Description
The Access Health Plan from Dean Health Plan by Medica is a comprehensive health plan that gives you freedom of choice among a broad network of hospitals and physicians in Wisconsin and nationwide. A higher level of benefits is available by using preferred or in-network providers, which are available nationwide. Out-of-network providers are available worldwide.
For nearly 40 years, we’ve been caring for local communities across southern Wisconsin. We proudly serve the State of Wisconsin Group Health Insurance Program, offering plans that deliver high-quality, cost-effective care. Our holistic approach to your well-being means we’ll meet you where you are and give you the benefits and support to help maintain balance in your life. We prioritize prevention and work to enhance your overall wellness. You’ll have access to a strong care network featuring preferred providers within the FirstHealth network, giving you choice and flexibility in receiving care for you and your family.
What’s New for 2024
Joint venture with Medica
In 2021, we formed a joint venture with Medica, a non-profit health plan serving nearly 1.5 million people. We have significant similarities in our histories, operations, cultures, and deep community commitment. Our relationship is driven by technology, a shared mission-driven vision, and innovation. Together we have an even greater opportunity to support your health care needs and to further enhance our provider relationships.
Provider Directory
The Access Plan and Access High Deductible Health Plan (HDHP) use the First Health provider network throughout Wisconsin and nationwide. In Southern Wisconsin, members also have access to Dean HMO providers. To search for providers, go to the Providers and Information Section on our State of Wisconsin Group Health Insurance Program webpage.
To search for nationwide wide providers under the First Health Network, select Access PPO Network and then click on Find a First Health Provider. Before seeking medical care with First Health providers, we suggest confirming your provider's network participation by calling your provider's office and asking if they participate in the First Health Network.
To search for Dean HMO providers in Southern Wisconsin, under Online Provider Search, select HMO Network. Then under Select Plan Type, select Commercial HMO/POS Insurance (Group or Individual Coverage).
If you choose to seek care from an out-of-network provider, you will be responsible for paying higher out-of-pocket costs.
Referrals, Authorizations, Out-of-Network
Prior authorizations are required for certain procedures or services before you receive care. A prior authorization is a written request that is completed by your Primary Care Provider and/or network specialist provider requesting authorization of a specific service(s) or procedure that is to be performed. Review our prior authorization list for examples of procedures and services requiring prior authorization. This is not a complete list. Contact Member Services at 1-800-279-1301 to verify whether a procedure or service needs prior authorization.
If your health care provider recommends a service or procedure that needs prior authorization, they should submit a prior authorization request form to us. It’s your responsibility to make sure your provider requests prior authorization at least 15 business days before the date of your service or procedure. We’ll notify you in writing of our decision.
If you receive services without an approved prior authorization request, the claim may be paid at the out-of-network benefit or denied if it’s found ineligible for coverage.
Out-of-Network Care
You can choose to seek care from health care providers that are not in our network. However, if you get care from an out-of-network provider you’ll be responsible for paying higher out-of-pocket costs.
If you see an out-of-network provider, we’ll pay charges up to our maximum allowable fee. If there’s a difference between the maximum allowable fee and the amount billed by your out-of-network provider, we’ll review the appropriateness of fees that exceed the maximum allowable fee, holding you harmless. Please call Member Services if you have questions about the maximum allowable fee.
If an in-network provider cannot provide care that you need, we may cover care you receive from an out-of-network provider as if that provider is in-network with an approved prior authorization.
Emergency and Urgent Care
If you require emergency or urgent care when outside of the network, seek care at the nearest medical facility. Contact Member Services at 1-800-279-1301, if possible, when you receive emergency care from an out-of-network provider.
No prior authorization is needed for emergency and urgent care. However, you should notify us as soon as possible if you are admitted as an inpatient.
Mental, Behavioral Health and Substance Abuse
More ways to access mental health services
If you or someone you know is struggling, you’re not alone. We offer many supports, services, and treatment options within our network.
For members with mental health and substance use disorders, our behavioral health and substance use case management provides an individualized approach. The goal is to help you manage your health and live your best life. Learn more about our behavioral health services.
Telemedicine continues to grow every day and more specialties are finding ways to provide virtual options for patients. Find an in-network provider to get started.
A prior authorization is required for the following mental health and substance use services:
- Detox
- Inpatient
- Residential
- Partial hospitalization/day treatment
- Intensive outpatient
- In-home therapy
24-Hour Nurseline
Nurse Advice Line is there whenever you have a health question. You can connect with an experienced registered nurse online or by calling 1-800-576-8773 (TTY: 711).
The Nurse Advice Line is available after-clinic hours from 5 p.m. - 8 p.m. and 24/7 on weekends and holidays to serve patient triage needs.
NOTE: Due to licensing restrictions Nurse Advice Line's triage services are only available to residents of Wisconsin.
Virtual Visits
E-visits: the lowest-cost option
SSM Express Virtual Care is there when you can’t meet with your regular physician or need after-hours care in the comfort of your home.
E-visits are used for minor medical concerns. By filling out a simple online form an SSM Health provider will respond to your care needs electronically. There’s no need to schedule an appointment and costs can vary by plan.*
Virtual visits connect you with an SSM Health provider through a video conference when you want to talk with a physician about an urgent health need. A conference usually happens in a few minutes during operating hours and cost can vary by plan.*
Learn more about choosing the right care.
*Reference your schedule of benefits for cost-sharing.
Care Outside the Service Area
The Access Plan will reimburse for covered services at 70% of our maximum allowable fee, subject to a $500 individual/$1,000 family deductible, up to a $2,000 individual and $4,000 family out-of-pocket limit. The HDHP Access Plan may have higher out-of-pocket expenses.
Major Health Systems
Search for a provider on First Health’s Locate a Provider webpage.