2018 State of Wisconsin - Group Health Insurance Program - Dean Health Plan

 
2018 State of Wisconsin - Group Health Insurance Program - Dean Health Plan
2018              State of Wisconsin
                                                                                 Group Health Insurance Program

                                                                        5-Star
                                                               Employee Trust Fund's
Dean Health Plan, Inc. | 1277 Deming Way | Madison, WI 53717
                                                               Quality Rating for 2018!
          800-279-1301 | TTY: 711 | deancare.com

                 ©2017 Dean Health Plan, Inc. • 4910_1708
2018 State of Wisconsin - Group Health Insurance Program - Dean Health Plan
We’re Here                                                                Provider
to Help                                                             Network

     Call
     Call the Customer Care Center 800-279-1301 (TTY: 711)
                                                                                                                                             Adams
     Monday through Thursday: 7:30 am to 6 pm
                                                                                                                                                 Friendship
     Friday: 7:30 am to 5 pm                                                                                                                                         Marquette
                                                                                                                      Juneau                                                  Westfield              Green                                        Mt. Calvary
                                                                                                                                                                                                     Lake             Ripon                Fond du Lac

                                                                                                                         Elroy                                            Oxford                                  Brandon       Fond du Lac
                                                                                                                                                                                                       Markesan

     Click                                                                      Vernon                   Hillsboro           Wonewoc
                                                                                                                                      Wisconsin Dells
                                                                                                                                                                                                                           Waupun

                                                                                                                                                                                                                     Fox Lake         Brownsville    Campbellsport
     Visit deancare.com/contact-us                                                                                                       Lake Delton
                                                                                                                                 Reedsburg
                                                                                                                                                                            Portage    Pardeeville        Randolph     Dodge
     and click the Dean Health Plan button.                                                                                                        Baraboo
                                                                                                                                                                             Columbia                              Beaver Dam            Mayville
                                                                                                                                          Sauk                                                Rio
                                                                                                       Richland Center
                                                                                                                                             Prairie du Sac          Lodi                                                    Juneau
                                                                                                                                  Plain                                                          Columbus
                                                                                                    Richland
                                                                                                                                             Sauk City                                                                     Watertown
                                                                                                                               Spring Green                                Dane
                                                                                                                                                                                            Sun Prairie
     Come in                                                                        Boscobel       Muscoda                                                                  Waunakee                            Waterloo                   Oconomowoc
                                                                                                                                                                                                                                Ixonia                      Sussex
                                                                                                                                                         Black Earth                                          Lake Mills
                                                                                                                                                                                             Deerfield                                                      Pewaukee
     Our Insurance Desk is open Monday through Friday,                                                                       Iowa                                 Madison
                                                                                                                                                                                                                     Johnson Creek           Hartland
                                                                                                                                                                                                                                                             Brookfield
                                                                                      Fennimore
                                                                                                                 Highland
                                                                                                                                          Barneveld                  Verona
                                                                                                                                                                                   Cottage Grove                Jefferson                       Delafield
                                                                                                                                                                                                                                                     Waukesha New Berlin
                                                                                                                                                                                                                                                                        Wauwatosa

     8 am to 4:30 pm. Come in to our Health Plan Office or one                                     Montfort                                                                                  Cambridge             Jefferson
                                                                                                                              Dodgeville                                         Oregon Stoughton
                                                                                                                                                                                                                                          WaukeshaMuskego
     of the following SSM Health Dean Medical Group locations:                      Grant                                                                           Belleville                                   Fort Atkinson               Eagle   Mukwonago
                                                                                                                             Mineral Point
                                                                                                                                                                                                     Edgerton                   Whitewater
     Business Office: 1277 Deming Way, Madison                                             Lancaster                               Blanchardville
                                                                                                                                                              New Glarus
                                                                                                                                                                                                                 Milton
                                                                                                  Platteville                                                                          Evansville
     East: 1821 S. Stoughton Road, Madison                                                                                       Darlington Argyle            Green                                                            Walworth
                                                                                                                                                                             Albany         Rock Janesville                  Darien
                                                                                                  Cuba City          Lafayette                                   Monroe                                                               Delavan
     West: 752 N. High Point Road, Madison                                                                                                                                            Brodhead
                                                                                                                         Shullsburg                                                                  Beloit      Clinton

     Fish Hatchery: 1313 Fish Hatchery Road, Madison                              Dubuque, IA                                                         Lena, IL
                                                                                                                Galena, IL                                                            Durand, IL
                                                                                                                                                                   Freeport, IL                                 Roscoe, IL
     Janesville East: 3200 E. Racine Street, Janesville

                                                                   Hospital and Primary Care Provider location
                                                                   Primary Care Provider location only
                                                                   Hospital only

                                                                 Dean Health Plan offers a current and complete listing of physicians, clinics, pharmacies and more at
                                                                 deancare.com/doctors.
                                                                 Important contact information such as phone numbers and locations are listed on our website. If you would like a
                                                                 printed copy of the provider directory, please call our Customer Care Center at 800-279-1301. Please keep in
                                                                 mind that the online directory has the most up-to-date listing of providers.
2018 State of Wisconsin - Group Health Insurance Program - Dean Health Plan
Table of
Contents
page(s)

4-5 		    Introduction to Dean Health Plan

6 		      Convenient Tools and Resources

7 		      New Member Checklist

8 		      The Dean Provider Network

9		       Understanding Your Benefits
          Claims and Payment
          Explanation of Benefits

10-11		   Getting the Right Care
          Urgent and Emergency Care
          Out-of-Area Care
          Authorizations

12		      Common Insurance Terms

13		      Member Rights and Responsibilities

14		      Plan Details

15-16		   Privacy and Confidentiality

17-18		   Your Notes

                                               deancare.com | 3
2018 State of Wisconsin - Group Health Insurance Program - Dean Health Plan
Serving You
for More than 30 Years
Dean Health Plan is proud to serve the State of Wisconsin Group Health Insurance Program! Over three
decades ago, we responded to the needs of the state by creating managed care plans and effectively
managing the cost and quality of that care. That long history has helped Dean Health Plan become a
market leader in health insurance in southern Wisconsin. Here are some exceptional reasons why so many
choose Dean Health Plan:

                                           Access to Providers
                                           Dean Health Plan has been providing award-winning health care
                                           coverage since 1983. Our network is staffed with health care
                                           professionals who are dedicated to helping you and your loved ones
                                           remain as healthy as possible, even when you’re on the road.

                                           Dean On Call
                                           Answers to your health-related questions are available 24/7/365.
                                           If you’re not sure where to go for care or you have a health concern,
                                           experienced registered nurses at Dean On Call are here to help.
                                           Call 800-57-NURSE (800-576-8773).*

                                           *D
                                             ue to licensing regulations, Dean On Call’s triage services are only available to
                                            Wisconsin residents. For any life-threatening emergencies, always dial 911.

4 | 2018 State of Wisconsin Group Health Insurance Program
5-Star Quality Rating from Employee Trust Fund!

5
    Dean Health Plan is proud to have earned Employee Trust Fund’s 5-Star
    quality rating. We are always striving to find better ways of serving you.

    Care Management
    While you should always start with your primary care provider for non-
    emergency care, sometimes you might need additional help navigating
    through the health care system. That’s where the Dean Health Plan
    Care Management team comes in. If you’re diagnosed with a chronic
    health condition or have a complex health care need, we can help guide
    you to the most appropriate method of care and ensure your needs are
    met and your questions and concerns are addressed. Learn more about
    Care Management at deancare.com/caremanagement.

    Prevention Focused
    It’s easy to get well and stay well with Dean Health Plan. We
    emphasize a proactive, preventive approach to care — one in which
    a primary care provider (PCP) oversees all aspects of your health
    care needs and keeps you well through regular visits. These visits
    are a good time to receive needed immunizations or health and
    cancer screenings.

    Accredited by National Committee for
    Quality Assurance
    Accreditation is by the National Committee for Quality Assurance
    (NCQA). NCQA is an independent, not-for-profit organization that
    evaluates health plans based on more than 50 standards of care and
    service to determine health plan accreditation.

                                                               deancare.com | 5
Convenient
Tools and Resources
Get the information you need, when you need it. Find it within member tools that easily connect you
to health information, benefit details and much more.

           ❯❯    Activate these accounts today! deancare.com/newmember

                      Your online                                              Your online
                     member portal                                            health record

         	View details of your insurance plan                        end and receive secure messages
                                                                     S
           benefits                                                  with your primary care provider and/
                                                                     or Care Management team
         	Change your primary care provider
                                                                   	Get real-time lab and test results
         	Request ID cards or download a digital
           ID card                                                 	Schedule appointments or review
                                                                     past visit details
         	Review and print claims history
           and information                                         	Request prescription refills
         	Check the status of prior authorizations                	View current medical records
           for services                                              Pay medical bills online
           Find your Explanations of Benefits (EOB)
                                                                        Want information on the go?
           Tip: You’ll need your member number                      Activate MyChart then download the
        from your ID card to activate your account.                  mobile app onto your smartphone.

                                   Online Answers
                                   ●●   Visit deancare.com/wi-employees for links to important member
                                        documents with details of your benefits and coverage. There
                                        you’ll also find a link for our online directory so you can search
                                        for a provider, clinic or pharmacy near you.

6 | 2018 State of Wisconsin Group Health Insurance Program
New Member
Checklist
Begin your experience with Dean Health Plan by taking a few simple steps. Complete this checklist
to unlock resources and take important actions so you can get the most out of being a member. This
checklist is helpful even if you are continuing your coverage with Dean Health Plan.

Activate Your Accounts
Get access anytime to your personal health information with your MyChart account. Have your health
insurance and member information available at your fingertips with your DeanConnect account.
See page 6 to learn more.

Review Your Health Care Benefits
Together, the “It’s Your Choice” materials from the Wisconsin Department of Employee Trust Funds (ETF)
and the “Summary of Benefits and Coverage” documents from Dean Health Plan specifically outline the
benefits, services, exclusions and limitations under your policy. The same Guide is issued for each of the
many State of Wisconsin Group Health Insurance Program plans, but the Summary reflects Dean Health
Plan’s specific benefits, so be sure to read both. Visit deancare.com/wi-employees to access them online.
Please also see etf.wi.gov for more information.

Choose a Primary Care Provider
Choose a primary care provider (PCP) who is right for you. Go online or call our Customer Care Center
at 800-279-1301. Fostering an open and honest relationship with a primary care provider whom you can
trust is an important part of Dean’s integrated care model.

Transfer Your Medical Records
Once you’ve chosen a primary care provider and made an initial appointment, have your medical
records sent over from your previous clinic. Simply fill out an “Authorization to Release Protected Health
Information” form, available at deancare.com/members under Member Forms, and give it to your previous
provider. He or she will transfer the records to your new Dean provider.

Let Us Know if You Have Health Concerns
If you have a chronic health condition or have a complex health care need, we encourage you to take
advantage of our Care Management services. Visit deancare.com or call the Customer Care Center at
800-279-1301 for more information.

                                                       Visit our State of Wisconsin Group Health
                                                       Insurance Program website to access your
                                                       policy’s specific benefits and coverage
                                                       details: deancare.com/wi-employees

                                                                                            deancare.com | 7
The Dean
Provider Network
As a Dean Health Plan member, you have access to more than 2,000 in-network providers
throughout our 20-county service area. Visit our State of Wisconsin Group Health Insurance Program
website at deancare.com/wi-employees for the online provider directory to easily find excellent doctors
available in our network. Please see the back inside cover of this book for a detailed service area map.
• To search the directory, select Online Provider Directory.
• To download an electronic copy of the directory, select Printable Provider Directory.
• You may also call our Customer Care Center at 800-279-1301 to request a copy to be mailed to you.

Providers in the Network
Madison and Beyond
SSM Health Dean Medical Group is a major provider of health care to Madison and its surrounding
communities. Our reach goes beyond the Capital City with more than two dozen clinic locations, all
owned by SSM Health.
To complement our clinics, more than 2,000 other doctors across southern Wisconsin have joined the
Dean Health Plan network. In addition to unsurpassed access, patients enjoy consistent, high-quality care
that’s been recognized in a variety of independent measures. Our health plan, clinics and hospitals have
a long tradition of collaborating to provide you with the care you need, where and when you need it. We
work together – for you.

                           SSM Health Dean Medical Group
                           Where Quality Soars
                           We lead the pack in a variety of key measures linked to prevention and
                           management of chronic conditions, as compiled by the Wisconsin Collaborative
                           for Healthcare Quality in 2016.

                           Hospitals You Can Trust
                           SSM Health St. Mary’s Hospital –Madison, SSM Health St. Mary’s Hospital –Janesville
                           and SSM Health St. Clare Hospital – Baraboo offer high-quality care and an
                           exceptional patient experience. SSM Health St. Mary’s Hospital – Madison is
                           recognized as one of the best hospitals for 2017–18 in Wisconsin by U.S. News &
                           World Report; it was also named a Best Regional Hospital, a status earned by just
                           10 percent of the nearly 5,000 hospitals evaluated. SSM Health St. Mary’s Hospital –
                           Janesville achieved the most improved door-to-imaging time for stroke patients in
                           the first quarter of 2017 among all 46 state hospitals participating in the Wisconsin
                           Coverdell Stroke Program. SSM Health St. Clare Hospital – Baraboo was one of only
                           six hospitals nationally to receive the Premier QUEST award for high-value health
                           care in all six categories.

8 | 2018 State of Wisconsin Group Health Insurance Program
Understanding
Your Benefits
The State of Wisconsin Group Health Insurance Program is a network-based plan. That means your
primary care provider from our Dean Health Plan network oversees all aspects of your health care needs
and emphasizes preventive care to keep you as healthy as possible. Please refer to the State of Wisconsin
Group Health Insurance Program’s “It’s Your Choice” materials and your “Summary of Benefits and
Coverage” from Dean for details.

                                     deancare.com/wi-employees or etf.wi.gov
                                     Your place to go for policy information, including:
                                         • Provider listings
                                         • Plan information and details
                                         • Dean Health Plan Communication – copies of letters and other
                                            correspondence sent to members

Claims and Payment
Filing Claims
Time is valuable to all of us; that’s why Dean Health Plan minimizes the amount of paperwork required
for our members. In most cases, claims are submitted directly to Dean Health Plan by providers or clinic
staff. On occasion, if you’re traveling out of the area or have a college-age dependent, for example, it may
be necessary for you to submit a claim for reimbursement. When submitting the claim, please be sure to
follow these guidelines:
        1. Send an itemized bill from the provider of services. If services were received outside of the
            United States, you will need to submit the original bill along with an itemized bill that has been
            translated into English and indicate the appropriate currency exchange rate at the time the
            services were received.
        2. Send the bill within 60 days of receiving the services to:
		                Dean Health Plan
		                Attn: Claims Department
		                P.O. Box 56099
		                Madison, WI 53705
If you have another insurance company that is the primary payer, you will need to send the Explanation of
Benefits (described below) to Dean Health Plan or to your health care provider.

Explanation of Benefits (EOB)
The EOB contains important information including the total amount charged, the amount paid by Dean
Health Plan, and the amount that is your (the member’s) responsibility. You may access all of your EOBs
online at any time through your DeanConnect account, accessible at deancare.com/wi-employees.
Remember, an EOB is not a bill.

                                                                                                deancare.com | 9
Getting the
Right Care
                                                  URGENT
    PRIMARY                                        CARE                       EMERGENCY
     CARE                                                                       CARE

You may be wondering why we stress the importance of selecting a primary care provider (or location)
within the Dean Health Plan network as you enroll. It’s because we emphasize a proactive, preventive
approach to care—one in which a primary care provider oversees all aspects your health care needs. This
keeps you and your family well and decreases the duplication of services. Your primary care provider
should be your first choice for care whenever possible. But know that when a more immediate need arises,
you do have other options.
If you’re unsure where to get care, call Dean On Call, our 24-hour nurse hotline for help. See page 3 for
more information about Dean On Call. Making the right choice when it comes to the care you need ensures
you receive the right care in the right place without unnecessary costs.

Urgent and Emergency Care
If immediate care is needed, visit urgent care. Urgent care is designed to treat medical problems that
require attention sooner than a regular office visit, but are not serious enough to warrant a visit to an
emergency department. Urgent care sites are also generally open on evenings and weekends.
For critical illness or injury, seek emergency care. Though urgent care centers are convenient and a
good option for some illnesses and injuries, more serious symptoms need immediate care at an emergency
department. Dial 911 if you think a health problem is life threatening or could worsen on the way to
the hospital.

Out-of-Area Care
With Dean Health Plan, there’s no need to worry about health insurance while on vacation. Both urgent
and emergency care are covered by Dean Health Plan if you or your covered family member are unable
to return to the service area for immediate treatment. It’s also a good idea to familiarize yourself with the
types of ailments that can be treated as urgent care vs. emergency care. Visit deancare.com/rightcare
for details.

10 | 2018 State of Wisconsin Group Health Insurance Program
Behind the Scenes at Dean
Ways we’re helping you get the right care

Prior Authorization
As you navigate your health care, it’s important to note that there are certain medical services or provider
visits that will require prior authorization by Dean Health Plan. These authorizations are required so our
Medical Affairs team can make sure you are getting the appropriate care. A good rule to remember
is that any time you seek services with an out-of-network provider, you will need to obtain a prior
authorization.

Utilization Management
When you need to discuss issues or have questions related to the requirement of an authorization for a
particular service, Dean Health Plan is here to help. Contact the Customer Care Center at 800-279-1301
(TTY: 711), and you will be connected to the Utilization Management department. This department ensures
you receive the appropriate and necessary care for your condition.
Utilization Management staff members are available Monday through Friday, 8 am to 4:30 pm. If you have an
urgent need outside of those hours, please leave a message with the Customer Care Center and your call will
be returned within one business day.

New Medical Technology
Every year Dean Health Plan evaluates new medical technology and reviews existing technology to
determine if any changes or updates are needed to guidelines outlining appropriate use. During this
process, we review requests for ongoing care or treatment recommendations for all utilization management
decisions, including medical, behavioral health care, pharmaceuticals and medical devices. Dean Health Plan
follows the review process set by the National Commission for Quality Assurance (NCQA). Based upon the
results of the technology assessment, we will draft or revise medical policies if necessary.
For help to translate or understand this information, please call 800-279-1301 (TTY: 711).

                                                                                               deancare.com | 11
Common
Insurance Terms
Allowed amount: The maximum amount on which payment is based for a health plan’s covered health
care services.
Annual maximum out-of-pocket: The maximum amount a member could pay out-of-pocket for
covered health care services in a plan year before the plan would pay 100 percent of the cost of covered
services. The maximum does not include premium payments.
Benefit maximum: A benefit maximum is a limit on a covered service. A service may be limited by
duration or number of visits – and if not an Essential Health Benefit, by dollar limit. To review your benefit
maximums please refer to your member policy document.
Coinsurance: Your share of the costs of a covered health care service, calculated as a percent of the
allowed amount for the service. You pay coinsurance plus any deductibles you owe first. For example,
if Dean Health Plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your
coinsurance payment of 20% would be $20. Dean Health Plan pays the rest of the allowed amount.
Copay: A fixed amount that you pay for a covered health care service, usually when you get the service.
The amount can vary by the type of covered health care service.
Deductible: The amount you owe for covered services before the plan begins to pay. For example, if your
deductible is $1,000, Dean Health Plan won’t pay anything for covered services subject to the deductible
until you’ve met your $1,000. Not all services are subject to the deductible, such as preventive services.
Essential Health Benefits (EHB): Essential Health Benefits consist of 10 health care benefit categories.
Plans that cover EHB may put an annual or lifetime dollar limit on the amount of EHB.
Formulary: A list of prescription drugs covered by an insurance plan offering prescription drug benefits.
Also called a drug list. Normally a formulary will also tell you what tier (or cost-sharing level) a particular
drug will be in.
Guaranteed issue: A requirement that health plans must allow you to enroll for coverage regardless of
health status, age, gender or any other factors that might predict the future use of health services.
Health Savings Account (HSA): A medical savings account available to taxpayers who are enrolled in
a High Deductible Health Plan. The funds contributed to the account aren’t subject to federal income tax at
the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending
Account (FSA), funds roll over year to year if you don’t spend them.
Individual mandate: All individuals, with certain exceptions, are required to maintain minimum essential
health coverage under the Affordable Care Act provisions.
In-network providers: Refers to physicians, hospitals or other health care providers who are contracted
with Dean Health Plan.
Out-of-network providers: Refers to physicians, hospitals or other health care providers who are not
contracted with Dean Health Plan, which could result in a greater cost for services for you.
Pre-existing condition: A health problem you had before the date that new health coverage starts.
Under the Affordable Care Act, insurers may no longer impose benefit limitations or exclusions due to a pre-
existing condition.
Preventive care: Routine health care that includes screenings, check-ups and patient counseling to
prevent illnesses, disease or other health problems.
Prior authorization: Approval from a health plan that may be required before you receive services or fill a
prescription in order for the service or prescription to be covered by your plan.

12 | 2018 State of Wisconsin Group Health Insurance Program
Member
Rights & Responsibilities
You deserve the best service and health care possible. Rights and responsibilities help foster cooperation
among members, practitioners and Dean Health Plan.

Members have the right to:
  • Be treated with respect and recognition of their dignity and right to privacy.
  • Receive a listing of Dean Health Plan participating practitioners in order to choose a Primary Care Physician.
  •P
    resent a question or complaint or grievance to Dean Health Plan, about the organization or the care it
   provides, without fear of discrimination or repercussion.
  • Receive information on procedures and policies regarding their health care benefits.
  • Timely responses to requests regarding their health care plan.
  • Request information regarding Advance Directives.
  • Participate with practitioners in making decisions about their health care.
  •A
    candid discussion of appropriate or medically necessary treatment options for their conditions,
   regardless of cost or benefit coverage.
  •R
    eceive information about the organization, its services, its practitioners and providers, and members’
   rights and responsibilities.
  • Make recommendations regarding the organization’s members’ rights and responsibilities policies.
  •R
    eceive a copy of the Dean Health Plan Notice of Privacy Practices, which describes how medical
   information about you may be used or disclosed and how you can get access to this information.
   The notice is available at deancare.com/privacy.

Members have the responsibility to:
  •R
    ead and understand the materials provided by Dean Health Plan concerning their health care benefits.
   Dean Health Plan encourages members to contact Dean Health Plan if they have any questions.
  •P
    resent their ID card in order to identify themselves as Dean Health Plan members before receiving
   health care services.
  • Notify Dean Health Plan of any enrollment status changes such as family size or address You must also
     communicate enrollment status changes to your employer so that your system of record can be updated.
  •S
    upply information (to the extent possible) that the organization and its practitioners and providers
   need in order to provide care.
  • Follow plans and instructions for care that they have agreed on with their practitioners.
  •U
    nderstand their health problems and participate in developing mutually agreed upon treatment goals
   to the degree possible.
  •F
    ulfill financial obligations as they relate to any copays, deductibles and/or premiums as outlined
   in your policy.
  •P
    rovide information about any other health insurance coverage you have so that Dean Health Plan can
   coordinate benefits with the other insurance plan(s).

                                                                                                 deancare.com | 13
Plan
Details
Limitations & Exclusions
For a list of services, treatments, equipment or supplies that are excluded (meaning no benefits are
payable under the Plan Benefits); or have some limitations on the benefit provide, please refer to the
State of Wisconsin Group Health Insurance Program’s “Its Your Choice” materials, under Uniform Benefits
Exclusions and Limitations.

Complaints, Grievances and Appeals Process
We know that at times you may have questions and concerns about benefits, claims or services you have
received from Dean Health Plan. Sharing your concerns will help us to identify areas of improvement or
clarification needed in our processes or documents as well as help clear up areas of confusion with your
benefits or coverage. When a question or concern arises, we encourage you to reach out to our Customer
Care Center at 800-279-1301. Our Customer Care Specialists will make every effort to resolve your
concern promptly and completely. Your input matters, and we encourage you to call with any concerns
you may have regarding your health care.

If after contacting us, you continue to feel
a decision has adversely affected your
coverage, benefits or relationship with
Dean Health Plan, you may file a grievance
(sometimes called an appeal). For details
on how to file or for more information
about these procedures, please visit the
online Member Handbook accessible on
deancare.com/members under Member
Benefits. Or feel free to contact the
Customer Care Center at 800-279-1301 with
any questions about the process.

As a member of the State of Wisconsin
Group Health Insurance Program, you also
have the right to request an administrative
review through ETF if an independent review
organization has not rendered a decision on
your grievance that is final and binding. Refer
to your “It’s Your Choice” materials for details
on this process.

14 | 2018 State of Wisconsin Group Health Insurance Program
Privacy and
Confidentiality
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Privacy and Confidentiality                                                          If you do give us written authorization to use or disclose your
This notice describes how medical information about you may                          health information for a particular purpose, you may change
be used and disclosed and how you can get access to this                             your mind at any time. You must let us know in writing if you
information. Please review it carefully.                                             change your mind.

Protecting the Privacy of Your Personal Health Information                           How Dean May Use or Disclose Your Health Information
Dean is required by law to maintain the privacy of your personal                     We will not disclose your nonpublic personal information
health and financial information (collectively referred to as “non-                  unless we are allowed or required by law to do so. The following
public personal information”) and provide you with written                           categories describe the ways that Dean may use and disclose
notification of our legal duties and privacy practices concerning                    your nonpublic personal information. For each category of uses
that information. This Notice describes how we protect the                           and disclosures, we will explain what we mean and present
confidentiality of our members’ (and former members’) nonpublic                      some examples. Not every use or disclosure we might make will
personal information. It includes brief explanations on how we                       be listed. However, all the ways we are permitted to use and
obtain, use, and protect your nonpublic personal information.                        disclose information will fall within one of the categories.

Types of Nonpublic Personal Information Dean Collects                                Note: Some of the uses and disclosures described in this notice may be
                                                                                            limited in certain cases by applicable State laws that are more stringent
About You
                                                                                            than Federal laws, including disclosures related to mental health and
We collect a variety of nonpublic personal information needed                               substance abuse, developmental disability, alcohol and other drug
to administer health insurance coverage and benefits. We collect                            abuse (AODA), and HIV testing.
nonpublic personal information about you from some of the
following sources:                                                                   We are allowed to use and disclose information that falls within
                                                                                     one of the following categories:
   • Information we receive directly or indirectly from you or your
      employer or benefits plan sponsor through applications,                        1. Payment. We may use and disclose your health information
      surveys or other forms. The information may be received in                         to make and collect payment for treatment and services
      writing, in person, by telephone or electronically. Examples                       you receive, such as: determining your eligibility for plan
      include name, address, social security number, date of birth,                      benefits, obtaining premiums, determining your health plan’s
      marital status and medical history.                                                responsibility for benefits, and collecting payment for your
   • Information about your transactions with us, our affiliates,                       health services.
      our providers, our agents and others. This includes                            2. H
                                                                                         ealth Care Operations. We may use and disclose your health
      information from health care claims, medical history,                             information to support our business activities and improve
      eligibility information, payment information, service                             our coverage and services. However, we are not allowed to
      request, and appeal and grievance information.                                    use genetic information to decide whether we will give you
   • Information you authorize us to collect from others.                              coverage or the price of that coverage. Health care operations
                                                                                        include such activities as:
Choices about Your Health Information
                                                                                         • Underwriting
We will not use or disclose your health information without your
written authorization, except as described in this Notice. You                           • Premium rating
generally have the right and choice to tell us to:                                       • Other functions related to plan coverage
   • Share information with your family, close friends or others                        • Quality assessment and improvement activities
      involved in payment for your care.
                                                                                         • Activities designed to improve health and reduce health
   • Share information in a disaster relief situation.                                     care cost
In the following cases we never share your information unless                            • Case management and care coordination
you give us written permission:
   • Most uses and disclosures of psychotherapy notes
   • Marketing purposes
   • Sale of your information

                                                                                                                                         deancare.com | 15
Notice: We are part of an Organized Health Care Arrangement (OHCA) with          Your Health Information Rights
SSM Health and Dean Health System. As part of the OHCA, we may from time         1. Right to Request Restrictions. You have the right to request
to time share your information with other members of the OHCA in order to
perform joint health care operations. These uses and disclosures allow the
                                                                                     restrictions on certain uses and disclosures of your health
OHCA to run efficiently. For example, we may share your information in order         information.
to: improve population health management; conduct quality assessment and
                                                                                 2. Right to Request Confidential Communications. You have the
improvement activities; conduct or arrange for medical review, legal services,
audit services, and fraud and abuse detection programs; business planning            right to receive your health information through a reasonable
and development such as cost management; and business management and                 alternative means or at an alternative location.
general OHCA administrative activities.
                                                                                 3. Right to See and Copy. You have the right to see and copy
1. Treatment. We may disclose your health information to a                          certain health information about you.
    physician or other health care provider that is treating you. We             4. Right to Correct Records. You have a right to request that
    may contact you with information on treatment alternatives                       Dean correct certain health information held by Dean if you
    and other related functions that may be of interest to you.                      think it is incorrect or incomplete.
2. Distributing Health-related Benefits and Services. We may                    5. R
                                                                                     ight to Accounting of Disclosures. You have the right to
   use and disclose your health information to provide information                  receive a list “accounting of disclosures” of your health
   on health-related benefits and services that may be of interest                  information made by us in the past six years. The list will not
   to you.                                                                          include disclosures made for purposes of treatment, payment,
3. Disclosure to Plan Sponsors. If applicable, we may disclose                     health care operations, or certain other disclosures (such as
    your health information to the sponsor of your group                            those you asked us to make).
    health plan for purposes of administering benefits under                     6. Right to Copy of Notice. You have a right to receive a paper
    the plan. If you have a group health plan, your employer is                      copy of this Notice at any time.
    the plan sponsor.
                                                                                 7. Right to be Notified of a Breach. You will be notified
4. P
    ublic Safety. We can share health information about you for                     in the event of a breach of your unsecured protected
   certain situations such as: preventing disease; helping with                      health information.
   product recalls; reporting adverse reactions to medications;
   reporting suspected abuse, neglect, or domestic violence; and                 8. R
                                                                                     ight to a Representative. You have the right to appoint
   preventing or reducing a serious and imminent threat to the                      a medical power of attorney, of if someone is your legal
   health or safety of a particular person or the public.                           guardian, that person can exercise your rights and makes
                                                                                    choices about your health information.
5. Research. Under certain circumstances, and only after a
    special approval process, we may use and disclose your health                Changes to this Notice of Privacy Practices
    information to help conduct research.                                        Dean may change this Notice from time to time and make the
                                                                                 new provisions effective for all nonpublic personal information
6. Required by Law. We will share information about you if laws                 we maintain, including information we created or received
    require it, including with the Department of Health and Human                before the change.
    Services if it wants to see that we are complying with federal
    privacy law.                                                                 Dean will always comply with the current version of this Notice.
7. Workers’ Compensation, Law Enforcement, and Other
                                                                                 Complaints
    Government Requests. We can use and share health
                                                                                 Please submit complaints about this Notice or how we handle
    information about you: for workers’ compensation claims; for
                                                                                 your health information, in writing, to our Privacy Officer.
    law enforcement purposes or with a law enforcement official;
                                                                                 Dean will not hold any complaint you submit against you in any
    with health oversight agencies for activities authorized by law;
                                                                                 way. In addition, if you believe your privacy rights have been
    and for special government functions such as military, national
                                                                                 violated, you may file a complaint with the Secretary of the
    security, and presidential protective services.
                                                                                 U.S. Department of Health and Human Services.
8. Legal Actions. We may disclose your health information in the
                                                                                 If you have questions, complaints, or want to exercise any of
    course of any administrative or judicial proceeding.
                                                                                 your health information rights, call the Customer Care Center at
How Dean Protects This Information                                               800-279-1301 (TTY: 711) or contact us at the following address:
We limit the collection of nonpublic personal information to that
which is necessary to administer our business, provide quality                   Privacy Officer
service, and meet regulatory requirements. We maintain physical,                 PO Box 56099
electronic, and procedural safeguards that comply with federal                   Madison, Wisconsin 53705
regulations to safeguard your nonpublic personal information.                    The effective date of this notice is 8/1/2017.
We limit the internal use of oral, written, and electronic nonpublic
personal information about you and ensure that only authorized
staff and business associates with the need to know have access
to it. We maintain safeguards for your nonpublic personal
information and review them regularly to protect your privacy.

16 | 2018 State of Wisconsin Group Health Insurance Program
Your
Notes

        deancare.com | 17
Your
Notes

18 | 2018 State of Wisconsin Group Health Insurance Program
We’re Here                                                                    Provider
to Help                                                                 Network

     Call
     Call the Customer Care Center 800-279-1301 (TTY: 711)
                                                                                                                                                 Adams
     Monday through Thursday: 7:30 am to 6 pm
                                                                                                                                                     Friendship
     Friday: 7:30 am to 5 pm                                                                                                                                             Marquette
                                                                                                                          Juneau                                                  Westfield              Green                                        Mt. Calvary
                                                                                                                                                                                                         Lake             Ripon                Fond du Lac

                                                                                                                             Elroy                                            Oxford                                  Brandon       Fond du Lac
                                                                                                                                                                                                           Markesan

     Click                                                                          Vernon                   Hillsboro           Wonewoc
                                                                                                                                          Wisconsin Dells
                                                                                                                                                                                                                               Waupun

                                                                                                                                                                                                                         Fox Lake         Brownsville    Campbellsport
     Visit deancare.com/contact-us                                                                                                           Lake Delton
                                                                                                                                     Reedsburg
                                                                                                                                                                                Portage    Pardeeville        Randolph     Dodge
     and click the Dean Health Plan button.                                                                                                            Baraboo
                                                                                                                                                                                 Columbia                              Beaver Dam            Mayville
                                                                                                                                              Sauk                                                Rio
                                                                                                           Richland Center
                                                                                                                                                 Prairie du Sac          Lodi                                                    Juneau
                                                                                                                                      Plain                                                          Columbus
                                                                                                        Richland
                                                                                                                                                 Sauk City                                                                     Watertown
                                                                                                                                   Spring Green                                Dane
                                                                                                                                                                                                Sun Prairie
     Come in                                                                            Boscobel       Muscoda                                                                  Waunakee                            Waterloo                   Oconomowoc
                                                                                                                                                                                                                                    Ixonia                      Sussex
                                                                                                                                                             Black Earth                                          Lake Mills
                                                                                                                                                                                                 Deerfield                                                      Pewaukee
     Our Insurance Desk is open Monday through Friday,                                                                           Iowa                                 Madison
                                                                                                                                                                                                                         Johnson Creek           Hartland
                                                                                                                                                                                                                                                                 Brookfield
                                                                                          Fennimore
                                                                                                                     Highland
                                                                                                                                              Barneveld                  Verona
                                                                                                                                                                                       Cottage Grove                Jefferson                       Delafield
                                                                                                                                                                                                                                                         Waukesha New Berlin
                                                                                                                                                                                                                                                                            Wauwatosa

     7:30 am to 5 pm. Come in to our Health Plan Office or                                             Montfort                                                                                  Cambridge             Jefferson
                                                                                                                                  Dodgeville                                         Oregon Stoughton
                                                                                                                                                                                                                                              WaukeshaMuskego
     one of the following SSM Health Dean Medical Group locations:                      Grant                                                                           Belleville                                   Fort Atkinson               Eagle   Mukwonago
                                                                                                                                 Mineral Point
                                                                                                                                                                                                         Edgerton                   Whitewater
     Business Office: 1277 Deming Way, Madison                                                 Lancaster                               Blanchardville
                                                                                                                                                                  New Glarus
                                                                                                                                                                                                                     Milton
                                                                                                      Platteville                                                                          Evansville
     East: 1821 S. Stoughton Road, Madison                                                                                           Darlington Argyle            Green                                                            Walworth
                                                                                                                                                                                 Albany         Rock Janesville                  Darien
                                                                                                      Cuba City          Lafayette                                   Monroe                                                               Delavan
     West: 752 N. High Point Road, Madison                                                                                                                                                Brodhead
                                                                                                                             Shullsburg                                                                  Beloit      Clinton

     Fish Hatchery: 1313 Fish Hatchery Road, Madison                                  Dubuque, IA                                                         Lena, IL
                                                                                                                    Galena, IL                                                            Durand, IL
                                                                                                                                                                       Freeport, IL                                 Roscoe, IL
     Janesville East: 3200 E. Racine Street, Janesville

                                                                       Hospital and Primary Care Provider location
                                                                       Primary Care Provider location only
                                                                       Hospital only

                                                                     Dean Health Plan offers a current and complete listing of physicians, clinics, pharmacies and more at
                                                                     deancare.com/doctors.
                                                                     Important contact information such as phone numbers and locations are listed on our website. If you would like a
                                                                     printed copy of the provider directory, please call our Customer Care Center at 800-279-1301. Please keep in
                                                                     mind that the online directory has the most up-to-date listing of providers.
2018              State of Wisconsin
                                                                                 Group Health Insurance Program

                                                                        5-Star
                                                               Employee Trust Fund's
Dean Health Plan, Inc. | 1277 Deming Way | Madison, WI 53717
                                                               Quality Rating for 2018!
          800-279-1301 | TTY: 711 | deancare.com

                 ©2018 Dean Health Plan, Inc. • 4910_1803
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