Description
The State Maintenance Plan (SMP) is a health plan that offers Uniform Benefits. SMP is made up of providers in designated areas in Wisconsin and Michigan’s Upper Peninsula.
The SMP is available in counties where there are no qualified Tier 1 health plans.
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.
SMP is available in the following counties:
|
Adams County |
Douglas County |
Langlade County |
Polk County |
Taylor County |
|
Ashland County |
Florence County |
Lincoln County |
Portage County |
Vilas County |
|
Bayfield County |
Forest County |
Marathon County |
Price County |
Washburn County |
|
Burnett County |
Green County |
Marquette County |
Richland County |
Waupaca County |
|
Clark County |
Iron County |
Menominee County |
Sauk County |
Waushara County |
|
Columbia County |
Juneau County |
Oneida County |
Sawyer County |
Wood County |
Provider Directory
View the SMP provider directories found under the Providers and Information (Printable Provider Directory) section of our State of Wisconsin Group Health Insurance Program webpage. The SMP providers will be a combination of Dean Health Plan HMO providers and First Health PPO providers located within the designated SMP counties. To request a printed directory by mail, call 1-800-279-1301.
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 (PCP) 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 healthcare 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 will notify you in writing of our decision.
If you receive services without an approved prior authorization request, the claim may be denied if it’s found ineligible for coverage.
Out-of-Network Care
You can choose to seek care from healthcare 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 a 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 our 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
If you or someone you know is struggling, you are 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 disorder 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 disorder 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 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. Go online for additional information.
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 SMP, offered by Dean Health Plan, will reimburse for covered services at 50% of our maximum allowable fee, subject to a $5,000 individual/$10,000 family deductible.
Major Health Systems
Available in select counties. See SMP provider directories.