Q&A: Point of Service (POS) Plan

An in-plan provider is a doctor, hospital, pharmacy or other medical provider who has contracted with Dean Health Plan to provide services through our network and is listed in our provider directory. Out-of-network providers do not participate in our network and are therefore not listed in the directory. Members who see plan providers will receive the highest benefit level available at the lowest out-of-pocket cost.

No, you are not required to select a Primary Care Provider. You simply choose the provider you wish to see at the time you seek services. However, you are encouraged to choose a provider that you feel comfortable seeing on a continuing basis.

Yes. Any member can see in-network providers for some services and out-of-network providers for others. Covered benefits, deductibles, coinsurance and copayment costs are calculated for each person, for each visit or treatment, depending on the provider chosen for that service.

If you see an out-of-network provider, services will be paid according to the out-of-network benefit level. Payment for charges submitted by out-of-network providers are limited to the maximum allowable fee (after the deductible and coinsurance are applied).

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

You will always pay a copayment each time you receive a service. The copayment amounts you pay accumulate to fulfill the maximum out-of-pocket amount stated in your policy. Deductible and coinsurance amounts also apply to maximum out-of-pocket expense.

The deductible is the amount that you must pay before your insurance begins to cover expenses. For families, each member must meet the “single” amount to begin receiving benefits, but once the “family” amount has been met, no more deductibles will be collected for any family member.

Deductible amounts can be combined between in-network and out-of-network providers. Please refer to your plan documents to confirm if your deductible amounts are combined or not. In-network copayments do not apply toward the deductible. However, they do apply to the maximum out-of-pocket.

Payments for charges submitted by out-of-network providers will be limited to the maximum allowable fee. Any amount that exceeds this is your responsibility and does not apply to the maximum out-of-pocket.

Members are not required to obtain referrals to see their provider of choice, even if that provider is an out-of-network provider. However, some services of these providers do require prior authorization. If you use an in-network provider, the prior approval requirements are lessened. See your Member Certificate for more detailed information.

For a planned hospital admission, call our Customer Care Center at (800) 279-1301 at least 10 business days before admission to obtain certification approval. For an emergency admission, call our Customer Care Center by the next business day for certification approval.

Prior authorization is approval for certain prescription drugs, medical equipment purchase or rental and certain services. Some services require prior authorization only if received from an out-of-network provider. It is the member’s responsibility to obtain prior authorization from Dean Health Plan before services are received and charges are incurred.

To request prior authorization, or inquire whether or not you need prior authorization, call our Customer Care Center at (800) 279-1301. A representative will make the necessary arrangements for your request to be filed.

When you call our Customer Care Center for prior authorization, we will verify coverage of the service or drug in question, notify you of coinsurance or deductibles that may apply, and provide information that may help you minimize your out-of-pocket costs. If you are receiving long-term treatment, we may assign a case manager who can help you understand your coverage for different provider and treatment options.

In some cases, prior authorization helps us ensure that the health care services that you receive are coordinated between providers and consistent with the guidelines for most effective care that have been written by our physicians.

Precertification is approval of an admission to a facility and/or the approval of a specified number of days for a facility confinement prior to the services being received. If possible, you must request precertification at least 10 days prior to the planned admission to allow time for us to review your needs and estimate the number of days of inpatient treatment required.

You can call our Customer Care Center at (800) 279-1301 after hours and leave a message for prior authorization or admission certification. A representative will return your call the next business day.

A qualified dependent may be:

• a legally married spouse
• an unmarried biological child from birth, adopted child, child placed for adoption, or stepchild to the maximum dependent age limitation selected by your employer
• an unmarried 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

Disabled children may also be covered after the limiting age. Call our Customer Care Center for more information.

Qualified dependents who are currently living outside the service area may take advantage of the option to use non-plan providers and receive benefits at the reduced, out-of-network level. To receive the higher plan provider benefit level, they must use in-network providers.

The deductible, coinsurance or copayment amount for an out-of-network provider would apply. Talk with your provider about whether prior authorization is needed before receiving services.

If you fill your prescription at an in-network pharmacy, prescriptions are covered as outlined in your policy. If you go to an out-of-network pharmacy, you must pay for the full amount of the prescription, then submit a claim to Dean Health Plan to receive reimbursement at the reduced level.

If you are out of the service area, you can receive benefits by using one of the national pharmacies listed in the provider directory. Note that some prescription drugs require prior authorization. A list of these drugs can be obtained by calling our Customer Care Center.

You may choose to see either an in-network or out-of-network specialist at any time without a referral. However, many services provided by specialists require approval prior to being received (see your Member Certificate).

There are numerous area medical specialists affiliated with Dean Health Plan, including but not limited to Dean Medical Center, one of the largest multi-specialty clinics in the nation.

Some policies include a lifetime benefit limit per member, combined between plan and non-plan providers. Refer to your Member Certificate for the lifetime benefit maximum (if applicable).