CurrentCareSourcePolicy N/A

Adult Vision and Fitness Rider

Defines optional, non‑Essential Health Benefits for adult vision and fitness programs provided to CareSource marketplace members in West Virginia, including covered services, limits, network rules, and program details. Affects covered adults (generally ages 18/19 and older) enrolled in the Plan.

Policy Summary

PayerCareSource

PolicyAdult Vision and Fitness Rider

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf no in‑network vision provider is available in the area, an out‑of‑network provider may request prior authorization on behalf of the member.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1comprehensive eye exam per benefit year

$250annual eyewear allowance

1eyewear allowance (glasses or contacts)

1retinal imaging per benefit year

18+ / 19+age eligibility

Adult Vision and Fitness Benefit Criteria

Covered vision services, program benefits, limits, and exclusions for adult members (Benefit Year unless noted).

Vision and fitness benefits apply to covered adults while enrolled in the Plan; vision benefits are administered through the network (EyeMed) and fitness benefits via Active & Fit.

Comprehensive eye exam with dilation if medically necessary; limited to one (1) per Benefit Year. Cost share applies.

Eyewear allowance: Up to a $250 allowance per Benefit Year toward eyewear (one allowance per Benefit Year). Allowance may be used for either glasses (frames, lenses, lens options) or contact lenses once per Benefit Year.

Eyewear discounts and additional purchases: After the $250 allowance is exhausted, members receive a 20% discount on frame/lens balance for eyeglasses; conventional contact lenses receive a 15% discount on the balance; disposable contacts receive no discount. The Plan provides benefits for one (1) pair of glasses or contact lenses; additional eyewear may be purchased at member cost with a 40% discount off complete-pair eyeglass purchases and 15% off conventional contact lenses after benefits are exhausted.

Policy Summary

PayerCareSource

PolicyAdult Vision and Fitness Rider

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf no in‑network vision provider is available in the area, an out‑of‑network provider may request prior authorization on behalf of the member.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Requirements and Authorization

Prior Authorization

Out‑of‑Network Prior Authorization when No In‑Network Provider Exists

If there is no in‑network Provider available in the member’s area who can provide the covered service within required time and distance standards, an out‑of‑network Provider may submit a Prior Authorization request on behalf of the member. The request should document that no in‑network Provider exists or can meet the applicable access standards. If CareSource determines no in‑network Provider is available, the Prior Authorization for the out‑of‑network Provider will be approved for the covered service.

Action: Out‑of‑network Provider may request Prior Authorization on member’s behalf when no in‑network Provider is available.
Required documentation: statement or evidence that no in‑network Provider can provide the service within required time/distance/access standards.
Decision rule: CareSource will review the request and, if no in‑network Provider is available, approve Prior Authorization for the out‑of‑network Provider to deliver the covered service.

Key Definitions for Adult Vision and Fitness

inv-03: Adult Vision Benefits

ScopeOptional Rider benefits attached to the EOC offered at extra cost; not Essential Health Benefits.

Eligibility AgeCovered adults aged 19 and older for Vision Benefits; fitness programs available to covered adults aged 18 and older.

Network RequirementVision and fitness benefits must be obtained from Network Providers (EyeMed administers vision benefits); non-network services are not covered except as allowed in EOC Section 3.

Annual LimitsOne comprehensive eye exam per Benefit Year; one eyewear allowance per Benefit Year; retinal imaging limited to one per Benefit Year.

Administrator ContactsVision benefits administered by EyeMed; member service numbers and Access Plan available online or via 1-833-230-2099 and EyeMed help at 1-833-337-3129.

inv-04: Adult Fitness Programs

Program NameActive & Fit fitness program (Adult Fitness Programs).

EligibilityCovered adults aged 18 and older while enrolled in the Plan.

Cost to MemberVoluntary program provided at no cost to the member; some center-specific fees may apply per program limitations.

Included ServicesAccess to participating fitness centers (cardio/strength equipment, select classes, amenities where available), digital on-demand workouts, healthy living coaching, personalized workout plans, and one home fitness kit per Benefit Year.

LimitationsAvailability and included services vary by center; program fees, if required, do not count toward Annual OOP maximum and may be non-refundable.

inv-05: Medically Necessary Contact Lenses

DefinitionContact lenses dispensed in lieu of eyeglasses when they provide significantly better visual and/or improved binocular function (e.g., avoidance of diplopia or suppression).

Clinical IndicationsMay be determined Medically Necessary for keratoconus, pathological myopia, aphakia, anisometropia, aniseikonia, aniridia, corneal disorders, post-traumatic disorders, and irregular astigmatism.

Coverage ScopeWhen determined Medically Necessary, contact lenses and associated services are covered in lieu of other eyewear; fitting and follow-up visits are covered as described in the Rider.

Substitution RuleMedically Necessary contact lenses are dispensed in lieu of other eyewear (not in addition to the eyewear allowance).