dean health plan medical policy

OPM is the United States Office of Personnel Management. The list is also on our website at www.deancare.com. Refer to Other services in Section 3 for prior authorization procedures: These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plans medical director in accordance with the Plans protocols. 5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and 6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. We will not pay more than our allowance. When you receive services from Plan providers, you will not have to submit claim forms or pay bills. Individual Member Policy and Benefit Summary . If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8. Visit our Focus Map for an overview of this service area. Important contact information such as phone numbers and locations are listed on our website. OPM may disclose the information it collects during the review process to support their disputed claim decision. Claims process when you have the Original Medicare Plan You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan. Access to confirm claims submission and receipt. We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required. We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits. In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Ask your doctor, Who will manage my care when I am in the hospital?, "How can I expect to feel during recovery?". All complimentary, youll receive three coaching interactions (call, text or chat), two group video sessions, plus 24/7 support through unlimited access to a Quit Coach for the duration of the program. This term is the umbrella term that includes a wide range oftechnologies that support Telehealth and Virtual Care/VirtualVisits. Married children Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday. Services listed in this subsection will not be paid unless you: Prior Authorization may only be granted after you have consulted with a Program provider. For the schedule of upcoming dates and locations visit, A highly trained Quit Coach can help you gain the knowledge, skills and behavioral strategies to quit for life. Section 5 is divided into subsections. Your case manager works with you, your health care provider and other members of your health care team to establish the best plan of care for you. Providing your FEHB information may reduce your out-of-pocket cost. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service. We will write to you with our decision. For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. All FEHB brochures are written in plain language to make them easy to understand. If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate,in the same option of the same plan; or. Examples of fraud include, falsifying a claim to obtain FEHB benefits,trying to or obtaining service or coverage for yourself or for someone else who is noteligible for coverage, or enrolling in the Plan when you are no longer eligible. physical therapy, occupational therapy), Facet joint injections and radio-frequency ablation, Spinal cord or dorsal column stimulation and dorsal ganglion stimulation, New technologies not commonly accepted as standard of care, Elective inpatient admissions and services, Skilled nursing facility/swing beds (SNF). Make sure you, your doctor and your surgeon all agree on exactly what will be done during the operation. Coverage under this plan qualifies as minimum essential coverage (MEC). Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan providerwould result in death, disability or significant jeopardy to your condition. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another. In such cases, the hospitalized family members benefits under the new plan begin on the effective date of enrollment. To take advantage of these perks, just show your Dean Health Plan member ID card at participating locations. $300 copayment (Hearing Assistive Devices)Cochlear Implants subject to inpatient hospitalfacility copayment. The SBC shows you how you and the plan would share the cost for covered health care services. You can also file a civil rights complaint with the Office of Personnel Management by mail at: Bring the actual medication or give your doctor and pharmacist a list of all themedications and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements. When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. hospital, surgical center, etc.). Prevea360 Health Plan offers various programs that focus on the whole person across eight dimensions of wellnessmaking healthy living achievable and fun. These include: We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program. Search by specialty, name, location, gender and/or language. Internet Explorer is no longer supported. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. By law, you have the right to access your protected health information (PHI). You can be prosecuted for fraudand your agency may take action against you. Cutting of accessory sinuses, salivary glands or ducts. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected. Verified diagnosis must be conducted by aprovider skilled in testing and in the use of empiricallyvalidated tools specific for autism spectrum disorders. for chargesassociated with the facility (i.e. A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Description Dean Health Plan is focused on a holistic approach to your well-being, meeting you where you are and providing benefits and support to help maintain balance in your life. Crutches, splints, trusses, orthopedic braces and appliances, Oxygen therapy and other inhalation therapy and related itemsfor home use. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). Box 56099, Madison WI 53705. If you receive prescription drugs from a non-network pharmacy in an emergency or urgent situation, please submit your receipts along with a Prescription Drug Claim Form found on ourwebsite at www.deancare.com/members/pharmacy-benefits under "Forms" and then selecting Reimbursement Form. Removal of tumors and cysts that are not related to non-bony impacted teeth. Medical judgments and decisions of a medical nature remain with the health care providers, and they are responsible for all such medical judgments and related . You may call OPMs FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time. Services provided by out-of-network providers that have not been prior authorized, Inpatient hospital or other covered facility, Outpatient hospital or other covered facility. Note: If there is no Tier 1 generic equivalent available, you will be required to pay the higher Tier 2 or Tier 3 copayment. Please contact the Customer Care Center for a current list of services that require prior authorization. Services, drugs, or supplies you receive without charge while in active military service. Contact the government facility directly for more information. Know how to use your medication. This is the maximum allowable amount payable based upon the average charge for the same service provided other providers of a similar type, training, and experience, the same or similar geographical area and should not exceed the fees that the provider would charge any other payor for the same service. If you are a participant in a clinical trail, this health plan will provide related care as follows, if it is not provided by the clinical trial: See Section 4, Your Costs for Covered Services, page(Applies to printed brochure only). If you have questions about referrals, contact the Customer Care Center. Physical therapy, occupational therapy and speech therapy. Dean Health Plan is the medical claims administrator for colleagues who reside in Wisconsin. These programs provide services to people with chronic behavioral health illnesses that, due to history or prognosis, require repeated acute treatment or prolonged periods of inpatient care. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. Contact your employing office for further information. If you request a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate. This brochure describes the benefits ofthe Basic Option underDean Health Plan, Inc. contract (CS 1966) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Each session is designed to help tobacco users understand their triggers and urges, and develop coping strategies to stay committed to quitting. We pay hospitalization and surgeon services for non-maternitycare the same as for illness and injury. If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. Always contact your primary care provider first. Zyban is covered through the Tobacco Cessation benefit with no member cost share (see Tobacco cessation found in Section 5(a) - Educational classes and programs). Assisted Reproductive Technology (ART): All treatments orprocedures that include the handling of human eggs, sperm, and/orembryos to help an individualbecome pregnant. We do not cover the dental procedures. Emergency Services/Accidents, Section 5(e). Treatment can frequently include surgical services to resolve an urgent, unforeseen condition. Dialysis - hemodialysis and peritoneal dialysis, Intravenous (IV)/infusion therapy - home IV and antibiotic therapy. If you need assistance accessing information or documents on the Dean Health Plan website and require the information be provided in an alternate format, please contact our call center at 1-800-279-1301 (TTY: 711). MyChart gives you secure access to your health information. Surgical treatment for gender affirmation is limited to the following: Court-ordered services may not be covered if those services are NOT performed by a Plan Provider, unless the services are a result of an Emergency Detention or received on an emergency basis. *Note: A complete list of preventive care services recommended under the U.S. Preventive Services Task Force is available(USPSTF) is available online at:www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations, HHS: www.healthcare.gov/coverage/preventive-care-benefits/. For information on the hospital and/or ambulatorysurgery center benefits, see Section 5(c) Services provided by ahospital or other facility, and ambulance services. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs. For information on suspending your FEHB enrollment, contact your retirement or employing office. A term used to describe the inability to get pregnant or the inability to carry a pregnancy to term. Failure to do so may result in a penalty of 100% of cost. Alternative benefits will be made available for a limited time period and are subject to our ongoing review. The benefit period is 36 consecutive months from the date thebenefit is first used. If your medical treatment is accepted by the Dept. External/ internal incision and drainage of facial abscess of soft tissues. If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial: For more detailed information on "What is Medicare?" You should also see Important Notice About Surprise Billing Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act. Plan pays reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers; this is called maximum allowable fee. Use this tool to find documentation related to your health plan benefits, including certificate of coverage, member policy or certificate and member handbook. If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Services for persons with chronic behavioral health illness provided through a community program. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender. All product and company names are trademarks or registered trademarks of their respective holders. Except in the case of an emergency, medical services must be obtained from a Focus Plan network provider in these counties to ensure coverage. Protect Yourself From Fraud Here are some things that you can do to prevent fraud: CALL THE HEALTH CARE FRAUD HOTLINE877-499-7295OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.You can also write to:United States Office of Personnel ManagementOffice of the Inspector General Fraud Hotline1900 E Street NW Room 6400Washington, DC 20415-1100. Genetic Testing Aortopathies Connective. Over-the-counter contraceptives are a covered benefit with a prescription. Maximum Allowable Fee is the maximum amount We allow for a given service/procedure with an Out-of-Network Provider. Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. January 2023 Dean Health Plan Medical Policy Updates: Actigraphy. Services or supplies for, or in connection with, a non-covered procedure or service, including complications; a denied referral or prior authorization; or a denied admission. Discounts for gyms, spas, golfing, devices, equipment, nutrition and more. PDF Dean Health Plan, Inc. Click here to view the Dean Health Plan Medical Policy Updates . $40 Copayment per visit - Primary Care Provider, $80 Copayment per visit - SpecialistVirtual Visit, Genetic testing (contact Plan for specifics; requires priorauthorization), Immunizations such as pneumococcal, influenza, shingles,tetanus/DTaP and human papillomavirus (HPV). Servicesprovided by an out-of-network provider require priorauthorization. PDF Dean Health Plan, Inc. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. If you need assistance accessing information or documents on the Dean Health Plan website and require the information be provided in an alternate format, please contact our call center at 1-800-279-1301 (TTY: 711). If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction ortermination takes effect. providers have entered into participating agreements with Dean. The No Surprises Act (NSA) is a federal law that provides you with protections against surprise billing and balance billing under certain circumstances. Drugs provided or administered by a physician or other provider, except those drugs that meet the definition of Professionally Administered Drugs. If you need to file the claim, here is the process: In most cases, providers and facilities file claims for you. Mini-transplants performed in a clinical trial setting (nonmyeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. OPM will base its review of disputes about treatment plans on the treatment plans clinical appropriateness. A copayment is a specified dollar amount that you may be required to pay each time covered services are provided, subject to any maximums specified in this policy. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plans network and/or service area (if you use our Plan providers). If you enter an incorrect . Ward, semiprivate, or intensive care accommodations, Operating, recovery, maternity, and other treatment rooms, Administration of blood and blood products, Dressings, splints, casts, and sterile tray services, Medical supplies and equipment, including oxygen, Anesthetics, including nurse anesthetist services, Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home, Operating, recovery, and other treatment rooms, Diagnostic laboratory tests, X-rays , and pathology services, Administration of blood, blood plasma, and other biologicals, Blood and blood plasma, if not donated or replaced, Dressings, casts, and sterile tray services, Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor, Hospice services while at a skilled nursing facility. The terms of the plan are set by the Wisconsin Department of Employee Trust Funds ("ETF") and the Group Insurance Board ("GIB"), also defendants in this Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. Many factors can determine the primary payer of your health claims, due to Medicare eligibility and coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. Only certain Dean Health Plan providers qualify as Program providers. See Section 5(c). You will experience a lower out-of-pocket cost using our Costco mail order pharmacy (90-day supply for 2 copayments) vs. retail pharmacy (90-day supply for 3 copayments). ), or home health aide. Ask about any risks or side effects of the medication and what to avoid while taking it. A range of voluntary family planning services, limited to: Note: We cover oral contraceptives under the prescription drugbenefit. The annual health benefits open enrollment period is September 26 - October 21, 2022. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. We retain the right to choose the provider. You can receive any ofthe tobacco cessation medications listed on the drug formularywith no member cost-sharing. Removal of exostoses of the jaw and hard palate when not performed to facilitate denture placement. This Plan is a (health maintenance organization (HMO) plan). Our HMO offers Open Access benefits. The PBM will approve the request if the provider notes that the non-formulary contraceptive product is medically necessary. You should join an HMO because you prefer the Plans benefits, not because a particular provider is available. Copayment amounts are applied to our contracted fee or Maximum Allowable Fee, andapply at the benefit level. Refer to Other services in Section 3 for priorauthorization procedures. Dean Health Plan offers separate, supplemental provider manuals for certain . Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits. Cochlear implants for children and adults, including proceduresfor implantation and post-cochlear implant aural therapy. We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. Voluntary sterilization (e.g., vasectomy), Obtain Prior Authorization to participate in the Dean Comprehensive Weight Management Program ("Program"); and. Although some of these conditions may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. 2 Plans Sort by: Plans Medicare Advantage Plus Prescription Drug Medicare Advantage Prescription Drug (Part D) Location or Star Rating (out of 5 stars) 1 Star - 5 Stars Monthly Plan Premium. Medical Necessity will be reviewed by our Quality and Care Management division. AG1 Basic Option Self OnlyAG3 Basic Option Self Plus OneAG2 Basic Option Self and Family, Important Notice from Dean Health Plan AboutOur Prescription Drug Coverage and Medicare. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare. Routine physical once annually.The following preventive services are covered at the time intervalrecommended at each of the links below. Additionally, in order to be covered under the plan, preventiveservices must: Dean Health Plan follows the United States Preventive Service'sTask Force (USPSTF) recommendations for preventive services. Box 56099, Madison, WI 53705 ; and, c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and. Enter Group number or Member ID: Re-enter Group number or Member ID: Be sure to check the number you enter. Intensive outpatient programs for the treatment of behavioral health disorders. Hospital services are covered under Section 5(c) and Surgicalbenefits Section 5(b). Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers. This decision is important since your primary care physician provides or arranges for most of your health care. Drugs to treat sexual dysfunction are limited to Viagra and Cialis. If you choose a clinic rather than a physician, you may see any primary care provider in that clinic without a referral. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. Complete the form below to create your Policy Alerts Dashboard account. Conquer Your Urges to Smoke: Gain the skills you need to control cravings, urges and situations involving alcohol.

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