CurrentCareSourcePolicy N/A
Certificate of Coverage — CareSource
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Governs the terms, conditions, exclusions, and limitations of CareSource insurance coverage for enrolled members, including how to obtain benefits, network requirements, and prior authorization rules.
Policy Summary
PayerCareSource
PolicyCertificate of Coverage — CareSource
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders must submit Prior Authorization on behalf of members before listed services are provided.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
EPOPlan type (EPO)
No coverageOut-of-network stance
PA requiredPre-authorization
877-514-2442Member services
50% / $1,500Provider PA penalty
5Formulary tiers
Coverage Criteria and Limits
Coverage stance and criteria (partial)
Summary of coverage rules and limitations present in this portion of the Certificate:
Coverage limited to Covered Health Services delivered by In-Network Providers (EPO plan).
Exceptions: Limited Out-of-Network coverage allowed only for Emergency Health Services, out-of-service-area urgent care, or other circumstances authorized via an approved Out-of-Network Authorization.
Certain treatments and procedures require Prior Authorization; failure to obtain Prior Authorization may reduce or exclude benefits and Prior Authorization is not a guarantee of payment.
Pediatric dental services required by the ACA are not included in this Certificate (members may purchase stand-alone dental plans).
CareSource may modify the Certificate via Riders or Amendments; the Certificate governs benefits effective per member ID card and posted effective dates.
Members should verify provider network status and out-of-pocket responsibilities via Member Services or the Find a Doctor tool.
Core coverage criteria
Coverage depends on medical necessity, whether a service is described as a Covered Health Service, and not excluded in Section 9. Experimental or investigational services are excluded per criteria.
Service must be Medically Necessary as defined by CareSource.
Service must be listed as a Covered Health Service in Section 7 and consistent with the Schedule of Benefits.
Service must not be excluded under Section 9 (Exclusions).
Services meeting Experimental or Investigational criteria are not covered; determination made by CareSource using listed criteria (e.g., lack of credible evidence, not FDA-approved for proposed use, clinical trial status).
EPO network requirement: services generally must be from In-Network Providers except for Emergencies or authorized out-of-network exceptions.
Coverage is subject to Deductible, Copayment, Coinsurance, Maximum Allowed Amount, and Out-of-Pocket Maximum rules; amounts in excess of Maximum Allowed Amount and non-covered services do not count toward Out-of-Pocket Maximum.
Coverage-related definitions and procedural nodes
Coverage-related definitions and procedural requirements referenced in these chunks.
Certain mental health and substance use disorder services are recognized as Covered Health Services when clinically appropriate, but listing in diagnostic manuals alone does not guarantee coverage.
Prior Authorization is a required written determination based on Medical Necessity; failure to obtain prior authorization when required may trigger penalties.
Out-of-Network Authorization must be requested by an In-Network Provider and will not be approved if In-Network Providers can reasonably provide the same or substantially similar care.
Telehealth Service is defined as a virtual visit using audio-video or audio-only systems by a qualified provider; telehealth delivered via telephone-only, text, email, asynchronous messaging, and remote patient monitoring generally do not qualify as Telehealth Visits for coverage.
COVERAGE CRITERIA
Coverage continuation and termination tied to premium payment and other events.
Premium nonpayment rules
- If member does not receive Advance Premium Tax Credit (APTC) and fails to pay premium within 31 days after due date, coverage may terminate as of last day of last paid month.
- If member receives APTC and fails to pay premium when due, a three-month grace period applies beginning the first of the coverage month for which premium was not received; if full payment not made by end of grace, coverage terminates as of last day of first month of grace period.
Payments received for periods when policy is not active will be returned less claims paid for that inactive period; acceptance of premium does not automatically reactivate policy absent terms.
Coverage begins on the Effective Date; no benefits for services before the Effective Date except specified inpatient situations where member notifies within 48 hours.
Events ending coverage
- Coverage ends for nonpayment, fraud/misrepresentation, policy termination, loss of eligibility, moving out of service area (coverage ends 60 days after move), and dependent aging out (end of calendar year when turning 26).
Coverage rules and member responsibilities
Stance on coverage and exceptions for Out-of-Network services, emergency services, and member financial responsibilities.
Emergency Health Services provided by In-Network or Out-of-Network Providers are covered at In-Network level of benefits; once stabilized, ongoing hospitalization and follow-up care must be provided by In-Network Providers.
Limited out-of-network circumstances: Out-of-Network benefits payable only for Emergency Health Services, medically necessary urgent care while traveling outside the service area, approved written Out-of-Network Authorization obtained and approved before services, and certain student behavioral health services for WI in-state students.
A written Out-of-Network Authorization initiated by an In-Network Provider and approved by CareSource must be obtained before services are rendered; failure to obtain approved authorization may result in no payment or penalty per Prior Authorization rules.
Out-of-Network Providers may balance bill members for amounts over the Maximum Allowed Amount for specified services (ground ambulance, urgent care, non-emergency services, referral disagreements); members cannot be balance billed for emergency services or covered ancillary services at In-Network facilities; In-Network Providers may not balance bill.
Members are responsible for differences between provider charges and the Maximum Allowed Amount for Out-of-Network limited services, and for applicable deductible, copayment or coinsurance; Eligible Expenses determined per CareSource reimbursement guidelines.
If a provider fails to obtain required Prior Authorization, the member may be responsible for a penalty of 50% up to $1,500 per Covered Health Service.
Coverage criteria and stance
Coverage stance and criteria for services described in these sections.
Continuity of Care: PCPs who were in-network at enrollment may be continued at In-Network benefits through end of policy year; non-PCP providers may be continued up to 90 days, end of course of treatment, or end of policy year (whichever is shorter); special protections for pregnant members to complete postpartum care.
Prior Authorization: Providers must obtain Prior Authorization for listed Covered Health Services; non-emergency requests must be submitted at least 15 business days before service; urgent/emergency admission notification required within 48 hours; Prior Authorization is based on Medical Necessity and not a guarantee of payment.
Autism coverage: Intensive-level evidence-based behavioral therapy covered when criteria met (qualified providers, treatment plan with >=20 hours/week over six months, direct observation at least once every two months, services commence after age 2 and before age 9 unless exceptions); intensive services covered up to four cumulative years; progress must be documented.
Non-intensive autism services: Non-intensive services covered after intensive services to sustain gains, or as alternative when intensive services are not provided but would improve condition; must be evidence-based with documented treatment plan and progress.
Limitations: Multiple exclusions and limitations apply (non-evidence-based autism treatments, school-based tuition, services during residential/inpatient stays, travel time, fraudulent claims, and other items listed in Exclusions).
General coverage requirements: Covered Health Services must be Medically Necessary, not experimental/investigational, obtained from In-Network Providers except as allowed, received while policy is in effect, and proper proof of loss/claims must be submitted.
Limitations and Exclusions
Services that are specifically excluded or limited under the policy
Experimental/Non-evidence: Treatments for Autism Spectrum Disorder or other services not supported by credible research (Experimental, Investigational or Unproven) are excluded.
Tuition for school-based services under IDEA and services duplicative of school system services are not covered.
Listed non‑evidence‑based modalities (e.g., acupuncture, auditory integration, animal-based therapy, chelation, cranial sacral therapy, hyperbaric oxygen, special diets/supplements) are excluded.
Services provided while residing in a residential treatment center or inpatient facility (room and board) are excluded unless medically necessary; travel time and facility costs for out‑of‑home services are excluded.
Behavioral issues without a clinical mental health diagnosis, custodial or long‑term maintenance care, and services beyond evidence‑based treatment duration are excluded.
Biofeedback is covered for migraine, spastic torticollis and urinary incontinence when clinically appropriate; biofeedback for TMD is not covered.
Botulinum toxin (Botox) covered for medically necessary non‑cosmetic indications (e.g., spasticity); Botox for hyperhidrosis is not covered.
Breast reconstruction following mastectomy and related services required by WHCRA are covered; cosmetic breast augmentation not covered.
Cochlear implants covered when FDA indications met; post‑implant aural therapy limited and accessories excluded (see cochlear implant criteria).
Cochlear implant criteria
Cochlear Implant Coverage and Limits
Indication: Cochlear implants covered for individuals with severe-to-profound hearing loss who receive limited benefit from hearing aids.
Regulatory requirement: Implants must be used in accordance with FDA label indications to be considered Medically Necessary.
Post-implant aural therapy is limited to 30 visits per year.
Accessories such as batteries, cords and other accessories are excluded from coverage.
Dental coverage and accident-only criteria
Dental services coverage and accident-only provisions
Covered dental services are limited to oral exam, x-rays, extractions, and non-surgical elimination of oral infection when directly treating a covered medical condition (e.g., trauma, cancer, cleft palate, transplant prep, pre-immunosuppression).
Routine dental care (general dental care, x-rays, supplies, appliances, hospitalizations and anesthesia) is excluded except for accident-related dental services as specified.
Accident-only dental coverage: treatment is covered when necessary due to accidental damage, provided by DDS/Oral Surgeon/Doctor of Medical Dentistry, with initial provider contact within 72 hours (extensions possible).
Accident treatment timeframes: treatment must start within 3 months of the accident and be completed within 12 months; covered items include emergency exam, diagnostic x-rays, splinting, endodontics, extractions, maxillofacial surgery, anesthesia, post-traumatic crowns, and replacement of lost teeth.
DME and diabetes supplies criteria
Durable Medical Equipment (DME), diabetes supplies, and related limitations
Diabetes supplies covered when listed on the Prescription Drug List: insulin, diabetes drugs, test strips, lancets, syringes, and certain non-invasive CGMs; insulin pumps and non-invasive CGMs covered as DME when appropriate.
DME covered when prescribed by an In-Network Provider and obtained from an In-Network DME supplier; includes wheelchairs, hospital beds, prosthetics, infusion pumps and specialized feeding equipment.
CareSource may establish reasonable quantity limits for certain supplies, equipment or appliances.
If multiple DME options meet functional needs, benefits available only for equipment meeting CareSource minimum/cost-effective specifications; member pays cost difference for upgraded items.
Certain devices are excluded or limited (e.g., cranial helmets, some speech devices except as specified, disposable supplies outside specified sections, devices for sports or convenience, replacement for lost/stolen items, routine maintenance).
Repair/replacement not covered for misuse, malicious breakage, or gross neglect.
Emergency services criteria
Emergency services coverage rules
Emergency Health Services required to stabilize or initiate treatment are covered whether provided by In-Network or Out-of-Network Providers and are paid at the In-Network level subject to the Qualifying Payment Amount; members cannot be balance billed for emergency services above the Qualifying Payment Amount.
Observation stays are covered up to 48 hours; observation beyond 48 hours requires Prior Authorization.
Examples of emergencies include chest pain, difficulty breathing, choking, neurological deficits, severe burns, head injuries, fractures, seizures, severe cuts, fever with rash, severe flu, and vaginal bleeding in pregnancy.
Genetic testing coverage
Genetic testing and counseling
Genetic testing and genetic counseling are Covered Benefits when Medically Necessary for diagnostic purposes; may also be provided for other diseases or conditions as appropriate.
Habilitative services criteria
Habilitative services
Habilitative services (evidence-based PT/OT/ST) are covered when provided by an appropriately licensed therapist under a Provider-directed written treatment plan.
Visit limits: physical therapy 20 visits/year, occupational therapy 20 visits/year, speech therapy 20 visits/year; these services are not to be combined with rehabilitative services limits.
Hearing Aid Coverage Criteria
Hearing aids and bone-anchored hearing aids coverage and limitations
Hearing aids covered for persons certified as deaf or hearing impaired by a Provider or audiologist licensed under state law.
Bone-anchored hearing aids covered only for craniofacial anomalies precluding wearable aids or for hearing loss severe enough that wearable aids are inadequate.
Limit: one hearing aid per ear every 36 months; bone-anchored hearing aids limited to one per lifetime except for medically necessary repair/replacement due to malfunction; batteries, cords and accessories excluded.
Home Health Criteria
Home Health coverage criteria and limits
Home Health services must be ordered by a Provider and provided by an In-Network, state-licensed or Medicare-certified Home Health Agency.
Services must be part-time or intermittent, require skilled care (nursing, teaching, or rehabilitation), and would otherwise require inpatient or SNF confinement without these services.
Home health benefits limited to 60 visits per calendar year; up to four consecutive hours of skilled care equals one visit; services by nursing assistants/home health aide visits are excluded.
Hospice/Palliative Care Criteria
Hospice and palliative care coverage
Hospice benefits require attending Provider certification of terminal illness with life expectancy of one year or less and hospice medical director certification; Provider must consent and be consulted on treatment plan.
Covered hospice services include interdisciplinary team care, skilled nursing, short-term inpatient facility care for crisis/respite, social services, therapies, dietary support, pharmaceuticals and medical equipment necessary for palliation.
Palliative care is covered when ordered by a Provider with an in-network hospice-certified Provider and delivered by an interdisciplinary team focused on symptom management and quality of life.
Inpatient and Rehabilitation Criteria
Inpatient confinement and inpatient rehabilitation coverage
Covered inpatient services include room and board (semi-private or private when semi-private unavailable), ancillary services, provider services, therapies, and related supplies.
Inpatient rehabilitation is covered when the individual can participate at least 3 hours/day for at least 5 days/week and requires provider visits ≥3 times/week.
Coverage for inpatient skilled rehabilitation is limited to 60 days per calendar year; custodial or long-term care is not covered.
Maternity/Newborn Criteria
Maternity, newborn, and related exclusions
Maternity coverage includes prenatal, postnatal, delivery services and related complications; includes surrogate/gestational carrier services when the Covered Person is pregnant.
Newborn inpatient coverage includes 48 hours after vaginal delivery and 96 hours after cesarean for mother and newborn; routine exams and circumcision prior to discharge covered.
Exclusions: elective abortions (except to save life/health or in rape/incest), home/out-of-hospital deliveries, certain prenatal tests for non-medical reasons, birthing classes, donor milk excluded, breast pumps limited to specified types and counts.
Nutrition Criteria
Nutritional education and exclusions
Nutritional education is covered when required for disease/condition self-management and a knowledge deficit exists that requires intervention by a licensed/registered nutrition professional.
Exclusions: individual/group nutritional counseling (except when specified for diabetes or preventive care), infant formula, donor breast milk, OTC nutritional formulas/supplements, and nutrition counseling for weight loss are excluded unless specified elsewhere.
Oral Surgery Criteria
Oral surgery coverage and exclusions
Covered oral surgery includes excision of tumors, cysts and abscesses of jaws/cheeks/tongue/roof and floor of mouth and repair of traumatic maxillofacial injuries or fractures.
Excluded: oral surgeries for routine tooth extraction (e.g., wisdom teeth) and treatment related to dental tooth abscesses.
Ostomy Supplies Criteria
Ostomy supplies coverage and exclusions
Covered ostomy supplies include pouches, face plates, belts, irrigation sleeves, bags, ostomy irrigation catheters and skin barriers; reasonable quantity limits may apply.
Excluded items include deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive remover and other items not listed as covered.
Ostomy supplies
Ostomy supplies
Covered: pouches, face plates, belts, irrigation sleeves, bags, ostomy irrigation catheters, skin barriers when criteria met; plan may establish reasonable quantity limits.
Enteral/parenteral nutrition
Oral enteral and parenteral nutrition
Covered when product is a medical food for oral or tube feeding, is the primary source of nutrition (>50%), labeled for dietary management of a specific medical disorder with distinctive nutritional requirements, and used under supervision or ordered by a Provider or registered dietician.
When medically appropriate, introduction to oral nutrition is preferred and enteral/parenteral feeding should be weaned as able; reasonable quantity limits may apply.
Pharmaceuticals and podiatry
Outpatient-administered pharmaceuticals and podiatry
Outpatient-administered pharmaceutical products are Covered when their characteristics require administration or direct supervision by a qualified Provider; plan may set quantity limits and providers should contact CareSource for details.
Podiatry services covered for treatment of foot disorders and medically necessary routine foot care for members with certain chronic conditions (e.g., diabetes, peripheral vascular disease); routine foot care generally not covered otherwise.
Preventive Care
Preventive care
Certain preventive services are Covered at 100% In-Network when USPSTF A/B, ACIP immunizations, or HRSA-supported guidelines apply; other preventive services may have cost-share or be Not Covered depending on medical necessity and policy limits.
Preventive services must be provided In-Network in outpatient primary care settings and be appropriate for age; examples include first screening colonoscopy at 45 paid 100% and annual wellness check-ups.
Prosthetics and office services
Prosthetics and office-based services
External prosthetic devices that replace a limb or body part are covered when medically necessary; repairs/replacements covered except for misuse/loss/theft; if device exceeds minimum specs the plan pays only amount for device meeting minimum specs.
Provider office services for diagnosis/treatment and education are covered when appropriate; excludes major diagnostics (CT, MRI, PET, nuclear medicine) which are not part of office services coverage.
Outpatient rehabilitation
Rehabilitation services
Short-term outpatient rehabilitation covered with visit limits: PT 20/year, OT 20/year, SLP 20/year; cardiac rehab 36/year; cognitive rehab 20/year; post-cochlear implant aural therapy 30/year; pulmonary rehab 36/year.
Services must be provided in a Provider office or outpatient facility, must progress toward goals and may be denied or shortened if no progress or goals previously met; maintenance/long-term/ preventive manipulative treatment is excluded.
Reproductive services exclusions
Reproductive and infertility services
Covered: tubal ligation and vasectomy; removal of fallopian tubes when medically necessary.
Excluded: reversal of sterilization, infertility diagnostics/treatments (including IVF, IUI, AI), gamete/embryo storage, assisted reproductive technologies, and related services; medications for infertility excluded.
Diagnosis/treatment of medically necessary underlying causes of infertility may be covered, but assisted reproductive technologies are excluded.
Skilled Nursing Facility care
Skilled Nursing Facility (SNF) and skilled care
SNF services covered when medically necessary: room and board up to 30 days per stay; ancillary services included; benefit renews after 60 consecutive days without inpatient or skilled SNF care; no limit on number of benefit periods.
Coverage requires services to be skilled (delivered/supervised by licensed personnel), ordered by a Provider, be a cost-effective alternative to hospital inpatient care, and not primarily custodial; custodial/long-term care is excluded.
Outpatient surgery
Outpatient surgery
Outpatient surgical services in hospital ambulatory surgical centers or provider offices are covered when Medically Necessary within stated parameters; includes certain endoscopic procedures.
Facility charges and supplies, and provider services for radiology, anesthesia and pathology tied to surgical services are covered per Provider Fees provision; refer to Exclusions for surgery-specific limits.
Skilled Care Coverage Criteria
Skilled Nursing and Rehabilitation Services are covered only when all conditions are met:
ALL of the following
- Services must be delivered or supervised by licensed technical or professional medical personnel.
- Services must be ordered by a Provider.
- Services must not be exclusively for assistance with Activities of Daily Living (dressing, feeding, bathing, transferring).
- Coverage requires Provider-directed medical management and that the services be skilled in nature.
CareSource determines skilled nature and eligibility; services will not be considered skilled solely because no caregiver is available.
Outpatient Surgery Coverage
Outpatient surgery and related services may be covered when Medically Necessary and within stated parameters:
ALL of the following
- Facility charges and supplies for medically necessary outpatient services are covered.
- Provider services for radiology, anesthesia, pathology tied to surgical services are covered per Provider Fees.
- Breast reconstruction after mastectomy, symmetry surgery and prostheses and lymphedema treatment are covered per special rules.
Refer to Section 9 Exclusions for surgery-specific limitations and non-covered elective/cosmetic procedures.
Telehealth Coverage Criteria
Telehealth coverage rules:
ALL of the following
- Telehealth visits by in-network providers for acute physical and behavioral symptoms are covered when appropriate.
- Telephone-only communication, text, email, asynchronous messaging, and remote patient monitoring are not covered as Telehealth Visits.
- CareSource may deny virtual visits that cannot reasonably be completed online (e.g., comprehensive physical exams).
Telehealth services must be provided by CareSource network qualified providers to be covered; Telehealth rendered by Out-of-Network providers is not covered.
TMD Coverage and Limitations
Temporomandibular disorder (TMD) coverage and exclusions:
ALL of the following
- Coverage for diagnostic procedures and surgical/non-surgical treatment is allowed when there is clear radiographic evidence of significant joint abnormality.
- Condition must be caused by congenital, developmental, acquired deformity, disease or injury.
- Procedures/devices must be reasonable, appropriate and intended to control/eliminate infection, pain, disease or dysfunction.
- Excluded diagnostics and treatments considered unproven include EMG, jaw-tracking, thermography, ultrasonography, occlusal adjustment, orthodontic/orthognathic surgery for bite change, restorative prosthodontics, TENS, biofeedback, nutritional/home therapy, and other listed services.
Services that continue after expected improvement or that are not expected to provide predictable improvement are excluded.
Transplant Coverage Criteria
Transplant coverage conditions and exclusions:
ALL of the following
- Certain organ and tissue transplants are covered when ordered by a Provider and performed at a Designated Facility/Center of Excellence.
- Donor costs directly related to organ removal are covered only if the transplant recipient is a Covered Person and are payable through the recipient's benefits.
- Transplant services and related supplies require Prior Authorization; experimental/investigational transplants and transplants involving non-human or artificial organs are not covered.
- Donor non-medical costs (hotel, transportation) are not covered.
Contact CareSource for specific transplant guidelines and Prior Authorization requirements.
Vision Coverage
Vision and related limitations:
ALL of the following
- One annual eye exam by an optometrist or ophthalmologist for children through the end of the month they turn 19 is covered.
- One pair of eyeglasses per calendar year for children through the end of the month they turn 19; contact lenses covered with potential effect on eyeglass benefit frequency.
- Exclusions for adults: purchase cost and fitting of eyeglasses and contact lenses, refractive surgery (LASIK), eye exercises, low vision aids, and implantable lenses solely for refractive error are excluded (except intraocular lenses with cataract surgery).
If a child receives contact lenses, eyeglass benefits for that year may be affected as described in the policy.
Dialysis/Infusion/Transfusion Coverage
Dialysis, infusion, transfusion coverage:
ALL of the following
- Therapeutic treatments including dialysis (hemodialysis and peritoneal), IV chemotherapy/infusion, and radiation oncology are covered when Medically Necessary.
- Transfusions and supervised infusions in office or home settings are covered for treatment of a covered condition and must be provided in the most cost-effective setting.
- Patient education by licensed professionals for disease self-management is covered when a knowledge deficit exists.
Contact CareSource for setting- and prior authorization-related guidance for infusion and dialysis services.
Urgent Care Coverage
Urgent care coverage:
ALL of the following
- Medically necessary urgent care services are covered at in-network urgent care centers when the member is within the service area.
- Outside the service area, out-of-network urgent care is allowed but payment is limited to the Maximum Allowed Amount.
Balance billing rules apply per Section 5 for out-of-network urgent care as applicable.
Prescription Drug Benefit
Prescription drug benefit overview and use:
ALL of the following
- Prescription Drug Benefit covers outpatient pharmacy prescriptions; some provider-administered drugs are covered under the Medical Benefit.
- Formulary lists preferred drugs; non-formulary drugs may be covered through a drug exception process; prescriptions should be filled at network pharmacies for coverage.
- If a member pays out-of-pocket, a direct claim for reimbursement must be submitted within 12 months from payment to be considered.
Present ID at pharmacy for billing; failure to present may require out-of-pocket payment and subsequent direct claim for reimbursement.
Formulary Coverage Criteria and Processes
Coverage generally provided for medically necessary drugs and devices listed on the formulary; non-formulary drugs may be covered through a drug exception process subject to requirements and timelines.
Formulary coverage: drugs on the formulary are usually covered but may have limits (Prior Authorization, Quantity Limits, Step Therapy, Age Limits).
Only drugs and devices that are Medically Necessary are covered; FDA-approved uses covered and some off-label uses may be covered if supported by standard medical literature.
Non-formulary Drug Exception: Members or providers may request an exception via Member Exception Request Form or Member Services; if granted, the drug is treated as an Essential Health Benefit and cost-sharing applies and counts toward Out-of-Pocket Maximum.
Decision timelines: standard determinations for formulary and non-formulary requests are 72 hours; expedited (urgent) requests have faster timelines and external independent review decisions provided within 72 hours (24 hours if expedited).
Opioid analgesics for chronic pain require Prior Authorization; other controlled substances may also require Prior Authorization.
Specialty drugs typically require specialty network pharmacy fill and are generally limited to a 30-day supply; mail-order options may be available.
Tiered cost-sharing determines member cost-share; copay cards may reduce member cost but manufacturer payments may not count toward Deductible/Out-of-Pocket unless required by law.
Providers must submit clinical information electronically or by fax to support Prior Authorization or limit-bypass requests; appeals and independent external review available for denied exceptions.
Coverage stance and exclusions (partial document)
Summary of coverage stance and exclusions present in these chunks:
Pharmacy services include pharmacist consultations (Medication Therapy Management) to review medications, provide education, identify interactions, and cost-saving alternatives.
Opioid analgesics prescribed for chronic pain require Prior Authorization; other controlled substances may require Prior Authorization.
Prescription drug exclusions: drugs not FDA-approved, not on the formulary without an approved exception, dispensed outside coverage eligibility dates, or covered by other government programs are not covered.
Compounded drugs with non-FDA-approved ingredients, drugs dispensed by non-network pharmacies, or drugs dispensed outside the U.S. are excluded except in emergencies.
Members should consult the Prescription Drug Formulary or Member Services to determine specific drug coverage.
Section 9 Exclusions include experimental/investigational services, numerous personal care/comfort items, many outpatient supplies, cosmetic procedures, most travel-related services, custodial care, private duty nursing, and other explicitly listed exclusions.
Certain types of care such as multidisciplinary inpatient pain programs, private duty nursing, and custodial care are excluded.
Specific surgical exclusions include bariatric surgery, many cosmetic/elective procedures, and a broad set of alternative/holistic therapies explicitly excluded.
Exclusions
Listed exclusions — services and items not covered under this Certificate excerpt include (non-exhaustive):
Holistic medicine, homeopathy, iridology, hypnosis, naturopathy, meditation, yoga, reflexology, and many other alternative/holistic therapies are excluded.
Services provided by massage therapists; custodial or long-term care after stabilization; cosmetic surgeries and procedures to improve appearance are excluded except where reconstructive and medically necessary.
Orthognathic/jaw alignment surgery excluded except when reconstructive for congenital anomaly, trauma, tumor, cancer, OSA, or TMJ disorder; stand-alone multidisciplinary smoking cessation programs excluded.
Vitamins and most nutritional supplements excluded except as required by law; services before effective date or after coverage ends excluded; claims billed more than one year after proof required may be excluded.
Long-term (>30 days) storage of body fluids/tissue (cryopreservation) excluded; CAR T-cell and gene therapies and related services/drugs excluded.
Coordination of Benefits
Order of Benefit Determination rules — how primary and secondary plans are determined and how payments are coordinated:
Primary Plan pays benefits according to its terms without regard to other plans; secondary plans apply coordination of benefits rules to avoid payments exceeding Allowable Expenses.
Dependent-child order of benefits determined by parents' marital status, birthdays, court decrees, and custodial parent rules as specified.
Active employee coverage is primary over retired/laid-off employee coverage; COBRA or state continuation coverage is secondary to employer/group plan.
If order of benefits cannot be determined by rules, Allowable Expenses are shared equally and CareSource will not pay more than it would as Primary Plan.
CareSource may reduce its benefits so total payments across plans do not exceed total Allowable Expenses and may recover overpayments or offset future payments as needed.
Administrative coverage-related provisions
Operational rules governing certain covered processes and financial recoveries.
Second opinion: One second opinion per injury or illness by an In-Network Provider is covered; Prior Authorization required when Section 6 requires it; Out-of-Network second opinions require Out-of-Network Authorization.
Right of recovery: If CareSource paid more than should have been paid under coordination rules, CareSource may recover excess payments from payees or responsible parties and may offset future payments.
Subrogation and reimbursement: CareSource is subrogated to rights of recovery for the reasonable value of services provided and may recover from third parties (insurers, tortfeasors, workers' compensation); members must cooperate and may be required to assign recovery rights.
Coding, Code Tables, and Limits
Experimental/InvestigationalmixedNot Covered
| Experimental or Investigational services are identified using listed criteria (not FDA-approved, in clinical trials, lack credible evidence). |
Prescription drug tieringmixed
| Prescription Drug List tiers and classification; list is reviewed periodically (generally quarterly, up to six times per calendar year). |
Coding references used for reimbursementmixed
| CPT | May rely on CPT coding for reimbursement determinations |
Illustrative covered service categoriesmixedCovered
| Advanced imaging (MRI, CT, PET) covered when performed in hospital or freestanding facility | |
| Emergency ambulance (ground/air) covered when medically necessary; out-of-network ambulance paid at Maximum Allowed Amount | |
| Anesthesia services covered in connection with medical services; anesthesia for certain dental care covered under conditions |
Cochlear implant indicationneutralCovered
| Cochlear implants deemed Medically Necessary when used in accordance with FDA label indications for individuals with severe-to-profound hearing loss; post-implant aural therapy limited to 30 visits per year; accessories excluded. |
Diabetes supplies & devicesmixed
| Insulin, diabetes prescription drugs, test strips, lancets, syringes, certain non-invasive continuous glucose monitors, and insulin infusion devices when included on the Prescription Drug List or ordered as DME; CareSource may establish reasonable quantity limits. |
Kidney disease treatment servicesmixedCovered
| Inpatient and outpatient kidney disease treatment including dialysis, transplantation, and donor-related services; donor charges payable only if recipient is Covered; Experimental or Investigational transplants excluded. |
Outpatient rehabilitation visit limitsmixedCovered
| Visit limits for outpatient rehabilitation services: Physical therapy 20 visits/year; Occupational therapy 20 visits/year; Speech therapy 20 visits/year; post-cochlear implant aural therapy 30 visits/year; cardiac/pulmonary/cognitive limits as specified. |
Formulary Tiersmixed
| Formulary organized into Tier 0 (preventive) through Tier 4 (specialty) with differing cost-share and coverage rules; specialty drugs typically limited to 30-day supply. |
Explicit exclusionsmixedNot Covered
| Chimeric Antigen Receptor (CAR) T-cell therapy and gene therapy, including related services, items, and drugs, and long-term (>30 days) cryopreservation of body fluids/tissue are excluded. |
Recovery / Overpaymentmixed
| Right of recovery and refund/offset of overpayments: CareSource may recover excess payments from recipients, providers, or responsible third parties and may offset future payments. |
Out-of-Pocket Maximum applicability
Out-of-Pocket Maximum applicabilityAmounts paid for non‑Covered services and amounts in excess of the Maximum Allowed Amount do NOT count toward the Out‑of‑Pocket Maximum; financial assistance (coupons, savings cards, grants) generally does not count unless required by law.
Balance billing effectWhen the Plan pays an Out‑of‑Network Provider for limited Covered Health Services, amounts paid in excess of the Maximum Allowed Amount do NOT count toward the Out‑of‑Pocket Maximum.
Definition referenceOut‑of‑Pocket Maximum is defined as the maximum amount a member is required to pay for medical and Prescription Drugs in a single year.
Prescription Drug List review frequency
Review frequencyPrescription Drug List (Formulary) is reviewed generally quarterly, but no more than six times per calendar year.
GovernanceFormulary content and changes are governed by the Pharmacy & Therapeutics (P&T) Committee (see formulary processes).
NotificationMembers are notified of formulary content and changes via available tools (Formulary Search Tool on website) and P&T committee communications.
Claims review steps
Claims pre-review stepsClaims are reviewed upon receipt for accuracy and validity including correct coding, billing errors, and abuse/fraud reviews before reimbursement policies are applied.
Application of reimbursement policiesAfter initial claim review, CareSource applies reimbursement policies consistently across claims.
Use of consultantsCareSource may use medical and outside medical consultants to assist determinations during claim review.
Intensive-level autism therapy hours and duration
Intensity thresholdIntensive‑level autism therapy defined as evidence‑based behavioral therapy averaging at least 20 hours per week over a continuous six‑month period.
Duration limitIntensive‑level services are covered for up to four cumulative years; prior intensive services may be credited toward the four‑year limit.
Provider & plan requirementsServices must be implemented by qualified providers, based on a treatment plan with measurable goals, member engagement, and periodic direct observation (at least once every two months).
Post‑operative aural therapy visits
Post‑operative aural therapy visitsOutpatient rehabilitation post‑cochlear implant aural therapy is limited to 30 visits per year.
Accessories exclusionBatteries, cords and other accessories for cochlear implants are listed as limited/excluded items.
Progress/documentationProgress must be assessed and documented; prior treatment history may be requested to verify coverage and limits.
DME selection rule
DME selection ruleIf more than one DME item can meet the member's functional needs, Benefits are available only for the equipment that meets the minimum specifications and is determined by CareSource to be the most cost‑effective; member pays any cost difference for a more expensive choice.
Purchase vs rentalCareSource may decide whether DME will be purchased or rented and may pay rental up to purchase price; DME must be obtained from an In‑Network DME provider.
Quantity limits and repairsCareSource may establish reasonable quantity limits; repairs/replacements are covered except for misuse, malicious breakage, gross neglect, lost or stolen items.
Home health visit count limit
Home health visit count limitHome health benefits are limited to 60 visits per calendar year; up to four consecutive hours of skilled care equals one home health visit.
Provider and skilled needServices must be ordered by a Provider and provided by an in‑network, state‑licensed or Medicare‑certified Home Health Agency; care must be skilled (not custodial).
Home health aide servicesServices by nursing assistants and/or personal care workers are listed with limitations and may not be covered as skilled home health benefits.
Hearing aid replacement frequency
Hearing aid replacement frequencyHearing aids are limited to one hearing aid per ear every thirty‑six (36) months.
Bone‑anchored devicesBone‑anchored hearing aids limited to one per lifetime except when repair/replacement required for malfunction or specific medical indications (e.g., craniofacial anomalies).
Accessories exclusionBatteries, cords and other accessories are listed separately and may be limited/excluded.
Quantity limits policy
Quantity limits policyCareSource may establish reasonable quantity limits (QL) for certain supplies, equipment, appliances, and medications; Quantity Limits will appear on the Formulary and can be bypassed by Provider request.
Step Therapy and Age LimitsStep Therapy (ST) may require trying lower‑cost drugs first and Age Limits (AL) restrict coverage by age; Providers can request bypasses electronically or by fax.
Provider bypass processIf higher amounts or exceptions are needed (QL, ST, AL), the Provider can submit a request to bypass limits; approval is required before coverage for the higher amount is provided.
Vision benefit frequency (children)
Vision benefit frequency (children)One annual eye exam and one pair of eyeglasses per calendar year are covered for children through the end of the month they turn 19 years old.
Contact lens interactionIf a covered child receives elective or non‑elective contact lenses, eyeglass benefits for that year may be affected (no eyeglass benefits until next benefit period as specified).
Lens specificationsCovered eyeglass lenses include standard plastic lenses with factory scratch coating; lenses offered include single vision, bifocal, trifocal and progressive options.
Pharmacy direct claim time limit
Pharmacy direct claim time limitMembers must submit a direct claim for reimbursement to the PBM within twelve (12) months of paying for a prescription.
Non‑network pharmacy riskDirect claims may be denied if the drug is not covered by the plan, the pharmacy is not a Network pharmacy, or the amount paid was less than the applicable cost‑share.
Documentation requirementWhen submitting a direct claim, members should provide an itemized receipt; final reimbursed cost may differ from out‑of‑pocket payment after adjudication.
Quantity, Step Therapy, Age limits
Quantity, Step Therapy, Age limits summaryQuantity Limits (QL) set maximum amounts over a time period; Step Therapy (ST) may require trying a lower‑cost alternative first; Age Limits (AL) restrict coverage by age—Providers can request bypasses for QL/ST/AL.
Formulary tiers and decision timingFormulary organized into tiers; standard determinations for formulary/non‑formulary requests are 72 hours with expedited timelines available; appeals and independent external review processes apply for denials.
Bypass/exception processProviders may request bypasses electronically or by fax; an approved request is not a guarantee of payment—drug must be covered and member eligible for benefits.
billing_timeline (claims submission time limit)
Claims submission time limit (billing timeline)Health services must be billed to CareSource (proof submitted) within one (1) year from the time proof is otherwise required; services billed after one year may be excluded.
Effect of late billingServices received before the Effective Date or after coverage ends are excluded; late billing beyond one year may result in no payment even if service would otherwise be covered.
Exceptions and documentationMembers may request exceptions where permitted; submission of required documentation within timeframes supports reimbursement determinations.
cryopreservation_storage_duration_limit
Cryopreservation storage duration limitLong‑term storage (more than 30 days) of body fluids and/or tissue (e.g., cryopreservation of tissue, blood, or cellular components) is excluded from coverage.
Examples excludedExamples specifically listed include cryopreservation of tissue, blood, or cellular components; associated storage costs beyond 30 days are not covered.
Related exclusionsOther exclusions (CAR T‑cell/gene therapies) are listed nearby and may affect coverage for advanced biologic services or storage‑related items.
Amendment notice period
Amendment notice periodAmendments to the Policy are effective 31 days after CareSource sends written notice to the Subscriber; if the Amendment reduces Benefits, it becomes effective 60 days after prior written notice.
Rider effective dateRiders are effective on the date specified in the Rider (as stated by CareSource).
Authority and limitationsNo oral changes are permitted; only signed Amendments or Riders by an authorized CareSource officer effect Policy changes.
Provider Requirements, Authorizations, and Billing Actions
Prior Authorization
Prior Authorization Requirement
Certain treatments and procedures require prior authorization. Section 6 lists services requiring prior authorization; benefits may be reduced or excluded if services are not pre‑authorized. Prior Authorization is not a guarantee of payment.
Prior Authorization
Prior Authorization overview
Prior Authorization determinations are made based on Medical Necessity, whether the Provider is in‑network, applicable Deductible/Copayment/Coinsurance and Plan limits (for example the member's Maximum Out‑of‑Pocket). Providers must submit clinical information to support medical necessity.
Prior Authorization
Prior Authorization requirement (list availability)
Prior Authorization is required for services listed on the Prior Authorization list; the list is available via Member Services or the CareSource website. Failure to obtain required Prior Authorization will result in the penalties described in Section 6.
Documentation Required
Out‑of‑Network Authorization must be requested by In‑Network Provider
An Out‑of‑Network Authorization must be initiated and submitted by an In‑Network Provider and will not be approved if In‑Network Providers can reasonably provide the same or substantially similar care.
Documentation Required
Claims determinations and authorizations
Claims and benefit determinations will be made by applying provider network status, existing authorizations, and the limitations and exclusions set out in the Certificate, Schedule of Benefits, and any Riders/Amendments.
Prior Authorization
Providers must submit PA on member’s behalf
Providers are required to submit Prior Authorization requests on behalf of members before listed Covered Health Services are provided. If Prior Authorization is not obtained, the member may be responsible for a penalty (see Section 6). Prior Authorization decisions are determinations of Medical Necessity and do not guarantee payment.
Prior Authorization
Out‑of‑Network Authorization process
For out‑of‑network care, an In‑Network Provider must complete and submit an Out‑of‑Network Authorization that CareSource must approve before services are rendered; if the process is not followed, Benefits will not be payable.
Prior Authorization
Prior Authorization timing for non‑emergency services
Prior Authorization requests for non‑emergency/non‑urgent services must be received at least 15 business days prior to the anticipated service; for urgent/emergency admissions, hospital admission notification must be given within 48 hours after admission or as soon as medically able.
Billing Rule
Provider failure to obtain PA — member penalty
If a Provider fails to obtain required Prior Authorization, the member may be held responsible for a penalty equal to 50% of the charge up to a maximum of $1,500 per Covered Health Service.
Documentation Required
Continuity of Care process and member rights
Members have Continuity of Care rights when an in‑network Provider who was in the network at enrollment leaves: PCP access through end of policy year; non‑PCP up to 90 days, the end of the course of treatment, or end of policy year (whichever is shorter). Members should contact Member Services to arrange continuation or assistance selecting a new in‑network Provider.
Documentation Required
Behavioral Health and SUD covered services — provider requirement
Mental health and substance use disorder services are covered when performed by a licensed, in‑network professional and include inpatient, partial hospitalization, day treatment, intensive outpatient, residential services, medication management, crisis intervention, and telehealth.
Prior Authorization
Observation stays >48 hours require PA
Observation stays are covered up to 48 hours; observation stays beyond 48 hours require Prior Authorization.
Prior Authorization
Home Health ordering and in‑network provider requirements
Home Health services must be ordered by a Provider and provided by an in‑network, state‑licensed or Medicare‑certified Home Health Agency; services must be part‑time/intermittent, skilled in nature, and such that hospital or SNF confinement would otherwise be needed.
Prior Authorization
Hospice certification and Provider involvement required
To receive hospice benefits, the attending Provider and the hospice medical director must certify the patient is terminally ill with life expectancy of one year or less, and the Provider must consent to hospice care and be consulted in developing the hospice treatment plan.
Documentation Required
Outpatient‑administered pharmaceuticals — provider notification
Certain outpatient‑administered pharmaceutical products are covered only when administered or directly supervised by a qualified provider; Providers must contact the plan for details and note that quantity limits may apply.
Prior Authorization
SNF admission — order and skilled determination required
Skilled Nursing Facility benefits require services to be ordered by a Provider, be a cost‑effective alternative to inpatient hospital care, and be skilled (not primarily custodial); benefits are available up to 30 days per stay and subject to medical necessity.
Prior Authorization
Transplant services require PA
Transplant services and related supplies require Prior Authorization by CareSource; donor costs directly related to organ removal are payable through the recipient's benefits. Experimental or investigational transplants are not covered.
Prior Authorization
How to submit PA and bypass requests
Providers must submit Prior Authorization and limit‑bypass requests (for Quantity Limits, Step Therapy, Age Limits) electronically or by fax using forms on the website; supporting clinical information (medical history, prior drugs, tests) is required.
- Providers may request bypasses for QL, ST, and AL by submitting clinical justification.
- Use the Formulary Search Tool and PA forms on the Provider page of CareSource's website.
Prior Authorization
Controlled substances (opioid) Prior Authorization required
Opioid analgesics prescribed for chronic pain require Prior Authorization; other controlled substances may also require Prior Authorization in accordance with federal and state rules.
Documentation Required
Timely submission of records and information required
Providers must provide requested information (medical records, authorization of records, repricing information, pending claim details) within specified timeframes (generally within 30 days when requested) to determine reimbursement; failure to provide required information may affect payment.
Prior Authorization
Second opinion authorization — PA required when applicable
A second opinion from an In‑Network Provider is covered (one per injury or illness). When a second opinion requires Prior Authorization, the Provider must obtain it; an Out‑of‑Network Authorization is required if the second opinion is requested from an Out‑of‑Network Provider.
Defined Terms
Certificate of Coverage definition
Legal documentCertificate of Coverage is part of the Policy and is the legal document between CareSource and the Covered Person governing Benefits, subject to terms, conditions, exclusions, and limitations.
Includes other documentsThe Policy includes the Certificate of Coverage, Schedule of Benefits, any Amendments and Riders, Notices, and the Application.
Controls over summariesThe Certificate and Schedule of Benefits are the primary source for accurate benefit information and supersede other summaries.
Network Status (In-Network Providers)
In‑Network definitionIn‑Network Providers have contracted with CareSource to provide Covered Health Services and accept CareSource's contracted rates with no additional billing to the member other than Copayment, Coinsurance and Deductible amounts.
Out‑of‑Network stanceThe Policy is an Exclusive Provider Organization (EPO): coverage is limited to In‑Network Providers; Out‑of‑Network benefits generally are not payable except limited circumstances (emergency services, out‑of‑service‑area urgent care, or approved Out‑of‑Network Authorization).
Balance billing noteMembers may be responsible for charges above the Maximum Allowed Amount when services are received from Out‑of‑Network Providers; In‑Network Providers may not balance bill for Covered Health Services.
Activities of Daily Living (ADL)
DefinitionActivities of Daily Living (ADL) are basic self‑care tasks such as bathing, eating, dressing, toileting, and transferring.
Context of useADLs are used in policy evaluations to distinguish skilled care from custodial care and to determine eligibility for certain services.
Examples listedExamples explicitly include bathing, eating, dressing, toileting, and transferring.
Copayment (Copay)
What it isCopayment (Copay) is a fixed amount a member pays to the Provider for a Covered health care service.
Counts toward OOPCopayments apply toward the member's Out‑of‑Pocket Maximum.
Collected at time of serviceCopayments are typically collected at the time of service by the Provider.
Maximum Allowed Amount (MAA)
DefinitionMaximum Allowed Amount (MAA) is the maximum amount the plan will pay for a covered service; for Out‑of‑Network Providers it is a rate similar to what the plan would have paid had the service been rendered by a contracted provider in the same geographic region.
Balance billing implicationMembers may be responsible for the difference between provider charges and the Maximum Allowed Amount when using Out‑of‑Network Providers.
Use in benefit calculationsCareSource uses the MAA to determine payment for limited Out‑of‑Network Covered Health Services and to assess amounts that count toward Out‑of‑Pocket Maximum.
Medically Necessary
Core meaningMedically Necessary services are those that meet accepted standards of medical care, are clinically appropriate in type, frequency, extent, site and duration, and are not primarily for convenience or experimental.
Evidence baseDeterminations rely on credible scientific evidence, specialty society recommendations, prevailing clinical opinion, and CareSource clinical policies; CareSource may consult external experts.
Not automaticProvider ordering a service does not, by itself, make it Medically Necessary; benefits depend on Medical Necessity determinations under the policy.
Out-of-Network Authorization
What it isOut‑of‑Network Authorization is a written request (initiated by an In‑Network Provider) asking CareSource to approve services from an Out‑of‑Network Provider.
Approval conditionsAuthorization will not be approved if In‑Network Providers can reasonably provide the same or substantially similar care.
Consequences of no authorizationIf Out‑of‑Network Authorization is not obtained and services are rendered, benefits will not be payable for those services.
Out-of-Pocket Maximum
Definition summaryOut‑of‑Pocket Maximum is the maximum amount a member is required to pay for medical services and prescription drugs in a calendar year.
What doesn't countAmounts for non‑covered services and amounts in excess of the Maximum Allowed Amount do not count toward the Out‑of‑Pocket Maximum; financial assistance/coupons generally do not count unless required by law.
Applies across cost‑share typesDeductibles, Copayments and Coinsurance generally apply toward the Out‑of‑Pocket Maximum subject to policy rules.
Prior Authorization definition
DefinitionPrior Authorization is the determination of coverage made after review of an advanced written authorization and appropriate documentation, based on Medical Necessity.
Not a guarantee of paymentA Prior Authorization determination of Medical Necessity is not a guarantee of payment; benefits remain subject to policy terms and provider status.
Provider responsibilityProviders are expected to request Prior Authorization on behalf of members for services listed on the Prior Authorization list.
Telehealth Service
What it isTelehealth Service is a virtual visit/appointment using audio‑video or audio‑only telecommunication to provide care by a qualified Provider.
Coverage limitsTelehealth Visits by in‑network providers for acute physical and behavioral symptoms are covered when appropriate; telephone‑only, text, email, asynchronous messaging and remote patient monitoring are not considered Telehealth Visits under this policy.
Provider network requirementTelehealth services must be provided by in‑network qualified Providers to be covered under Telehealth Visit provisions.
Eligible Person definition
Eligible Person termEligible Person (Covered Person or member) is an individual who meets enrollment criteria and resides within CareSource's service area.
Subscriber relationshipWhen an Eligible Person enrolls, CareSource refers to that person as the Covered Person; definitions and enrollment terms are in Section 2.
ScopeEligibility determinations may be made by the Marketplace or directly by CareSource depending on the enrollment pathway.
Dependent definition
Who is a DependentDependent generally refers to the Subscriber's spouse and children; when enrolled called an Enrolled Dependent.
Enrollment implicationDependents who enroll are referenced as Enrolled Dependents and are covered subject to policy terms and eligibility rules.
See Section 2Complete definition and qualifications for Dependents are detailed in Section 2: Terms and Definitions.
Termination of eligibility / age 26 rule
Age 26 ruleDependent coverage ends on the last day of the calendar year in which the dependent reaches age 26 (subject to exceptions for disabled dependents).
Coverage end timingIn general, coverage ends on the last day of the calendar month in which the Subscriber or Enrolled Dependent is no longer eligible; specific rules apply for special cases.
Disabled dependent exceptionCoverage for an unmarried disabled Enrolled Dependent may be extended beyond limiting age if medically certified and dependent on Subscriber; proof required within 31 days.
Disabled dependent continuation
Continuation for disabled dependentsCoverage for an unmarried enrolled dependent child who is disabled may be extended beyond the limiting age if the child depends mainly on the Subscriber and is medically certified as disabled.
Proof timeframeProof of disability must be furnished within 31 days of the date coverage would otherwise end; CareSource may require examinations at its expense.
Ongoing verificationCareSource may request annual proof of continued disability but will not request it more than once per year after the first two years following the limiting age.
In-Network vs Out-of-Network
In‑Network vs Out‑of‑NetworkIn‑Network Providers contract with CareSource; Benefits are provided when services are obtained from In‑Network Providers. Out‑of‑Network Providers generally have no benefits except limited circumstances (emergencies, out‑of‑service‑area urgent care, approved Out‑of‑Network Authorization).
Member responsibilityMembers are responsible for verifying provider network status, obtaining required Prior Authorization, and presenting ID cards at time of service.
Balance billing and MAAOut‑of‑Network Providers may balance bill members for amounts above the Maximum Allowed Amount; limited Out‑of‑Network payments are subject to the MAA and balance billing rules.
Intensive Level Services definition
DefinitionIntensive Level Services are evidence‑based behavioral therapies for Autism Spectrum Disorder that address cognitive, social and behavioral deficits and may include speech and occupational therapy when tied to behavioral goals.
Treatment plan requirementIntensive services require a treatment plan with at least 20 hours per week over six months, implemented by qualified providers, with ongoing measurement and direct observation at least once every two months.
Age and durationTypically provided for members diagnosed after age 2 and before age 9 (exceptions allowed); coverage up to four cumulative years with possible credit for prior services.
Non-Intensive Level Services
DefinitionNon‑Intensive Level Services are evidence‑based therapies provided after intensive services to sustain gains or as an alternative when intensive services are not provided but would improve the member's condition.
Provider and plan reviewThese services must be evidence‑based, provided by qualified clinicians with a defined treatment plan and documented progress; CareSource may periodically review plans and progress.
Relation to intensive servicesNon‑intensive services may be covered for members who completed intensive services or for those who will not receive intensive services but would benefit clinically.
Experimental/Investigational/Unproven definition
What counts as Experimental/InvestigationalServices lacking credible scientific evidence, those provided in clinical research protocols, or not recognized as standard of care are considered Experimental/Investigational/Unproven and are not covered.
Determination processCareSource determines experimental/investigational status in consultation with expert panels and specialty societies; FDA approval alone does not guarantee coverage if criteria are not met.
ScopeThis exclusion applies to medical, surgical, diagnostic, psychiatric, pharmacological, device, and other treatments and related complications.
Covered mental health services definition
Scope of servicesCovered mental health services include evaluations, diagnostic testing, treatment planning, medication management, inpatient and outpatient therapies, partial hospitalization, day treatment, intensive outpatient, residential services, and crisis intervention when provided by licensed in‑network professionals.
Telehealth inclusionMental health services provided via Telehealth by in‑network licensed professionals are included as Covered Health Services.
LimitationsServices that are not evidence‑based, not clinically appropriate, or excluded under Section 9 are not covered even if related to mental health diagnosis.
Cochlear implant medical necessity
Medical necessity standardCochlear implants are medically necessary when used in accordance with FDA label indications for individuals with severe‑to‑profound hearing loss who receive limited benefit from hearing aids.
Post‑implant therapy limitPost‑implant aural therapy is limited to 30 visits per year (see cochlear implant limits).
Accessory exclusionBatteries, cords and other accessories for cochlear implants are excluded from coverage.
Habilitative Services definition
DefinitionHabilitative services are health care services that help a person keep, learn, or improve skills and functioning for daily living (e.g., therapy for developmental delays).
Provider and plan requirementsServices must be evidence‑based PT/OT/ST provided by appropriately licensed therapists under a written treatment plan established or certified by the treating Provider.
Annual visit limitsHabilitative PT/OT/ST limited to 20 visits each per year and are not to be combined with Rehabilitative Services.
Skilled care definition
DefinitionSkilled care is nursing, skilled teaching, or skilled rehabilitation (PT/OT/ST) delivered or supervised by licensed medical personnel to obtain a specified medical outcome and ensure patient safety; it is not custodial care.
Order and supervisionSkilled services must be ordered by a Provider and delivered or supervised by licensed technical or professional medical personnel.
Not custodialServices delivered primarily for assistance with ADLs (dressing, feeding, bathing, transferring) are custodial and not considered skilled care.
Hospice care definition
What hospice isHospice care is palliative care for the terminally ill focused on pain relief and symptom management, provided by a licensed hospice agency as part of an interdisciplinary plan.
EligibilityTo receive hospice benefits, the attending Provider and hospice medical director must certify that the patient is terminally ill with a life expectancy of one year or less and the Provider must consent to hospice care.
Covered servicesCovered hospice services include interdisciplinary team care, skilled nursing, short‑term inpatient care for crisis/respite, social services, therapies, dietary support, pharmaceuticals and equipment necessary for palliation.
Palliative care definition
DefinitionPalliative care is supportive care for chronic medical conditions focused on symptom management and quality of life improvement; it must be ordered by a Provider with an in‑network hospice‑certified Provider.
Care teamPalliative care is provided by an interdisciplinary team working with the member's Provider to manage symptoms, medications, and advance care planning.
Not curativePalliative care is not intended to cure life‑limiting illness but to improve comfort and quality of life.
Skilled care (duplicate entry)
Skilled care restatedSkilled care means services delivered or supervised by licensed professionals, ordered by a Provider, and not primarily for assistance with ADLs; CareSource reviews both skilled nature and need for Provider‑directed medical management.
Denial if not progressingBenefits can be denied or discontinued for members not progressing in goal‑directed rehabilitation services or when discharge goals have been met.
Examples of non‑covered custodial tasksRoutine turning, bathing, routine medication administration, and general maintenance of ostomies/catheters are examples of custodial care not covered as skilled care.
Preventive Care (no cost share) definition
DefinitionPreventive Care (no cost share) are evidence‑based items/services recommended by USPSTF (A/B), ACIP immunizations, and HRSA guidelines for children and women, provided In‑Network and meeting policy provisions.
ConditionsPreventive services must be screening tests appropriate for age, provided In‑Network in an outpatient primary care setting, and meet Medical Necessity and policy limitations.
No cost share caveatSome preventive services are Covered at 100% In‑Network (no Deductible, Copay or Coinsurance) but remain subject to policy provisions and limitations.
Telehealth Visit definition
Telehealth Visit definitionTelehealth Visit is a virtual visit (video) by an in‑network Provider; telephone‑only, text, email, asynchronous EHR messaging and remote patient monitoring are not covered as Telehealth Visits.
Coverage limitsCareSource may deny coverage for virtual visits that cannot reasonably be completed online or via technology (e.g., comprehensive physical exams).
Provider requirementTelehealth Visits must be provided by in‑network qualified Providers to be covered under the Telehealth Visit provisions.
Permanent urinary retention
DefinitionPermanent urinary retention is retention not expected to be medically or surgically corrected within three months; coverage for intermittent and indwelling catheters may apply when Medically Necessary.
Quantity limitsCareSource may establish reasonable quantity limits for supplies such as catheters per policy rules.
Setting and necessityCoverage applies when provided in an appropriate setting and when medically necessary for the Covered Person's condition.
Formulary definition
Formulary definitionFormulary is a list of cost‑effective drugs and devices indicating coverage and any limits (e.g., Prior Authorization, Quantity Limits, Step Therapy, Age Limits).
Where to find itThe Formulary is available online via CareSource's website and can be printed upon request through Member Services.
Role in coverageDrugs on the Formulary are usually covered but may have limits; non‑formulary drugs may be requested via the drug exception process.
Pharmacy Benefit Manager (PBM)
Role of PBMA Pharmacy Benefit Manager (PBM) assists with formulary tools, pharmacy billing, network maintenance, mail‑order and specialty pharmacy management, and cost‑savings programs on CareSource's behalf.
Limits to PBM authorityThe PBM helps administer benefits but does not make final benefit decisions or change plan terms except as directed by CareSource.
Member supportPBM provides tools and support for pharmacies, helps check drug interactions, and assists with mail‑order and specialty dispensing.
Medication Therapy Management (MTM)
What MTM isMedication Therapy Management (MTM) is a free program offering pharmacist consultations to review medications, provide education, identify interactions, and suggest cost‑saving options.
Services offeredPharmacists provide medication review, education on proper use, interaction checks, and recommendations to optimize therapy and reduce costs.
How to accessMembers are encouraged to meet with pharmacists as part of the MTM program; contact Member Services or the PBM for details.
Prior Authorization (drug/services) — determinations and expert panels
Prior Authorization rolePrior Authorization is required before certain prescriptions (e.g., opioid analgesics for chronic pain) or other services will be covered; determinations involve review of clinical information and Medical Necessity.
Expert panels and reviewsCareSource consults expert panels (e.g., pharmacy and therapeutics review panels) when determining experimental/investigational status or complex drug decisions.
Provider submission requirementsProviders must submit clinical information electronically or by fax to support PA requests; failure to obtain PA may result in penalties and is not a guarantee of payment.
Primary Plan definition
Primary Plan meaningPrimary Plan is the plan required to pay first when a person is covered by two or more policies or plans; it may include group, non‑group, HMO contracts, closed panel plans, Medicare, and other governmental plans as permitted by law.
Notification obligationMembers must notify CareSource if they have other coverage that constitutes a plan to enable coordination of benefits.
Primary Plan exclusionsCertain coverages (hospital indemnity, fixed indemnity, specified disease, school accident, Medicare supplement, Medicaid) are not considered Primary Plans for coordination rules.
Allowable Expense
Allowable Expense definitionAllowable Expense is a health care expense (including Deductibles, Copayments, Coinsurance) that is Covered at least in part by any Primary Plan and the CareSource Policy; expenses not covered by any plan are not Allowable Expenses.
Examples of non‑allowableExpenses a Provider is prohibited by law or contract from charging a Covered Person, or amounts in excess of highest negotiated/reimbursement amounts, are not Allowable Expenses.
Effect on coordinationAllowable Expenses are used to determine payment sharing when more than one plan applies; CareSource may reduce Benefits so total payments do not exceed Allowable Expenses.
Closed Panel Plan
Closed Panel Plan meaningA Closed Panel Plan provides benefits primarily through a panel of contracted providers and generally excludes out‑of‑network benefits except in Emergency or when referred by an In‑Network Provider and approved by CareSource.
Implication for membersMembers under a Closed Panel Plan must use the panel providers for coverage except in specified exceptions; CareSource may have similar restrictions for its EPO structure.
Coordination nuanceClosed Panel Plan rules affect coordination of benefits when multiple plans apply and determine allowable expenses when panels differ.
Custodial Parent
Who is custodial parentCustodial Parent is the parent awarded custody by a court decree or, absent decree, the parent with whom the child resides more than half the calendar year.
RelevanceCustodial Parent status is used in Coordination of Benefits rules to determine order of payment for dependent children covered by multiple plans.
DocumentationCareSource may require proof of custodial arrangements when applying dependent coordination rules.
Subrogation
Subrogation rightSubrogation is CareSource's right to be substituted to the Covered Person's legal claims and to recover the reasonable value of services provided from third parties responsible for payment.
Scope of recoveryCareSource may pursue recovery from insurers, tortfeasors, workers' compensation, and other responsible parties and may seek reimbursement from settlements or awards.
Member cooperationMembers must cooperate, provide information, and may be required to assign recovery rights to CareSource; failure to cooperate may affect benefits or recovery actions.
Policy Summary
PayerCareSource
PolicyCertificate of Coverage — CareSource
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders must submit Prior Authorization on behalf of members before listed services are provided.
SourceLink
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