Covered Services

CareSource covers all medically necessary Medicaid-covered services. These services are available at no charge to you. You should not be billed for these services. If you receive a bill, please call us.

You can get some services without a referral from your Primary Care Provider (PCP). This means that the PCP does not need to arrange or approve these services for you. Just check your Provider Directory or the Find a Doctor online tool to find a provider near you. You can just call for an appointment. For more information, see No Referral Required.

Other services Require a Referral. That means you must get an okay from your PCP before you can get the service. The PCP will done of the following:

  • Arrange the services for you
  • Give you a written okay to take with you when you get the service
  • Tell you how to get the service

For more information, see Referral Required.

 

CareSource covers vision and mental health services. To learn more, please see Mental Health Services or your Member Handbook.

CareSource also covers prescription drugs. To learn more, please see Pharmacy.

No referral required

As a CareSource member, you can get some services without a referral from your Primary Care Provider (PCP). Just call and schedule a visit. Then let your PCP know about it.

These services include:

  • Primary Care Provider services - You can visit your PCP as often as needed. PCP services include, but are not limited to:
    • Routine office visits
    • Preventive health screenings and physical exams (including well-child EPSDT services)
    • Immunizations
    • Blood lead screening and follow-up for members younger than 21
    • Maternal and Infant Health Program (MIHP)
  • Nurse practitioner services - You may go to any participating certified pediatric and family nurse practitioner.
  • Services available at an FQHC - If there is a Federally Qualified Health Center (FQHC) in your area, you may choose to receive services from it. You do not need a referral from your PCP.
  • Prescription drugs - Health care providers will write prescriptions for you. They can be filled at CareSource participating pharmacies. Prescriptions are filled with generic drugs, when available. Some prescriptions require Prior Authorization.
  • Obstetric and gynecological services - You may go to any participating Obstetrician or Gynecologist (OB/GYN) provider.
  • Family planning services and supplies - You may receive services from your PCP, health department, family planning clinic, or participating OB/GYN Provider listed in your Provider Directory. CareSource covers counseling, pregnancy tests, some birth control, HIV testing, and testing and treatment for sexually transmitted diseases. No referral is required.
  • Hearing services - This includes hearing tests for all members and hearing aids for members under the age of 21. For members age 21 and older, hearing aids are not covered by Medicaid or CareSource.
  • Communicable disease services - From local health departments.
  • Child and Adolescent Health Centers and Programs (CAHCP) services.
  • Parenting and birthing classes
  • Emergency services - You do not have to go to a participating provider in an emergency. If you aren't sure where to go, call your PCP or our 24-hour nurse advice line at 1-866-206-0488.
  • Medically necessary transportation - To get a ride to your doctor's office, call Transportation Services at 1-866-712-1057. For emergencies, call 911.

To learn more, please see your Member Handbook.

Referral required

CareSource members need a referral for some services.

Your PCP or specialist will work with you to get you the care you need. Your doctor will:

  • Arrange the services for you
  • Give you a written okay to take with you when you get the service
  • Tell you how to get the service

Services that require a referral are:

  • Specialist services - This includes visits to most participating specialists. Specialists are listed in the Provider Directory.
  • Medical supplies - These require a prescription. They include diabetic supplies, surgical dressings, splints, casts and other items that cannot be reused.
  • Diagnostic services - This includes X-rays and lab work.
  • Chiropractic services (back care) - Members may go to any participating chiropractor with a referral. Members age 21 and older are limited to 5 visits per year.
  • Podiatry services (foot care) - Members may go to any participating podiatrist with a referral. Members age 21 and older are limited to 5 visits per year.
  • End-stage renal disease services (for kidney disease)

Prior Authorization

A few services also need approval from CareSource. This is called Prior Authorization. Your PCP or specialist will help you if you need these services.

These services include:

  • All Inpatient Care
  • All Abortions
  • All Home Care Services
  • Nursing Facility Services
  • Inpatient Rehabilitative Services
  • Organ Transplants
  • Durable Medical Equipment over $750.00 billed charges
    • The $750.00 rule does not apply to the below DME/other items – these require prior authorization:
      • All powered or customized wheelchairs.
      • Manual wheelchair rentals over 3 months
      • All miscellaneous codes (example E 1399)
  • Cosmetic procedures and Plastic Surgery
  • Prescription drugs not on the Preferred Drug List
  • Ambulance and ambulette transportation – except for emergent or facility- to-facility transfers
  • Diagnostic Procedures
    • MRI's
    • PET scans
    • Gastrointestinal Tract Imaging (video capsule)
  • Pain management/clinic
    • Spinal Injections and Blocks
  • Office visits to non-participating specialists
  • Rehabilitative services
    • Physical therapy over 18 visits per calendar year
    • Occupational therapy over 18 visits per calendar year
    • Speech therapy
  • Food Supplements/nutritional supplements
  • All services rendered by non-participating Providers

Please note that all services beyond the benefit limit and all services provided by non-participating providers require Prior Authorization.

If you have any questions, call Member Services at 1-800-390-7102 (TTY for hearing impaired: 1-800-649-3777 or 711).

Mental health services

For all mental health services, please call Comprehensive Behavioral Care at 1-800-435-5348.

Services covered include:

  • Routine mental health care - CACM covers up to 20 mental health visits per year. When you call, a care manager will find out what kind of treatment you need. The care manager will give you the Provider's name, address, telephone number, and an authorization number.
  • Urgent or emergency care - Members get urgent and emergency care from their local community mental health agency. Comprehensive Behavioral Care will help you find the right agency.
  • After-hours care - Comprehensive Behavioral Care staff are available 24 hours a day, 7 days a week.