Medical Benefits
CareSource has a network of doctors, hospitals and other providers. If you use providers who are not in our network, the plan may not pay for these services unless you needed emergency services or CareSource specifically authorized the services.
Use our Find a Doctor/Provider tool to see if your doctor is in our network.
Learn more about out-of-network coverage by reviewing your Evidence of Coverage on our Plan Documents page.
2021 Copayments and Fees
Doctor Office Visits (In-Network) | CareSource Advantage Zero Premium (HMO) | CareSource Advantage (HMO) |
Primary Care Physician (PCP) | $10 – $15 copay | $0 – $10 copay |
Specialist | $50 copay | $35 copay |
Other Medical Benefits (In-Network) | ||
Inpatient Hospital Care | Days 1-5: $365 per day | Days 1-7: $285 per day |
Skilled Nursing Facility (SNF) | Our plan covers up to 100 days in an SNF: | Our plan covers up to 100 days in an SNF: |
Outpatient Hospital Services | $295 copay | $295 copay |
Ambulatory Surgical Center | $250 copay | $250 copay |
Diabetes Testing Supplies | $0 copay | $0 copay |
Durable Medical Equipment (DME) | 20% coinsurance | 20% coinsurance |
Home Health Care | $0 coinsurance | $0 coinsurance |
Ambulance Services | $225 copay | $225 copay |
Urgent Care | $45 copay | $35 copay |
Emergency Care | $90 copay | $90 copay |
Lab Services and Other Tests (In-Network) | ||
Laboratory Tests | $35 copay | $0 – $10 copay |
Diagnostic Tests (Non-Radiology) and Procedures | $35 copay | $0 – $10 copay |
Diagnostic Radiology Tests (such as MRIs, CT scans) | $175 copay | $150 copay |
Outpatient X-Rays | $50 copay | $25 copay |
Preventive Care
You pay nothing for in-network preventive care. We encourage you to take advantage of preventive services, which are covered by CareSource Medicare Advantage. We also offer CareSource24®, our 24/7/365 nurse advice line. Call the the toll-free number on your CareSource member ID card.
Prior Authorization
Some services require prior authorization from CareSource. This means your doctor or health care provider must get approval from CareSource before you can get the service.
The Prior Authorization List shows which services need a prior authorization before you can get them.
Usually your primary care provider (PCP) will ask for prior authorization from us and then schedule these services for you. If you are seeing a specialist, he or she will get approval from your PCP. Then your services will be scheduled. If you have questions about the prior authorization process or status, please call Member Services.
Network Providers
CareSource has a network of doctors, hospitals, pharmacies and other providers. In order to have your health care services covered by your plan, you must get them from a network provider.
You can find the most current list of network providers using our online search tool, Find a Doctor, under the Quick Links to the left. Select the state where you live and your health care plan to get started.
Network Exceptions
It is important to know which providers are part of our network because – with limited exceptions – while you are a member of our plan, you must use network providers to get your medical care and services. The only exceptions are:
- Emergencies
- Urgently needed services when the network is not available (generally, when you are out of the area)
- Out-of-area dialysis services
- If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area
- Cases in which CareSource authorizes use of out-of-network providers
Please refer to the Evidence of Coverage for your plan on the Plan Documents page for full information on in-network and out-of-network copayments, as well as applicable conditions and limitations.
When You Are Outside of Our Service Area
If you get sick or hurt while traveling outside of our service area, you can get medically necessary covered services from a provider not in our network.
Prior to seeking urgent care, we encourage you to call your PCP for guidance, but this is not required.
You should get urgent care from the nearest and most appropriate health care provider. Emergency care is covered both in and out of our service area.
If you receive emergency care from a provider who is not a network provider, or urgent care services outside the service area, you will need to submit the bill you receive to CareSource with a claim form found on our Forms page. You may also obtain a claim form by calling Member Services at 1-844-607-2827 (TTY: 711). We are open 8 a.m. – 8 p.m. Monday through Friday, and from October 1 – March 31 we are open the same hours 7 days a week.
Out-of-network/non-contracted providers are under no obligation to treat CareSource members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.
This information is not a complete description of benefits. Call 1-844-607-2827 (TTY: 711) for more information.