Health Plan doesn’t require you to create an advance directive. We’re simply letting you know you have the option to do so, as required by law. For more information about advance directives, contact your state’s agency on aging or visit their website. Women’s Health and Cancer Rights Act: Coverage after a mastectomy The Women’s Health and Cancer Rights Act requires health insurers and group health plans that cover mastectomies to provide certain benefits if a member chooses reconstructive surgery after a mastectomy. The law also requires health plans to provide members with written notice that this coverage is available. Refer to your member account at Deancare.com/Login to see how your plan covers the following: • Reconstruction of the breast on which the mastectomy was performed. • Surgery and reconstruction of the other breast to produce a balanced look. • The cost of prosthesis and the treatment of any physical complications resulting from mastectomy. This includes treatment of lymphedema (swelling sometimes caused by surgery). Some members may have to pay a deductible, copayment, or coinsurance. The amount will be consistent with the deductibles, copayments, or coinsurance for other benefits in your plan. To determine the amount you would have to pay, see your coverage document available on your member account at Deancare.com/Login .
YOUR COVERAGE DOCUMENT Finding coverage information
You can find important information about your health care coverage in your coverage document. It describes what your plan covers, what your share of the costs will be when you get care, and other details about your plan. Member account If you haven’t checked out your Dean Health Plan account, now’s the time! It’s your digital one-stop resource for all kinds of information to help you manage your health plan benefits, and improve your health. Go to Deancare.com/Login and follow the instructions to create your account. Manage your health plan online Did you know you can find your coverage document, and other helpful information in your member account? Just sign into Deancare.com/Login. You can view, print, or download a copy of your current coverage document. Want your coverage document mailed to you free of charge? Order a copy through your member account or call Member Services at the number on the back of your Dean Health Plan ID card. Find forms and more online Check out your member account to find out more about how to manage your plan, get claim forms, and learn about notices we’re required by Federal and State law to provide to our members, such as:
• Your rights as a Dean Health Plan member • Coverage for services after a mastectomy • How to document your health care wishes
Your health care rights: What you need to know Advance directives: Making your wishes known
The Patient Self-Determination Act of 1990 requires health plans to tell members about their health care decision- making rights. These rights allow you to create written instructions that tell doctors and family members what kind of care you want if you’re too sick to make health care decisions yourself. This type of document is called an advance directive. Your instructions are written and witnessed in advance of the possible need for them.
Have questions? We’re here to help. Call our Customer Care Center at 800-279-1301 (TTY: 711)
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Have questions? We’re here to help.
Contact Member Services to turn health insurance confusion into clarity. • Get answers to benefit and coverage questions • Figure out what your financial responsibility is for a bill • Learn the details about a provider 1 (800) 279-1301 (TTY: 711 ) Monday – Thursday, 7:30 am – 5 pm Friday, 8 am – 4:30 pm
Support is just a click away. Visit DeanCare.com/Contact
Stop by our Insurance Desk, Monday – Friday, 8 am – 4:30 pm, or one of the SSM Health Dean Medical Group locations listed here: Madison Health Plan Business Office: 1277 Deming Way
South Madison Campus: 1211 Fish Hatchery Road
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