Q&A: Individual and Family Plans

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.

As you become eligible for Medicare, you can continue your Individual Plan coverage. 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.

Your coverage date is determined by the date that you enroll.

Dean Health Plan works 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 finding an agent in your area, contact our Customer Care Center.at (800) 279-1302.

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

You can 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.
 

When you enroll as a member of Dean Health Plan, you 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're able to see any primary care provider in that clinic without a referral.

You may change your PCP at any time. But continuity of care is important to maintain good health. and we encourage you to select a physician who you feel comfortable seeing on a continuing basis.

Dean Health Plan doesn't 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. 

This does not affect DHP requirements to obtain a referral for services with out-of-network providers or prior authorization for selected services.
 

Contact your primary care provider first. If he or she determines that you should be seen by a specialist, they will refer you to one within our network.

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


 

If you want to continue seeing a non-plan provider for services you're 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 select a non-plan provider as your primary care provider.

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. 
 

Individual plans are 12-month policies. Depending when your policy began, your benefits and deductible will start over 12 months later on your policy renewal date. For example, if your Individual Plan coverage began on Aug. 1, your policy benefits and deductible will start over one year later on Aug. 1. 
 

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--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.

 

Many factors determine your premium, including:

• Your deductible, coinsurance and benefit options
• Coverage option—for example: single, applicant/spouse, applicant and child(ren) or full family
• Health status of all applicants
• The gender and age of you and your spouse (if applicable) on the policy effective date
• Where you live
• Whether you use tobacco products

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, we pay a percentage of the coinsurance until you have met the dollar amount listed in the annual out-of-pocket limit.

A qualified dependent may include:

• your legally married spouse.
• your 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.

Open enrollment is the period of time when individuals can enroll in a qualified health plan. Outside of open enrollment, you may enroll in a health plan during the special enrollment period–if you experience a qualifying life event.