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HMO Coverage Frequently Asked Questions

Q. In completing the application, I noticed that I am asked to choose a clinic or provider. What does this mean?

A. 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 health care. This is your primary care provider (PCP) and is the provider you contact first whenever you need health care 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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Q. Can I change primary care providers?

A. We encourage you to select a physician that you feel comfortable seeing on a continuing basis. However, if you wish to change, you may do so at any time. Please call our Customer Care Center for assistance at (800) 279-1301.

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Q. If I need to see a specialist, where would I go?

A. Always 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 providers. There are numerous area medical specialists affiliated with Dean Health Plan, including but not limited to Dean Medical Center, one of the largest multispecialty clinics in the nation. Should you have a problem which cannot be addressed by a plan provider, prior authorization from Dean Health Plan will be required. Your primary care provider will help you obtain a written referral to see a specialist that fits your needs.

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Q. What about referrals?

A. You need a written referral request when your Dean Health Plan physician recommends that you receive services from a non-plan provider. Your Dean Health Plan network physician will request that the referral be reviewed by Dean Health Plan. You and the non-plan physician will receive written confirmation of approval or denial of the requested services. Services received without prior authorization may be denied and would be the responsibility of the Dean Health Plan member. If you have questions about referrals, please contact the Customer Care Center.

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

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

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Q. My plan includes copayments. How does this work?

A. A copayment is a fixed dollar amount or a percentage of cost that must be paid each time services are received. Copayments contribute to the maximum out-of-pocket amount for each plan. You should be prepared to pay your copayment to the provider at the time of your visit.

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Q. What do you consider emergency care?

A. An emergency is the sudden an unexpected onset of conditions that a prudent layperson could reasonably expect the absence of medical attention to result in serious jeopardy to the member's health. Such emergencies include, but are not limited to, heart attack, stroke, severe shortness of breath or significant blood loss.

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Q. What do you consider urgent care?

A. 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.

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

A. If you need emergency care, you should proceed immediately to the nearest medical facility. If you are out of our service area and must use a out-of-network provider, call the Customer Care Center as soon as reasonably possible. Emergency care is covered anywhere in the world. If you need urgent care and are within our service area, you must use an in-network provider, clinic or urgent care facility. If you are outside our service area and cannot safely return to receive care from an in-network provider, go to the nearest appropriate medical facility and notify the Customer Care Center as soon as possible. Follow-up care must be received from a plan provider if not prior authorized by Dean Health Plan.

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Q. How do I get reimbursed for emergency care I received while overseas?

A. In order to reimburse you, Dean Health Plan needs an itemized bill, in English, with the current U.S. exchange rate, along with the foreign claim form. You can download the foreign claim form.

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Q. Who is a qualified dependent?

A. A qualified dependent may be:

  1. a legally married spouse
  2. a biological child from birth, adopted child, child placed for adoption, or stepchild to the maximum dependent age limitation selected by your employer
  3. 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
  4. a grandchild, until the eligible parent dependent child reaches age 18

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

A. 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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Q. How are qualified dependent students living out of the service area covered?

A. Emergency or urgent care for qualified dependent students is covered out of the service area. Any follow-up care out of the service area must be prior authorized and will be covered at 50 percent of the maximum allowable fee.

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Q. In what way does Medicare Eligibility affect my DHP insurance coverage?

A. Many factors can determine the primary payer of your health claims, due to Medicare eligibility and coverage. For information, please contact a Medicare Analyst through the Customer Care Center at (800) 279-1301.

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