CurrentCareSource GeorgiaPolicy POLMP-IN(2025)
Marketplace Evidence of Coverage (EOC) and HMO Contract — Indiana Marketplace Plan (2025)
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This Evidence of Coverage and HMO contract governs member rights, benefits, limitations, prior authorization, appeals, and administrative procedures for CareSource's Qualified Health Plan offered in the Marketplace for Indiana members for plan year 2025.
Policy Summary
PayerCareSource Georgia
PolicyMarketplace Evidence of Coverage (EOC) and HMO Contract — Indiana Marketplace Plan
Policy CodePolicy POLMP-IN(2025)
Change TypeNo material changes
Effective DateJan 1, 2025
Next Review Date
Key ActionObtain required prior authorization for services on the Prior Authorization list before providing or billing those services.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
2025Plan year covered
IndianaService / jurisdiction
24/7CareSource24
10 daysReturn period
Coverage Rules, Benefits, and Limits
Covered Services (referenced)
The EOC contains a detailed table of contents listing covered services, exclusions, and member processes; covered services sections include ambulance, autism services, behavioral health, clinical trials, dental, diabetes supplies, diagnostic services, emergency care, habilitative services, home health, hospice, infertility, inpatient/maternity, DME, outpatient/physician services, prescription drugs, preventive care, rehabilitative/therapy, hearing, sterilization, surgery, telehealth, TMJ, transplant, urgent care, and pediatric vision.
Table of contents lists Covered Services sections including Ambulance, Autism Spectrum Disorder Services, Behavioral Health Care Services, Covered Clinical Trials, Dental Services (Other), Diabetes Education/Equipment/Supplies, Diagnostic Services, Emergency Health Care Services, Habilitative Services, Home Health Care Services, Hospice Services, Infertility Services, Inpatient Services, Maternity Services, Medical Supplies/DME, Outpatient Services, Physician Home Visit and Office Services, Prescription Drugs, Preventive Health Care Services, Reconstructive Services, Rehabilitative Therapy, Routine Hearing Services, Sterilization, Surgical Services, Telehealth Services, TMJ/Jaw Disorders, Transplant Services, Urgent Care, and Pediatric Vision (EyeMed).
Referenced content: Prior Authorization requirements, exclusions, and member processes (appeals, grievances, External Review) are cross-referenced in these Covered Services sections; providers and members are directed to member services and the Prior Authorization list on CareSource.com for details.
Eligibility, Enrollment, Member Responsibilities, and Coverage Access
Enrollment rules and member obligations that affect access to Benefits under the Plan.
You must be enrolled and pay required Premiums to be eligible for Benefits; enrollment must follow Marketplace and/or CareSource requirements.
Eligibility for Marketplace coverage is determined by the Marketplace; CareSource confirms eligibility for direct enrollments; members may not be denied enrollment due to health condition.
Members generally must be residents of Indiana and reside within the Plan's Service Area to be eligible; verify Service Area via Member Services or website.
Dependents eligible include spouse, qualified domestic partner (meeting specified conditions), children up to limiting age 26, and disabled adult children meeting dependency/medical proof rules.
Members must present their CareSource ID card at each visit and follow network/provider rules; use Network Providers and Network Pharmacies to receive Benefits except as allowed by EOC.
Members are responsible for timely Premium payment, copayments, coinsurance, and Annual Deductible as specified in the Schedule of Benefits; failure to pay may trigger Grace Period rules and affect claims processing.
Language assistance (oral and written interpretation) is available at no cost; contact Member Services for assistance and to request EOC materials (mailed within seven business days upon request).
Eligibility, Enrollment, and Special Enrollment Criteria
Rules and timelines for enrollment effective dates, open enrollment, special enrollment events, and appeals of eligibility decisions.
Marketplace confirms eligibility and effective date for Marketplace enrollments; CareSource confirms eligibility in writing for direct enrollments.
Coverage becomes effective on the coverage effective date once enrollment is confirmed and sufficient payment to effectuate coverage is received.
Open enrollment is held annually during the Marketplace-designated period; members enrolled through Marketplace receive open enrollment info from the Marketplace.
Special enrollment periods are available for qualifying events (listed examples include loss of minimum essential coverage, pregnancy-related coverage loss, loss of Medicaid, birth/adoption/placement, error in enrollment, move outside service area, domestic abuse, change in immigration status, change in APTC/CSR eligibility, release from incarceration, etc.); standard special enrollment length is 60 calendar days from triggering event unless otherwise stated.
New dependents: newly born or newly adopted children are covered initially for 31 days; continuation requires request within 60 days and premium payment; proof of disability for over-limit dependents must be furnished within required timeframe.
Appeal of ineligibility: If Marketplace or CareSource determines ineligibility, the individual will be notified and provided appeal rights; Marketplace appeals follow Marketplace procedures and direct-enrollment appeals follow EOC Section 9 processes.
Members must notify CareSource and the Marketplace within 60 days of certain life/status changes (income, address, pregnancy, dependents aging out, Medicare entitlement, gain of other coverage); failure to notify may affect coverage eligibility.
Coverage criteria and exclusions (definitions section)
Definitions and baseline coverage criteria — what makes a service a Covered Service and common exclusions.
Covered Services must: (1) be covered by a specific Benefit provision, (2) not be excluded, and (3) be Medically Necessary per CareSource medical policies and nationally recognized guidelines to prevent, diagnose, or treat sickness, injury, behavioral health or substance use disorders.
Medically Necessary (Medical Necessity) means appropriate per CareSource medical policies and nationally recognized clinical guidelines, not Experimental/Investigational, necessary to meet basic health needs, rendered in the most cost-efficient appropriate setting, consistent with diagnosis, and supported by peer-reviewed literature or safe with promising efficacy in controlled research settings for life-threatening conditions.
Experimental or Investigational services are excluded unless narrow exceptions apply (e.g., certain humanitarian use devices or specified life‑threatening situations); CareSource has sole authority to determine Experimental/Investigational status.
Prior Authorization may be required for certain services; benefits depend on obtaining necessary Prior Authorization as listed on the Prior Authorization list.
Preventive Health Care Services recommended by USPSTF, ACIP, and HRSA are included as Essential Health Benefits where applicable and may be exempt from deductibles per the Schedule of Benefits.
Network and Non-Network Coverage Rules
Network vs non-network coverage rules and exceptions.
Members must generally use Network Providers to receive Benefits; exceptions are specified in the EOC.
Non-Network covered only when: Non-Network services are Covered only in specified situations: Emergency Health Care Services (including Emergency Ambulance), Urgent Care while temporarily outside the Service Area, continuity of care situations, Non-Network providers while in a Network facility, or when services are not available from a Network Provider with Prior Authorization.
For Non-Network services (except emergency and certain in-facility services), Prior Authorization is required — failure to obtain it will result in Non-Covered Services and the member (or Non-Network provider) being responsible for payment.
Non-Network services payable at Network level are limited to the Maximum Allowable Amount; members may be responsible for amounts in excess of Allowed Amount plus deductible/coinsurance/copay.
Members are protected from surprise bills for emergency and certain in-facility non-network services; non-network ancillary providers must notify and obtain consent for out-of-network care to permit balance-billing only with member consent and required notice timelines.
Financial Obligations, Deductible, Coinsurance, Copay
Member financial obligations, premium and grace period rules that affect access to benefits.
Premiums must be paid by due date (online, phone, or mail) to maintain Benefits; premium rate is guaranteed for the Benefit Year with 60 days' notice for changes; refunds for premiums paid after termination issued within 30 days.
Grace Period differs by APTC status: with APTC, grace is three months (first month coverage continues, claims held months 2–3, prescription drugs rejected months 2–3); without APTC, grace is 31 days with similar claims handling rules; failure to cure results in termination and denial of held claims.
Annual Deductible applies to most services (see Schedule of Benefits); preventive services and some prescription drugs may be exempt from deductible.
Coinsurance is a fixed percentage of Eligible Expenses after deductible is met; copayments are fixed dollar amounts usually paid at time of service and vary by service type.
Service Area, Out-of-Area Dependent Coverage, and Network Access
Service area rules, out‑of‑area dependent coverage, and network access guidance.
The Plan is available to members who live in the Plan's Service Area; members should verify exact Service Area via the website or Member Services.
Out-of-Service-Area dependent child coverage is provided in limited circumstances (court-ordered coverage, attending out-of-area accredited higher education, residing with a former spouse); benefits payable at Network level and limited to Maximum Allowable Amount; member may owe amounts above Maximum Allowable Amount and remain subject to coinsurance/copay/deductible.
Network Provider directory ('Find A Doctor') is available online and updated at least monthly; printed directory available free upon request.
Members must verify a provider's Network status via Member Services or the website because Network participation may change and providers may limit patient acceptance.
Covered Services and Continuity of Care conditions
Covered services are limited to Covered Services; continuity of care and coverage of certain non-network services are available under specified conditions.
Benefits are limited to Covered Services as defined in Section 2; not all health care services are covered by the Plan.
Continuity of Care: Plan will manage continuity of care requests to avoid disruption when a Non-Network Provider was treating you at enrollment or a Network Provider leaves the Network; eligibility for continuity depends on circumstances and prior authorization as described in Continuity provisions.
Coverage of Non-Network services for continuity requires provider agreement to accept Plan payment at Network rates, accept payment as payment in full, comply with quality and Plan procedures, and provide necessary medical information to CareSource.
Continuity of Care criteria
Specific continuity of care eligibility and duration rules.
Existing Covered Persons continuity: If your PCP leaves the Network, Plan will continue to pay for Covered Services from that PCP for 60 days after departure unless termination was for fraud/quality; if removed without cause and special circumstances apply (serious/complex treatment, inpatient, scheduled non-elective surgery), Plan may authorize up to 90 days continuance.
Terminal or chronic illness continuity: If you have a Terminal Illness, are pregnant, or have a chronic life‑threatening/degenerative condition requiring specialized prolonged care, you may continue to receive coverage from the Provider with Prior Authorization until you no longer need services (duration variable, may continue through delivery/postpartum or until treatment complete).
New Covered Persons continuity: New Covered Persons may receive coverage for services from an existing Non-Network physician for up to 30 days after coverage effective date (longer if PCP/Active Course of Treatment/pregnant/terminal as specified) provided Prior Authorization is obtained.
All continuity coverage requires Prior Authorization and the Non‑Network Provider must agree to Plan terms (payment rates, not balance-bill the member beyond allowed amounts, comply with Plan quality and procedural requirements).
Prior Authorization and Benefit Determinations
Prior Authorization and benefit determination mechanics, decision timeframes, and operational expectations.
Prior Authorization is required for Health Care Services listed on the Prior Authorization list to determine evidence-based medical necessity before the service is provided; Network Providers are responsible for obtaining Prior Authorization; Non-Network Providers or members must obtain Prior Authorization for Non-Network care when required.
Prior Authorization list is available via Member Services or the website and is subject to change with 45 calendar days' prior notice to Network Provider and member when applicable.
If a Network Provider fails to obtain Prior Authorization, the Network Provider is responsible for costs; if a Non-Network Provider or member fails to obtain Prior Authorization, the member is responsible for full payment.
Request types and timeframes: Request types include Urgent, Pre-service (preservice), Concurrent, and Retrospective. Decision timeframes: Urgent/Expedited decisions within 48 hours; Preservice within 5 business days; Retrospective within 2 business days after receipt of complete information; concurrent initial reviews within 3 calendar days and continued stay within 48 hours as applicable.
Benefit determinations use CareSource clinical coverage guidelines and are subject to member eligibility, Covered Service status, benefit limits, and Exclusions; Prior Authorization does not guarantee payment if other conditions are not met.
Members/providers are entitled to reasonable access to documents relevant to requests free of charge upon request.
Coverage criteria and operational rules
Operational rules that determine coverage decisions — medical necessity, limits, exclusions, prior authorization interactions, and decision timing.
Prior Authorization approvals do not guarantee payment; payment also depends on member eligibility, Covered Service status, benefit limits, and Exclusions as described in the EOC and Schedule of Benefits.
The Plan uses clinical coverage guidelines and medical policies to determine Covered Services and reserves the right to update these guidelines; members/providers can request access to relevant documents.
Emergency and urgent coverage operational notes: Emergency Health Care Services and Emergency Ambulance Services from Non-Network providers are Covered without Prior Authorization; for inpatient stays following ER visit, Prior Authorization is required and members/providers must notify the Plan within 24 hours when possible.
Decision timeframe summary: Timing: concurrent inpatient initial reviews within 3 calendar days; concurrent continued stay within 48 hours; urgent/expedited decisions within 48 hours; preservice within 5 business days; retrospective within 2 business days after a complete request.
Coverage and payment for diagnostic, therapy, and other services are subject to specified limits (e.g., therapy visit limits) and network requirements (e.g., network laboratory requirement); non-network lab claims are Non-Covered.
Behavioral health and autism services have extensive coverage categories with many items listed as 'Benefit Limit = None' and parity protections applied so behavioral health benefits are not less favorable than physical health benefits.
Behavioral Health Coverage
Behavioral health benefits, covered service categories, and explicit exclusions.
Behavioral Health covered services: Behavioral health services covered include inpatient psychiatric hospitalization, detoxification, residential treatment, partial hospitalization (PHP), intensive outpatient programs (IOP), opioid treatment programs (OTP), outpatient diagnostic and therapy services, individual/group/family psychotherapy, medication management including MAT, crisis services, and other outpatient services as clinically appropriate.
Benefit limits and parity: Many behavioral health service categories indicate 'Benefit Limit = None,' and coverage for behavioral health will not be subject to limitations (deductible/copay/coinsurance) that are less favorable than those for physical sickness under the EOC.
Behavioral health exclusions: Not covered: custodial/domiciliary care, supervised living/halfway houses, room and board unless meets Medical Necessity for inpatient care, services billed by schools/halfway houses/developmental custodial centers/outward-bound programs even if psychotherapy included.
Clinical Trial Coverage
Clinical trial coverage rules and what is excluded.
Routine patient care services that are part of an approved Clinical Trial are covered if those services would otherwise be Covered Services under the Plan and the Clinical Trial meets the EOC definition of an approved Clinical Trial.
Not covered: services provided solely for data collection/analysis not used in direct clinical management, services inconsistent with accepted standards of care, Experimental or Investigational drugs/devices not FDA-approved, travel/lodging/food, services provided free by the trial sponsor, and services eligible for reimbursement by another payer or sponsor.
Accidental Dental Injury Coverage
Coverage for dental services resulting from accidental injury and applicable limits.
Outpatient, physician home visits, office, emergency and urgent care services for initial repair of injury to jaw/teeth/mouth/face due to an accident are Covered when performed within 12 months (or clinically appropriate) and include exams, X-rays, restorations, prosthetics, oral surgery, reconstruction, anesthesia as needed.
Limits: Covered services for accidental dental injury are limited to $3,000 per Member per Injury; injuries from chewing or biting are not considered accidental and are not covered.
Diabetes Education and Supplies
Coverage rules for diabetes self-management training and supplies.
Diabetes self-management training is covered when Medically Necessary, ordered in writing by a Physician or Podiatrist, and rendered by an appropriately licensed, registered, or certified Network Provider with diabetes expertise.
Covered Services include physician/podiatrist-prescribed medically necessary equipment and supplies for diabetes management; a limited list of diabetic testing supplies may be on the Prescription Drug Formulary.
Diagnostic Services
Diagnostic services coverage and network laboratory requirement.
Non-invasive diagnostic services (X-ray/radiology, laboratory/pathology, biomarker testing per criteria, advanced imaging such as MRI/MRA/PET/SPECT/CT, cardiographic/encephalographic/radioisotope tests) are covered when Medically Necessary; central supply or pharmacy materials needed for diagnostic services are covered.
Laboratory requirement: The laboratory used must be a Network Provider; claims from non-Network laboratories will be considered Non-Covered Services.
Emergency and Habilitative Services
Emergency services coverage and habilitative therapy limits and documentation requirements.
Emergency Health Care Services to evaluate, stabilize, or treat an Emergency Medical Condition are Covered whether rendered by Network or Non-Network Providers; when admitted from ER, the entire visit is treated as an inpatient stay and Prior Authorization is required for the inpatient stay with notification within 24 hours if possible.
Habilitative therapy limits: Habilitative services include physical, occupational, and speech therapy; benefit limits: Physical Therapy 20 visits/Benefit Year, Occupational Therapy 20 visits, Speech Therapy 20 visits; habilitative services exclude purely educational services and custodial care.
Documentation: Plan may require a treatment plan, medical records, and clinical notes to substantiate medical necessity and clinical improvement; treatment plan must list diagnosis, proposed treatment, frequency, anticipated duration and goals, and update frequency.
Home Health Care
Home health care benefits, home infusion coverage, and applicable visit limits and exclusions.
Home Health Care Services are covered when confined to home for medical reasons and physically unable to obtain outpatient services; covered items include intermittent skilled nursing, medical/social services, diagnostic services, nutritional guidance, home health aide when receiving skilled nursing/therapy, therapy services (except manipulation therapy in home), supplies, DME, certain prescription drugs billed by Home Health Agency, private duty nursing, and home infusion therapy (nursing, DME, pharmaceuticals administered intravenously).
Limits: Up to 100 combined Home Health Care Service visits per Benefit Year (one visit = at least 4 hours); Private Duty Nursing limited separately to 100 eight-hour visits per Benefit Year; the 100‑visit Home Health limit excludes private duty nursing and home infusion therapy.
Non-covered items: Not covered: food, housing, homemaker services, home-delivered meals, custodial care, maintenance therapy, home/outpatient hemodialysis, physician charges billed by Home Health Agency, environmental modifications, services by family members or volunteers, services by non-contracted providers.
Hospice Coverage
Hospice eligibility and covered hospice services.
Hospice benefits are available for members with a Terminal Illness and life expectancy of 12 months or less as confirmed by the attending Physician; benefits continue if member lives longer.
Covered hospice services include skilled nursing, diagnostic services, selected therapies per treatment plan, supplies/DME, counseling, inpatient hospice, hospice-prescribed drugs, home health aide services, and bereavement services to immediate family for one year post-death.
Exclusions: Non-covered hospice items include equipment/supplies the facility should provide, services if not terminal illness, volunteer-provided services, and housekeeping services.
Infertility Treatment
Infertility services coverage scope and exclusions.
Covers services for diagnosis and treatment of underlying causes of infertility when provided by or under direction of a Network Provider; includes medically necessary treatments/procedures for medical causes of infertility (e.g., endometriosis, tubal blockage, varicocele).
Exclusion note: Not all services connected with infertility treatment are covered; refer to 'What Is Not Covered' for excluded items such as ART, cryopreservation, storage, and related services unless specifically listed as covered.
Inpatient Services and Ancillary Coverage
Inpatient facility services, ancillary coverage, and associated physician visit rules.
Covers hospital/SNF/authorized provider charges for room and board (semi-private as standard; private room allowance equals semi-private rate unless medically necessary), special care units, ancillary services (OR/delivery/treatment rooms and equipment, prescription drugs, anesthesia, medical/surgical supplies, diagnostic and therapy services).
Physician inpatient services: Physician services during inpatient stay include physician visits (limited to one visit per day per physician), intensive constant attendance when required, concurrent care by non-surgeon physicians as needed, consultations on bedside exam when requested, surgery and anesthesia, and newborn exam by physician other than delivering physician.
Same-day transfers: When transferred between facilities on the same day, the copayment for the second admission in the Schedule of Benefits is waived.
Coverage and limitations for services in this section
Summary of covered items, common limits, and important exclusions across inpatient, DME, prosthetics, orthotics, outpatient and newborn care.
Inpatient hospital services covered including room and board (semi-private standard; private rooms per medical necessity), special care units, ancillary services, and limited physician inpatient visits; copayment waiver for second same-day transfer applies.
SNF benefit limited to a maximum of 90 days per Benefit Year; Inpatient Rehabilitation Facility limited to 60 days per Benefit Year; certain consultations and professional charge limitations apply.
Maternity: covers inpatient/outpatient/physician home visits for pregnancy and delivery; postpartum minimum inpatient stay 48 hours vaginal/96 hours cesarean; longer stays may require Prior Authorization; at-home post-delivery visit within 72 hours covered.
Newborn care includes physician exam, follow-up care, newborn screening tests, and separate inpatient admission if newborn requires stay beyond mother's discharge (subject to separate cost-sharing).
Medical supplies and DME: covers medically necessary medical/surgical supplies, therapeutic foods for inborn errors of metabolism when directed by physician, diabetic testing supplies per formulary, ostomy supplies (excluding fitting services), and contraceptive devices; DME covered by rental or purchase with rental limited so cumulative rental does not exceed purchase price and delivery/installation covered.
Prosthetics: purchase, fitting, adjustment, repairs and replacements covered when Medically Necessary; prosthetics generally purchased not rented; reimbursement for artificial limbs aligns with federal Medicare standards unless negotiated otherwise.
Orthotics: initial purchase, fitting, repair of custom rigid or semi-rigid orthotic devices covered; orthotics may be replaced once per Benefit Year when Medically Necessary; exclusions for orthopedic shoes and standard elastic stockings except as specified.
Outpatient services: covers facility, ancillary and professional charges when provided as outpatient at hospital, AlternativeCare Facility, retail clinic or other Plan-determined provider; when diagnostic or therapy services are sole outpatient charges as part of outpatient surgery, no copayment required though coinsurance may apply.
Repairs and replacements of DME or prosthetics covered when item is covered, continued use is Medically Necessary, and reasonable justification exists; warranty expiration alone is not justification; exclusions for misuse, loss, or malicious damage.
Members should contact Member Services for questions about coverage applicability for specific medical/surgical supplies, DME, prosthetics, or orthotics.
Coverage and limitations for services in this section
Section-specific coverage highlights, therapy limits, routine hearing and telehealth program requirements, and explicit non-covered items.
Non-covered items include orthopedic shoes (except therapeutic shoes for diabetics), standard elastic stockings except as specified, foot support devices unless integral to a leg brace, reversals of sterilization, non-routine hearing exams excluded from routine hearing category, maintenance therapy not covered except habilitative services, occlusal analysis and certain irreversible dental procedures for TMJ, and a broad set of other exclusions described in the EOC.
Network/program-specific requirements: routine hearing services administered by TruHearing require use of TruHearing Network Provider for benefits; Telehealth via Zero Cost Telehealth Partners available with no member cost share while other telehealth follows Schedule of Benefits cost shares.
Therapy visit limits: Physical Therapy 20 visits/Benefit Year; Occupational Therapy 20 visits; Speech Therapy 20 visits; Manipulation Therapy 12 visits; Physical Medicine & Rehabilitation 60 visits; Cardiac Rehabilitation 36 visits; Pulmonary Rehab 20 visits. Chemotherapy, dialysis, radiation, and inhalation therapy have no numeric visit limits. Therapy must be expected to produce practical improvement within a reasonable period; maintenance therapy not covered except habilitative services.
Preventive Health Care Services covered at no cost when provided by a Network Provider as required by federal/state law (USPSTF A/B, ACIP immunizations, HRSA services including contraceptives and breastfeeding support).
Diagnostic and surgical notes: Outpatient diagnostic services may have no copayment when part of outpatient surgery (coinsurance may still apply); surgical services covered when medically necessary and may be subject to Prior Authorization and setting determination by Plan.
TMJ coverage: Jaw joint problems coverage includes examination, diagnostics, multi-modality physical therapy, diagnostic/therapeutic injections, reversible appliance therapy (single appliance allowance covering related services), and surgical procedures; excludes occlusal analysis and irreversible dental procedures such as orthodontics, crowns, dentures.
Temporomandibular/jaw joint disorder coverage
Coverage and explicit non‑covered services for temporomandibular/jaw joint disorders.
Covered TMJ/jaw joint services include examination (history, physical, muscle testing, range of motion, psychological evaluation as necessary), diagnostic x-rays, physical therapy (multi-modality when more than one treatment same date), diagnostic/therapeutic masticatory muscle and TMJ injections, reversible appliance therapy (benefit based on single appliance maximum allowable fee inclusive of diagnostics, visits, adjustments, repairs, replacements), and surgical procedures.
Exclusions: occlusal analysis and irreversible dental procedures (orthodontics, occlusal adjustment, crowns, onlays, fixed/removable partial/full dentures) and expenses covered elsewhere in the EOC are excluded from TMJ benefit coverage.
Transplant services
Transplant coverage scope, donor benefits, prior authorization, and monetary limits for travel/lodging and donor location costs.
Plan covers human organ and stem cell/bone marrow transplants and transfusions determined Medically Necessary, including acquisition, harvest/storage, and preparatory myeloablative therapy when Medically Necessary; cornea and kidney transplants treated as Surgical Services (transplant benefits not applicable).
Live donor benefits provided for procurement and donor complications up to six weeks post-procurement; donor benefits limited to benefits not available from other sources and donor charges do not apply to member Out-of-Pocket Limit.
Transplant Benefit Period begins one day prior to transplant and continues for applicable case rate/global time period or until discharge for Non-Network transplant Provider Facility; duration varies by transplant type and Network agreement.
Travel and lodging/reimbursement limits: Reimbursement up to $10,000 for travel and lodging if required to travel more than 75 miles for transplant (patient plus one companion; two companions if minor) with itemized receipts required; donor location costs reimbursed up to $30,000 for unrelated donor searches for bone marrow/stem cell transplants.
Authorization requirement: Provider must call Utilization Management for Prior Authorization before evaluation/work-up for a transplant (including live donor, transportation/lodging, or donor location costs); prior approvals for HLA testing/donor search/harvest/storage do not constitute authorization for the subsequent transplant — a separate determination is required.
Pediatric vision coverage and exclusions
Pediatric vision benefits administered by EyeMed, eligibility, covered services, and exclusions.
Pediatric vision benefits are administered by EyeMed; members must use an EyeMed Network Provider to receive benefits; benefits apply through the end of the month in which the child turns 19 years of age.
Covered services include one comprehensive eye exam with dilation per Benefit Year, contact lens fitting and follow-up (standard/premium options), eyewear (frames and lenses) with limits, retinal imaging once per Benefit Year at no cost share, supplemental testing and low vision aids (limits apply), and medically necessary contact lenses in lieu of other eyewear when clinically indicated with no limit on follow-ups when required.
Exclusions and discounts: Not covered: services from non-EyeMed providers, services/materials not listed as covered, experimental/investigational services, services prior to effective date or after termination, replacement for lost/stolen eyewear, visual therapy, certain special lens designs, cosmetic services, telephone consultations; laser vision correction not covered but discounted via network.
Pharmacy and prescription drug coverage
Pharmacy benefit overview, network pharmacy requirement, and operational guidance for members using the Prescription Drug Benefit.
Prescription Drug Benefit covers prescriptions filled at Network Pharmacies; members should present ID card at pharmacy to have pharmacy bill the plan and determine copayment/coinsurance/deductible amounts; direct claims for reimbursement must be submitted to the Pharmacy Innovation Partner within 12 months if member paid out-of-pocket.
Some drugs require specialty network pharmacies or mail order (managed by Pharmacy Innovation Partner); limited distribution drugs may require special dispensing arrangements and plan will assist in locating appropriate pharmacy.
Eye drop refill rules: Eye drop refill windows: 30-day supply refill allowed between days 25-30 after original prescription or last refill; 90-day supply refill allowed between days 80-90; one additional bottle covered if required for daycare/school.
Prescription Drug Coverage Criteria
Prescription drug coverage criteria, formulary controls, specialty pharmacy and exception processes.
Prescriptions are covered only if filled at a Network Pharmacy; specialty drugs must be filled at Network specialty pharmacies and are generally limited to a 30-day supply unless otherwise specified.
Drugs on the Formulary are usually covered but may have limits such as Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), and Age Limits (AL); the Formulary (tier structure) is available online and in print by request.
Exception and step therapy process: Members/providers may request a drug exception (non-formulary) review via the drug exception process; if granted the drug is treated as an Essential Health Benefit with applicable cost sharing; providers can submit step therapy bypass (exceptions) requests when required lower-cost agent is not appropriate.
Opioid analgesics and certain controlled substances require Prior Authorization consistent with state/federal controlled substance rules and plan policies.
Prescription Drug Exclusions
Prescription drug exclusions and limitations.
Excluded: prescription drugs available OTC or therapeutically equivalent to OTC products (except federally mandated preventive OTC), compounded drugs with non-FDA-approved ingredients or not on Formulary, drugs dispensed by Non-Network Pharmacies, drugs dispensed outside the U.S. (except emergency/urgent), drugs intended for inpatient or skilled nursing stay use, appetite suppression/weight loss primary diagnosis drugs, hyperhidrosis, sexual dysfunction as primary diagnosis, cosmetic uses, onychomycosis, experimental/unproven uses, many fertility drugs unless treating infertility, and natural/homeopathic remedies.
CareSource may exclude drugs it determines do not meet Covered Service criteria; some formulary exclusions may be overridden via drug exception process per federal requirements.
General Exclusions
Broad list of general exclusions that render services non‑covered under the Plan.
Services not Medically Necessary, services that do not meet medical/benefit policy guidelines, and services received from Non‑Network Providers without authorization (except as allowed) are excluded.
Experimental or Investigational services are excluded per Plan determination (with narrow exceptions); Plan has sole authority to make such determinations.
Excluded categories include custodial/convalescent/domiciliary care, cosmetic procedures, commercial weight loss programs and bariatric surgery, routine foot care, vision/hearing exclusions except as listed, assisted reproductive technology and related storage/cryopreservation (unless specified), reversal of sterilization, private duty nursing in hospital/SNF (except when covered via Home Health), alternative/complementary medicine (acupuncture, homeopathy, massage, herbal remedies), and many other identified items and non‑covered services.
Travel expenses, missed appointment charges, stand-by provider charges, services before coverage effective date or after termination, services covered by other governmental units or workers' compensation, and items of convenience or personal comfort are excluded unless specifically authorized.
Limitations and Benefit Year rules
How benefit limits apply and how Benefit Year rules affect utilization counting.
Benefit limits are detailed in the Schedule of Benefits or Section 5 and are generally expressed as maximums per Benefit Year (visits/days); when a limit applies, covered days/visits reduce the remaining available benefit; phrases like 'this includes' are illustrative unless the EOC explicitly states a list 'is limited to.'
Members should consult the Schedule of Benefits and Section 5 for specific numeric limits and exceptions that govern benefit application in the Benefit Year.
Care Management and Member Resources
Care management programs and member resources to support care coordination and chronic condition management.
Voluntary disease management programs for conditions (diabetes, asthma, hypertension, chronic kidney disease) are available at no cost; services may be added/modified or removed; contact Member Services or visit CareSource.com for details.
CareSource provides self-service tools, health and well-being resources, and integrated care management services to assist members with serious or complex conditions to navigate care and resources.
CareSource24 24-hour Nurse Advice Line is available for non-emergency health concerns; call the toll-free number on the member ID card for assistance and triage recommendations.
Grievance and Appeal Procedures
Grievance and internal appeal procedures, required content, timelines, and when External Review is available.
Members or Authorized Representatives may file grievances or Internal Appeals (written except expedited/urgent appeals may be verbal); grievance acknowledgements provided within 3 business days and standard grievances resolved within 20 business days; appeals related to Adverse Benefit Determinations follow Internal Appeal timelines.
Internal Appeal submission and content: Internal Appeals for Adverse Benefit Determinations must be submitted within 180 days of the decision and include member name/ID, provider name, date of service, reason for disagreement, supporting documentation, and signed consent if represented; submission address: CareSource, Attention: Indiana Member Appeals, P.O. Box 1947, Dayton, OH 45401 or via MyCareSource.com; expedited internal appeals may be requested verbally via Member Services.
Standard vs expedited timelines: Standard Internal Appeal: acknowledge within 3 business days; decision within 30 calendar days after receipt of all necessary info (with limited delay mechanics). Expedited Internal Appeal: decision within 48 hours after receipt; acknowledgement as soon as possible no later than 3 business days.
Reviewer qualifications and member rights: Appeals reviewed by individuals with knowledge of the condition/service and same licensed profession as the provider involved; reviewers must not have been involved in the prior decision; members have right to access claim file, submit comments, and obtain copies of relevant documents free of charge.
Exhaustion and exceptions: Internal Appeals must generally be exhausted before initiating External Review, except where Plan waives exhaustion, plan fails to provide timely decision, plan fails to meet process requirements (with limited carve-outs), or an expedited External Review is sought simultaneously with an expedited Internal Appeal.
External Review basics: External Review by an Independent Review Organization (IRO) is available at no cost within 120 days of notice of an Adverse Benefit Determination or Final Adverse Benefit Determination; expedited external review may be requested verbally for urgent cases and members must authorize release of medical records; IRO decisions are binding on the Plan.
External Review criteria
When External Review is available, types of reviews, reconsideration process, and IRO decision timelines and binding nature.
Standard External Review eligibility: Standard External Review is available for adverse utilization review determinations, adverse benefit determinations of medical necessity, determinations that a service is experimental/investigational, and rescissions of coverage.
Expedited External Review eligibility: Expedited External Review is available when the review concerns an admission, availability of care, continued stay, or service following emergency care when member not yet discharged, or when the condition would seriously jeopardize life/health or ability to maintain maximum function.
Reconsideration and new information: If new relevant information is submitted during External Review, the Plan must reconsider and may pause IRO review; plan must notify within 72 hours for urgent conditions or within 15 calendar days for others; if still adverse, member may resume IRO review.
IRO timing and binding: IRO determinations: standard IRO should determine within 15 business days and notify within 72 hours after determination; expedited IRO should determine and notify within 72 hours of filing; IRO decision is binding on the Plan and IRO determinations are confidential.
Code Lists, Metrics, and Key Benefit Values
Prior Authorization / Clinical Coverage Guidelinesmixed
| No codes listed |
Ambulance servicesmixedCovered
| Emergency Ambulance Services to the nearest Network Hospital Emergency Room or nearest Emergency Room when condition does not allow transport to a Network Hospital | |
| Non-Emergency ground or air ambulance between Hospitals and Facilities when transport meets specified clinical or site criteria (e.g., Non-Network to Network, to higher level of care, to more cost-effective facility, to sub-acute setting, to Skilled Nursing Facility, or to Covered Person's home) | |
| Emergency medical responder services at home/scene or during transport when subsequently transported to a Facility |
Ambulance services exclusionsmixedNot Covered
| Ambulette or similar vehicle transports, taxi or other public transportation | |
| Trips to a physician's office, clinic, morgue, or funeral home |
Autism Spectrum Disorder servicesmixedCovered
| Inpatient services (Benefit Limit = None) | |
| Diagnostic evaluation (Benefit Limit = None) | |
| Screening, testing, and assessments (Benefit Limit = None) | |
| Outpatient services | |
| Adaptive behavior treatment, including Applied Behavioral Analysis (ABA) (Benefit Limit = None) | |
| Physical Therapy (included in Habilitative Benefits) | |
| Speech Therapy (included in Habilitative Benefits) | |
| Occupational Therapy (included in Habilitative Benefits) | |
| Psychotherapy (Benefit Limit = None) | |
| Medication management (Benefit Limit = None) |
1–10 of 13
1/2
Behavioral Health servicesmixedCovered
| Inpatient behavioral health stays (Benefit Limit = None) | |
| Residential treatment services (Benefit Limit = None) | |
| Partial hospitalization (PHP) services | |
| Intensive Outpatient Program (IOP) services | |
| Opioid Treatment Program (OTP)/Medication Assisted Treatment (MAT) | |
| Outpatient diagnostic and therapy services, individual/group/family psychotherapy (Benefit Limit = None) |
Diagnostic and imaging servicesmixedCovered
| X-ray and radiology services (including mammograms for persons diagnosed with breast disease) | |
| Laboratory and pathology services, including allergy testing and bone density testing as determined medically necessary | |
| Biomarker testing when medically necessary and supported by FDA indications, CMS coverage decisions, or nationally recognized clinical practice guidelines | |
| Advanced imaging (MRI, MRA, PET, SPECT, CT) | |
| Cardiographic, encephalographic, and radioisotope tests | |
| Central supply and pharmacy items necessary to perform Diagnostic Services (e.g., IV tubing, dye) |
Prostheticsmixed
| Artificial substitutes for body parts and tissues (artificial limbs, eyes, intraocular lenses, cochlear implants, LVAD as bridge to transplant, colostomy and ostomy supplies, restoration prostheses, wigs after cancer) | |
| Breast prostheses and surgical bras following mastectomy; one custom fabricated prosthesis as required by law | |
| Reimbursement for an artificial leg or arm will equal federal Medicare program standards unless a different rate is negotiated |
Sterilization and surgical servicesmixedCovered
| Surgical sterilization procedures and related services performed in physician office or outpatient hospital/alternate facility (reversals not covered) | |
| Operative and other invasive procedures (operative/cutting procedures, endoscopic examinations, angiogram/arteriogram, amniocentesis, taps/punctures) | |
| Anesthesia and surgical assistance, pre- and post-operative care, fracture/dislocation correction and other approved procedures |
Other therapy services (oncology, dialysis, inhalation, cardiac/pulmonary rehab)mixedCovered
| Chemotherapy (including cost of antineoplastic agents) - no numeric visit limits | |
| Dialysis treatments (acute or chronic) - no numeric visit limits | |
| Radiation therapy (teletherapy, brachytherapy, intraoperative radiation) - no numeric visit limits | |
| Inhalation therapy and related respiratory treatments and equipment | |
| Cardiac rehabilitation services (programs of medical evaluation, education, supervised exercise training) | |
| Pulmonary rehabilitation and short-term respiratory services when expected to show significant improvement |
Jaw joint / TMJ services (inventory placeholder)mixed
| Services for jaw joint problems described in the EOC; no explicit billing/procedure codes specified in this section |
Formulary tiersmixed
| Tier 0 | Preventive drugs designated by law; no copayment or coinsurance for Tier 0 |
| Tier 1 | Low-cost generics with lowest copayment/coinsurance |
| Tier 2 | Preferred brand-name drugs with higher copayment/coinsurance than Tier 1 |
| Tier 3 | Non-preferred brand-name drugs with higher copayment/coinsurance and may be subject to step therapy |
| Tier 4 | Specialty drugs requiring specialty pharmacy; generally limited to 30-day supply and highest copayment/coinsurance |
Annual Out-of-Pocket Maximum — Plan pays 100% after met
Annual Out-of-Pocket MaximumAfter you meet the Annual Out-of-Pocket Maximum for a Benefit Year, the Plan pays 100% of Eligible Expenses for Covered Services through the end of that Benefit Year.
What counts toward OOPPayments toward the Annual Deductible, Copayments, and Coinsurance for Covered Services apply to the Annual Out-of-Pocket Maximum (unless otherwise noted).
What does not count toward OOPCharges for Non-Covered Services and certain optional Rider/Enhancement copayments/coinsurance do not apply to the Annual Out-of-Pocket Maximum.
Retrospective review decision timeframe
Retrospective review timeframeRetrospective Care Reviews: decision within 2 business days after receipt of a request that includes all necessary information.
Preservice timeframePre-service Care Reviews: decision within 5 business days from receipt of the request.
Urgent review timeframeUrgent Care Reviews: decision within 48 hours from receipt of request.
Laboratory network requirement
Network laboratory requirementYou must ensure the laboratory your Provider uses is a Network Provider; claims from non-Network laboratories will be considered Non-Covered Services.
Check with ProviderMembers should check with their Provider to confirm the lab is a Network Provider before testing is performed.
Diagnostic services coverageNon-invasive diagnostic services (x-ray, lab/pathology, biomarker testing, advanced imaging) are covered when Medically Necessary, provided network requirements are met.
Rental vs purchase threshold — DME operational rule
DME rental vs purchase ruleDurable Medical Equipment: rental (or purchase at Plan's option) is covered, but rental costs must not exceed the purchase price; the Plan will not pay rental longer than it would cost to purchase—equipment must be purchased when purchase cost is less than cumulative rental cost.
Delivery and installationCosts for delivering and installing DME are Covered Services when equipment is covered.
Repairs/replacementsRepair of DME may be covered; replacement rules apply when item is worn out, not repairable, or repair cost equals/exceeds replacement cost.
Manipulation Therapy limit
Manipulation Therapy limitManipulation Therapy benefit limit: 12 visits per Benefit Year.
Related therapy limitsPhysical, Occupational, and Speech Therapy each limited to 20 visits per Benefit Year; Physical Medicine & Rehabilitation 60 visits; Cardiac Rehab 36 visits.
Clinical expectationTherapy covered when Provider expects practical improvement in a reasonable period; maintenance therapy not covered except habilitative services.
Monetary limits — transport/lodging and donor cost caps
Transplant travel and lodging capReimbursement for patient transportation and lodging related to transplant: up to $10,000 if required to travel >75 miles (includes patient and one companion; two for minors).
Donor location cost capReimbursement for unrelated donor location expenses (bone marrow/stem cell transplants): up to $30,000.
Receipt requirementItemized receipts satisfactory to the Plan must be submitted when filing claims for transportation and lodging reimbursement.
Eye drop refill windows
30/90‑day eye drop refill windows30‑day supplies: refill allowed between days 25–30 after original prescription or last refill; 90‑day supplies: refill allowed between days 80–90 after original prescription or last refill.
Additional bottle allowanceIf an additional bottle is required for daycare or school, the Plan will cover one additional bottle.
Questions and supportFor refill questions contact your pharmacy or Member Services at the number on your ID card.
Specialty drug supply limit
Specialty drug supply limitSpecialty drugs (Tier 4) are generally limited to a 30‑day supply and must be filled by a specialty pharmacy or as directed by the PIP.
Formulary and PA/ST rulesSpecialty drugs may be subject to Prior Authorization, Step Therapy, Quantity Limits, and Age Limits per the Formulary; exceptions can be requested.
PIP supportThe Pharmacy Innovation Partner (PIP) manages specialty/mailing networks and supports access, billing, and specialty dispensing requirements.
Prior Authorization, Submission, and Provider Responsibilities
Note
Prior Authorization is listed in the EOC
Prior Authorization is listed in the EOC Table of Contents and is a defined section of the plan describing request types and timing for determinations. Providers should reference the Prior Authorization list and process in the EOC when planning care.
Prior Authorization
Obtain Prior Authorization before providing listed services
Certain services require Prior Authorization and must be approved before reimbursement; providers should obtain necessary prior authorizations and can view the Prior Authorization List on CareSource.com or call Member Services.
- See Tools & Resources > Prior Authorization List on CareSource.com or call Member Services at 1-833-230-2099 for the current list.
- Obtain Prior Authorization before providing services that appear on the Prior Authorization list to avoid non-coverage.
Documentation Required
15‑day timeframe to provide appeal/grievance information
Failure of a Non‑Network Provider (or Covered Person) to provide information requested by the Plan within fifteen (15) calendar days when necessary to review a Standard Internal Appeal or Grievance is treated as a circumstance beyond the Plan's control.
- If information is not provided within 15 days, the Plan may treat the delay as beyond its control for appeal/grievance processing.
Prior Authorization
Definition: Prior Authorization
Prior Authorization means a process where Benefits for a Health Care Service depend on the Covered Person or Provider obtaining approval from the Plan prior to the service being performed, received, or dispensed.
Prior Authorization
Prior Authorization required for most Non‑Network services
Prior Authorization is required for Non‑Network services except for Emergency Health Care Services and Emergency Ambulance Services; if needed for a non-network service because no Network Provider is available, you, your PCP or Non‑Network Provider must obtain Prior Authorization.
- Except for emergency care and certain in‑facility ancillary services, failure to obtain Prior Authorization for Non‑Network services will result in the services being Non‑Covered and the member or provider responsible for payment.
Prior Authorization
Who must obtain Prior Authorization and notice of list changes
Network Providers are responsible for obtaining Prior Authorization for services listed on the Prior Authorization list; Non‑Network Providers or the member are responsible when services are provided by Non‑Network Providers. The Prior Authorization list is available via Member Services or the website and is subject to 45 days' notice before change.
- Network Provider responsibility to secure authorizations for listed services.
- Prior Authorization list available at CareSource.com/mp-IN-pa or by calling 1-833-230-2099.
- Plan will provide 45 calendar days' notice before changing the Prior Authorization list.
Prior Authorization
Authorized services not retroactively denied when rendered in good faith
An authorization will not be retroactively denied if a Network Provider rendered the authorized service in good faith and in accordance with the authorization and contract; additional unanticipated medically necessary services found during an authorized procedure may not be denied solely for lack of prior authorization but may be subject to retrospective review and possible payment withholding.
- Authorized services rendered in good faith will not be retroactively denied.
- Unanticipated additional medically necessary services during an authorized procedure may require retrospective review and payment may be withheld pending review.
Billing Rule
Financial responsibility if Prior Authorization not obtained
If a Network Provider fails to obtain required Prior Authorization, the Network Provider is responsible for the costs; if a Non‑Network Provider (or member) fails to obtain Prior Authorization, the member is responsible for full payment.
- Network Provider financial responsibility for services rendered without required authorization.
- Non‑Network Provider or member bears financial responsibility if Prior Authorization not obtained for Non‑Network services.
Prior Authorization
Obtain Prior Authorization or request Predetermination
Network providers should obtain required Prior Authorization or request a Predetermination; CareSource or delegated utilization review organizations issue prior authorizations and will generally not retroactively deny when services were rendered in good faith per authorization.
- Providers may request a Predetermination when unsure whether authorization is required.
- CareSource may delegate utilization review; contact the ordering Network Provider to request Prior Authorization or Predetermination.
Documentation Required
Request types and decision timeframes
Prior Authorization and related requests may be submitted as Urgent, Pre‑service, Concurrent, or Retrospective reviews; decision timeframes are: Urgent — within 48 hours; Pre‑service — within 5 business days; Concurrent inpatient initial reviews — within 3 calendar days and continued stay reviews within 48 hours; Retrospective — 2 business days after receipt of all necessary information.
- Urgent Review decision timeframe: within 48 hours of receipt.
- Pre‑service (preservice) decision timeframe: within 5 business days.
- Concurrent initial inpatient review: within 3 calendar days; continued stay: within 48 hours.
- Retrospective review: within 2 business days after complete request.
Prior Authorization
Notify CareSource for inpatient admission after ER visit
When an inpatient admission follows Emergency Health Care Services, Prior Authorization is required for the inpatient stay; you must notify CareSource or verify your Physician has notified CareSource of the admission within twenty‑four (24) hours or as soon as possible.
- ER-to-inpatient admissions: notify CareSource within 24 hours or as soon as reasonably possible.
- The entire ER visit will be treated as an Inpatient Stay when admitted from the ER and applicable cost sharing applies.
Prior Authorization
Prior Authorization for extended postpartum stays
Postpartum inpatient stays beyond the minimum length (48 hours for vaginal delivery; 96 hours for cesarean section) may require Prior Authorization.
- Coverage minimums: 48 hours (vaginal), 96 hours (cesarean).
- Stays longer than these minimums may require Prior Authorization.
Denial Risk
Use TruHearing network for routine hearing benefits
Routine hearing benefits are administered by TruHearing; members must use a TruHearing Network Provider to receive benefits for routine hearing services, otherwise the services are Non‑Covered and the member is responsible for all costs.
- Call TruHearing at 1-866-202-2582 to locate network providers.
- Non‑routine and medical‑based hearing exams are not covered under the routine hearing category.
Billing Rule
Telehealth routing and member cost‑share rules
Telehealth services are supported through Network Providers and Zero Cost Telehealth Partners; Telehealth via Zero Cost partners is available with no member cost share, while telehealth not via a Zero Cost partner is subject to standard Schedule of Benefits cost shares.
- Zero Cost Telehealth Partners list available on caresource.com or via Member Services.
- Telehealth from Network Providers not in Zero Cost partners will follow your Schedule of Benefits cost sharing.
Prior Authorization
Call Utilization Management before transplant evaluation/work‑up
Providers must call Utilization Management to obtain Prior Authorization before any transplant evaluation or work‑up (including live donor work‑up, transportation/lodging, or donor location costs); prior approval for HLA testing, donor search, or harvest/storage does not constitute authorization for the transplant itself.
- Call Utilization Management before evaluations or work‑ups for transplant or live donor procedures.
- Separate authorization required for the transplant even if HLA testing or donor search was previously approved.
Prior Authorization
Prior Authorization submission requirements for drugs (electronic/fax)
When a drug on the Formulary has a Prior Authorization limit, providers must submit the required information electronically or by fax using forms on the website; opioid analgesics for chronic pain and some other controlled substances require Prior Authorization.
- Use the Provider page/Formulary Search Tool on the website to view required information and submission forms.
- Opioid analgesics for chronic pain require Prior Authorization per state and federal rules.
Step Therapy
Submit step therapy bypass requests electronically or by fax
If a Formulary drug has a Step Therapy (ST) requirement, providers may submit a Step Therapy bypass (exception) request electronically or by fax if the required lower‑cost agent is not appropriate; the plan will not cover the higher‑tier drug until the bypass is approved or the step is completed.
- Step Therapy limits show as 'ST' on the Formulary; providers can use electronic or fax submission to request a bypass.
- If a bypass request is denied, the denial can be appealed under the grievance and appeals process.
Prior Authorization
Plan has sole authority for Experimental/Investigational determinations
CareSource has sole authority to determine whether a drug/device/service is Experimental or Investigational; in limited life‑threatening situations the Plan may cover Experimental or Investigational services if criteria are met (promising/unproven service with research protocol meeting NIH‑equivalent standards).
- Plan retains sole authority to deem services Experimental/Investigational.
- For life‑threatening conditions, Experimental/Investigational services may be covered if specific criteria and research protocol standards are met.
Prior Authorization
Peer‑to‑peer reconsideration available via Utilization Management
Providers may request a peer‑to‑peer discussion or reconsideration of an Adverse Benefit Determination by calling Utilization Management; the peer‑to‑peer discussion should occur within seven (7) business days after the Provider is notified and will be conducted by the reviewer who made the determination or a designee.
- Peer‑to‑peer requests initiated by the provider via Utilization Management.
- Target timeframe: within 7 business days of provider notification.
Prior Authorization
Plan selects and rotates certified Indiana IROs for External Review
When an External Review is initiated, the Plan selects a certified Indiana Department of Insurance Independent Review Organization (IRO), rotating among certified IROs; the IRO assigns a board‑certified medical reviewer in the applicable specialty and will not select an IRO with material conflicts of interest.
- IROs are chosen from certified Indiana IROs and rotated to avoid selection repetition.
- IRO assigns a board‑certified specialist reviewer appropriate to the case and excludes IROs with material conflicts.
Documentation Required
How to request External Review and reconsideration rules
A member or authorized representative must request External Review in writing within 120 days of the notice of an Adverse Benefit Determination or Final Adverse Benefit Determination; expedited External Review may be requested verbally or electronically, and the member must authorize release of medical records; new information submitted during External Review triggers Plan reconsideration with specified timeframes.
- Standard External Review requests must be in writing and sent to CareSource, Attention: Indiana Member Appeals, P.O. Box 1947, Dayton, OH 45401; phone 1-833-230-2099.
- Expedited External Review may be requested verbally by calling 1-833-230-2099.
- If new relevant information is submitted during External Review, the Plan must reconsider within 72 hours for urgent life/health jeopardy issues or within 15 calendar days for other situations.
Defined Terms and Interpretive Guidance
Evidence of Coverage (EOC) / HMO Contract — member‑facing contract definition
Member contract documentEvidence of Coverage (EOC) / HMO Contract: the member‑facing contract that explains benefits, rights, obligations, and includes defined terms and plan provisions.
Where to find detailsThe EOC should be read with your Schedule of Benefits to understand the comprehensive health benefits available under the plan.
Return rightMembers may return the EOC within ten (10) calendar days for a refund as described in the contract introduction.
Defined Terms and Section 2 reference
Defined Terms locationDefined capitalized terms used throughout the EOC are explained in Section 2: Definitions and inform meanings of words like 'we/us/our' (CareSource) and 'you/your' (Covered Person).
Use of definitionsRefer to Section 2 often to understand capitalized terms as they appear throughout the EOC.
Section cross‑referenceSection 2 definitions are referenced across the EOC to clarify eligibility, benefits, exclusions, and process terms.
Active Course of Treatment — definition and scope
Active Course of Treatment definitionAn ongoing course of treatment for life‑threatening or serious acute conditions, pregnancy through postpartum, chronic life‑threatening/degenerative conditions requiring specialized care, ongoing institutional/inpatient care, scheduled non‑elective surgery, or treatment where discontinuation would worsen the condition (examples include chemotherapy, radiation, post‑operative visits).
Scope examplesIncludes pregnancy through postpartum, chemotherapy/radiation, scheduled non‑elective surgery and post‑operative care, and chronic conditions requiring specialized prolonged care.
PurposeUsed to determine continuity of care and special handling under the Plan for ongoing treatment scenarios.
Annual Deductible — deductible definition
Annual Deductible definitionAnnual Deductible is the amount you must pay in a Benefit Year for Covered Services before the Plan begins paying for most Benefits; Copayments do not count toward the Annual Deductible; Network preventive services are not subject to the deductible.
Effect on benefitsOnce deductible is met, Coinsurance/Copay apply per Schedule of Benefits; some services may be exempt from deductible as noted.
ReferenceSee Schedule of Benefits for your specific deductible amounts and applicability.
Annual Out-of-Pocket Maximum — OOP max definition
Annual Out‑of‑Pocket Maximum definitionThe maximum amount you will pay each Benefit Year for most Covered Services; when reached, eligible Covered Services are payable at 100% for the remainder of the Benefit Year.
What counts toward itPayments toward the Annual Deductible, Copayments, and Coinsurance for Covered Services apply to the Annual Out‑of‑Pocket Maximum unless noted otherwise.
Exclusions from OOPCharges for Non‑Covered Services and certain Rider/Enhancement copays/coinsurance do not apply to the Annual Out‑of‑Pocket Maximum.
CareSource24 — 24/7 nurse advice line definition and access
CareSource24 definitionCareSource24 is CareSource's free 24/7 Nurse Advice Line for non‑emergency health situations; members speak with a registered nurse and a fax is sent to the member's PCP to help coordinate care.
AvailabilityAvailable 24 hours a day, seven days a week, including holidays.
When to useFor non‑emergency health concerns; call 911 for emergencies.
Covered Services — definition and medical necessity cross‑reference
Covered Services definitionCovered Services are Health Care Services that (1) are covered by a specific Benefit provision, (2) are not Excluded, and (3) are determined to be Medically Necessary per CareSource medical policies and nationally recognized guidelines.
Purpose criteriaServices must prevent, diagnose, or treat sickness/injury/behavioral health/substance use disorder and be consistent with scientific evidence and prevailing medical standards.
Exclusions noteServices that are Experimental/Investigational or otherwise Excluded are not Covered Services unless exceptions apply.
Custodial Care — custodial care definition
Custodial Care definitionCustodial Care means care primarily to assist with activities of daily living or personal needs rather than specific medical treatment; it is not expected to substantially improve a medical condition and is generally excluded as a medical benefit.
ExamplesIncludes assistance with walking, bathing, dressing, feeding, oral hygiene, catheter care, meal preparation, and supervision over medical equipment when not requiring trained medical personnel.
Coverage implicationCustodial Care is not a Covered Service unless specifically listed as a benefit.
Covered Person — covered person definition
Covered Person definitionCovered Person means an individual, including you or your Dependent, who is properly enrolled by the Marketplace and/or CareSource and is entitled to receive Benefits under the Plan.
Who it includesIncludes the enrollee and eligible dependents as defined in Section 1 (Eligibility/Dependent provisions).
Enrollment requirementCoverage rights and Benefits apply only while the individual is properly enrolled and premiums are paid as required.
Covered Services — alternate entry
Covered Services (alternate)Covered Services are those Health Care Services that are covered by a Benefit provision, not Excluded, and determined to be Medically Necessary per CareSource policies and national guidelines.
Determination basisMedical Necessity determinations reference CareSource medical policies and nationally recognized clinical guidelines.
Benefit dependenceCoverage depends on eligibility, Medical Necessity, benefit limits, exclusions, and Prior Authorization requirements where applicable.
Custodial Care (duplicate)
Custodial Care (duplicate)Custodial Care: care primarily for assistance with daily living or personal needs, not specific treatment for a Sickness or Injury, not expected to substantially improve medical condition and generally excluded.
Typical settingsIncludes care by family, friends, unlicensed health aides, or non‑medical residential institutions providing mainly room and board.
Coverage noteOnly Covered if explicitly listed as a benefit in another section.
Durable Medical Equipment — DME definition
Durable Medical Equipment (DME) definitionDurable Medical Equipment means medical equipment that can withstand repeated use, is not disposable, serves a medical purpose, is appropriate for home use, and is not implantable.
Rental vs purchase guidancePlan covers rental (or purchase at Plan's option); rental costs must not exceed purchase price and rental not paid longer than purchase cost; equipment must be purchased when purchase is less expensive than cumulative rental.
Covered items examplesExamples include wheelchairs, hospital beds, oxygen equipment, CPAP machines, infusion pumps, glucometers (select brands), and monitors.
Emergency / Emergency Medical Condition — emergency definition
Emergency / Emergency Medical ConditionAn Emergency Medical Condition is one with signs/symptoms of sufficient severity that a prudent layperson would reasonably believe absence of immediate medical attention could result in serious jeopardy, impairment, dysfunction, or risks related to delivery for pregnant women; Emergency Health Care Services are covered to evaluate, stabilize, and treat such conditions.
Emergency provider coverageEmergency services are covered whether rendered by Network or Non‑Network Providers; Inpatient admission after ER may require notification/authorization as described.
ExamplesIncludes heart attack, stroke, severe head trauma, major blood loss, choking, seizures, and other life‑threatening acute events.
Experimental or Investigational — definition
Experimental or Investigational definitionExperimental or Investigational Services are services, technologies, drugs, devices, or procedures not FDA‑approved for the proposed use, subject to IRB review, part of Phase I‑III clinical trials, or billed with temporary procedure codes; such services are generally not covered unless narrow exceptions apply.
Determination criteriaPlan will deem a service Experimental/Investigational if it lacks FDA approval for the proposed use, is part of clinical research, subject to IRB review, or described as experimental in consent documents.
Coverage exceptionsDevices approved under the Humanitarian Use Device exemption are not considered Experimental; limited life‑threatening exceptions may apply per policy.
Medically Necessary / Medical Necessity — definition
Medically Necessary / Medical NecessityMedical Necessity means services appropriate per CareSource medical policies and nationally recognized guidelines; not Experimental/Investigational; necessary to meet basic health needs; rendered in most cost‑efficient appropriate setting; consistent with diagnosis and peer‑reviewed literature.
Life‑threatening research allowanceFor life‑threatening conditions, services with promising efficacy in controlled research settings may be considered when meeting standards equivalent to NIH criteria.
Retrospective review relationPredetermination/Prior Authorization and Retrospective Medical Review processes reference Medical Necessity determinations when evaluating coverage.
Network Provider — network provider definition
Network Provider definitionNetwork Provider means a provider contracted with the Plan to provide services to Covered Persons at contracted rates; a provider may be in‑network for some services and out‑of‑network for others.
Pharmacy networkFor a Pharmacy to be a Network Provider it must have an agreement with the PIP and accept specified reimbursement rates and designation as a Network Pharmacy.
Coverage implicationServices from Non‑Network Providers are not Covered except in specified situations (emergency, urgent out‑of‑area, continuity, in‑facility non‑network ancillary providers, or prior‑authorized unavailability).
Preventive Health Care Services — definition
Preventive Health Care ServicesRoutine or screening services designated to keep you in good health, including USPSTF 'A' or 'B' services, ACIP immunizations, and HRSA‑supported preventive care for infants, children, adolescents, and women.
Cost sharingNetwork preventive services are not subject to the Annual Deductible and may be covered at no cost share as required by law.
Where to find listComplete list of recommendations and guidelines referenced at HealthCare.gov and in Section 5: Your Covered Services.
Telehealth Services — telehealth definition
Telehealth ServicesDelivery of health care using interactive electronic communications (secure videoconferencing, store‑and‑forward, remote patient monitoring, audio‑only) in HIPAA‑compliant manner; excludes email/IM/fax/internet questionnaires unless an established practitioner‑patient relationship exists.
Zero Cost partnersTelehealth Services may be available at no member cost share through Zero Cost Telehealth Partners; otherwise standard Schedule of Benefits cost shares apply.
Provider routingTelehealth may be delivered by your PCP, other Network Providers, or Zero Cost partners; services not delivered by Zero Cost partners will be subject to usual cost shares but not less favorable than in‑person services.
Out-of-Pocket Maximum — OOP max definition (alternate)
Out‑of‑Pocket Maximum (alternate)Out‑of‑Pocket Maximum means the maximum amount you must pay before the Plan pays 100% of the allowed amount; excludes Premiums, balance‑billed charges, adult vision/fitness benefits, and services not covered by the Plan.
ApplicabilityApplies for each Benefit Year; specific inclusions/exclusions detailed in Definitions and Schedule of Benefits.
Effect once metOnce met, Plan pays 100% of Eligible Expenses for Covered Services for remainder of Benefit Year.
Semi-private Room — semi-private room definition
Semi‑private Room definitionA Semi‑private Room is a room with two or more beds; when a Semi‑private Room is Covered, the difference in cost to a private room is a Benefit only when a private room is Medically Necessary or a Semi‑private Room is not available.
Private room allowancePrivate room allowance equals the hospital's average semi‑private room rate unless private room is Medically Necessary for isolation.
Inpatient implicationRoom type cost‑sharing is governed by medical necessity and inpatient benefit rules in the Inpatient Services section.
Sickness — sickness definition
Sickness definitionSickness means physical sickness, disease, or Pregnancy; the term does not include Behavioral Health Disorders or Substance Use Disorders.
Coverage implicationServices to treat Behavioral Health Disorders or Substance Use Disorders are defined and covered under separate Behavioral Health provisions.
Use in EOCTerm used to determine benefit applicability and exclusions throughout the EOC.
Skilled Nursing Facility — SNF definition
Skilled Nursing Facility definitionSkilled Nursing Facility means a Hospital or nursing Facility that is licensed and operated as required by law.
SNF benefit limitSNF stays are subject to a maximum of 90 days per Benefit Year as described in inpatient limitations.
Covered servicesSNF coverage includes room, board, nursing, and ancillary services as authorized by the Plan.
Telehealth Services (duplicate)
Telehealth Services (duplicate)Telehealth Services: medical consultations via interactive electronic communications (secure videoconferencing, store‑and‑forward, remote monitoring, audio‑only) in HIPAA‑compliant manner; certain routine communications are excluded unless practitioner‑patient relationship exists.
Zero Cost partners noteZero Cost Telehealth Partners may offer services at no member cost share; availability and service types vary.
SchedulingSee member handbook or call Member Services for details on scheduling telehealth visits.
Terminal Condition — terminal condition definition
Terminal Condition definitionTerminal Condition is an irreversible, incurable, untreatable condition likely to result in death; no recovery although remission possible.
Terminal Illness (hospice) distinctionTerminal Illness for hospice eligibility is defined as life expectancy of 12 months or less as confirmed by attending Physician; hospice benefits continue if member lives longer.
Benefit implicationTerminal Condition/Illness definitions inform eligibility for Hospice and continuity of care provisions.
Therapeutic Abortion — definition
Therapeutic Abortion definitionTherapeutic Abortion means an abortion necessary to prevent serious health risk or save life, for fetal lethal anomaly, or resulting from incest/rape per Indiana Code 16‑34‑2‑1.
Coverage contextIncluded as part of maternity and related services where medically necessary and consistent with state law.
Legal referenceDefined in accordance with Indiana statutory requirements cited in the EOC.
Unproven Service — unproven service definition
Unproven Service definitionUnproven Service means Health Care Services not consistent with prevailing medical research from well‑conducted randomized trials or cohort studies; decisions about covering new technologies will follow prevailing research conclusions.
Relation to Experimental/InvesigationalUnproven services overlap with Experimental/Investigational criteria and are generally excluded absent compelling evidence.
Coverage standardPlan evaluates new technologies against scientific evidence and may deny coverage if standards are not met.
Zero Cost Telehealth Partner — definition
Zero Cost Telehealth Partner definitionZero Cost Telehealth Partner: contracted providers offering telehealth at no member cost share; availability and services vary and may exclude certain specialties like Behavioral Health.
No guaranteeNo guarantee you will be able to receive services from a specific Zero Cost partner during the Benefit Year; partners may limit patients.
Cost share implicationServices through these partners are at no member cost share; other telehealth services follow Schedule of Benefits cost sharing.
Section Scope — scope summary and authorization note
Section scope summaryThis section includes Benefits, Financial Obligations, Primary Care Provider (PCP) rules, Specialty Care, and Authorization Requirements relevant to Covered Services.
Authorization noteSome services require Prior Authorization; See Authorization Requirements and Prior Authorization list for specifics.
Use with ScheduleRefer to your Schedule of Benefits for detailed cost‑sharing, limits, and specific benefit amounts.
Non-Network Covered Services — list of non‑network covered service types
Non‑Network Covered Services overviewServices from Non‑Network Providers are Covered only in specified situations: Emergency Health Care Services (including Emergency Ambulance); Urgent Care while temporarily outside the Service Area; continuity of care situations; non‑network providers while in a Network Facility; or when services are not available from Network Providers with Prior Authorization.
Prior Authorization requirementExcept for Emergency Health Care Services and Emergency Ambulance Services, Non‑Network services require Prior Authorization; failure to obtain it makes services Non‑Covered.
Member financial responsibilityNon‑Network services paid at Network level limited to Maximum Allowable Amount; member may owe amounts above Allowed Amount plus deductible/coinsurance/copayment and is responsible for filing claims unless provider does so.
Coinsurance — coinsurance definition and example
Coinsurance definitionCoinsurance is the percentage of the Allowed Amount you pay after meeting your deductible (example: you pay 20% when the Plan pays 80%).
ExampleAfter meeting your Annual Deductible, if the Plan pays 80% for a covered service, you are responsible for the remaining 20% as Coinsurance.
Interaction with OOPCoinsurance payments for Covered Services apply toward the Annual Out‑of‑Pocket Maximum.
Copayment — copayment definition
Copayment definitionCopayment is a fixed dollar amount required for certain Covered Services, usually paid at the time of service and variable by service type.
TimingCopayments are generally paid when the service is received and may differ by service (office visit, ER, pharmacy, etc.).
OOP applicationCopayments for Covered Services count toward the Annual Out‑of‑Pocket Maximum unless specifically excluded.
Annual Out-of-Pocket Maximum (duplicate)
Annual Out‑of‑Pocket Maximum (duplicate)The Annual Out‑of‑Pocket Maximum is the maximum amount you will pay each Benefit Year for most Covered Services; after met, the Plan pays 100% of eligible expenses for Covered Services through the end of the Benefit Year.
ComponentsIncludes payments toward deductible, copayments, and coinsurance for Covered Services unless noted otherwise.
ExclusionsExcludes Premiums, balance‑billed charges, adult vision/fitness benefits, and services not covered by the Plan.
Prior Authorization — prior authorization (definition duplicate)
Prior Authorization definitionPrior Authorization is a process to determine whether Health Care Services listed on the Prior Authorization list meet evidence‑based criteria for Medical Necessity and are Covered Services prior to being provided; Network Providers are responsible for obtaining required authorizations.
Provider responsibilityNetwork Providers must obtain Prior Authorization for listed services; Non‑Network Providers or members are responsible when services are provided by Non‑Network Providers.
List access and noticePrior Authorization list is available via Member Services or website and is subject to change with 45 days' prior notice to members and providers.
Urgent Review — urgent review definition
Urgent Review definitionUrgent Review: a request where applying non‑urgent timeframes could seriously jeopardize life/health or cause severe unmanaged pain as defined by a treating Physician; urgent decisions made within 48 hours.
Request typesRequest types include Pre‑service (before service), Concurrent (before or during service), Retrospective (after service), and Urgent reviews.
TimeframesConcurrent initial inpatient reviews: within 3 calendar days; concurrent continued stay: within 48 hours; preservice: within 5 business days; retrospective: within 2 business days after complete request.
Request types — pre-service, concurrent, retrospective definitions
Request types referencePre‑service Review: prior authorization/predetermination submitted before service; Concurrent Review: submitted before or during service; Retrospective Review: submitted after service.
Timing summaryTimeframes vary by request type (urgent 48 hrs, preservice 5 business days, retrospective 2 business days when complete).
How to submitProviders/members should submit requests per instructions in the EOC and contact Member Services for guidance.
Clinical Trial coverage note
Clinical Trial coverage noteRoutine Health Care Services provided as part of an approved Clinical Trial are covered if those services would otherwise be Covered Services under the Plan.
Approved trial definitionSee Section 2: Definitions for what constitutes an approved Clinical Trial and applicable criteria.
Exclusions for trialsServices provided solely for data collection, or services covered by trial sponsor/other payers, or experimental uses may be excluded per policy—see Clinical Trial section for details.
Terminal Illness — hospice eligibility terminal illness definition
Terminal Illness (hospice) definitionTerminal Illness for hospice eligibility: life expectancy of twelve (12) months or less as confirmed by the attending Physician; hospice benefits continue if member lives longer.
Hospice benefit scopeHospice services include skilled nursing, diagnostic services, selected therapies, supplies/DME, counseling, inpatient hospice, hospice‑prescribed drugs, home health aide services, and bereavement services for immediate family for one year post‑death.
Eligibility confirmationPhysician confirmation of life expectancy required to qualify for hospice benefits as described.
Inpatient Services — inpatient services definition and included items
Inpatient Services definitionInpatient Services include authorized charges from a Hospital, Skilled Nursing Facility, or other Provider for room, board, nursing services, ancillary services (OR, delivery, supplies), prescription drugs, anesthesia, diagnostic and therapy services, and limited physician visits during an Inpatient Stay.
Physician visit limitsPhysician visits limited to one visit per day per physician; provisions allow intensive attendance or multiple physicians when medically required.
Private room allowancePrivate room allowance equals average semi‑private room rate unless private room is Medically Necessary for isolation.
Durable Medical Equipment (DME) — DME definition including rental/purchase
DME (detailed) definitionDurable Medical Equipment includes rental or purchase of medically necessary equipment prescribed by a Physician, with delivery/installation costs covered and reasonable quantity limits applicable.
Rental/purchase operational ruleRental permitted but must not exceed purchase cost; Plan will not pay rental longer than purchase cost; purchase required when cheaper than cumulative rental.
Repairs/replacements policyRepairs and replacements covered when item remains Medically Necessary and repair is not feasible or cost‑effective; warranty expiration alone is not justification.
Outpatient Services — outpatient services definition
Outpatient Services definitionOutpatient Services include facility, ancillary, facility use, and professional charges when given as an outpatient at a Hospital, AlternativeCare Facility, Retail Health Clinic, or other Plan‑determined provider site.
No copayment for certain outpatient diagnosticsWhen Diagnostic or certain therapy services are the only Outpatient charges as part of an Outpatient surgery, no Copayment is required though Coinsurance may still apply.
Providers includedIncludes services provided by PCPs, Specialists, nurse practitioners, physician assistants in office or home visit settings.
Office/Home Visits — office and home visit definition
Office/Home Visits definitionOffice Visits: examinations, diagnosis, treatment, allergy testing, injections/serum; Home Visits: similar services provided in the member's home by Physician or qualified Provider.
InclusionsAlso covers Telehealth Services, Diagnostic Services, Surgery, Therapy Services as applicable per other sections.
Copayment noteWhen allergy serum is sole Physician office charge, no Copayment is required.
Telehealth Services — telehealth definition (section‑specific)
Telehealth Services (section‑specific)Telehealth Services are medical/health consultations for diagnosis and/or treatment via smartphone, tablet, computer or other device using interactive electronic communications; certain routine communications (e.g., result reporting, appointment requests) are not considered Telehealth Covered Services.
Zero Cost partnersTelehealth available at no member cost share through Zero Cost Telehealth Partners; other telehealth through Network Providers follows Schedule of Benefits cost sharing.
How to accessSee member handbook or call Member Services for scheduling and partner lists.
Examination (pediatric vision) — pediatric vision exam definition
Pediatric vision exam definitionExamination: comprehensive pediatric eye examination including case history, visual acuity, biomicroscopy, tonometry, refraction, dilation as required, and Provider assessment and signature; covered as one (1) per Benefit Year.
Administering partnerPediatric vision benefits are administered by EyeMed and must be received from an EyeMed Network Provider to be covered.
Non‑coverage if out‑of‑networkServices by non‑EyeMed Network Providers are Non‑Covered and the member is responsible for all costs.
Jaw joint problems — TMJ/jaw disorder definition
Jaw joint problems definitionJaw joint problems include temporomandibular joint disorder, cranio‑maxillary disorder, craniomandibular disorder, head and neck neuromuscular disorder, and other conditions of the joint linking the jawbone and skull; benefits include exams, diagnostics, physical therapy, injections, reversible appliance therapy, and surgery.
ExclusionsDoes not include occlusal analysis or irreversible dental procedures (orthodontics, crowns, fixed/removable dentures) or items covered elsewhere in the EOC.
Appliance therapy limitAppliance therapy benefits based on maximum allowable fee for a single reversible appliance, including related diagnostic services, visits, adjustments, repairs, and replacements.
Medically Necessary drugs and devices — definition regarding FDA/off‑label uses
Medically Necessary drugs and devicesMedically Necessary drugs and devices are those used for FDA‑approved purposes or off‑label uses supported by standard medical literature as safe and effective.
Formulary relianceCoverage decisions reference the Prescription Drug Formulary and P&T Committee guidance for tiers, limits, and prior authorization criteria.
Exceptions processProviders may request exceptions for non‑formulary drugs or bypass limits via the drug exception process; appeal rights apply if denied.
Formulary tiers — tier structure (Tier 0–Tier 4) definition
Formulary tiersFormulary organized into tiers (Tier 0–Tier 4) indicating coverage level and cost sharing; Tier 0 preventive (no cost), Tier 1 generics (lowest cost), Tier 2 preferred brand, Tier 3 non‑preferred brand, Tier 4 specialty drugs (highest cost).
Tier impactsTier determines Copayment/Coinsurance and may affect whether Deductible applies; specialty drugs typically limited to 30‑day supplies.
Formulary updatesP&T Committee reviews the Formulary regularly; members notified before changes that affect their drugs; exceptions may be requested.
Pharmacy Innovation Partner (PIP) — definition of third‑party mail‑order/specialty manager
Pharmacy Innovation Partner (PIP)Pharmacy Innovation Partner (PIP) is a third‑party partner that manages mail order and specialty pharmacy network functions, supports formulary tools, billing processes, and helps with nationwide pharmacy access.
PIP rolesPIP assists with formulary management, pharmacy billing, specialty dispensing, drug cost tools, and may support medication management programs but does not make final benefit decisions.
Contact and helpMembers may contact Member Services for questions about the PIP, mail‑order/specialty pharmacy access, and formulary assistance.
Benefit limits — definition of benefit limits and counting rules
Benefit limits definitionBenefit limits are maximums listed in your Schedule of Benefits or Section 5; visit/day limited services count against these limits for the Benefit Year.
How limits applyLimits apply per Benefit Year and are reduced by days/visits used; when exceeded, Plan will not pay benefits beyond limits unless otherwise stated.
Interpretation notePhrases like 'this includes' are illustrative unless the document explicitly states a list 'is limited to.'
Experimental or Investigational — experimental criteria examples
Experimental or Investigational (duplicate)Any drug/biologic/device/procedure/etc. meeting criteria such as lacking final FDA approval for the use, being part of a clinical trial, subject to IRB review, or described as experimental in consent documents is considered Experimental or Investigational and not covered unless exceptions apply.
Determination authorityCareSource has sole authority to decide Experimental/Investigational status; limited life‑threatening exceptions may be evaluated per policy.
Appeal pathDenials based on Experimental/Investigational status can be appealed via internal and external review processes described in the EOC.
Adverse Benefit Determination — adverse determination definition
Adverse Benefit Determination definitionAdverse Benefit Determination means a decision to deny, reduce, or terminate a requested Health Care Service or Benefit in whole or in part, including determinations about Medical Necessity, eligibility, Covered Service status, exclusions, rescissions, and Experimental/Investigational status.
IncludesIncludes decisions that a service is not Medically Necessary, not a Covered Service, imposes an Exclusion or limit, or rescinds coverage.
RemediesMembers have internal appeal and External Review rights as described in the Grievance and Appeals sections when an Adverse Benefit Determination is issued.
Prior Authorization (definition duplicate)
Prior Authorization (duplicate)Prior Authorization: a determination that a Health Care Service has been reviewed and, based on information provided, is a Covered Service prior to performance of the service.
Relation to PredeterminationPredetermination is a voluntary authorization request made before or during care to determine exclusions or Medical Necessity; both relate to Prior Authorization processes.
Provider roleProviders should verify authorization status and obtain required approvals to prevent denial or financial responsibility by the member or provider.
Predetermination — predetermination definition
Predetermination definitionPredetermination is an authorization requested voluntarily before or during care to determine if a service is excluded, meets Medical Necessity, or is Experimental/Investigational under the Plan.
Use caseMembers and providers may request a Predetermination to clarify coverage and payment expectations prior to receiving services.
Relation to appealsPredetermination outcomes may be relied upon but do not eliminate appeal rights if circumstances or information change.
Retrospective Medical Review — retrospective review definition and scope
Retrospective Medical Review definitionRetrospective Medical Review is a review of whether an already‑received Health Care Service is a Covered Service; applies only if Prior Authorization and Predetermination were not required or performed and excludes reviews limited to reimbursement, documentation veracity, coding accuracy, or payment adjudication.
ScopeUsed to evaluate coverage for services already provided when preauthorization was not applicable or obtained.
TimeframeRetrospective Care Reviews decisions are made within 2 business days after receiving a complete request.
Health Plan — health plan definition
Health Plan definitionHealth Plan includes group and nongroup insurance contracts, HMOs, subscriber contracts, uninsured arrangements of group or group‑type coverage, and other plans as permitted by state law; used in Coordination of Benefits rules.
COB purposeCoordination of Benefits determines primary vs secondary payer when multiple Health Plans cover the same Benefits to avoid payments exceeding the Primary Plan's Allowable Amount.
Order of benefit rulesOrder of Benefit Determination Rules govern which Health Plan pays first; when This Health Plan is Secondary it may reduce benefits so total payments do not exceed primary Allowable Expense.
Allowable Expense / Closed Panel Health Plan / Custodial Parent — assorted definitions
Allowable Expense definitionAllowable Expense is a health care expense (including deductibles, coinsurance, copayments) covered at least in part by any Plan; expenses not covered by any Plan are not Allowable Expenses.
Closed Panel Health PlanA Closed Panel Health Plan provides benefits primarily through a contracted panel of providers and excludes other providers except in emergencies or referrals.
Custodial Parent definitionCustodial Parent is the parent awarded custody by court decree or, absent decree, the parent with whom the child resides more than half the calendar year.
Policy Summary
PayerCareSource Georgia
PolicyMarketplace Evidence of Coverage (EOC) and HMO Contract — Indiana Marketplace Plan
Policy CodePolicy POLMP-IN(2025)
Change TypeNo material changes
Effective DateJan 1, 2025
Next Review Date
Key ActionObtain required prior authorization for services on the Prior Authorization list before providing or billing those services.
SourceLink
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