Individual Plan FAQs, Dean Health Plan

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Individual Plan Frequently Asked Questions

What is an Individual Plan?

An Individual Plan is available for individuals and families who do not have group health insurance provided by any carrier though an employer. Dean Health Plan offers different Individual Plan designs with varying benefit and coverage levels to fit your family's healthcare and financial needs.

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How can I get answers to other questions I have about the Individual Plans?

Call our Customer Care Center at (800) 279-1302.

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What happens if I have the Individual Plan and will soon become eligible for Medicare?

As you become eligible for Medicare, you may continue your Individual Plan coverage. Please note when Individual Plan members become eligible for Medicare, Dean Health Plan becomes secondary payer to Medicare.

To prevent additional out-of-pocket costs for Individual Plan members in this situation, we encourage Medicare eligible members to review our current Medicare supplement plans to receive the best possible coverage options. Eligibility under Medicare includes turning 65 years of age, qualifying for Medicare disability or meeting the End Stage Renal Disease provisions.

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What do I need to send in to start the application process?

To be complete, Dean Health Plan must receive:

  • Fully completed application form
  • Check for your first month’s premium or complete the Authorization for Automatic Transfer of Funds page within the application form

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What is the effective date for a new plan?

Your coverage date is determined by the date that you enroll. See our Open Enrollment page for more information.

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What if I want to go through an agency to get my health insurance?

Dean Health Plan is contracted with independent agencies who specialize in Individual Health Plans. Agents can help you find the best plan for your current needs. If you need help in finding an agent in your area, contact the Customer Care Center.

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What if I decide not to sign up for health insurance?

Under the law, everybody is required to be insured. Failure to do so will result in a government penalty.

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What if I just wait until I need care to sign up?

You may only sign up for health insurance during the enrollment period or under special circumstances, such as losing your coverage because of a job layoff, etc. If you become ill and do not have insurance, you will be responsible for 100% of your health care costs.

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What does it mean to have a primary care provider (PCP)?

When you enroll as a member of Dean Health Plan, you will choose a physician or clinic from our network of plan providers to be responsible for managing your healthcare. This is your primary care provider and is the provider you contact first whenever you need healthcare services.

If you choose a clinic rather than a physician, you may see any primary care provider in that clinic without a referral.

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Can I change my primary care provider?

Continuity of care is important in maintaining good health so we encourage you to select a physician who you feel comfortable seeing on a continuing basis; however, you may change your PCP at any time.

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What about referrals?

Dean Health Plan will no longer require you to obtain a written referral to see a DHP Network Provider outside of your primary care clinic. This includes specialty providers who are part of the DHP Network. Please Note: This does not affect DHP requirements to obtain a referral for services with Out-of-Network providers or prior authorization for selected services.

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Where would I go if I need to see a specialist?

Contact your primary care provider first. If he or she determines that you should be seen by a specialist, one will be sought within the Dean Health Plan network of plan providers. There are numerous specialists affiliated with Dean Health Plan, including but not limited to Dean Medical Center, one of the largest multi-specialty clinics in the nation.

If you have an exceptional problem which cannot be addressed by a plan provider, prior authorization is required. Your primary care provider will help you obtain a written referral to see a specialist that fits your needs.

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I am currently seeing a provider who is not in the Dean Health Plan network. Will you pay for this service?

If you wish to continue seeing a non-plan provider for services you are unable to obtain within the network, your Dean Health Plan primary care physician may request a referral. Without an approved referral from Dean Health Plan, you are liable for any charges. You may not choose a non-plan provider as your primary care provider.

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What preventive care coverage do I have?

Dean Health Plan encourages you to be proactive about your health. Preventive care such as routine physical exams, mammograms, well-baby care and more are covered. Immunizations are covered at 100 percent for all plan designs.

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When are premium rates calculated for the Individual Plan?

The premium rates are calculated annually. Your premium rate may increase on your policy renewal date. You will be notified of a premium rate increase at least 30 days in advance. Please note premium rates are subject to change immediately if a member’s resident address changes.

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When do my benefits and deductible start over?

The Individual Plan is a 12-month policy. Depending on which calendar month your policy began, your benefits and deductible will start over 12 months later on your policy renewal date. (Example: If your Individual Plan coverage began on Aug. 1, your policy benefits and deductible will start over one year later on Aug. 1)

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Do Individual plans have different rates for tobacco users?

Members who use tobacco and are over the age of 21 are rated differently from those who do not use tobacco. Only the tobacco user's rates are affected, and not every family member or person on the policy.

You must be tobacco free for one year and are subject to a nicotine test before you would be eligible for non-tobacco use rates. Tobacco use rating can be adjusted on the policy renewal date only.

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What are my payment options?

Dean Health Plan offers the following premium payment methods:

  • Automated Cash Handling (ACH) – ACH is our automated bank withdrawal program. With ACH, the exact premium amount is automatically withdrawn from your bank account monthly.
  • Direct Billing – If you choose direct billing, Dean Health Plan will bill you monthly. You may prepay your monthly premium up to twelve months in advance.

Note: Premium Checks must be from a personal checking account. DHP will accept business account checks under these following guidelines:

  • Subscriber is self employed.
  • The business is not paying for more than two employees.
  • The billing address will remain the subscriber's address.

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What factors affect my premium?

Many factors determine your premium, such as:

  • Tobacco/non-tobacco use;
  • Selection of deductible, coinsurance and benefit options;
  • The gender and age of you and your spouse (if applicable) on the policy effective date;
  • Coverage option, for example: single, applicant/spouse, applicant and child(ren) or full family;
  • Health status of all applicants;
  • Location of residence.

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What is a copayment?

A copayment (or copay) is a fixed dollar amount or a percentage of cost that must be paid each time services are received. There is no annual limit. You should be prepared to pay your copayment to the provider at the time of your visit.

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What is co-insurance?

Co-insurance is generally a fixed percent of a covered healthcare cost for which you have financial responsibility.

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What are my Annual Out-of-Pocket Limits?

Please refer to your Schedule of Benefits for your specific Individual Plan. Co-pays do apply to your Annual Out-of-Pocket limit.

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How do the deductible and Annual Out-of-Pocket Limit work?

You must first pay up to the amount of your deductible before Dean Health Plan will make payments toward services. After the deductible is met, Dean will pay a percentage of the coinsurance until you have met the dollar amount listed in the Annual Out-of-Pocket Limit.

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What is a deductible?

A deductible is a specified dollar amount that the member or family is required to pay out-of-pocket each contract year before Dean will pay for specific services. Depending on your policy, some services may or may not require you to pay your deductible. Please reference your Individual Member Policy and Benefit Summary for more information regarding your deductible.

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What do you consider emergency care?

An emergency is the sudden and unexpected onset of conditions requiring immediate medical attention. Such emergencies include but are not limited to: heart attack, stroke, severe shortness of breath, significant blood loss or onset of these symptoms.

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What do you consider urgent care?

Urgent care is care you need sooner than a routine doctor's visit. Urgent care is not emergency care. Examples of urgent care include: broken bones, sprains, minor cuts, minor burns, drug reactions and non-severe bleeding. See for more information.

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What should I do if I have an emergency or urgent situation?

If you need emergency care, you should proceed immediately to the nearest medical facility. Emergency care is covered anywhere in the world. If you are out of our service area and must use a non-plan provider, call the Customer Service Department as soon as reasonably possible. If you need urgent care and are within our service area, you must use a plan physician, clinic or urgent care facility.

If you are outside our service area and cannot safely return to receive care from a plan provider, go to the nearest appropriate medical facility and notify the Customer Service Department as soon as possible. Follow-up care must be received from a plan provider.

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Who is a qualified dependent?

A qualified dependent may be:

  • a legally married spouse.
  • a biological child from birth, adopted child, child placed for adoption, or stepchild to the maximum dependent age limitation selected by your employer.
  • a legal ward residing with you in a parent-child relationship who is dependent on you for at least 50 percent of support and maintenance.
  • a grandchild, until the eligible parent dependent child reaches age 18.

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How do I add a qualified dependent to my existing Individual Plan?

The policyholder must complete a new Individual Plan application and submit to Dean Health Plan.

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How are qualified dependents living out of the service area covered?

Qualified dependents who are currently living away from home are covered for urgent or emergency treatments that need immediate attention. Follow-up care and any covered elective procedure must be obtained from plan providers.

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What is Open Enrollment?

Open enrollment is the period of time during which individuals may enroll in a Qualified Health Plan. The next open enrollment period runs from Nov. 1 2016 until Jan. 31, 2017. Qualified individuals may enroll in a health plan during the special enrollment period, if that individual experiences a qualifying life event.

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What is Special Enrollment?

Special enrollment is the period of time between open enrollment periods where qualifying individuals may enroll in a health plan for 60 days after a qualifying life event. Examples of a life event include moving to a new state, changes to income and changes to your family size (such as marriage or the birth of a child).

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