HSHS Healthy Plan - Aetna PPO Plan

There are three in-network benefit levels under the HSHS Healthy Plan - Aetna PPO Plan:

HSHS
Provides the highest benefit level. HSHS is proud of the quality of care our system provides. We encourage you to consider using HSHS physicians and facilities for medical care whenever you can. The office visit charge is covered at 100% and the deductible does not apply to most services. To receive this benefit, you must use HSHS facilities or HSHS physicians. HSHS physicians include the HSHS Medical Group and Prairie Cardiovascular Consultants.

PCIN-Aetna Supplemental
Provides the next highest benefit level. The Physician Clinical Integration Network (PCIN) includes providers throughout Illinois and Wisconsin who are focused on quality, performance improvement and patient safety.

Other Aetna
Provides the lowest in-network benefit, however, you have access to health services through Aetna’s national provider network. Generally, if you use a provider in the Other Aetna level, you will be responsible for the deductible before the plan pays benefits.

When you use HSHS, PCIN-Aetna Supplemental or Other Aetna providers, you receive: 
  • Protection against unexpected charges above reasonable and customary (R&C), since HSHS and network providers charge preferred rates well within R&C limits.
  • Freedom from claim forms, since HSHS and network providers file claims and bill the plan for payment — as a result, your money isn’t tied up waiting for reimbursement.
  • Savings through lower rates for services negotiated by Aetna, the network administrator.


HSHS Healthy Plan - Dean EPO Plan

Using Network Providers
Your medical options will be Exclusive Provider Organization (EPO) options that, in most cases, only cover services received from HSHS/Prevea360 network providers. This means if you receive care outside the network you will most likely be responsible for the full cost of care.

You are inside the HSHS/Prevea360 network service area if your listed residence is in one of the designated ZIP codes. If your address is in the HSHS/Prevea360 network service area, for 2019 you'll see providers in the Exclusive Provider Organization (EPO). In most cases, this covers service received only from HSHS/Prevea 360 network providers. This means if you receive care outside the network, you will most likely be responsible for the full cost of care.

If your ZIP code is not listed within the designated ZIP codes—and you live in Wisconsin—your network providers for 2019 is also the Exclusive Provider Organization (EPO). Since you live outside of the service area, you can also use the HealthEOS network. In most cases, the plan covers services received from only HSHS/Prevea 360 network providers, and the HealthEOS network, with the exception of Marshfield or Mayo providers. Care received from Marshfield or Mayo providers without an approved prior authorization from Dean will most likely result in you being responsible for the full cost of care. If you receive care outside these networks, you will most likely be responsible for the full cost of care.

When you need care from a non-network provider
  • Out-of-network services will not be covered unless you first obtain a referral from your network provider and prior authorization from Dean Health Plan.
  • Your network provider will need to submit a referral request to Dean Health.
  • If HealthEOS is your primary network, you need a referral if the provider required for your care is not in either the HSHS/Prevea360 or the HealthEOS network.
  • In order for services to be covered, the referral needs to be reviewed and approved prior to services being received.
To learn more, contact the Dean Customer Service Center at 1-888-895-1188.