CurrentCareSourcePolicy POLMP-WI(2026) v2
Individual & Family Plan Certificate of Coverage (Wisconsin)
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This document is the Certificate of Coverage for CareSource (Common Ground Healthcare) Individual & Family Marketplace plans offered in Wisconsin, describing benefits, limitations, member rights/responsibilities, prior authorization requirements, network rules, and how to obtain covered services for enrolled members.
Policy Summary
PayerCareSource
PolicyIndividual & Family Plan Certificate of Coverage (Wisconsin)
Policy CodePolicy POLMP-WI(2026) v2
Change TypeNo material changes
Effective DateJan 1, 2026
Next Review Date
Key ActionObtain required prior authorization before non-emergency services listed in Section 6 to avoid penalties and potential reduced or denied benefits.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
EPOPlan type (EPO)
PA RequiredPrior auth required
Not IncludedPediatric dental
Jan 1, 2026Effective
877-514-2442Member services
Covered Health Services and Limits
Network, Prior Authorization, and Notable Coverage Limits
Network, prior authorization, and notable coverage limits applicable to Covered Health Services under this Certificate:
ALL of the following
- Plan is an Exclusive Provider Organization (EPO); Covered Health Services must be provided by In-Network Providers except in limited circumstances (Emergency Health Services, out-of-Service-Area Urgent Care, or when an approved Out-of-Network Authorization applies).
In-Network Providers accept contracted rates; members generally are not billed beyond applicable cost sharing for In-Network services.
- Out-of-Network coverage is not available except as specified; when limited Out-of-Network benefits apply payment is limited to the Maximum Allowed Amount and the member may be responsible for amounts billed above that limit (balance billing).
See Balance Billing rules and Maximum Allowed Amount definitions.
ALL of the following
- Certain services require Prior Authorization; Prior Authorization determinations are based on Medical Necessity and other plan criteria and are listed on the Prior Authorization list available via Member Services or online.
Prior Authorization is not a guarantee of payment and is determined from submitted clinical information.
- Non-emergency Prior Authorization requests must be received at least 15 business days before the service; urgent/emergency admission notification required within 48 hours.
- If Provider fails to obtain required Prior Authorization, the member may be responsible for a penalty (50% up to $1,500 per Covered Health Service).
- Prior Authorization requirements do not apply when Medicare is the primary payer; CareSource acts as secondary payer in those cases.
ALL of the following
- Designated Facility/Designated Provider requirement: CareSource may require care at designated facilities/providers for certain complex services; In-Network benefits apply only if CareSource-arranged Designated Provider/facility is used; travel reimbursement is discretionary.
- Observation stays are covered up to 48 hours; Prior Authorization required after 48 hours.
- For Dependent students attending out-of-service-area institutions within-state, limited Out-of-Network outpatient behavioral health or addiction treatment (clinical assessment plus up to five visits) may be treated as Covered Health Services when notified in advance or as soon as possible.
- Members must present ID card when requesting services; failure may result in provider billing member directly.
ALL of the following
- Approvals or authorizations issued after services are rendered (except emergencies) may result in penalties or nonpayment; Prior Authorization approvals are subject to plan terms including Medical Necessity and eligibility at time of service.
- Eligible Expenses and reimbursements are determined in accordance with CareSource reimbursement policies and are subject to the Maximum Allowed Amount and applicable cost sharing (Deductible, Copayment, Coinsurance).
- CareSource may reduce Benefits under Coordination of Benefits so that combined payments from multiple plans do not exceed Allowable Expense; special Medicare coordination rules apply when Medicare is primary.
ALL of the following
- Members and Providers may confirm Provider network status and find the Prior Authorization list via Member Services or online (Find a Doctor / Prior Authorization web pages).
- Providers are responsible for initiating Prior Authorization and Out-of-Network Authorization requests on the member's behalf; required forms and electronic submission processes are available on the website or via Member Services.
Core coverage criteria from Certificate
Core coverage criteria from the Certificate — services are covered only when ALL of the following are met:
Service is a Covered Health Service provided while the Policy is in effect and the person receiving the service is a Covered Person under the Policy.
Service is provided by an In-Network Provider unless a limited Out-of-Network provision applies (see Network rules).
Service must be Medically Necessary / Clinically Appropriate as defined in the Certificate (consistent with accepted standards, clinically appropriate in type/frequency/extent/site/duration, the least costly effective alternative, not primarily convenience or cosmetic, and not Experimental/Investigational).
Service must not be Experimental or Investigational unless an allowance is specified (e.g., routine patient costs for qualifying clinical trials per clinical trial criteria).
Services are subject to Deductible, Copayment, Coinsurance and any Benefit limits or quantity limits stated in the Schedule of Benefits or Section 7; Benefit limits and quantity limits will result in nonpayment for amounts and services exceeding the limits.
Coverage Criteria (excerpt)
Coverage criteria (excerpt) — decisions are based on Medical Necessity and applicable plan rules; some items additionally require prior authorization:
Medically Necessary: services must meet the Certificate definition to be covered (see definition of Medically Necessary / Clinically Appropriate).
Prior Authorization: services listed on the Prior Authorization list require advanced written authorization; failure to obtain may trigger penalties described in Prior Authorization section.
Out-of-Network Authorization: care from Out-of-Network providers requires an Out-of-Network Authorization submitted by an In-Network Provider and will not be approved if In-Network providers can reasonably provide substantially similar care.
Preventive vs diagnostic distinctions: certain preventive services are Covered with no cost share when delivered In-Network per Preventive Care rules; diagnostic testing prompted by symptoms may be subject to cost-sharing and Medical Necessity review.
Prescription drugs: drugs categorized into formulary tiers and may have Prior Authorization, Step Therapy, Quantity Limit, and Age Limit restrictions; formulary/PA/ST determinations follow stated timelines (standard 72 hours, expedited 24 hours).
Premiums, grace periods, enrollment, and termination criteria
Premiums, grace periods, enrollment, and termination criteria — key rules:
Premiums are generally age-based and fixed except for permitted annual changes; premium increases >25% require 60 days prior notice.
Grace periods: members without APTC have a 31-day grace period for Premium payment; members receiving APTC have a three-month grace period beginning the first day of the coverage month for which the Premium was not received; failure to pay by end of the grace period may result in termination with retroactive effect as described.
Acceptance of Premium payments does not by itself activate or continue a Policy for periods when the policy is inactive; payments for inactive periods will be returned less any claims paid for that inactive period.
Newborn enrollment: notification of birth and required Premium must be received within 60 days to continue coverage for a newborn; rules for retroactive coverage described in the Certificate.
If a member is hospitalized on the coverage start date, CareSource will pay Covered Health Services received on or after the first day of coverage if the member notifies CareSource within 48 hours or as soon as reasonably possible.
Network and Coverage Criteria
Network and coverage criteria — rules governing where and how services are covered:
In-Network requirement: Covered Health Services must be provided by In-Network Providers to receive In-Network benefits; In-Network Providers bill CareSource directly and members are responsible only for applicable cost sharing.
Limited Out-of-Network coverage (ONE of): Out-of-Network services are not generally covered except in these limited circumstances: (1) Emergency Health Services, (2) out-of-Service-Area Urgent Care when traveling, or (3) when an approved Out-of-Network Authorization exists; Dependent students in-state may have limited outpatient behavioral health visits (up to five visits).
Out-of-Network Authorization: must be initiated by an In-Network Provider and approved before services are rendered; failure to obtain an approved Out-of-Network Authorization will result in no payment. Post-service approvals (except emergencies) may result in penalties.
Designated Facilities/Providers: for special/complex services CareSource may require use of designated network facilities/providers (possibly outside the local area); In-Network benefits apply only if services are provided or arranged by those designated providers and travel reimbursement is discretionary.
Continuity of Care: PCPs who leave network after enrollment may be continued at In-Network benefit levels through end of policy year; non-PCP providers whose participation terminates may be continued for up to 90 days or course of treatment; special pregnancy-related continuity rules apply.
Coverage criteria and program rules
Coverage criteria and program rules — general rules plus Autism Spectrum Disorder program criteria:
Operational requirements: Members must present ID card each time services are requested; Providers must follow Prior Authorization and admission notification timelines; approvals are based on clinical information submitted and do not guarantee payment.
Medical Necessity and limits: Covered Health Services must meet Medical Necessity, not be Experimental/Investigational (except as described), be received from In-Network Providers (unless limited exception), and be provided while policy is in effect with proper proof of loss submitted timely; Benefit and quantity limits apply as stated in the Schedule of Benefits.
ALL of the following
- Treatment plan requirement: evidence-based intensive behavioral therapy based on a treatment plan developed by a qualified provider including at least 20 hours per week over a continuous six-month period; member must be present and engaged.
- Provider qualifications and observation: services implemented by qualified providers/professionals/therapists/paraprofessionals; enrolled member directly observed at least once every two months; progress must be assessed and documented; CareSource may review records.
- Age and duration limits: intensive services typically commence after age 2 and before age 9 (exceptions for medical necessity) and intensive-level services covered up to four cumulative years; prior intensive service history may be credited.
Autism—Non-Intensive Level criteria: non-intensive evidence-based services are Covered when used to sustain gains after intensive services or when non-intensive services alone are expected to improve the member's condition; treatment plans, qualified providers, documentation and progress monitoring required.
Examples of other program rules: advanced imaging covered when performed in hospital or freestanding facility; ambulance services covered when essential and paid per Maximum Allowed Amount for out-of-network ambulances; inpatient rehab requires minimum participation (3 hours/day, 5 days/week) and provider visits ≥3/week.
Covered behavioral health and related services
Covered behavioral health and related services — covered items and conditions:
ASD therapy requirements: evidence-based therapy must be based on a treatment plan with specific measurable goals, the enrolled child present and engaged, implemented by qualified personnel, provided in an appropriate environment, and include training/consultation and family involvement; progress must be documented and may be reviewed by CareSource.
Mental health services covered: evaluations/assessments, diagnostic testing, treatment planning, referral services, medication management, inpatient care, partial hospitalization, day treatment, intensive outpatient treatment, residential services, individual/family/group therapy, and crisis intervention when Medically Necessary and delivered by In-Network licensed providers or via approved Telehealth.
Substance use disorder services covered: evaluations/assessments, diagnosis and treatment planning, detox, inpatient services, partial hospitalization, day treatment, intensive outpatient treatment, residential services, referral services, medication management including MAT, and crisis intervention when Medically Necessary and provided by qualified network providers.
Clinical trial routine patient care: routine patient care costs incurred during participation in qualifying in-network clinical trials are covered when trial and participant meet specified federal/sponsor criteria; exclusions apply for trial costs and investigational items themselves.
Covered behavioral health and related services
Limitations, exclusions and utilization constraints — examples and general rules:
Exclusions—key categories (ANY of): Services not supported by credible research (deemed Experimental/Investigational), school-provided services under IDEA, treatments for diagnoses unlikely to improve, therapy provided in residential/inpatient/day-treatment facilities (including room/board), travel time for providers, and many enumerated modalities (e.g., acupuncture, animal-based therapy, auditory integration training, chelation, cranial sacral, hyperbaric oxygen, special diets/supplements, childcare fees, custodial/respite care, certain pharmaceuticals and DME).
Utilization constraints: CareSource may establish reasonable quantity limits for supplies, equipment, appliances and medications; Benefit limits are stated in the Schedule of Benefits and exceeding limits will result in nonpayment.
Behavioral health-specific exclusions: treatments unrelated to a clinical mental health diagnosis (e.g., antisocial behavior, uncomplicated bereavement), services beyond evidence-based treatment periods, wilderness/camp programs, custodial/long-term care, and services for certain conditions not meeting Medical Necessity are excluded.
Limited coverage exceptions: biofeedback is covered only for specific indications (migraine, spastic torticollis, urinary incontinence) and botulinum toxin covered only for medically necessary non-cosmetic indications; other modality-specific inclusions/exclusions are enumerated in Section 7.
Limitations, exclusions and utilization constraints
Limitations, exclusions and utilization constraints (expanded):
Services, supplies or therapies that are not evidence-based, not clinically appropriate in type/frequency/extent/site/duration, experimental/investigational, primarily cosmetic, or otherwise excluded by the Certificate are not Covered Health Services.
Therapies or services provided while a member is residing in a residential treatment center, inpatient treatment or day treatment facility (including associated facility charges and room/board) are excluded for many ASD and behavioral health services unless otherwise specified.
CareSource may deny or shorten Rehabilitation benefits for members not progressing toward goal-directed rehabilitation or when treatment goals have been met; quantity and visit limits apply as stated in the Schedule of Benefits.
Clinical Trial Coverage
Clinical trial coverage — routine patient care costs are covered when ALL of the following are met:
Member participates in an in-network qualifying clinical trial and incurs routine patient care costs that would otherwise be Covered under the Plan.
Member is eligible to participate according to the trial protocol and the referring participating Provider concludes trial participation is appropriate, or medical/scientific information establishes appropriateness.
The study meets one of the listed qualifying criteria (e.g., NIH/CDC/AHRQ/CMS approval or funding; FDA investigational new drug application; or an FDA-exempt drug trial).
Exclusions—trial items (ANY of): Cost of the clinical trial itself; the investigational items/devices/services themselves; items provided at no cost by research sponsors; services obtained Out-of-Network when non-network benefits do not exist; routine patient care costs for Out-of-Network clinical trials are limited as described.
Cochlear Implant
Cochlear implant coverage and limits — covered when ALL criteria met:
Cochlear implants are Covered Health Services for individuals with severe-to-profound hearing loss who receive limited benefit from hearing aids and when used in accordance with FDA label indications.
Outpatient post-cochlear implant aural therapy is limited to 30 visits per year; batteries, cords and other accessories are excluded.
Contraceptives
Contraceptive coverage — scope and conditions:
FDA-approved drugs or devices to prevent pregnancy are Covered; coverage may be subject to the Prescription Drug formulary and associated formulary limits (PA/ST/QL/AL) as applicable.
Contraceptive medications and devices defined as preventive on the formulary will be dispensed at no cost to the member; medical services necessary to prescribe, administer, maintain, or remove a contraceptive are Covered.
For contraceptives, the Plan will defer to the attending Provider's recommendation of Medical Necessity and provide the contraceptive service or FDA-approved item without cost sharing upon request per the drug exception process guidance.
Dental and Dental - Accident Only
Dental services and accident-only provisions — coverage rules and limits:
Dental coverage (ONE of): Limited general dental services are Covered only when directly required for treatment of a medical condition (e.g., acute traumatic injury, cancer, cleft palate), for transplant preparation, or prior to immunosuppressive therapy; most general dental care is excluded except specified exceptions and accident-only provisions.
Accidental dental services are Covered when treatment is necessary due to accidental damage, provided by an appropriately licensed dental provider, initial contact occurs within 72 hours (extensions possible), treatment starts within 3 months and completes within 12 months, and the services provided are among the enumerated covered items (emergency exam, diagnostic x-rays, splinting, endodontics, extractions, maxillofacial surgery, anesthesia, crowns, replacement of lost teeth due to injury).
Diagnostic Testing
Diagnostic testing — coverage condition:
Diagnostic tests and procedures (X-ray, CT, laboratory) are Covered when performed to detect or monitor a condition for symptomatic patients and when Medically Necessary; preventive screening tests are addressed under Preventive Care.
Diabetes Supplies and Equipment
Diabetes supplies and equipment — coverage and limits:
Insulin, prescription diabetes drugs, test strips, lancets, syringes, certain non-invasive CGMs, insulin infusion devices and other DME are Covered when included on the Prescription Drug List; nutritional counseling and self-management training for diabetes are Covered; CareSource may establish reasonable quantity limits.
Durable Medical Equipment
Durable Medical Equipment (DME) — coverage rules, selection rule, and exclusions:
DME must be prescribed by an In-Network Provider and obtained from an In-Network DME provider to be Covered; includes home-use equipment and prosthetics; repairs and replacements Covered except for misuse/gross neglect/loss/theft.
If more than one piece of DME can meet functional needs, Benefits are limited to equipment meeting CareSource's minimum specifications; CareSource may decide rental vs purchase and may establish quantity limits.
DME exclusions/limits (ONE of): Enumerated items and categories are excluded or limited (post-mastectomy bras limits, cranial helmets, certain disposable supplies, patient lift systems, phototherapy beds in limited situations, tubing/masks except when used with covered DME, certain insulin infusion devices except as provided, convenience/preference items, fully implanted devices, routine maintenance, over-the-counter items not listed), and CareSource will determine coverage per its criteria.
Emergency Services
Emergency services — coverage and observation rules:
Emergency Health Services that meet the definition of Emergency are Covered whether rendered by In-Network or Out-of-Network providers; Out-of-Network emergency services are paid at the Qualifying Payment Amount and members cannot be balance-billed over QPA; member cost sharing still applies.
Observation stays are Covered for up to 48 hours without prior authorization; Prior Authorization is required after 48 hours; facility, supplies and professional services to stabilize/initiate treatment are included.
Genetic Testing
Genetic testing and counseling — coverage condition:
Genetic testing and genetic counseling are Covered when Medically Necessary for diagnostic purposes; may also be provided for other diseases or conditions as appropriate.
Habilitative Services
Habilitative services — definitions and visit limits:
Habilitative services are evidence-based physical, occupational, or speech therapies provided under a written treatment plan by appropriately licensed therapists; limited to 20 PT, 20 OT, and 20 ST visits per year and not to be combined with Rehabilitative Services.
Covered services and limits (chunks 144-163)
Covered services and limits (summary of selected services and key limits):
Genetic testing and counseling covered when Medically Necessary for diagnostic purposes (see Genetic Testing section).
Habilitative PT/OT/ST: evidence-based therapy under licensed therapist and written plan; limited to 20 PT, 20 OT, and 20 ST visits per year; not combinable with Rehabilitative Services.
Hearing services and hearing aids: diagnostic testing and hearing aids covered when criteria met; hearing aids limited to one per ear every 36 months; bone-anchored aids covered for specified anatomical/severity indications; accessories generally excluded.
Home health services: Provider-ordered, provided by In-Network licensed/Medicare-certified agency, part-time/intermittent, skilled care required, limited to 60 visits per calendar year (definitions and visit counting rules apply).
Hospice and palliative care: hospice requires Provider and hospice medical director certification of life expectancy ≤1 year; interdisciplinary services and specified supports covered; palliative care ordered by Provider and delivered by an in-network hospice-certified Provider.
Inpatient hospitalization and inpatient rehabilitation: covers room/board, ancillary services and provider services; inpatient rehab requires ability to participate min 3 hours/day, 5 days/week and provider visits ≥3/week; rehab coverage limited and custodial long-term rehab not covered.
Kidney disease treatment: inpatient/outpatient dialysis, transplantation and donor-related services covered when recipient is Covered; exclusions for experimental transplants and coordination with Medicare when applicable.
Maternity and newborn care: includes prenatal, postnatal, delivery and complications; minimum inpatient stays: 48 hours for vaginal, 96 hours for cesarean for mother and newborn; routine newborn services prior to hospital release covered.
Nutritional education: covered when required for disease/condition self-management and a knowledge deficit exists; many nutrition counseling items and infant formula/donor breast milk excluded except as specified for diabetes/preventive care.
Nutrition services
Nutrition services — coverage and exclusions:
Nutritional education services are Covered when (1) required for disease/condition where patient self-management is necessary and (2) a knowledge deficit exists requiring a trained nutritional health professional; services must be provided by licensed or registered professionals.
Nutrition exclusions (ANY of): Individual/group nutritional counseling is not Covered except when required as Preventive Care; infant formula and donor breast milk excluded; high-dose nutrition therapies, OTC formulas/supplements and weight-loss counseling are excluded except as specified elsewhere.
Oral surgery
Oral surgery — covered procedures and exclusions:
Covered: excision of tumors/cysts/abscesses of jaws/cheeks/tongue/roof/floor of mouth and repair of traumatic maxillofacial injuries or fractures when Medically Necessary.
Excluded: oral surgeries for routine tooth extraction (e.g., wisdom teeth) and excision/treatment related to tooth abscesses are not Covered.
Ostomy supplies
Ostomy supplies — covered items and exclusions/limits:
Covered: ostomy pouches, face plates, belts, irrigation sleeves/bags/catheters and skin barriers when Medically Necessary; reasonable quantity limits may apply.
Not Covered: deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive remover and other items not specifically listed as covered.
Oral enteral and parenteral nutrition
Oral enteral and parenteral nutrition — coverage criteria and management:
Enteral/parenteral nutrition is Covered when the product is a labeled medical food used as the primary source of nutrition (>50%), labeled for dietary management of a specific medical disorder to avert serious disability or promote normal development/function, and used under Provider supervision or dietician order; introduction to oral nutrition is preferred and weaning should occur as medically appropriate; quantity limits may apply.
Pharmaceuticals and podiatry
Pharmaceuticals and podiatry — outpatient-administered drugs and podiatry coverage rules:
Outpatient-administered pharmaceutical products that must be administered or directly supervised by a qualified Provider or licensed professional are Covered when Medically Necessary; some medications typically obtained at a pharmacy are excluded from this Medical Benefit and are covered under the Prescription Drug Benefit instead.
Podiatry: treatment of foot disorders including medical/surgical treatment related to disease, injury or defects is Covered; routine foot care generally not Covered except for certain chronic conditions that meet criteria.
Exclusions: routine foot care (nail trimming, corn/callus removal, hygienic care), treatment of flat feet, cosmetic procedures, and reimbursement for custom shoes/fitments are not Covered except where systemic conditions create specific medical need.
Preventive care services
Preventive care services — types and conditions for no-cost coverage:
Preventive Care types: (1) Covered with no cost share (100% In-Network when criteria met), (2) Covered with cost share, (3) Not Covered. Services paid at 100% must be screening tests appropriate for age and performed In-Network and are still subject to Medical Necessity and limitations.
Preventive coverage examples (ONE of): Examples: first screening colonoscopy at age 45 paid at 100% (subsequent colonoscopies after polyp findings may not be at 100%); abnormal Pap follow-up tests may not be Covered at 100%; some lab tests during annual visit may be subject to cost sharing.
Prosthetics
Prosthetics — coverage rules and selection limits:
External prosthetic devices that replace limbs or body parts are Covered when medically necessary; repairs/replacements Covered except for misuse/loss/theft; CareSource may set quantity limits and will pay only for the device meeting minimum functional specifications if more than one device can meet needs (member pays difference for upgrades).
Provider office services and education
Provider office services and education — coverage scope:
Provider office services for diagnosis and treatment are Covered, including medical education/self-management education when a knowledge deficit exists and is delivered by licensed/registered professionals; includes allergy injections, labs and basic radiology/X-rays (major diagnostics like CT/MRI/PET excluded).
Outpatient rehabilitation
Outpatient rehabilitation — visit limits and exclusions:
Outpatient rehabilitation visit limits: Physical therapy 20 visits/year, Occupational therapy 20 visits/year, Speech therapy 20 visits/year (excluding habilitative or autism services), Cardiac rehabilitation 36 visits/year, Pulmonary rehabilitation 36 visits/year, Cognitive rehabilitation 20 visits/year (post-TBI/stroke), Post-cochlear implant aural therapy 30 visits/year.
CareSource may deny or shorten rehab benefits for lack of progress; rehabilitation services for general physical maintenance or long-term/maintenance preventive treatment are not Covered.
Rehabilitation and speech therapy
Rehabilitation and speech therapy — coverage conditions and exclusions:
Speech therapy covered for disorders of speech, language, voice, communication and auditory processing; speech therapy related to Autism and habilitative services addressed under those sections; outpatient cognitive rehabilitation covered only when Medically Necessary following post-TBI or stroke.
Exclusions: speech therapy for non-specified indications and outpatient cognitive rehab when not post-TBI/stroke are excluded; rehabilitation for general conditioning/maintenance not Covered.
Infertility and sterilization
Infertility and sterilization — covered and excluded services:
Covered: tubal ligation, oviduct occlusion, removal of both fallopian tubes, and office vasectomy when meeting Medical Necessity and setting rules.
Infertility exclusions (ANY of): Excluded: reversal of sterilization, infertility diagnostic tests and treatments, assisted reproductive technologies (IVF, GIFT, ZIFT, ICSI), artificial insemination, sperm/embryo storage, donor gamete services, surrogate services and related medications; diagnosis and treatment of medically necessary underlying causes of infertility may be Covered but ART is excluded.
Skilled Nursing Facility
Skilled Nursing Facility (SNF) — coverage conditions and limits:
SNF benefits available up to and including 30 days per stay; room/board, ancillary services and supplies Covered when medically necessary and skilled (not custodial); benefit renews when no inpatient hospital or skilled SNF care for same/similar diagnosis for 60 consecutive days; services must be skilled and ordered by a Provider.
Exclusion: custodial or long-term care is not Covered even if delivered by licensed staff; CareSource will determine skilled nature and may deny/discontinue services not progressing toward goals.
Surgery and special coverage
Surgery and special coverage — outpatient and reconstructive surgery rules and exclusions:
Outpatient surgery at ambulatory surgical centers or provider offices covered when Medically Necessary; facility charges, supplies and provider services included per section rules.
Breast reconstruction following mastectomy and related prostheses and treatment of complications (including lymphedema) are Covered with special rules and requirements.
Surgery exclusions (ANY of): Excluded: cosmetic or primarily appearance-improving surgeries, bariatric surgery and related procedures (except where law requires coverage), animal-to-human transplants, artificial mechanical organ replacements, and procedures deemed unsafe/ineffective or unproven; services included in global surgical fee may be excluded.
Telehealth
Telehealth — coverage and exclusions:
Telehealth visits are Covered when rendered by network providers for non-emergency care and where the service itself would be Covered in-person; excluded or limited services remain excluded when delivered via Telehealth.
Telephone-only, text, email, portal messages, remote patient monitoring, asynchronous provider-to-provider communications and other non-visit electronic communications are not Covered as Telehealth Visits; CareSource may deny coverage for virtual visits that cannot reasonably be completed online (e.g., comprehensive physical exams).
Temporomandibular disorders
Temporomandibular disorders (TMD) — coverage criteria and exclusions:
TMD diagnostic and surgical/non-surgical treatment covered when condition is due to congenital/developmental/acquired deformity, disease or injury with radiographic evidence of significant joint abnormality and the procedure/device is reasonable and appropriate for diagnosis or treatment.
TMD exclusions (ANY of): Excluded or not covered: unconventional/unproven diagnostic services (EMG, jaw-tracking, thermography, kinesiography, ultrasonography for TMD), many modalities such as TENS, biofeedback for TMD, nutritional counseling, restorative dental procedures and services not expected to lead to predictable improvement.
Dialysis/Infusion/Transplant
Dialysis/Infusion/Transplant — covered services and prior authorization requirements:
Therapeutic treatments including hemodialysis, peritoneal dialysis, intravenous chemotherapy/infusions, radiation oncology, transfusions and infusions are Covered when Medically Necessary; facility charges and related supplies included.
Transplant services Covered when ordered by a Provider at Designated Facilities/Designated Providers or Centers of Excellence; donor costs directly related to organ removal are Covered only if the recipient is a Covered Person; transplant services require Prior Authorization and specific guidelines; Experimental or Investigational transplants and transplants involving non-human/artificial organs are excluded.
Education by licensed professionals for self-management is Covered when a knowledge deficit exists and education is required for treatment.
Urgent care, catheters, and pediatric vision
Urgent care, catheters, and pediatric vision — coverage highlights:
Urgent care: medically necessary urgent care services are Covered at In-Network Urgent Care Centers within the Service Area; outside the Service Area out-of-network urgent care may be payable up to the Maximum Allowed Amount.
Intermittent and indwelling urinary catheters are Covered when medically necessary for permanent urinary incontinence or permanent urinary retention (not expected to be corrected within three months); quantity limits may apply.
Pediatric vision: 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; lenses include standard options and basic frames covered once every 12 months; contact lenses covered but may affect eyeglass benefit frequency.
Vision and Prescription Drug Coverage Criteria
Vision and prescription drug coverage criteria — summary of key rules:
Prescription Drug Benefit: drugs/devices on the formulary are usually covered subject to formulary rules; non-formulary drugs may be requested through a drug exception process; PA/ST/QL/AL indicators appear on the formulary and determinations follow specified timelines (standard 72 hours, expedited 24 hours).
Formulary rules: five-tier formulary with tier-specific cost sharing; specialty drugs often limited to 30-day supply; prior authorization, step therapy and exceptions processes exist and are described online and via Member Services.
Vision: pediatric vision benefits described in Urgent Care/Pediatric Vision section; adult eyeglass/contact lens purchases and fittings are excluded and refractive surgeries are excluded except as specified.
Drug exception process: non-formulary drug exception requests may be submitted via Member Exception Request Form or by Provider; if approved, drug treated as Essential Health Benefit and counts toward OOP maximum; contraceptive exceptions defer to provider recommendation and may be provided without cost sharing upon request.
Appeals and external review: if non-formulary or other requests are denied, written notice will explain how to request next-level review and external independent review as required by law; timelines for standard and expedited determinations apply.
Prescription Drug and Related Service Exclusions
Prescription drug and related service exclusions — major categories:
Drug exclusions (ANY of): Drugs/devices not on the formulary lacking clinical appropriateness, non-FDA approved drugs/devices, drugs dispensed outside coverage eligibility, drugs for work-related conditions covered by workers' comp, drugs covered under other government plans (e.g., Medicare), OTC drugs without prescription/formulary designation, therapeutically equivalent OTCs, compounded drugs with non-FDA ingredients, drugs dispensed by non-network pharmacies or outside the US (except emergencies) are excluded from the Prescription Drug Benefit.
Clinical/service exclusions (ANY of): Durable medical equipment and outpatient supplies unless specifically covered on the formulary, drugs intended for inpatient/skilled nursing stays, appetite suppression/weight-loss drugs, cosmetic indications, fertility drugs (except for infertility treatment), natural/homeopathic remedies, and drugs typically administered by a provider in outpatient setting (medical benefit) are excluded from the Prescription Drug Benefit where specified.
Provider/facility exclusions: out-of-network providers/facilities are generally not covered except under limited circumstances; services provided by out-of-network providers without completed authorization and follow-up urgent/emergency care from out-of-network providers are excluded.
Exclusions and Coordination of Benefits
Exclusions and Coordination of Benefits — exclusions summary and COB rules:
Service and provider exclusions (ANY of): Wide range of services, providers and scenarios are excluded (out-of-network services except limited circumstances, services required to be provided under other plans such as workers' comp or military, travel-only immunizations, custodial/long-term care, private duty nursing/home health aides except as specified, bariatric surgery, many cosmetic and alternative therapies, CAR T-cell and gene therapies, and numerous other enumerated exclusions).
Administrative exclusions: claims billed after one year may be excluded; failure to provide requested records/authorizations/information within 30 days may result in denial or inability to determine benefits; if an Out-of-Network provider waives member cost-sharing, no benefits are due for that service.
Coordination of Benefits: CareSource may reduce Benefits so total payments from all plans do not exceed Allowable Expense; specific order-of-benefit rules (including birthday rule, primary plan definitions, Closed Panel exceptions) apply; when Medicare is primary, CareSource coordinates as described and treats Medicare benefits as if Parts A & B paid in full for calculation purposes.
Right of recovery: CareSource may recover excess payments made under Coordination of Benefits from persons or organizations responsible for payment.
Codes, Formularies and Billing Constraints
Covered service categories (TOC)mixed
| No codes listed |
Prescription Drug / Pharmacy tiers and specialty drugsmixed
| Tier 0 | drugs considered preventive (no copayment/coinsurance) |
| Tier 1 | low-cost prescription drugs (generics) |
| Tier 2 | preferred brand name drugs |
| Tier 3 | non-preferred brand name drugs (may be subject to step therapy) |
| Tier 4 | specialty drugs (limited to 30-day supply; specialty pharmacy required) |
Coding sources referencedmixed
| CPT, CMS references | Reimbursement policies may follow CPT and CMS coding and methodologies |
General coverage determinationmixed
| No codes listed |
Service categories referenced (examples)mixed
| No codes listed |
Selected therapy-specific coverage notesmixedCovered
| Biofeedback | covered for migraine, spastic torticollis, urinary incontinence |
| Botulinum toxin (Botox) | covered for medically necessary non-cosmetic indications such as spasticity or dystonia |
Diabetes supplies and equipment (formulary dependent)mixedCovered
| No codes listed |
Cochlear implant (FDA indications)mixedCovered
| No codes listed |
Outpatient diagnostic labsmixedCovered
| Laboratory tests | medically necessary outpatient lab tests including therapeutic drug monitoring and infertility diagnostics |
Durable medical supplies and prostheticsmixedCovered
| No codes listed |
Temporomandibular disorders proceduresmixed
| No codes listed |
vision itemsmixedCovered
| Pediatric vision exam | one annual eye exam for children through end of month they turn 19 |
| Pediatric eyeglasses | one pair of eyeglasses per calendar year for children through end of month they turn 19; lenses include standard options |
vision exclusionsmixedNot Covered
| Adult eyeglass/contact fitting | purchase cost and fitting charge for adults not covered |
| Refraction/refractive surgery | refractions or refractive eye surgery (e.g., LASIK) not covered |
formulary tiersmixed
| Tier 0 | preventive drugs (no copay) |
| Tier 1 | generic—lowest copayment/coinsurance |
| Tier 2 | preferred brand |
| Tier 3 | non-preferred brand (may require step therapy) |
| Tier 4 | specialty drugs—30 day supply limit |
Prescription Drug Exclusions (enumerated)mixedNot Covered
| Non-formulary without clinical appropriateness | drugs or devices not on the Prescription Drug Formulary that do not meet clinical appropriateness |
| Non-FDA approved | drugs or devices not approved by the U.S. Food and Drug Administration |
| Dispensed outside eligibility | drugs dispensed with a date of service outside coverage eligibility |
| Workers' compensation related | drugs for conditions covered under workers' compensation or similar laws |
| Government-covered drugs | drugs for which payment is provided by local/state/federal government (e.g., Medicare) except as required by law |
| OTC without prescription/formulary designation | over-the-counter drugs without prescription/formulary designation |
| Compounded non-FDA ingredients | compounded drugs containing ingredients not approved by FDA or not on formulary |
| Dispensed by non-network pharmacy | drugs dispensed by a non-network pharmacy |
| Dispensed outside US | drugs dispensed outside the United States except for emergency/urgent care |
High-cost cellular and gene therapiesmixedNot Covered
| CAR T-cell and gene therapy | Chimeric Antigen Receptor (CAR) T-cell therapy and/or gene therapy excluded, including related services, items, and drugs |
Out-of-Network payment limit
RuleAmount paid for limited Out-of-Network Covered Health Services is limited to the Maximum Allowed Amount; member may be balance billed for any difference.
ScopeApplies only in limited circumstances: Emergency Health Services, out-of-service-area urgent care, or services CareSource determines qualify under limited Out-of-Network provisions.
Member actionCall Member Services or use Find a Doctor on the website to verify provider network status and potential out-of-pocket exposure.
Prescription Drug List review frequency
Review cadencePrescription Drug Formulary (Prescription Drug List) is reviewed generally quarterly, but no more than six times per calendar year.
AvailabilityFormulary and search tools available online at CareSource.com/Marketplace; printed copies available by calling Member Services.
Change controlFormulary may include limits such as PA, ST, QL, AL; changes communicated via member resources and website tools.
Premium acceptance and policy activation
Acceptance vs activationCareSource's acceptance of Premium does not constitute activation or continuation of a Policy; acceptance of payment will not reactivate a policy — payments for inactive periods will be returned less any claims paid for that period.
Effective DateCoverage takes effect on the date specified on the member ID card and begins at 12:00 midnight on the Effective Date; Benefits not provided for services before Effective Date.
Policy changesCareSource may change the Certificate via Riders/Amendments; changes are effective only when signed and members will be notified; no one may change the Policy except in writing.
Maximum Allowed Amount
DefinitionMaximum Allowed Amount (MAA) is the maximum amount CareSource will pay for a Covered Health Service; for In-Network Providers it is the agreed payment; for Out-of-Network it is a comparable regional rate or the Qualifying Payment Amount for certain emergency services.
Member responsibilityFor In-Network services members are not responsible for any difference between billed amount and MAA; for limited Out-of-Network services members may be balance billed for amounts exceeding MAA and remain responsible for applicable Deductible/Copay/Coinsurance.
DeterminationEligible Expenses and reimbursements are determined solely in accordance with CareSource's reimbursement policy guidelines.
Intensive autism therapy hours threshold
Weekly thresholdIntensive-level autism services are defined as averaging 20 or more hours per week of evidence-based behavioral therapy over a continuous 6-month period.
DocumentationTreatment plans must include specific, directly observed, continually measured goals and require the enrolled member be present and engaged; progress must be assessed and documented throughout treatment.
Provider qualificationsServices must be implemented by qualified Providers, professionals, therapists, or paraprofessionals in an environment conducive to achieving treatment goals.
Maximum intensive-level autism duration
Maximum durationIntensive-level autism services are Covered for up to four cumulative years; prior intensive services from any payer may be credited against the four-year limit.
Age windowIntensive services generally commence after age 2 and before the child's ninth birthday, with exceptions allowed for Medical Necessity.
ReviewCareSource may require documentation and may periodically review treatment plans and progress records.
Durable medical equipment selection rule
Selection ruleIf more than one piece of Durable Medical Equipment can meet the member's functional needs, Benefits are available only for the equipment that meets CareSource-determined minimum specifications; member pays any cost difference for upgraded equipment.
Rent vs purchaseCareSource reserves the right to decide whether DME will be rented or purchased and may pay rental up to the purchase price.
Source requirementDME must be prescribed by an In-Network Provider and obtained from an In-Network DME provider to be Covered.
Inpatient rehabilitation participation requirement
Participation requirementInpatient rehabilitation requires the individual to be able to participate a minimum of three hours per day for at least five days per week and to see a Provider at least three times per week.
ScopeRoom/board, physician, Skilled Nursing and Skilled Rehabilitation services and prescription medications are Covered while participating in an approved inpatient rehabilitation program.
ExclusionCustodial or long-term inpatient rehabilitation is not Covered; patient must be capable of active participation with expectation of improvement.
Quantity limits
General policyCareSource may establish reasonable quantity limits (Quantity Limits) for certain supplies, equipment, appliances, and medications to ensure appropriate dosing and cost-effectiveness.
ExamplesQuantity limits may apply to diabetic supplies, enteral/parenteral nutrition, outpatient-administered pharmaceutical products, and specialty medications.
Exceptions processProviders may request a bypass of a quantity limit by submitting an exception request (electronically or by fax) with supporting clinical information.
SNF maximum days per stay
Per-stay maximumSkilled Nursing Facility (SNF) benefits are available up to and including 30 days per stay.
Renewal gapSNF benefit renews when there has been no inpatient hospital or skilled SNF care for the same or similar diagnosis for 60 consecutive days; there is no limit to number of SNF benefit periods.
Skilled requirementBenefits apply only if care is skilled (not primarily custodial) and is a cost-effective alternative to inpatient hospital confinement.
eye exam frequency (children)
FrequencyOne annual eye exam is Covered for children through the end of the month they turn 19 years old.
EyewearOne pair of eyeglasses per calendar year is Covered for children through the end of the month they turn 19; lenses include standard lens options and basic frames covered once every 12 months.
ProviderExam must be performed by an optometrist or ophthalmologist in the Provider's office to qualify under this benefit.
specialty drug supply limit
Supply limitSpecialty drugs are generally limited to a 30-day supply per fill.
Specialty fulfillmentSpecialty prescriptions must be filled through a specialty pharmacy network capable of managing storage and monitoring requirements.
Cost-sharing noteDays' supply and cost-sharing details vary by plan and are specified in the Schedule of Benefits; mail-order may offer different day-supply options for non-specialty drugs.
External review response time
External review timingExternal review determinations: standard requests notified within 72 hours; expedited (urgent) requests notified within 24 hours.
Prescription drug determinationsStandard formulary/non-formulary drug request determinations: 72 hours; expedited (urgent) determinations: 24 hours.
ProcessIf a drug exception is denied, members/providers may request an independent external review by an IRE; timelines for IRE determinations mirror standard/expedited timeframes.
Timely billing window
DeadlineClaims must be received by CareSource within one (1) year from the time proof is otherwise required in order to be eligible for reimbursement.
ExceptionSome administrative rules or state/federal requirements may alter timeframes; members should submit claims promptly and contact Member Services for guidance.
Effect of late filingBills not received within one year may be excluded from reimbursement as specified in exclusions.
Information response
Response timeframeRequested authorizations, medical records, or other requested information must be provided within 30 days; failure to provide required information within 30 days may result in denial or inability to determine Benefits.
ConsequencesCareSource may deny reimbursement or not process claims if required documentation is not timely provided.
Provider responsibilityProviders and members must supply accurate and complete information as required by contracts and requests to avoid delays or denials.
Prior Authorization, Ordering, and Provider Requirements
Prior Authorization
Prior Authorization Requirement
Prior authorization is required for specified services and procedures; certain treatments and procedures must be pre-authorized and Prior Authorization is not a guarantee of payment. Services requiring Prior Authorization are listed on the Prior Authorization list available via Member Services or online.
- Benefits may be reduced or excluded if you fail to pre-authorize required services.
- Prior Authorization determinations are based on Medical Necessity and submitted clinical information.
Prior Authorization
Prior Authorization criteria
Prior Authorization determinations are based on whether the service/item is needed to diagnose or treat an Illness or Injury, is Medically Necessary, whether the Provider is In-Network, the Plan's Maximum Out‑of‑Pocket limit, and whether benefit limits for the plan year have been met.
Prior Authorization
Prior Authorization requirement
Providers must obtain Prior Authorization for services listed in the Prior Authorization list; the list is available by calling Member Services or viewing the website. Failure to obtain Prior Authorization will result in the penalties described in Section 6.
- Prior Authorization list available at CareSource.com/mp-WI-pa or via Member Services.
- Prior Authorization is a determination of Medical Necessity but does not guarantee payment.
Documentation Required
Administration of benefits and delegation
CareSource applies Benefits and authorizations by reviewing Provider network status, authorizations, limitations and exclusions, and may delegate administrative authority (e.g., pharmacy benefits administrator). Providers and members must cooperate with delegated service providers to receive benefits.
- CareSource may delegate discretionary administrative authority to entities that provide administrative services (such as PBMs).
- To receive Benefits, Providers and members must cooperate with those delegated service providers.
Prior Authorization
Out-of-Network Authorization requirement
If Out‑of‑Network care is needed, an In‑Network Provider must complete and submit a written Out‑of‑Network Authorization and CareSource must approve it before services are rendered; failure to follow the Out‑of‑Network Authorization process means Benefits will not be payable.
- Out‑of‑Network Authorization will not be approved if In‑Network providers can reasonably provide the same or substantially similar care.
- Approved Out‑of‑Network services remain subject to all Policy provisions, including Prior Authorization.
Prior Authorization
Prior Authorization timing and penalty
Non‑emergency Prior Authorization requests must be received at least 15 business days before the anticipated service; if Prior Authorization is approved after services are rendered (except emergencies) the penalty in the Prior Authorization section will apply.
- Minimum lead time for non‑emergency Prior Authorization requests: 15 business days.
- Post‑service approval (except emergencies) may trigger the applicable Prior Authorization penalty.
Prior Authorization
Prior Authorization & Hospital Admission Notification
Providers must obtain Prior Authorization for listed Covered Health Services; for urgent or emergency hospital admissions, hospital admission notification must be obtained within 48 hours after admission or as soon as medically able. Prior Authorization is based on submitted clinical information and is not a guarantee of benefits.
- Non‑emergency Prior Authorization request timing: ≥15 business days before service.
- Hospital admission notification for urgent/emergency admissions: within 48 hours or as soon as medically able.
- Authorization decisions rely on the clinical information submitted; billed services that differ from authorized services may not be paid.
Prior Authorization
Medicare exception
When Medicare is the primary payer Prior Authorization requirements do not apply; CareSource will act as a secondary payer and Prior Authorization is not required in that scenario.
Denial Risk
Penalty for missing authorization
If a Provider fails to obtain required Prior Authorization, the member may be responsible for a penalty equal to 50% of the charge up to a maximum of $1,500 per Covered Health Service.
Documentation Required
Periodic treatment plan review and documentation
CareSource may request and periodically review the enrolled member's treatment plan and a summary of progress; progress must be assessed and documented throughout treatment.
- Treatment plans must include specific, directly observed, continually measured goals and evidence of progress.
- CareSource may request records and review progress on a periodic basis.
Prior Authorization
Observation prior auth
Observation stays are covered up to 48 hours without Prior Authorization; Prior Authorization is required for Observation stays beyond 48 hours.
Documentation Required
Provider ordering and certification requirements
Home health, hospice, and palliative care require Provider ordering and certification: home health services must be ordered by a Provider and provided by an In‑Network licensed or Medicare‑certified agency; hospice benefits require certification by the attending Provider and hospice medical director and Provider consent to hospice care.
- Home health: Provider must order service; services provided by an In‑Network state‑licensed or Medicare‑certified Home Health Agency; part‑time or intermittent schedule; skilled care required.
- Hospice: attending Provider and hospice medical director must certify life expectancy ≤1 year and be consulted in treatment plan development.
- Palliative care must be ordered by the Provider with a hospice‑certified in‑network Provider.
Documentation Required
Ordering/supervision and quantity limits
Some enteral/parenteral nutrition products and outpatient‑administered pharmaceutical products require ordering or supervision by an authorized Provider or registered dietician, and CareSource may establish reasonable quantity limits for supplies, equipment, and medications.
- Enteral/parenteral nutrition must be used under supervision or ordered by a registered dietician or authorized Provider and be the primary source of nutrition to qualify.
- Outpatient‑administered pharmaceuticals require administration or direct supervision by a qualified Provider and may have quantity limits.
Prior Authorization
Transplant prior auth
Transplant services and related supplies require Prior Authorization by CareSource and are payable only when performed at Designated Facilities/Designated Providers or Centers of Excellence as specified; Experimental or Investigational transplants and certain transplant‑related services are excluded.
- Donor costs directly related to organ removal may be payable for transplant recipients, but other donor costs (e.g., hotel/transportation) are excluded.
- Any transplant not prior authorized or deemed Experimental/Investigational is not covered.
Step Therapy
Prior auth / step therapy / exceptions process
Providers may submit Prior Authorization requests, Step Therapy bypass requests, quantity‑limit or age‑limit exception requests electronically or by fax using forms on the website; specialty drugs must be filled at network specialty pharmacies and the Formulary indicates PA, ST, QL, and AL limits.
- Formulary shows 'PA' for Prior Authorization, 'ST' for Step Therapy, 'QL' for Quantity Limits, and 'AL' for Age Limits.
- Providers can use the Formulary Search Tool on the Provider's page and submit bypass/exception requests electronically or by fax.
Prior Authorization
Timing and External Review Process
Standard determinations for formulary and non‑formulary prescription drug requests are 72 hours; expedited (urgent) determinations are 24 hours. If a drug exception is denied, written notice explains how to request an independent external review and external review timelines are 72 hours (standard) or 24 hours (expedited).
- Standard decision time: 72 hours; expedited decision time: 24 hours for both formulary and non‑formulary requests.
- External independent review determinations: written notification within 72 hours (standard) or verbal notification within 24 hours (expedited).
- Requests for external review may be submitted online, by mail, or by phone.
Prior Authorization
Out-of-Network authorization and referral
Out‑of‑Network services require completion and approval of the Out‑of‑Network Authorization process; some services also require an approved referral to be covered. Failure to complete the Out‑of‑Network Authorization means services will not be payable and follow‑up urgent/emergency care from out‑of‑network providers is not covered.
- Out‑of‑Network Authorization must be submitted by an In‑Network Provider and approved before services are rendered.
- Limited exceptions (e.g., urgent care when traveling, dependent student outpatient behavioral visits up to five visits) require prior notice or approval.
- Follow‑up care from an Out‑of‑Network Provider related to urgent/emergency care is not covered.
Prior Authorization
Second opinion authorization
A second opinion by an In‑Network Provider is covered (one per injury or illness) and Prior Authorization for the second opinion must be obtained when Prior Authorization is required; Out‑of‑Network Authorization is required for out‑of‑network second opinions.
- One second opinion per injury or illness by an In‑Network Provider is covered.
- If Section 6 requires Prior Authorization for the service, Prior Authorization must be obtained for the second opinion.
- If the second opinion is sought from an Out‑of‑Network Provider, an Out‑of‑Network Authorization is required.
Key Terms and Definitions
Certificate of Coverage
NatureCertificate of Coverage is the legal document that is part of the Policy and describes Benefits subject to the Policy's terms, conditions, exclusions, and limitations.
Contract componentsThe Policy includes the Certificate, Schedule of Benefits, Application, Amendments, Riders and Notices; together they form the contract between CareSource and the Covered Person.
Storage and reviewMembers should read and retain their Certificate of Coverage and related documents for reference on benefits and obligations.
Application statements / corrections
Correction windowSubmit corrections to your application in writing within 10 days if any information is incorrect or incomplete.
ConsequencesMisstatements or omissions in the application could cause an otherwise valid claim to be denied.
Basis of issuanceInsurance coverage was issued on the basis that answers on the application are correct and complete.
Activities of Daily Living (ADL)
DefinitionActivities of Daily Living (ADL) are basic daily self-care tasks such as bathing, eating, dressing, toileting, and transferring.
ContextADLs are used in eligibility and care determinations to distinguish skilled care from custodial care.
ExamplesExamples include bathing, eating, dressing, toileting and transferring; not an exhaustive list.
Balance Billing
DefinitionBalance Billing occurs when a Provider bills the member the difference between the Provider's billed amount and CareSource's Maximum Allowed Amount.
When it may occurMembers may be balance billed by Out-of-Network Providers for amounts over the MAA in limited circumstances (e.g., non-emergency out-of-network services, certain urgent care, ground ambulance).
ProtectionsMembers cannot be balance billed for emergency services and In-Network Providers may not balance bill for Covered Health Services.
Deductible
DefinitionDeductible is the amount of Eligible Expenses you must pay per year before CareSource begins paying for Covered Health Services; refer to your Schedule of Benefits for amounts and application rules.
CalculationAmount applied to the Deductible is based on Eligible Expenses and does not include amounts exceeding Eligible Expenses.
InteractionDeductible interacts with Copayments, Coinsurance and Out-of-Pocket Maximum as described in the Schedule of Benefits.
Maximum Allowed Amount (MAA)
DefinitionMaximum Allowed Amount (MAA) is the maximum amount CareSource will pay for a Covered Health Service; for In-Network Providers it is the agreed payment amount; for Out-of-Network Providers it is a comparable regional rate or QPA for emergency services.
In-Network effectIn-Network Providers may not balance bill beyond the MAA; members are not responsible for any difference between billed amount and MAA for In-Network services.
Out-of-Network effectFor limited Out-of-Network Covered Health Services, members may be balance billed for amounts exceeding the MAA and such excess does not count toward the Out-of-Pocket Maximum.
Medically Necessary
DefinitionMedically Necessary (Medical Necessity) describes services needed to prevent, diagnose, or treat an Illness or Injury that are consistent with accepted standards of practice, clinically appropriate in type/frequency/extent/site/duration, not primarily for convenience, least costly effective alternative, not experimental, and consistent with CareSource clinical policies.
DeterminationCareSource (or its designee) makes Medical Necessity determinations and may consult experts; such determinations are for payment purposes only and do not direct clinical care.
Coverage implicationServices must meet Medical Necessity criteria to be Covered; services deemed Experimental/Investigational are excluded unless otherwise specified.
Experimental or Investigational Services
DefinitionExperimental or Investigational Services are services lacking credible, evidence-based support, not generally accepted as standard of care, in research or clinical trials, not FDA-approved for proposed use, or otherwise unproven; CareSource determines applicability.
ExclusionsThese services are excluded from coverage unless routine patient care costs for qualifying clinical trials are otherwise Covered as described in Section 7.
ReviewCareSource will evaluate evidence and may consult external experts in making determinations.
Exclusive Provider Organization (EPO)
DefinitionExclusive Provider Organization (EPO) is a managed care plan where services are Covered only if provided by In-Network Providers except in emergencies or other limited authorized circumstances.
Network effectMembers generally must use In-Network Providers to receive benefits; limited Out-of-Network coverage applies only in specified circumstances.
ImplicationPrior authorization and designated provider/facility rules still apply within the EPO framework for certain services.
Covered Health Service(s)
DefinitionCovered Health Service(s) are services, supplies, or Pharmaceuticals that are Medically Necessary, described as covered in Section 7 and the Schedule of Benefits, and not otherwise excluded.
Coverage conditionsServices must be provided while the Policy is in effect and meet Medical Necessity and documentation/timeframe requirements to be Covered.
ExamplesIncludes diagnostic, therapeutic, inpatient/outpatient services, and prescription drugs when meeting coverage rules and limits.
Medically Necessary / Clinically Appropriate
DefinitionMedically Necessary / Clinically Appropriate means care consistent with accepted standards, appropriate in type/frequency/extent/site/duration, not primarily for convenience or cosmetic reasons, and consistent with CareSource clinical policies.
ApplicationThis standard is used to determine coverage, prior authorization, and payment decisions across the Policy.
Evidence basisDeterminations rely on credible scientific literature, specialty society guidelines, or prevailing clinical opinion when evidence is limited.
Out-of-Network Authorization
DefinitionOut-of-Network Authorization is a written request from an In-Network Provider to obtain care from an Out-of-Network Provider; it will not be approved if In-Network Providers can reasonably provide the same or substantially similar care.
ProcessAn In-Network Provider must initiate the request and obtain approval before services are rendered; failure to follow process may result in benefits not payable.
LimitationsEven with authorization, payment for Out-of-Network services is limited to the Maximum Allowed Amount and members may be balance billed for amounts above it.
Out-of-Pocket Maximum
DefinitionOut-of-Pocket Maximum is the maximum amount a member is required to pay for medical and prescription drugs in a single year; amounts for non-covered services and amounts in excess of the Maximum Allowed Amount do not count toward it.
ExclusionsFinancial assistance (copay cards), amounts exceeding the Maximum Allowed Amount, and non-covered services do not count toward the Out-of-Pocket Maximum unless required by law.
ApplicabilityCopayments, Coinsurance and Deductibles for Covered services generally apply toward OOP limits as specified in the Schedule of Benefits.
Prior Authorization
DefinitionPrior Authorization is an advanced written determination of coverage for specific services or procedures based on Medical Necessity; a list of services requiring it is available by calling Member Services or online.
ConsequenceFailure to obtain Prior Authorization when required will result in application of penalties as described in Section 6, and prior authorization is not a guarantee of payment.
TimingNon-emergency prior authorization requests must be received at least 15 business days prior to the service; urgent/emergency notifications have different timelines.
Premium Grace Period
Grace periodsPremium grace period is 31 days if the member does not receive an Advance Premium Tax Credit (APTC); members receiving APTC have a three-month grace period.
Termination consequenceFailure to pay by the end of the applicable grace period may result in termination retroactive to the last paid month as described in examples.
ProcessingPayments are not considered received until CareSource processes them; allow up to seven days when mailing payments.
Eligible Person; Dependent; Enrolled Dependent
Eligible PersonEligible Person is a person who meets enrollment requirements and resides within the Service Area; when enrolled is referred to as a Covered Person.
DependentDependent generally refers to the Subscriber's spouse and children; Enrolled Dependent is a Dependent properly enrolled under the Policy.
Enrolled DependentAn Enrolled Dependent is covered under the Subscriber's Policy subject to the same terms and limits as defined in the Certificate and Schedule of Benefits.
How to enroll
How to enrollApply via the Federal Health Insurance Marketplace (Healthcare.gov), directly with CareSource, or through an appointed Agent; Benefits do not apply for services before the Effective Date.
DocumentationComplete an application; Marketplace determines eligibility when enrolled via Marketplace; CareSource determines eligibility for direct applications.
ContactFor assistance, contact Member Services or an appointed Agent; refer to Schedule of Benefits for plan-specific details.
Loss of eligibility / age-based termination
Age-based terminationCoverage ends on the last day of the calendar month in which a person is no longer eligible as a Subscriber or Enrolled Dependent; a Dependent who reaches age 26 ends coverage on the last day of the calendar year in which they turn 26 (subject to exceptions for disability).
Loss of eligibilityCoverage ends the last day of the calendar month when a person is no longer eligible to be a Subscriber or Enrolled Dependent; certain disabled dependents may have extended protections.
NotificationMembers should refer to Section 2 definitions and notify CareSource of changes affecting eligibility.
Policy termination
Policy terminationCoverage terminates when the Policy (including the Certificate) ends; the Certificate will be overruled by any future Certificate issued to you.
Effective dateThe Policy takes effect on the date specified on the member ID card and coverage begins at 12:00 midnight on the Effective Date.
AmendmentsCareSource may modify the Certificate by Riders or Amendments, which are effective only when signed and members will be notified of changes.
Balance Billing
DefinitionBalance Billing is when an Out-of-Network Provider bills the member for the amount over the Maximum Allowed Amount; exceptions (e.g., emergency services) may prevent balance billing.
When member may be billedMembers may be balance billed for ground ambulance, urgent care, non-emergency services, and certain referrals when Out-of-Network providers do not agree on payment rates.
In-Network protectionIn-Network Providers may not balance bill members for Covered Health Services.
Intensive Level Services
DefinitionIntensive Level Services are evidence-based behavioral therapies designed to address cognitive, social and behavioral deficits associated with Autism Spectrum Disorder and include services such as intensive behavioral therapy, speech and occupational therapies when provided as part of intensive treatment.
ComponentsIntensive services require a treatment plan, qualified providers, direct observation, family/support team involvement, and measurable goals.
Coverage startBenefits for intensive-level services begin at the time the diagnosis is made and are subject to hour and duration limits specified elsewhere.
Non-Intensive Level Services
DefinitionNon-Intensive Level Services are evidence-based therapies that occur after completion of intensive services to sustain gains, or for individuals who will not receive intensive services but for whom non-intensive therapy would improve condition.
RequirementsNon-intensive services require a treatment plan with measurable goals, qualified providers, progress monitoring and documentation.
ScopeMay include direct or consultative services provided by qualified Providers, supervising Providers, paraprofessionals, or therapists.
Evidence-based therapy
DefinitionEvidence-based therapy is therapy based on a treatment plan developed by a qualified provider with specific, directly observed, continually measured goals addressing ASD characteristics; the enrolled child must be present and engaged and therapy implemented by qualified personnel in appropriate environments.
ComponentsIncludes training, consultation, team participation, family involvement, and periodic progress documentation subject to CareSource review.
Coverage linkageEvidence-based therapy is required for both intensive and non-intensive ASD services to be Covered.
qualifying clinical trial
DefinitionQualifying clinical trial means a clinical trial that meets specified criteria (e.g., approved/funded by NIH/CDC/AHRQ/CMS, FDA investigational new drug application, or FDA-exempt drug trial) and for which routine patient care costs otherwise Covered are payable when the member is eligible and participation is appropriate.
CoverageRoutine patient care costs incurred during participation in an in‑network qualifying clinical trial that would otherwise be Covered are Covered Benefits.
ExclusionsThe cost of the clinical trial itself and investigational items/devices are not Covered; items provided at no cost by sponsors are excluded from payment.
Habilitative Services (definition)
DefinitionHabilitative Services are health care services that help a person keep, learn or improve skills and functioning for daily living; must be evidence-based and provided under a written treatment plan.
ScopeIncludes evidence-based physical, occupational, or speech therapies provided by licensed therapists under the direction of a Provider.
LimitsPhysical, occupational, and speech therapy as habilitative services are limited to 20 PT, 20 OT, and 20 ST visits per year and are not combined with Rehabilitative Services.
Habilitative Services (definition duplicate)
Alternate wordingHabilitative Services are evidence-based physical, occupational, or speech therapies that help maintain, learn, or improve skills for daily living and must be provided under a written treatment plan by licensed therapists.
Provider requirementServices must be provided by appropriately licensed therapists under the direction of a Provider.
Visit limitsLimited to twenty (20) visits per therapy type per year (PT/OT/ST) as stated in the Schedule of Benefits.
Skilled care
DefinitionSkilled care includes skilled nursing, skilled teaching, and/or skilled rehabilitation services (e.g., PT, OT, ST) that require clinical training and are delivered or supervised by licensed medical personnel to obtain a specified medical outcome.
RequirementsServices must be ordered by a Provider, delivered/supervised by licensed personnel, and not primarily for Activities of Daily Living; CareSource will determine whether services meet skilled criteria.
ExclusionsServices that are custodial in nature or not progressing toward therapeutic goals may be denied or discontinued as not skilled.
Hospice / Palliative Care
DefinitionHospice care provides palliative services and medical support for terminally ill persons (life expectancy ≤1 year) and includes interdisciplinary team care, short-term inpatient, skilled nursing, social work, therapies, pharmaceuticals and equipment necessary for symptom management.
EligibilityTo receive hospice Benefits, the attending Provider and hospice medical director must certify the patient is terminally ill with life expectancy of one year or less and the hospice must be licensed.
Palliative carePalliative care is supportive care focused on symptom management for chronic conditions; to be Covered it must be ordered by a Provider with an in-network hospice-certified Provider and interdisciplinary team involvement.
Nutritional education
DefinitionNutritional education consists of services provided by licensed or registered health care professionals when nutritional education is required for disease self-management and a knowledge deficit exists.
Coverage conditionsCovered when required for disease/condition self-management and a documented knowledge deficit necessitates intervention by a trained nutritional health professional.
ExclusionsGeneral nutrition counseling, infant formula, donor breast milk, high-dose nutrition therapies, OTC formulas/supplements and weight-loss counseling are generally excluded except where specifically described as Covered.
Medical food (oral enteral nutrition)
DefinitionMedical food (oral enteral nutrition) is an oral or tube feeding product used as the primary source of nutrition, labeled for dietary management of a specific medical disorder and used under Provider supervision.
Coverage criteriaCovered when product is a labeled medical food, is the primary source of nutrition (>50%), used for dietary management to avert serious disability or promote normal development, and ordered/supervised by an authorized Provider or registered dietician.
PreferenceWhen medically appropriate, introduction to oral nutrition is preferred and enteral/parenteral feeding should be weaned as able; reasonable quantity limits may apply.
Skilled care (duplicate)
DefinitionSkilled care (duplicate) includes skilled nursing, skilled teaching and skilled rehabilitation services delivering clinically trained interventions required to obtain a specified medical outcome and ensure patient safety.
OrderingSkilled services must be ordered by a Provider and delivered or supervised by licensed technical or professional medical personnel.
Non-covered examplesCareSource may consider services custodial (not skilled) if primarily for ADLs or routine tasks; such services are not Covered even if provided by licensed staff.
Permanent urinary retention
DefinitionPermanent urinary retention is retention not expected to be medically or surgically corrected within three months.
ImplicationCoverage for intermittent and indwelling urinary catheters requires permanent urinary incontinence or permanent urinary retention as defined.
Quantity limitsCareSource may establish reasonable quantity limits for associated supplies and appliances.
Formulary
DefinitionFormulary is the Prescription Drug List that identifies covered drugs, associated limits (PA, ST, QL, AL), and tiers used to determine coverage and member cost-sharing.
AccessFormulary is available online at CareSource.com/Marketplace with a search tool; printed copies available via Member Services.
TieringFormulary uses tiers (Tier 0–4) to assign cost-sharing and may impose prior authorization, step therapy, and quantity limits; specialty drugs (Tier 4) are generally limited to 30-day supply.
Prior Authorization (PA)
DefinitionPrior Authorization (PA) is a limit shown on the formulary or required for certain services requiring additional clinical information before coverage is approved.
SubmissionPA requests for drugs/services require clinical documentation and may be submitted electronically or by fax using forms on the website; non-emergency PAs must be received at least 15 business days before service.
TimingFormulary drug PA determinations follow standard/expedited timeframes (72 hours standard; 24 hours expedited) as applicable.
Step Therapy (ST)
DefinitionStep Therapy (ST) is a formulary limit requiring that a specified alternative drug be tried first (usually a lower-cost, effective option) unless a bypass is approved.
Bypass processProviders can request a bypass of Step Therapy limits by submitting a request electronically or by fax with supporting clinical rationale.
Formulary indicationStep Therapy limits show as 'ST' on the Formulary; cost-sharing and coverage consequences depend on plan specifics in the Schedule of Benefits.
PBM
DefinitionPBM (Pharmacy Benefit Manager) is the organization CareSource partners with to administer the Prescription Drug Benefit, maintain the formulary, operate pharmacy networks, and support utilization management.
FunctionsThe PBM assists with formulary recommendations to the P&T committee, pharmacy billing, mail-order/specialty pharmacy access, and programs to manage drug safety and cost.
LimitationsPBM supports administration but does not make unilateral decisions to change Benefits except as directed by CareSource.
MTM
DefinitionMedication Therapy Management (MTM) is a free program offered to help members take medications correctly, identify drug interactions, and find cost-saving alternatives.
AccessMembers are encouraged to meet with pharmacists for consultation as part of the MTM program.
PurposeMTM supports medication safety and adherence to improve health outcomes and optimize therapy.
Opioid analgesics / controlled substances
DefinitionOpioid analgesics are controlled substances subject to state and federal limits; prior authorization is required for opioid prescriptions for chronic pain and possibly other controlled substances.
Regulatory limitsState laws may limit amount, duration and quantity of opioid prescriptions; CareSource requires PA for chronic pain opioid prescriptions.
Clinical oversightProviders must follow legal prescribing limits and submit PA requests where required to obtain coverage.
Primary Plan
DefinitionPrimary Plan is the plan that is required to pay first when a person is covered by more than one policy or plan; examples include group plans, Medicare, and other primary coverages.
CoordinationCareSource requires notification of other coverage and applies coordination of benefits rules to prevent total payments from exceeding Allowable Expense.
ExceptionsClosed Panel Plans and certain specialized plans have specific coordination rules described in the COB section.
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 your CareSource Policy; non-covered amounts are not Allowable Expenses.
ExamplesWhen a plan provides services rather than cash, reasonable cash value of each service is considered an Allowable Expense; amounts prohibited by law from being charged are not Allowable Expenses.
Impact on COBCareSource may reduce benefits so total payments from all plans do not exceed the Allowable Expense for a Claim.
Closed Panel Plan
DefinitionClosed Panel Plan provides Benefits primarily through a panel of contracted providers and excludes Benefits for services by other providers except in emergencies or approved referrals.
Coordination exceptionCoordination of Benefits does not apply between Closed Panel Plans when Benefits are not payable by one Closed Panel Plan due to service by a non-panel provider.
Member implicationMembers must use panel providers to receive Benefits under a Closed Panel Plan except in specified circumstances.
Coordination of Benefits
DefinitionCoordination of Benefits are rules that determine benefit payment order when multiple plans cover a person, ensuring total payments do not exceed Allowable Expense.
Secondary calculationIf CareSource is secondary, it calculates what it would have paid absent other coverage, applies it to any unpaid Allowable Expense, and may reduce payment so combined payments do not exceed the Allowable Expense.
Medicare impactSpecial rules apply when Medicare is primary; CareSource determines Medicare benefits as if Medicare Parts A & B paid in full in certain circumstances.
Interpretation of Benefits
AuthorityCareSource has sole and exclusive discretion to interpret Benefits, terms, conditions, limitations, and exclusions of the Policy, and to make factual determinations related to the Policy.
DelegationCareSource may delegate discretionary authority to other persons or entities for policy administration.
Operational noteCareSource may offer Benefits for services that would otherwise not be Covered in specific cases at its discretion, but such offers do not create precedent.
Right of Recovery
Right to recoverCareSource may recover any excess payments it made under Coordination of Benefits provisions from any person or organization paid, or otherwise responsible for the Benefits or services provided.
Amount recoveredThe amount of payments includes the reasonable cash value of Benefits provided in the form of services.
ProcessRecovery may be sought from persons, organizations, or other payers responsible for payment of the Claim.
Policy Summary
PayerCareSource
PolicyIndividual & Family Plan Certificate of Coverage (Wisconsin)
Policy CodePolicy POLMP-WI(2026) v2
Change TypeNo material changes
Effective DateJan 1, 2026
Next Review Date
Key ActionObtain required prior authorization before non-emergency services listed in Section 6 to avoid penalties and potential reduced or denied benefits.
SourceLink
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