CurrentCareSourcePolicy POLMP-OH(2025) Rev.1

Routine Hearing Services, Hearing Aids, and Related Services (OH)

Defines coverage, limits, and administrative requirements for routine hearing services, hearing aids, and related services for CareSource Marketplace members in Ohio; describes TruHearing administration and member obligations.

Policy Summary

PayerCareSource

PolicyRoutine Hearing Services, Hearing Aids, and Related Services (OH)

Policy CodePolicy POLMP-OH(2025) Rev.1

Change TypeMinor/No material change

Effective DateApr 3, 2025

Next Review DateN/A

Key ActionUse a TruHearing network provider for hearing services to ensure coverage and avoid member financial responsibility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1routine hearing screening per benefit year

1routine hearing exam per benefit year

1hearing aid per impaired ear

$2,500benefit limit per ear (age ≤21)

60 dayshearing aid trial period

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extended warranty included

Coverage Criteria — Hearing and Related Services

Covered hearing services

Covered when ALL of the following are met:

Network and product eligibility: Member uses a TruHearing Network Provider and is a Covered Person under the Plan; services are administered through TruHearing

Services from non-TruHearing providers are Non-Covered Services

Routine service limits: One routine hearing screening and one routine hearing exam per Benefit Year are covered1 per Benefit Year

Hearing aid eligibility and limits: Hearing aids covered up to $2,500 per hearing impaired ear for Covered Persons age 21 or younger verified as deaf or hearing impaired by a licensed audiologist, otolaryngologist, or other licensed physician; member responsible for costs beyond the limit<= $2,500 per ear for age ≤21

Required device list and included related services: Hearing aids must be listed on the approved hearing aid list; related services included at no member cost share: first year follow-up visits, 60-day trial period, 3-year extended warranty, 80 batteries per aid for non-rechargeable models, and ear molds ordered by an Ohio-licensed physician or audiologist

Approved hearing aid list available via phone

Eligibility and Enrollment

Covered when ALL of the following are met

Marketplace enrollment and residency: Member and dependents must meet Marketplace eligibility requirements (citizen or lawfully present, not incarcerated except pending disposition, resident of Ohio within Plan's service area)

CareSource or Marketplace may request verification

Enrollment and premium payment: To be enrolled and receive benefits, enrollment must follow Marketplace/Plan rules and any required premiums must be paid

Benefits available only if enrolled and premiums paid

Dependent Coverage Rules

Newborn/adopted dependent temporary coverage: Newly born or newly adopted dependent receives coverage from moment of birth or adoption for 31 days without premium; to continue coverage the member must request enrollment within 60 days and pay applicable premium31 days, 60 days

Dependent age limit: Dependent child is eligible until end of Benefit Year in which child reaches limiting age of 26; dependents over 26 may remain if disabled and primarily dependent on member26 years

Network and Financial Responsibilities

Network provider requirement: Members must choose Network Providers and Network Pharmacies; services by Non-Network Providers are not covered except as described in the EOC

Failure to use Network Providers may result in no coverage

Member cost-sharing: Members are responsible for Copayments, Coinsurance, and the Annual Deductible for many Covered Services as specified in the Schedule of Benefits

Excluded services costs: Members must pay costs for services that exceed Plan limitations or are not Covered Services per Section 7: What Is Not Covered

Effectuation of Coverage

Coverage is provided when enrollment and payment requirements are met

Effectuation of coverage: Member is enrolled by the Marketplace or CareSource AND payment sufficient to effectuate coverage has been received

Marketplace advises CareSource of effective date when enrolled through Marketplace

Eligibility Change Notifications

Members must report certain events within the specified timeframe

Required member notifications: Member must notify CareSource and the Marketplace in writing within 60 days of events such as pregnancy, birth, address/phone change, immigration status change, income or marital status change, dependent aging out, Medicare entitlement, or obtaining other coverage60 days

Failure to notify may affect premiums or coverage termination for ineligible persons

Open and Special Enrollment

When enrollment is permitted

Open Enrollment: Open enrollment is held annually during the Marketplace-designated period; members cannot change Qualified Health Plan outside open enrollment unless they qualify for a special enrollment period

CareSource and Marketplace provide open enrollment information

Special Enrollment Triggers: Special enrollment periods (generally 60 days from triggering event) include loss of minimum essential coverage, gain of dependent via marriage/birth/adoption, loss of Medicaid, change in eligibility, moving, domestic abuse, incarceration release, changes in subsidy eligibility, and other Marketplace-specified events60 days

Additional Marketplace-specific circumstances may apply

General Coverage Determination

Coverage determinations are based on definitions and policy terms:

General coverage logic: Services must be Medically Necessary, not Experimental or Investigational, and provided in an appropriate setting to be Covered Services

Medically Necessary and Experimental/Investigational defined in policy

Network vs Non-Network Coverage Rules

Covered Services from Network vs Non-Network Providers

Network provider coverage: Plan provides Benefits when Covered Services are received from Network Providers; members must choose Network Providers to receive Benefits

See EOC for Network definitions

When Non-Network services are covered: Non-Network services are Covered when: emergency health care services (including ambulance); urgent care while temporarily outside service area; continuity situations; services by non-network providers while in a Network Facility; or when needed services are not available from a Network Provider and Prior Authorization is obtained

Prior Authorization required when applicable

Prior Authorization requirement for non-network services: Except for Emergency Health Care Services, Emergency Ambulance Services, and certain services provided by Non-Network Providers while in a Network Facility, Prior Authorization is required for Non-Network Provider services; failure to obtain it results in services being Non-Covered Services

Member or provider responsible for filing claims for Non-Network services

Continuity of Care Conditions

Continuity of care coverage is provided in specific situations when appropriate:

Continuity for existing members: When a provider you see on a regular basis leaves the network, the plan may offer continuing coverage for up to 90 days from the date the provider left the network or until treatment is complete, whichever is shorter, provided prior authorization and medical necessity criteria are met90 days

Exceptions if transitioned to Network provider, benefit limits exceeded, or treatment not medically necessary

Continuity for pregnancy: If pregnant and the network provider involved in your pregnancy leaves the network (not for fraud/quality), you may continue to receive covered services through delivery and postpartum with prior authorizationthrough delivery and postpartum

Provider should contact Medical Management for Prior Authorization

Continuity for terminal illness:

Benefit Determination and Emergency/Inpatient Coverage

Benefit determinations and coverage occur according to request type and stated timelines. Services must be medically necessary, covered by the plan, and prior authorized when required.

Timing for benefit determinations: Concurrent initial inpatient review within 3 calendar days after receipt of necessary information; concurrent continued stay reviews within 1 business day; pre-service urgent decisions within 48 hours; standard pre-service within 2 business days after necessary info or within 10 calendar days from receipt, whichever is less; retrospective within 30 calendar daystimeframes

Insufficient info timelines described in policy

Urgent review definition: Urgent Review applies when delay could seriously jeopardize life, health, or safety, or per physician opinion would cause severe pain or adverse consequences; all opioid use treatment requests treated as urgentclinical urgency

Emergency services coverage:

Autism Spectrum Disorder services

Autism Spectrum Disorder — covered services and visit limits where specified

Autism-related covered services: Medically necessary, evidence-based treatments for ASD are covered including inpatient services, diagnostic evaluation, screening/testing, outpatient services, adaptive behavioral treatment/ABA, speech therapy, occupational therapy, and behavioral health services; speech and occupational therapy limited to 20 visits eachSpeech/OT: 20 visits each

ABA must be provided by or under supervision of appropriately licensed/certified/registered professionals and follow a treatment plan

Ambulance services

Ambulance services coverage

Ambulance services covered situations: Emergency ambulance to nearest network or nearest ER is covered; non-emergency ambulance (ground or air) covered for specified interfacility transports (ordered by authority, non-network to network, to higher level of care, to more cost-effective acute facility, to sub-acute, to skilled nursing, or to home)transport reasons

Ambulettes, taxis and similar vehicles are not covered; transport must be to the closest facility that can provide appropriate covered services

Autism Spectrum Disorder services (alternate)

Covered when ALL of the following are met

Autism services coverage: Medically necessary, evidence-based treatment prescribed for an individual diagnosed with Autism Spectrum Disorder including inpatient services, diagnostic evaluation, screening/testing/assessments, outpatient services, Adaptive Behavioral Treatment (including ABA), speech therapy, and occupational therapy; speech and occupational therapy have benefit limits of 20 visits each; ABA provided by appropriately licensed/certified/registered professionals and following a treatment plan

Behavioral Health Services

Covered Behavioral Health services include:

Behavioral health care settings: Inpatient psychiatric hospitalization, inpatient detoxification, emergency evaluation and stabilization, residential treatment services (24-hour support), partial hospitalization (PHP), intensive outpatient programs (IOP), and other outpatient behavioral health services including psychotherapy and medication management are covered when medically necessary

Behavioral health benefits are not subject to less favorable financial limitations than for physical sickness

Clinical Trial Routine Care

Clinical trial coverage conditions

Routine care in approved clinical trials: Routine patient health care services received as part of an approved clinical trial are covered provided the services are otherwise covered under the plan

Services that are the subject of the trial, experimental/investigational products without FDA approval, sponsor-provided services, or services reimbursable by another party are excluded

Accidental Dental Services

Accidental dental services

Accidental dental coverage: Outpatient, home visit, office, emergency and urgent care services for dental/oral surgery are covered when for initial repair of injury to jaw, natural teeth, mouth, or face caused by an accident and not excessive in scope; initial repair within 12 months of injury unless clinically appropriate; covered services include exams, X-rays, tests, restorations, prosthetics, oral surgery, reconstruction, anesthesia; coverage limited to $3,000 per member per injury; chewing/biting injuries excluded$3,000 per Member per Injury

Injury from chewing or biting not considered accidental

Diabetes Education and Supplies

Diabetes self-management

Diabetes self-management training: Covered for insulin-dependent, non-insulin-dependent, or pregnancy/other condition–induced elevated glucose when medically necessary, ordered in writing by a physician or podiatrist, and provided by certified/registered/licensed network providers; includes prescribed equipment and supplies

Diagnostic Services

Diagnostic services

Non-invasive diagnostic services: Coverage includes X-ray and radiology, laboratory and pathology, advanced imaging (MRI/MRA/PET/SPECT/CT), allergy testing, bone density, cardiographic/encephalographic/radioisotope tests, nuclear cardiology, ultrasound, EKGs, EMG (surface EMG excluded), echocardiograms, transplant evaluation tests, evoked potentials (BAER/SSEP/VEP), nerve conduction studies, muscle testing, and electrocorticograms; central supply and pharmacy dye necessary to perform diagnostics are covered

Claims from non-network labs are non-covered except specified exceptions

Emergency Services

Emergency Health Care Services

Emergency care coverage: Emergency Health Care Services to evaluate, stabilize, or treat an Emergency Medical Condition are covered whether rendered by network or non-network providers without prior authorization when based on presenting symptoms; inpatient admissions from ER require prior authorization with notification within 24 hours or as soon as reasonably possible; follow-up care after stabilization is not emergency care and requires authorization to continue with non-network providers

Habilitative and Home Health Services

Habilitative and Home Health services

Habilitative services: Outpatient habilitative services (PT/OT/ST) are covered for congenital, genetic, or early acquired disorders when provided by licensed therapists and the treatment is not experimental or solely educational; benefit limits for PT/OT/ST are 20 visits eachPhysical/OT/SLP: 20 visits per Benefit Year

Services must show maintenance or progress; custodial/respite/vocational/therapeutic recreation and residential treatment are not habilitative services

Home health care: Covered when confined to the home for medical reasons and physically unable to obtain outpatient services; includes intermittent skilled nursing, medical/social services, diagnostics, nutritional guidance, home health aide services when receiving skilled nursing or therapy, therapy (home visit limits apply), medical/surgical supplies, DME, certain prescription drugs billed by the agency, private duty nursing (up to 100 eight-hour visits per year), and home infusion therapy; home health care visits limited to 100 visits per Benefit Year (private duty nursing and home infusion excluded from this count)<= 100 visits per Benefit Year

A home health care visit equals at least four hours for counting limits

Covered Services with criteria

Covered when Medically Necessary and provided by or under the direction of authorized providers or agencies, as described below.

Home Health Care Covered Services: Intermittent skilled nursing (RN/LPN), medical/social services, diagnostic services, nutritional guidance, home health aide services when receiving skilled nursing or therapy, therapy services (subject to home visit limits), medical/surgical supplies, DME, prescription drugs if provided and billed by Home Health Care Agency, private duty nursing (max 100 eight-hour visits/year), and home infusion therapy including nursing, DME and pharmaceuticals; organizations other than Home Health Care Agencies require Plan approval and nurse supervision

Hospice Covered Services: Eligible if Terminal Illness with physician-confirmed life expectancy <=6 months; includes skilled nursing, diagnostic services, physical/speech/inhalation therapy if part of plan, medical supplies/equipment, counseling, inpatient hospice/respite, prescription drugs given by hospice, and home health aide services

Benefits continue if life extends beyond 6 months

DME and Medical Supplies: DME and supplies covered when Medically Necessary; rental or purchase authorized with limits (rental not to exceed purchase cost), repairs/replacements covered if item is covered and medically necessary with justification; certain items excluded

Covered Services and Limits

Covered services and limits as described in the document.

Prosthetics and related devices: Plan provides benefits for aids and supports for defective parts of the body including internal devices, heart valves, pacemakers, vascular replacements, fracture fixation devices, mandibular reconstruction appliances, bone screws/plates, breast prosthesis post-mastectomy, cochlear implants, ostomy supplies, restoration facial prosthesis, and wigs (one per Benefit Year following cancer treatment)

Maximums for prosthetic devices, if any, do not apply where noted; specific exclusions exist

Orthotic devices: Plan covers initial purchase, fitting, and repair of medically necessary custom-made rigid or semi-rigid orthoses including casting, molding, fittings, adjustments, and shipping when billed appropriately; replacement allowed once per Benefit Year when medically necessary; additional replacements for damage or growth under age 18

Casting covered only when billed with the orthotic appliance

Outpatient services: Plan provides benefits for outpatient facility, ancillary, and professional charges at hospitals, alternative care facilities, retail clinics, or other Plan-determined providers; diagnostic and some therapy services provided as outpatient surgery may have no copayment but coinsurance applies

Covered services with limits

Covered services and limitations as described in document segments:

Therapy Services Covered: Cardiac rehabilitation, pulmonary rehabilitation (outpatient short-term), inhalation therapy, post-cochlear implant aural therapy, cognitive rehabilitation, and other listed therapies are covered when meeting clinical criteria; home programs and maintenance not covered

Prior Authorization may be required

Hearing Services Covered: Routine hearing screening and routine hearing exam are covered in full every Benefit Year; TruHearing Choice Discount Program offers access to discounted hearing aids outside Plan Benefitsannual

TruHearing-administered program information available via contact number

Hearing Limitations: Non-routine/medical hearing exams, ear molds, hearing aid accessories, additional provider visits, additional batteries beyond provided, hearing aids not in TruHearing catalog, and costs associated with loss/damage warranties are not covered under routine hearing benefit

Covered pediatric vision services

Covered pediatric vision services (summary):

Pediatric vision covered services: Comprehensive eye exam (limited to one per Benefit Year, dilation as professionally indicated); standard contact lens fit and follow-up (one per Benefit Year); premium contact lens fit (one per Benefit Year; member pays exam cost less 10% discount); eyewear (one pair per Benefit Year; replacement permitted once per Benefit Year if medically necessary); low vision aids and supplemental testing limited to one per Benefit Year; retinal imaging limited to one per Benefit Year at no member cost share

Member must use EyeMed Network Provider for coverage

Prescription drug coverage and utilization controls

Prescription Drug Benefit coverage principles and utilization controls:

General drug coverage: Covers medically necessary drugs and devices; covers FDA-approved uses and some off-label uses if supported by standard medical literature; drugs on the formulary are subject to tiers and may have Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), and Age Limits; specialty drugs generally limited to a 30-day supply and dispensed by specialty pharmacy

Formulary tiers affect cost sharing; exceptions process available

Utilization management actions: Prior Authorization requires submission of clinical info; Step Therapy requires trial of preferred alternatives unless bypass approved; Quantity Limits and Age Limits may apply; timelines for formulary determinations: standard 72 hours, expedited 24 hours72/24 hours

Provider may request bypass or exception

General prescription drug coverage and exclusions

Coverage is conditional and subject to formulary status, clinical appropriateness, and specific exclusions; when an exception is granted it becomes an Essential Health Benefit and is subject to cost-sharing.

Formulary/Exception coverage: Drug is on the Prescription Drug Formulary OR a non-formulary drug exception is granted through the Plan's exception process

Exception-treated drugs count toward out-of-pocket maximums

Prior authorization: Certain controlled substances (including opioid analgesics for chronic pain) and other drugs require prior authorization; prior auth decisions follow standard (72h) and expedited (24h) timeframes

Prescription exclusions: Drugs not FDA-approved; dispensed outside coverage eligibility; covered by other payors (government, workers' comp); OTC without prescription unless Plan permits; therapeutically equivalent drugs as determined by Plan; certain compounded drugs; inpatient/skilled nursing administered drugs; cosmetic, fertility, weight loss and other listed exclusions are not covered by the Prescription Drug Benefit

See exclusions section for full list

Excluded Services

Services expressly excluded from coverage or subject to Experimental/Investigational determination:

Excluded services list: Multiple services and supplies are explicitly excluded (examples include routine foot care, bariatric surgery and related services, reproductive technologies and storage, elective refractive eye surgery, hearing aids and fitting unless specifically covered, visual therapy, replacement of lost/stolen eyewear, many alternative/complementary therapies, nutritional supplements, dental services except where specified, and other items listed in the EOC)

See exclusions chunks for full itemized exclusions

Experimental/Investigational criteria: A service/device/drug/procedure may be deemed Experimental or Investigational if not legally marketable without FDA approval for the proposed use; contraindicated by FDA for the use; provided as part of a clinical trial; subject to IRB review; provided pursuant to informed consent describing it as experimental; or if scientific evidence is inconclusive regarding net health benefit

CareSource has sole authority to determine Experimental or Investigational status

Experimental or Investigational Determination

A service, device, drug, or procedure may be deemed Experimental or Investigational when one or more specific conditions apply:

E/I determination criteria: A service may be Experimental or Investigational if it cannot be legally marketed in the U.S. for the proposed use without final FDA approval; is contraindicated by the FDA for the proposed use; is part of a clinical research protocol or Clinical Trial; is subject to IRB review; or is provided pursuant to informed consent documents describing it as experimental; additional factors include inconclusive scientific evidence or lack of demonstrated net health benefit

CareSource will consider scientific literature, national evaluations, FDA filings, IRB documents, protocols, medical records, and expert opinions when determining E/I status

Appeals and External Review Criteria

Appeals and external reviews are available under specified timelines and criteria.

Internal Appeal filing: Member or authorized representative must submit Internal Appeal within 180 days of receiving the Adverse Benefit Determination; requests must be in writing except Urgent Care appeals which may be verbal or electronic; include member name/ID, date of service, reason for disagreement, supporting documentation, and signed authorization if filed by representative180 days

Submit to CareSource Ohio Member Appeals as instructed

Internal Appeal timeframes: For Pre-Service Review or Step Therapy exemption denials the Plan must notify within 10 calendar days; for all other denials within 30 calendar days10/30 days

Expedited internal appeals handled faster

Expedited Internal Appeal: Expedited review available when delay could seriously jeopardize life/health/regain function or per treating physician; decision as soon as possible but no later than 48 hours for Pre-Service/Step Therapy exemptions and 72 hours for other expedited cases; communication by telephone and follow-up in writing

Hearing aids that do not meet professional standards established by the state speech and hearing professionals board are not covered as Medically Necessary. The program specifically excludes: hearing aids not listed on the applicable TruHearing catalog, non‑routine or medical hearing exams (which may be covered elsewhere), hearing aid accessories except those explicitly listed as related services, additional provider visits, additional batteries beyond the quantity provided for non‑rechargeable models, replacement batteries for rechargeable models, and costs associated with loss and damage warranty claims.

Health Care Services provided by a Non‑Network Provider are not covered except in the limited situations described in the Evidence of Coverage. Non‑network services generally require Prior Authorization; failure to obtain required Prior Authorization will result in the service being treated as a Non‑Covered Service, with the member responsible for filing claims and for any amounts not payable by the Plan (including services the Plan deems not medically necessary and the difference between billed charges and the Allowed Amount).

Certain exceptions apply: Emergency Health Care Services and Emergency Ambulance Services are covered without prior authorization, and non‑network services delivered while a member is in a Network Facility are handled differently but still may require authorization and member consent for balance billing when applicable.

Members are responsible for payment of services and charges that are not Covered Services or that exceed Plan limits. Charges that are not Covered Services (including amounts that exceed Eligible Expenses), copayments/coinsurance for optional riders unless explicitly stated, and any amounts resulting from failure to obtain required authorization will not count toward the Annual Out‑of‑Pocket Maximum and remain the member's financial responsibility.

Providers and members should review Section 7: What Is Not Covered for the full list of exclusions and for guidance on which charges the member will be required to pay out‑of‑pocket.

Exclusions are services that do not meet the Plan's definition of Covered Services. Services that are Experimental or Investigational are generally excluded unless very narrow, life‑threatening exceptions are met and the Plan determines the service meets criteria for an unproven but promising treatment under a research protocol. Similarly, services that do not meet the Plan's definition of Medically Necessary are not covered and may be denied.

The policy explicitly lists a wide range of non‑covered items (see exclusions section), and reiterates that hearing aids not considered medically necessary by the applicable state board are excluded from coverage.

Services provided by Non‑Network Providers or Facilities are not covered unless Prior Authorization is obtained, except for Emergency Health Care Services and Emergency Ambulance Services. If Prior Authorization is required and not obtained, the services will be considered Non‑Covered Services, and the member and/or provider will be responsible for payment as described in the EOC.

Coding, Limits, and Quantitative Caps

Ambulance transport limitationsmixed

No codes listed

Therapy visit limits (Speech/Occupational/Physical)mixed

No codes listed

Dental accidental services monetary limitmixed

No codes listed

Diagnostic services list (imaging, labs, EMG, evoked potentials, etc.)mixed

No codes listed

Special Enrollment Period Length

Special enrollment period length60 days from the triggering event (unless otherwise stated)

Applicable eventsLoss of minimum essential coverage; marriage, birth, adoption or placement; loss of Medicaid; changes due to error/misrepresentation; moving out of service area; incarceration release; changes in subsidy eligibility

Who it applies toIndividuals enrolled through the Marketplace and individuals who enroll directly with the Plan as required by law

Home Health Care visit maximum

Home health care visit maximum per Benefit Year100 visits per Benefit Year

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Many services listed on our Prior Authorization list require approval before the service is performed, received, or dispensed. It is the responsibility of Network Providers to obtain Prior Authorization prior to rendering services that require it. If a Network Provider fails to obtain required Prior Authorization and still renders the service, the Network Provider will be financially responsible for the cost of those services and neither CareSource nor the Member will be required to pay. Non-Network Providers (or Members receiving care from Non-Network Providers) are also responsible for obtaining Prior Authorization for services on the Prior Authorization list. Prior Authorization is not required for Emergency Health Care Services or Emergency Ambulance Services.

Prior Authorization list available at CareSource Member Services 1-833-230-2099 or CareSource.com/mp-OH-pa
Network Provider financial responsibility if authorization not obtained
Non-Network Provider or Member responsible for prior auth when applicable

Prior Authorization

Prior Authorization for Non-Network Hospital Referral

Prior Authorization for Non-Network Hospital Referral: Except for Emergency Health Care Services and other statutory exceptions, when necessary Hospital services are not available from any Network Hospital, a PCP may refer a Member to a Non-Network Hospital only after obtaining Prior Authorization from CareSource. Failure to obtain Prior Authorization for Non-Network services (except emergency and other protected circumstances) will cause the services to be considered Non-Covered and the Member and/or Provider may be responsible for payment.

Background and Scope

This section governs routine hearing screenings, routine hearing exams, hearing aids and related services for eligible Marketplace members in Ohio. Routine hearing services (one screening and one comprehensive exam per Benefit Year) and hearing aid benefits are administered through TruHearing. Hearing aids must be on the approved TruHearing list and eligibility requires verification of hearing impairment by a licensed clinician; related services include a 60‑day trial period, a 3‑year extended warranty, first‑year follow‑up visits, and a defined supply of batteries for non‑rechargeable models.

Definitions and Key Terms

Routine hearing screening

Routine hearing screening frequencyOne screening per Benefit Year (simple pass/fail tones/beeps)

Administering networkServices administered by TruHearing; members must use a TruHearing Network Provider to receive benefits under this section

PurposeTo determine if the member has normal hearing; usually consists of a series of beeps or tones at the limit of normal range

Routine hearing exam

Routine hearing exam frequencyOne comprehensive hearing exam per Benefit Year by a licensed audiologist or hearing instrument specialist

Exam componentsFull case history, several types of hearing tests, counseling on results, and treatment recommendations

Policy Revision History

(Internal Appeal) filing deadlinepolicy_timeline

Internal Appeals must be submitted within 180 days of the Adverse Benefit Determination; Pre‑Service/Step Therapy internal appeal decisions are issued within 10 calendar days and other internal appeal decisions within 30 calendar days.

(Internal Appeal) expedited decision timeframepolicy_timeline

Expedited Internal Appeals for Pre‑Service/Step Therapy denials are decided as soon as possible but no later than 48 hours; other expedited internal appeals are decided no later than 72 hours.

(External Review) filing deadlinepolicy_timeline

Policy Summary

PayerCareSource

PolicyRoutine Hearing Services, Hearing Aids, and Related Services (OH)

Policy CodePolicy POLMP-OH(2025) Rev.1

Change TypeMinor/No material change

Effective DateApr 3, 2025

Next Review DateN/A

Key ActionUse a TruHearing network provider for hearing services to ensure coverage and avoid member financial responsibility.

SourceLink

On This Page

If you have a terminal illness and your provider is no longer participating, you may continue to receive coverage for Covered Services with Prior Authorization until you no longer need services

until no longer need services

Provider must obtain Prior Authorization

Continuity for new covered persons: New members may receive coverage for services from their existing non-network physician or nurse practitioner for up to 30 days after coverage effective date if clinician is not participating in another Marketplace QHP for which member is eligible or is providing an active course of treatment; extensions exist for pregnancy (through postpartum) and terminal illness (until death)30 days

Prior Authorization required to continue care

Emergency Health Care Services are covered without prior authorization; members should notify PCP and CareSource within specified timeframes depending on admission status (24 hours if admitted, 48 hours if treated and not admitted)

notification within 24 or 48 hours

Follow-up care beyond stabilization requires authorization for non-network providers

Non-network emergency care: Emergency care by non-network providers treated as covered services with same cost-sharing as network; follow-up care beyond stabilization requires prior authorization and medical necessityprior authorization for continuation

Non-network providers should not balance-bill member for emergency care

Inpatient admission and transfers: Except emergencies, call PCP before hospital; PCP will refer to Network hospital; if network unavailable PCP may refer to non-network hospital after obtaining Prior Authorization; transfers to network facility when medically appropriateprior authorization for non-network referral

Network provider responsibility and No Surprises Act protections apply

Replacement due to misuse, theft, or warranty expiration are not covered

Prosthetics Covered: Prosthetic devices that replace missing body parts or function, including internal devices, heart valves, pacemakers, LVAD as bridge to transplant, breast prostheses post-mastectomy, intraocular lenses for cataract/aphakia, cochlear implants, ostomy supplies, restoration prosthesis, and wigs (one per Benefit Year after cancer treatment)

Prosthetics should be purchased not rented and must be Medically Necessary

Preventive services: Plan covers preventive services as required by federal and state law at no cost when provided by a Network Provider, including USPSTF A/B services, ACIP immunizations, HRSA-recommended pediatric/adult services, and specified women's preventive services; includes routine hearing screenings where required

Notice required for material modification to covered preventive services

Reconstructive services: Plan covers certain reconstructive services to correct deformity from disease, trauma, congenital anomalies or prior therapy, including newborn congenital defect care, breast reconstruction post-mastectomy, pediatric hemangioma/port-wine stain treatment of head/neck, limb deformities, otoplasty when improving hearing, tongue release for tongue-tie, cranial congenital disorders, cleft lip and palate

Rehabilitative outpatient therapy: Therapy covered when a Network Provider expects practical improvement in function within a reasonable period. Benefit limits per Benefit Year include Physical Therapy 20 visits, Occupational Therapy 20 visits, Speech Therapy 20 visits, Manipulation Therapy 12 sessions, Physical Medicine & Rehabilitation 60 visits, Cardiac Rehabilitation 36 visits, Pulmonary Rehabilitation 20 visits, Post Cochlear Implant Aural Therapy 30 visits, Cognitive Rehabilitation 20 visits. Prior Authorization may be required

Home health limits apply when rendered in the home

Exclusions for therapies: Plan does not cover maintenance therapy, repetitive endurance exercises, passive ROM for maintenance, general exercise programs, certain modalities and long-term inpatient rehabilitation admissions primarily for therapy

Occupational therapy exclusions include arts/crafts, non-therapeutic supplies, home adaptations and other specified items

Surgical Services: Surgical procedures are covered when Medically Necessary in appropriate settings; includes facility, professional services, supplies, anesthesia, pre/post-operative care and related services

Reversal of sterilization is not covered

Transplant Coverage: Human organ and stem cell/bone marrow transplants and related medically necessary services are covered when ordered by a Provider and prior authorized; donor procurement costs covered and travel/lodging benefits available when prior authorized if travel >75 milesdistance >75 miles for travel benefit

Provider must obtain prior authorization before transplant evaluation/work-up; travel/lodging reimbursement limits apply

Pediatric Vision: Pediatric vision includes comprehensive eye exam with dilation (one per Benefit Year), standard contact lens fit and follow-up (one per Benefit Year), eyewear and low vision aids per Benefit Year, and retinal imaging (one per Benefit Year, no member cost share); EyeMed network required for vision benefitsannual

Prudent layperson standard applied for expedited eligibility

External Review eligibility and filing: Generally must exhaust Internal Appeal to request External Review; request must be submitted within 180 calendar days of Final Adverse Benefit Determination; expedited External Review may be requested verbally for qualified cases180 days

Authorization for release of medical records required; some exceptions to exhaustion noted in policy

Who conducts External Review: Ohio Department of Insurance reviews contractual/non-medical-judgment issues and certain emergency cases; Independent Review Organizations (IROs) review medical judgment and Experimental/Investigational determinations; IRO decisions are binding when applicable

Expedited External Review available in specified clinical circumstances

Each visit by an authorized representative of a Home Health Care Agency counts as one visit (a visit equals at least four hours of home health aide services)

Exclusions to visit countPrivate duty nursing and home infusion therapy are excluded from the 100-visit limit

Dental accidental services cap

Accidental dental services cap$3,000 per Member per Injury

Covered scopeInitial repair of injury to jaw, natural teeth, mouth, or face caused by an accident including exams, X-rays, restorations, prosthetics, oral surgery, reconstruction, anesthesia

ExclusionInjuries resulting from chewing or biting are not considered accidental injuries and are not covered

Home Health Care visit count

Home Health Care visit count (limitation)Up to 100 Home Health Care visits per Benefit Year

What counts as a visitOne visit = at least four hours of home health aide services by an authorized representative of a Home Health Care Agency

Does not includePrivate duty nursing or home infusion therapy do not count toward the 100-visit maximum

Skilled Nursing Facility stay days

Skilled Nursing Facility stay days per Benefit YearUp to 90 days per Benefit Year

Facility definitionSkilled Nursing Facility means a hospital or nursing facility licensed and operated as required by law

Related limitsDay limits apply per Benefit Year as stated in Schedule of Benefits; exceeding limits may trigger noncoverage

Inpatient Rehabilitation Facility stay days

Inpatient Rehabilitation Facility stay days per Benefit YearUp to 60 days per Benefit Year

Applies toInpatient Rehabilitation Facility stays as defined in the Plan

Consequence of exceedanceExceeding the stated day limits may result in benefit denial or noncoverage

Transplant travel distance

Transplant travel distance thresholdBenefits for travel and lodging available if travel is more than 75 miles from member residence to transplant facility (with prior authorization)

Documentation requiredItemized receipts for transportation and lodging must be submitted in a form satisfactory to the Plan when claims are filed

Reimbursement limitsMaximum reimbursement up to $10,000 for travel/lodging; up to $30,000 for unrelated donor search expenses when authorized

Benefits are limited to Covered Services. Not all health care services are covered by the Plan; coverage applies only where the service meets applicable policy definitions and criteria for a Covered Service.

PCP must obtain prior authorization before referring to Non-Network Hospital
No prior auth required for Emergency Health Care Services
Non-covered designation and Member payment responsibility if prior auth not obtained

Prior Authorization

Prior Authorization for Extended Postpartum Stay

Prior Authorization for Extended Postpartum Stay: Coverage for postpartum inpatient stays is at least 48 hours (vaginal) and 96 hours (cesarean). Stays that exceed these minimums may require Prior Authorization. Shorter stays than the minimum may be allowed with Member consent and clinician determination but any extended stay beyond the minimums should be coordinated with CareSource and prior authorization obtained when required.

Minimum inpatient postpartum coverage: 48 hours (vaginal), 96 hours (cesarean)
Prior Authorization may be required for stays exceeding minimums
Shorter-than-minimum stays require Member consent and attending clinician concurrence

Prior Authorization

Prior Authorization for Therapy Services

Prior Authorization for Therapy Services: Certain outpatient therapy services may require Prior Authorization. Check with the Provider to ensure any necessary authorization is obtained before services are rendered. Benefit limits apply to therapy types (e.g., Physical Therapy 20 visits, Occupational Therapy 20 visits, Speech Therapy 20 visits, Manipulation Therapy 12 visits, Rehabilitation Day/PM&R 60 visits, Cardiac Rehab 36 visits, Pulmonary Rehab 20 visits, Post-Cochlear Implant Aural Therapy 30 visits). When therapy is provided in the home, home health benefit limits apply.

Prior Authorization may be required for specific therapy services
List of benefit limits by therapy type (see therapy limits)
Home health limits apply for therapies rendered in the home

Prior Authorization

Prior Authorization and Formulary Limits

Prior Authorization and Formulary Limits: Prescription drugs may have Prior Authorization (PA), Step Therapy (ST), Quantity Limits (QL), and Age Limits (AL). If a drug requires PA, the Provider must submit clinical information (medical history, prior therapies, tests) for coverage consideration. Step Therapy requires trying a clinically appropriate lower‑step drug first unless an approved exemption is granted. Quantity and Age limits restrict dispensing; Providers may request exceptions. If formulary limits are not met or exceptions are not approved, coverage may be denied.

PA, ST, QL, AL noted on Formulary
Providers may submit requests to bypass limits electronically or by fax
Denied bypass requests may be appealed via Adverse Benefit Determination process

Denial Risk

Eligibility Determination May Trigger Denial / Triggers for Denial

Eligibility Determination and Coverage Denials: Eligibility determinations made by the Marketplace or CareSource may affect coverage. If eligibility is not established or a Member fails to meet Plan eligibility requirements, claims may be denied. Coverage denials may also be triggered by services that are not Medically Necessary, are Experimental/Investigational, not listed on an approved network-specific list (for example TruHearing or EyeMed catalogs), provided at a non‑approved dispensing location, or exceed Plan benefit limits. Providers should verify eligibility and obtain authorizations to reduce denial risk.

Eligibility is determined by the Marketplace (for Marketplace enrollees)
Services not Medically Necessary, Experimental/Investigational, or outside approved catalogs may be denied
Dispensing by Non-Network pharmacy may result in noncoverage

Denial Risk

Triggers for Adverse Benefit Determination and Appeal Rights

Coverage Denial Triggers and Adverse Benefit Determinations: Adverse Benefit Determinations may be issued when criteria are not met (medical necessity, experimental/investigational status, formulary/exemption limits not satisfied, or benefit limits exceeded). When a denial or adverse determination occurs, Members and Authorized Representatives have appeal rights (Internal Appeal, expedited review when criteria met, and External Review including IRO review). Providers may be contacted for clinical information during review.

Denial triggers include medical necessity, experimental/investigational, formulary noncoverage, dispensing from Non-Network pharmacy, benefit limit exceedance
Appeal and external review timeframes and processes apply

Denial Risk

Failure to Obtain Prior Authorization

Failure to Obtain Prior Authorization: Except for Emergency Health Care Services, Urgent Care, and certain protected circumstances (e.g., Non-Network ancillary services in a Network facility under federal/state statutes), failure to obtain Prior Authorization for services that require it will result in the services being considered Non-Covered. Members and Non-Network Providers may be held responsible for payment and must file claims if applicable.

Emergency services and certain statutorily protected services do not require prior auth
Non-Covered designation for services without prior auth (non-emergent)

Billing Rule

Provider Financial Responsibility for Lack of Prior Authorization

Provider Financial Responsibility for Lack of Prior Authorization / Network Provider Failures: If a Network Provider fails to obtain required Prior Authorization and renders the care, the Network Provider will be responsible for payment of those services. Members and the Plan will not be required to pay for such services. Non-Network Providers or Members who did not obtain required prior authorization are responsible for payment to the Non-Network Provider.

Network Provider pays if they failed to get prior auth and still rendered service
Non-Network Provider or Member financially responsible when prior auth not obtained

Note

Continuation of Care from a Non-Network Provider / When Network Unavailable

Continuation of Care from a Non-Network Provider: In certain continuity-of-care situations (for example, pregnant Members or when no Network Provider can provide needed services), the Plan may cover services from a Non-Network Provider if Prior Authorization is obtained. For services delivered in a Network facility by Non-Network clinicians (anesthesia, pathology, radiology, emergency medicine, etc.), federal and state patient protection rules apply including balance-billing protections and notice/consent requirements prior to scheduling non‑emergent ancillary out-of-network care.

Continuity-of-care referrals to Non-Network Providers require prior authorization
Ancillary Non-Network providers in Network facilities must provide notice and obtain consent when required by law

Denial Risk

Non-Network Laboratory / Dispensing Location Denial Risk

Non-Network Laboratory and Dispensing Location Risk: Services or drugs dispensed by a Non-Network pharmacy or services provided by Non-Network laboratories or suppliers may be noncovered unless prior authorization is obtained or the service meets an exception. Dispensing location (Non-Network pharmacy) is a listed trigger for noncoverage of prescription drugs.

Drugs dispensed by Non-Network pharmacies are excluded from the Prescription Drug Benefit
Obtain prior authorization or use Network dispensing locations to avoid denial

Prior Authorization

Prior Authorization and Notification for Inpatient Admissions from ER

Prior Authorization and Notification for Inpatient Admissions from the Emergency Room: When admitted as an Inpatient directly from an Emergency Room, the entire visit is treated as an Inpatient and Prior Authorization is required for the inpatient stay. Members or Providers must notify CareSource or ensure the admitting Physician notifies CareSource of the admission within 24 hours or as soon as reasonably possible.

ER-to-inpatient admissions: inpatient prior authorization required
Notification to CareSource within 24 hours or as soon as reasonably possible

Denial Risk

Benefit Limit Exceedance

Benefit Limit Exceedance: Services that exceed Plan benefit limits (for example therapy visit limits, DME replacement frequency, hearing aid monetary limits, transplant travel/lodging caps) may be denied or require prior authorization and documentation of medical necessity. Providers should verify remaining benefits and obtain needed authorizations prior to providing services that could exceed limits.

Therapy visit limits listed in outpatient therapy section
DME rental vs. purchase rules and replacement justification required
Hearing aid dollar limits and approved device list apply
Transplant travel and lodging reimbursement limits and receipt requirements

Note

Network Requirement for TruHearing and Vendor-Administered Benefits

Network Requirement for TruHearing and Other Network-Administered Benefits: Certain benefits (for example routine hearing services administered by TruHearing and vision services administered by EyeMed) require use of the program’s Network Providers. Services obtained outside the applicable vendor network will be considered Non-Covered and the Member will be responsible for all costs unless otherwise authorized.

TruHearing and EyeMed administered benefits require use of their Network Providers
Approved device lists (e.g., approved hearing aid list) determine coverage; call vendor for list and network assistance

Prior Authorization

Prior Authorization Required for Transplant

Prior Authorization Required for Transplant and Transplant-Related Services: Prior Authorization from the Utilization Management Department is required before any transplant evaluation, work‑up, or transplant procedure. Authorization is also required prior to reimbursement of transplant-related travel and lodging when applicable. Authorization for preliminary items (HLA testing, donor search, stem cell harvest/storage) does not constitute approval for a subsequent transplant; a separate determination will be made for the transplant procedure.

Provider must call Utilization Management before evaluation/work-up for transplant
Separate prior authorization required for transplant even if preliminary testing/harvest authorized
Itemized receipts required for transplant travel/lodging reimbursement

Documentation Required

Access to Relevant Documents

Access to Relevant Documents and Member Rights: Members are entitled to request, and receive free of charge, documents relevant to Prior Authorization and benefit determinations. Providers and Members may request clinical coverage guidelines, prior authorization criteria, and any information relied upon in a decision by contacting Member Services.

Members may request relevant documents free of charge
Clinical coverage guidelines used in benefit determinations are available upon request

Billing Rule

DME Repair / Replacement and Rental vs Purchase Policy

DME Repair/Replacement and Rental vs Purchase: Repairs, adjustments, and replacements of purchased Durable Medical Equipment (DME) may be covered if the item is a Covered Service, continued use is Medically Necessary, and reasonable justification is provided (warranty expiration is not sufficient). DME is rented unless purchase is more economical; the Plan will not pay rental costs exceeding purchase price. Replacement due to misuse, loss, or theft is not covered.

Justification required for replacement (damage, functional change, growth)
Plan will not pay rental longer than purchase cost; purchase required when more economical
Replacements for loss/theft or misuse are excluded

Denial Risk

Medical Necessity Standard

Medical Necessity Standard and Coverage Exclusions: Covered Services must be Medically Necessary and not Experimental or Investigational. The fact a Provider prescribes or recommends a service does not make it Medically Necessary or a Covered Service. Some vendor‑administered items (e.g., hearing aids) must meet state professional standards for medical necessity and appear on the approved device list to be covered.

Medically Necessary and not Experimental/Investigational to be covered
Vendor‑administered device lists and state standards govern coverage (e.g., hearing aids)

Documentation Required

Pharmacy Management and Grace Period Impacts

Pharmacy Management and Grace Period Impacts: The Prescription Drug Formulary includes Prior Authorization, Step Therapy, Quantity Limits, and Age Limits. During a premium Grace Period, prescription claims may be rejected (timing depends on APTC status). Providers should be notified that Claims may be denied during Grace Periods and coordinate with Members to reprocess claims if premiums are reinstated.

Formulary controls (PA, ST, QL, AL) govern coverage and bypass requests
During Grace Periods, prescription drug claims may be held or rejected depending on APTC status; providers will be notified of potential denials

Step Therapy

Step Therapy Requirement and Appeal Timeframe

Step Therapy Requirements and Appeal Timeframe: Some drugs are subject to Step Therapy (ST) which requires trying an initial preferred drug before a non‑preferred alternative is covered. Providers may request exemptions/bypasses electronically or by fax. If a Step Therapy exemption or other pre‑service denial is appealed via Internal Appeal, CareSource will notify the Member of the determination within ten (10) calendar days for Pre‑Service or Step Therapy exemption denials; expedited appeals are available when criteria are met.

Step Therapy must be followed unless an approved exemption is granted
Providers can request Step Therapy bypass; denials may be appealed
Internal Appeal timeframe for Pre‑Service/Step Therapy exemption: 10 calendar days; expedited internal appeals processed within 48 hours (pre‑service/step)

Related hearing aid policyHearing aids limited to one per impaired ear and subject to approved hearing aid list and age-based limits

Defined Terms reference

Defined Terms locationDefined capitalized terms are explained in Section 2: Definitions of the EOC

PurposeDefined terms clarify legal/coverage meanings (e.g., 'Covered Person', 'Responsible Party') used throughout the document

Reference guidanceRefer to Section 2 often for interpretation of capitalized terms in this EOC

Active Course of Treatment

Active Course of Treatment definitionIncludes conditions with high likelihood of death without intervention, ongoing complex care (e.g., chemotherapy, radiation, post-operative visits), pregnancy through postpartum, or ongoing treatment a provider attests would worsen if discontinued

ImplicationMay support continuity of care protections or temporary coverage for existing non-network providers for new members

Use in policyApplied when determining continuity of care, provider transitions, and special enrollment/coverage exceptions

Adverse Benefit Determination

Adverse Benefit Determination definitionA decision by CareSource to reduce, terminate, or deny a requested Health Care Service or Benefit in whole or in part, including denials for medical necessity, exclusions, eligibility, rescissions, or benefit limitations

Examples includedDeterminations that a service is not Medically Necessary, is Experimental/Investigational, not a Covered Service, or rescission of coverage

Appeal relevanceFinal Adverse Benefit Determinations may be appealed via Internal Appeal and External Review processes

Covered Services / Eligible Expenses

Covered Services / Eligible ExpensesServices are Covered Services if included in a specific benefit, not excluded, and determined Medically Necessary per policy and national guidelines; Eligible Expenses are our contracted fees or Maximum Allowable Amounts for approved non-network emergency/approved care

Cost-sharing implicationPayments toward Annual Deductible, Copayments, and Coinsurance apply to Out-of-Pocket Maximum unless otherwise noted; non-covered charges do not count

Coverage conditionCoverage is subject to Plan terms, limitations, exclusions, and prior authorization requirements where applicable

Durable Medical Equipment

Durable Medical Equipment (DME) definitionEquipment that can withstand repeated use, is non-disposable, used to serve a medical purpose in treatment of sickness or injury, appropriate for home use, and not implantable

Coverage notesDME may be rented or purchased; Plan may choose rental vs purchase and expects purchase when cost-to-rent exceeds purchase; rental not to exceed purchase cost

Repair/replacement rulesRepairs or replacements require justification; warranty expiration alone is not sufficient for replacement

Medically Necessary / Medical Necessity

Medically Necessary / Medical NecessityHealth Care Services appropriate per CareSource policies and nationally recognized guidelines; not Experimental/Investigational; necessary to meet basic health needs; provided in the most cost-efficient setting consistent with diagnosis and accepted medical literature

Exclusions based on NMServices not meeting Medical Necessity (including maintenance therapy, experimental procedures) are Non-Covered Services

Decision contextPhysician recommendation alone does not guarantee coverage; Plan definitions govern whether service is a Covered Service

Serious and Complex Condition

Serious and Complex ConditionAcute illnesses requiring specialized treatment to avoid death or permanent harm, or chronic conditions that are life-threatening, degenerative, potentially disabling, or congenital and require prolonged specialized care

ExamplesConditions requiring specialized medical care over a prolonged period (e.g., certain chronic or degenerative diseases)

RelevanceUsed to determine eligibility for continuity of care and expedited review processes

Telehealth Services

Telehealth Services definitionHealth Care Services provided through information and communication technology by a health care professional located at a different site than the patient

Coverage stanceTelehealth services are covered; cost shares apply per Schedule of Benefits and will not be less favorable than in-person equivalents

Network partnersZero-cost telehealth partners may be available for specific services; other network telehealth providers follow standard cost sharing

Terminal Condition / Terminal Illness

Terminal Condition / Terminal IllnessAn irreversible, incurable condition likely to result in death; Terminal Illness has a prognosis of six months or less if the condition runs its normal course as certified by the attending physician

Hospice implicationHospice eligibility requires physician confirmation of life expectancy ≤ 6 months; benefits continue if life extends beyond six months

Coverage relevanceUsed to determine eligibility for hospice benefits and certain continuity extensions

Unproven Service

Unproven Service definitionHealth Care Services or medications not consistent with prevailing medical research (lacking well-conducted randomized trials or cohort studies) and therefore may be considered Unproven

Coverage exceptionMay be considered for coverage in life-threatening conditions if deemed promising and used within a specific research protocol meeting standards equivalent to NIH

Policy authorityCareSource determines whether a service is Unproven or Experimental/Investigational based on scientific evidence and regulatory status

Emergency Health Care Services

Emergency Health Care Services definitionCare to evaluate, stabilize, or treat an Emergency Medical Condition; authorization not required prior to seeking such care

Notification requirementIf admitted as an inpatient, notify CareSource within 24 hours or as soon as reasonably possible; if treated and not admitted, notify within 48 hours

Coverage regardless of providerCovered whether provided by network or non-network providers when based on presenting symptoms

Non-Emergency Ambulance Services

Non-Emergency Ambulance Services definitionGround or air transports between hospitals and facilities when ordered for specified reasons (e.g., to higher level of care, to a Network Provider, to a more cost-effective acute care facility, to a sub-acute setting, to a Skilled Nursing Facility, or to the Covered Person's home)

Emergency vs non-emergencyEmergency ambulance to nearest Network Hospital ER or nearest ER is covered; ambulette/taxi-type services are not covered

LimitationAmbulance transports must be to the closest facility that can provide appropriate covered services; ambulettes and similar vehicles are excluded

Adaptive Behavioral Treatment / ABA

Adaptive Behavioral Treatment / ABABehavioral therapies provided by or under supervision of licensed professionals according to a treatment plan; must be evidence-based and delivered by appropriately licensed/certified providers

Coverage notesCovered as medically necessary treatment for Autism Spectrum Disorder; ABA must be provided per a treatment plan and supervision requirements

Benefit limitsSpeech and Occupational Therapy for ASD have specified visit limits (e.g., 20 visits each); other ASD services may have 'None' limits as noted

Emergency Health Care Services (definition duplicate)

Emergency Health Care Services (duplicate)Services to evaluate, stabilize, or treat an Emergency Medical Condition; covered without prior authorization and regardless of provider network status

Follow-up careFollow-up care after stabilization is not emergency care and requires authorization to continue with non-network providers

Notification timingInpatient admissions from ER require notification within 24 hours or as soon as reasonably possible

Terminal Illness (hospice)

Terminal Illness (hospice)A condition with life expectancy of six months or less as confirmed by the attending physician for hospice eligibility; benefits continue if life extends beyond six months

Covered hospice servicesSkilled nursing, diagnostic services, therapies if part of plan, medical supplies/equipment, counseling, inpatient hospice/respite, hospice-provided prescription drugs, and home health aide services

Certification requirementAttending physician must confirm Terminal Illness and ≤6 months life expectancy for hospice eligibility

Home Health Care visit

Home Health Care visit (definition)Each visit by an authorized representative of a Home Health Care Agency counts as one visit; for limitations a visit equals at least four hours of home health aide services

Included servicesIntermittent skilled nursing, therapy services (home visit limits apply), medical/surgical supplies, DME, private duty nursing (subject to separate limit), home infusion therapy, and related services

Counting exclusionsPrivate duty nursing and home infusion therapy are not included in the 100-visit Home Health Care visit maximum

Orthotic device definition

Orthotic device definitionCustom-made rigid or semi-rigid supportive device used to support, align, prevent, or correct deformities or to improve function or limit motion of a weak or diseased body part

Covered componentsInitial purchase, fitting, repair, casting/molding, fittings, adjustments, shipping, postage and handling when billed with the orthotic appliance

Replacement rulesOrthotic appliances may be replaced once per Benefit Year when Medically Necessary; additional replacements allowed for damage or growth under age 18

Routine Hearing Screening / Exam (duplicate key/value)

Routine Hearing Screening / Exam (duplicate)Routine hearing screening: annual simple pass/fail test; Routine hearing exam: annual comprehensive exam by licensed audiologist or hearing instrument specialist including history, multiple tests, counseling and recommendations

FrequencyOne screening and one comprehensive exam per Benefit Year

Administrative noteServices under this section are administered by TruHearing; members must use TruHearing network providers for benefits

Examination (pediatric)

Examination (pediatric) definitionComprehensive eye examination including case history, observation, clinical and diagnostic testing, evaluation, refraction, color vision, stereopsis testing, and dilation when professionally indicated

Provider/networkPediatric vision benefits administered by EyeMed; must use EyeMed Network Provider for coverage

FrequencyTypically limited to one comprehensive eye exam per Benefit Year for pediatric members

Drug exception (non-Formulary drug) process

Drug exception (non-Formulary) processMember or authorized representative may request a non-formulary drug exception; if granted the drug is treated as an Essential Health Benefit and subject to applicable cost-sharing

Submission and reviewRequests may be submitted by the member, authorized representative, or prescribing provider; determinations provided in writing

External review timelinesIf denied, an independent review (IRE) will provide determination within 72 hours (standard) or 24 hours if expedited

Independent Review Entity (IRE) external review

Independent Review Entity (IRE) external reviewAn independent review entity conducts external review of denials of exception requests; standard determinations within 72 hours, expedited within 24 hours

Who may requestMember, authorized representative, or prescribing provider may request the external review

Binding natureIRO determinations are binding and have specified decision timeframes per policy and law

Adverse Benefit Determination (duplicate)

Adverse Benefit Determination (duplicate)Decision by CareSource to reduce, terminate, or deny a requested Health Care Service or Benefit in whole or in part, including determinations for medical necessity, appropriateness, level of care, Experimental/Investigational status, exclusions, eligibility, or rescission

Appeal implicationSubject to Internal Appeal and External Review rights and timelines described in the policy

ExamplesDenials for medical necessity, not a Covered Service, or rescission of coverage

External Review

External Review processExternal Review means a review of an Adverse Benefit Determination conducted pursuant to state or federal law by an IRE or appropriate state agency

Timing to requestGenerally must exhaust Internal Appeal; External Review request must be submitted within 180 days of Final Adverse Benefit Determination (exceptions apply)

Expedited external reviewExpedited External Review available for qualified cases with faster decision timelines (per policy and law)

Adverse Benefit Determination (duplicate)

Adverse Benefit Determination (duplicate)A CareSource decision to reduce, terminate, or deny a requested Health Care Service or Benefit in whole or in part, including denials for medical necessity, appropriateness, level of care, Experimental/Investigational services, exclusions, rescissions, or determinations not to issue coverage

Appeal rightsAdverse Benefit Determinations are subject to Internal Appeal and may be eligible for External Review by an IRE or state agency

NotificationMembers will receive notice of determinations consistent with state and federal regulations

External Review (Ohio specific)

External Review (Ohio specific)External Review may be conducted by the Ohio Department of Insurance or an assigned IRO for matters within state jurisdiction; IRO decisions are binding and follow statutory timelines

Filing deadlineExternal Review requests generally must be filed within 180 days of a Final Adverse Benefit Determination, with expedited options for qualifying urgent cases

Process noteCertain expedited External Reviews may be requested verbally for qualified cases per policy guidance

Requests for External Review must be submitted within 180 calendar days of the Final Adverse Benefit Determination; expedited external review requests may be submitted verbally or electronically.