CurrentCareSource GeorgiaPolicy POLA-Rider-OH(2025) Rev.1

Vision, Hearing Aid, and Active & Fit Fitness Rider Coverage Criteria

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Amendments to the Evidence of Coverage describing routine hearing services and hearing aid coverage administered via TruHearing, adult vision benefits administered via EyeMed, and the Active & Fit fitness program; governs covered persons under the CareSource Ohio rider and network/provider use requirements.

Policy Summary

PayerCareSource Georgia

PolicyVision, Hearing Aid, and Active & Fit Fitness Rider Coverage Criteria

Policy CodePolicy POLA-Rider-OH(2025) Rev.1

Change TypeMinor wording amendment — no material coverage change

Effective DateApr 3, 2025

Last ReviewApr 3, 2025

Next Review DateN/A

Key ActionVerify member eligibility and use network vendors (TruHearing for hearing, EyeMed for adult vision) before providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1routine hearing screening per benefit year

1comprehensive eye exam per benefit year

$250annual eyewear allowance

$2,500

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CurrentCareSource GeorgiaPolicy POLA-Rider-OH(2025) Rev.1

Vision, Hearing Aid, and Active & Fit Fitness Rider Coverage Criteria

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Sign up for CareSource Georgia Policy POLA-Rider-OH(2025) Rev.1 alerts

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Policy Summary

PayerCareSource Georgia

PolicyVision, Hearing Aid, and Active & Fit Fitness Rider Coverage Criteria

Policy CodePolicy POLA-Rider-OH(2025) Rev.1

Change TypeMinor wording amendment — no material coverage change

Effective DateApr 3, 2025

Last ReviewApr 3, 2025

Next Review DateN/A

Key ActionVerify member eligibility and use network vendors (TruHearing for hearing, EyeMed for adult vision) before providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1routine hearing screening per benefit year

1comprehensive eye exam per benefit year

$250annual eyewear allowance

$2,500

hearing aid limit per ear (≤21)

18+eligible member age

Coverage Criteria and Limits

Covered services and limits

Covered when ALL of the following are met (by benefit area):

Routine hearing screening: One (1) screening per Benefit Year which includes a simple pass or fail test (series of beeps or tones) to determine normal hearing.1 per benefit year

TruHearing-administered; must use TruHearing Network Provider or service is non-covered.

Routine hearing exam: One (1) comprehensive hearing exam per Benefit Year performed by a licensed audiologist or hearing instrument specialist, including case history review, several types of hearing tests, counseling, and recommendations.1 per benefit year

TruHearing-administered; must use TruHearing Network Provider or service is non-covered.

Hearing aid benefit (age ≤21): One (1) hearing aid per hearing impaired ear up to $2,500 every 48 months for a Covered Person age 21 or younger who is verified as deaf or hearing impaired by a licensed audiologist, an otolaryngologist, or other licensed physician. Member is responsible for costs above $2,500.$2,500 every 48 months per ear; age ≤21

Hearing aids must be on the approved hearing aid list maintained by TruHearing.

Hearing aid product & related services: Hearing aids must be listed on the approved hearing aid list. Related services necessary to assess, select, fit, and optimize a hearing aid are included at no member cost share, including first-year follow-up visits, a 60-day trial period, a 3-year extended warranty, 80 batteries per aid for non-rechargeable models, and ear molds when ordered by a physician or audiologist.as listed

Approved hearing aid list is subject to periodic review and available via TruHearing; must use TruHearing Network Provider.

Adult vision - comprehensive exam: Comprehensive eye exam with dilation, if medically necessary, limited to one (1) per Benefit Year. Cost share applies.1 per benefit year

Vision benefits administered through EyeMed network providers.

Adult vision - eyewear allowance: Eyewear covered in full up to a $250 allowance per Benefit Year, limited to one eyewear allowance per Benefit Year; allowance may be used for glasses (frame, lenses, lens options) or contact lenses once per Benefit Year. Discounts apply to balances after the $250 allowance as specified.$250 per benefit year

Includes discounts (e.g., 20% on frames/lens options balance; conventional contact lenses 15% on balance).

Medically necessary contact lenses: When contact lenses are determined to be medically necessary for specified conditions (e.g., keratoconus, aphakia, anisometropia, aniridia, corneal disorders, irregular astigmatism, post‑traumatic disorders, pathological myopia, aniseikonia), lenses and associated services including fit and follow-ups are covered in full with no limitation on number of follow-ups.condition-specific

Contact lenses are dispensed in lieu of other eyewear when medically necessary.

Low-vision services: Supplemental diagnostic testing beyond a comprehensive eye exam and low-vision aids (e.g., spectacle-mounted magnifiers, hand-held or spectacle-mounted telescopes, video magnification) are available, limited to one (1) per Benefit Year.1 per benefit year

Low vision defined as significant loss of vision but not total blindness.

Retinal imaging is covered at no member cost share, limited to one (1) per Benefit Year.1 per benefit year

Active & Fit program coverage criteria

Covered when ALL of the following are met

Member eligibility and enrollment: Member is an adult aged 18 or older and enrolled in the Plan for the Benefit Year; enrollment in Active & Fit is voluntary and provided at no cost to eligible members.age >= 18

Verify eligibility and program availability with member services or ActiveandFit.com.

Program access and duration: Enrollment is limited to the current Benefit Year and access continues only while the member remains enrolled in the Plan; disenrollment or termination during the Benefit Year terminates program access.Benefit Year duration

Available fitness centers and included services may vary; some services may require upgraded memberships.

Home fitness kit: Member may receive one home fitness kit per Benefit Year from a variety of categories; kit contents are subject to change and some kits may include a wearable device (e.g., Fitbit or Garmin).

The Plan excludes certain hearing and vision items and services. Hearing aids that do not meet the state speech and hearing professionals board’s professional standards for medical necessity are not covered. Non-routine and medical-based hearing exams are excluded here (they may be covered elsewhere in the Evidence of Coverage). Hearing aid accessories are excluded except for items explicitly listed under related services, and additional provider visits and additional batteries for non-rechargeable models beyond the amounts stated are not covered. Any replacement batteries for rechargeable hearing aids are excluded, as are hearing aids not included in the applicable TruHearing catalog and costs associated with loss or damage warranty claims. For vision, services and materials not meeting accepted standards of optometric practice, state or territorial taxes on vision services, visual therapy, replacement of lost/stolen eyewear, non-prescription (Plano) lenses, two pairs of eyeglasses in lieu of bifocals, and insurance of contact lenses are specifically excluded.

Providers should note that services performed outside the specified vendor networks (e.g., TruHearing for hearing aids, EyeMed for adult vision) may be treated as non-covered under the Plan and result in member/provider financial responsibility or denial of coverage.

If fees are required for the Active & Fit program or related services, those fees are non-refundable, not prorated, and do not count toward the member’s Annual Out-of-Pocket Maximum. Fees may be charged by a third party rather than CareSource; confirm with the fitness center which services are included and which require additional or upgraded membership fees prior to enrollment. Available fitness centers and included services may change, and some services at a center may require an upgraded purchase that is not covered by the program.

Hearing aids that fail to meet the state board’s professional standards for medical necessity are not considered medically necessary and therefore are not covered under this Program. This includes any hearing devices that are not listed in the applicable TruHearing catalog or otherwise do not satisfy the state-established professional criteria for medical necessity.

Provider Requirements and Enrollment Actions

Prior Authorization

Prior authorization / network use — use specified network vendors

Use TruHearing (hearing) and EyeMed (adult vision) network providers for services under these benefit sections; services provided outside the specified network will be considered Non‑Covered and the member/provider will be responsible for all costs.

Hearing services must be provided by a TruHearing Network Provider; call 1‑866‑202‑2561 for help locating one.
Vision benefits must be provided by an EyeMed Network Provider; call 1‑833‑337‑3129 for help locating one.

Note

Program enrollment — verify eligibility and availability

Enrollment in the Active & Fit program is voluntary and provided at no cost to eligible adults; verify member eligibility and program availability with Active & Fit member services or ActiveandFit.com before enrolling.

Program is available to covered adults aged 18 and older.
For enrollment steps and available services in your area, contact the number on the member's ID card or ActiveandFit.com.

Definitions, Background, and Benefit Details

Hearing and vision services described in this Rider are administered through specified third‑party networks and vendors. Hearing aids and related routine hearing services are provided through TruHearing with defined eligibility and benefit limits; hearing devices must appear on the applicable TruHearing catalog and be verified by a licensed professional. The Active & Fit fitness program is offered to eligible adults aged 18 and over and provides access to participating fitness centers and one home kit per Benefit Year; availability of centers and included services may change, enrollment is limited to the current Benefit Year, and access ends if a member disenrolls or is terminated during the Benefit Year.

Medically Necessary Contact Lenses — definition and examples

DefinitionContact lenses determined necessary when use of contact lenses, in lieu of eyeglasses, will result in significantly better visual and/or improved binocular function (including avoidance of diplopia or suppression).

Examples of qualifying conditionsKeratoconus; pathological myopia; aphakia; anisometropia; aniseikonia; aniridia; corneal disorders; post‑traumatic disorders; irregular astigmatism.

Dispensing ruleMedically Necessary contact lenses are dispensed in lieu of other eyewear (covered instead of glasses).

Associated services

Policy Summary

PayerCareSource Georgia

PolicyVision, Hearing Aid, and Active & Fit Fitness Rider Coverage Criteria

Policy CodePolicy POLA-Rider-OH(2025) Rev.1

Change TypeMinor wording amendment — no material coverage change

Effective DateApr 3, 2025

Last ReviewApr 3, 2025

Next Review DateN/A

Key ActionVerify member eligibility and use network vendors (TruHearing for hearing, EyeMed for adult vision) before providing services.

SourceLink

On This Page

Home kits are subject to change.

Digital fitness services: Access to on-demand workouts, healthy living coaching (scheduled phone sessions), and personalized workout plans as part of program offerings when available.as available

Prior to enrollment verify which digital services and center amenities are included; fees paid may be non-refundable and not count toward Annual Out-of-Pocket Maximum.

Documentation Required

Provider action — confirm vendor verification and network instructions

Document and confirm any required verification steps or network‑specific instructions with the applicable vendor prior to providing services; follow vendor guidance for approved device lists and network participation.

Confirm device is on the approved hearing aid list before ordering (approved list available via TruHearing at 1‑866‑202‑2561).
Follow vendor requirements for fitting, trials, and warranty services.

Step Therapy

Step therapy — none specified

No step therapy requirements are specified for hearing, vision, or Active & Fit services in this excerpt.

Do not apply step therapy protocols unless additional policy language requires them; none are stated here.

Documentation Required

Hearing aid listing and verification — licensed professional verification required

Hearing aids must be verified as hearing impaired by a licensed audiologist, an otolaryngologist, or other licensed physician and must appear on the approved hearing aid list to be Covered Services.

Approved hearing aid list is subject to periodic review and is available by calling 1‑866‑202‑2561.
Related services (first‑year follow‑ups, 60‑day trial, 3‑year warranty, batteries, ear molds when ordered) are included at no member cost share when necessary to assess, select, and fit a hearing aid.

Documentation Required

Verify included services and potential additional fees prior to enrollment

Before enrolling a member in an Active & Fit fitness center, verify with the center which services are included under the program and which require additional fees; fees paid under the program may be non‑refundable and do not count toward the Annual Out‑of‑Pocket Maximum.

Confirm availability of amenities (e.g., classes, pools, saunas) and whether upgraded memberships or add‑ons are required.
Advise members that fees may be charged by a third party and are not prorated or refundable.

Billing Rule

Network provider requirement — out‑of‑network services are Non‑Covered

Do not bill CareSource for services obtained outside the specified networks (TruHearing for hearing; EyeMed for adult vision); such services are Non‑Covered and the member/provider will be responsible for all costs.

Participating network providers may charge normal fees for services or materials that are not covered benefits; obtain an estimated cost prior to providing non‑covered services upon request.

Denial Risk

Denial or loss of access triggers — fitness center restrictions and member termination

Be aware enrollment and access can be denied or lost if fitness centers enforce restrictions (e.g., age limits) or if the member disenrolls/terminates from the Plan during the Benefit Year; upgraded membership services may not be covered.

Available fitness centers may vary and not all services at a center are included under the program.
If a member disenrolls or is terminated during the Benefit Year, they will no longer be able to access fitness centers.

Includes related fit and follow‑up services when lenses are determined to be Medically Necessary.

Low-Vision — definition, includes supplemental testing and low-vision aids limit

DefinitionLow vision is a significant loss of vision but not total blindness.

Supplemental testingDiagnostic evaluation beyond a comprehensive eye exam (ocular function assessment, measurements, visual field evaluations). Limited to one (1) per Benefit Year.

Low‑vision aids limitLow‑vision aids (spectacle‑mounted magnifiers, hand‑held or spectacle‑mounted telescopes, video magnification, etc.) are limited to one (1) per Benefit Year.

Home Fitness Kits — one-per-Benefit-Year kit, may include wearable devices

DefinitionHome Fitness Kits: a kit provided through the Active & Fit program from a variety of fitness categories.

FrequencyOne home fitness kit per Benefit Year.

Possible contentsSome kits may include a wearable device (e.g., Fitbit or Garmin).

EligibilityAvailable to covered adults aged 18 and older enrolled in the Plan for the Benefit Year via the Active & Fit program.

On-Demand Workouts — access to workout videos for all fitness levels

DefinitionOn‑Demand Workouts: digital access to a variety of workout videos provided through the Active & Fit program.

AudienceAvailable for all fitness levels.

Access methodProvided as part of the Active & Fit digital offerings to enrolled members; details and enrollment through ActiveandFit.com or member services.

Healthy Living Coaching — scheduled phone sessions for fitness, nutrition, lifestyle goals

DefinitionHealthy Living Coaching: scheduled phone sessions with coaches to address fitness, nutrition, and lifestyle goals.

DeliveryProvided by phone as scheduled sessions through the Active & Fit program.

PurposeHelps members meet fitness, nutrition, and lifestyle goals and supports personalized workout plans.

AvailabilityOffered to covered adults aged 18 and older enrolled in the Active & Fit program for the Benefit Year.