Q&A: HMO Coverage

When you enroll as a member of Dean Health Plan, you choose a physician or clinic from our network of plan providers who will 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.

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. Call our Customer Care Center for assistance at (800) 279-1301.

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 SSM Health Dean Medical Group, one of the largest multispecialty clinics in the nation.

If you have a problem that can't 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 who fits your needs.

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, contact the Customer Care Center.

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.

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

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.

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.

If you need emergency care, go 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 unless you have prior authorization by Dean Health Plan.

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

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 our Customer Care Center at (800) 279-1301.