All CareSource plans on
the Marketplace include:

  • Preventive and wellness services (such as mammograms, diabetes screenings, flu shots and more)
  • Outpatient services (such as primary care and specialty doctor visits, urgent care services, diagnostic testing and more)
  • Hospitalization (such as surgery)
  • Prescription drugs
  • Emergency services
  • Mental health and substance use disorder services, including behavioral health treatment (includes counseling and psychotherapy)
  • Pediatric health and vision services
  • Maternity and newborn care
  • Laboratory services
  • Rehabilitative services and devices (to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)

What’s new for 2017

Pediatric dental (including orthodontia)

Our Gold, Silver, and Bronze plans now offer pediatric dental (including orthodontia).

Fitness club membership

You can now join a fitness center network or get at-home fitness kits when you choose one of our Gold, Silver, or Bronze Dental & Vision plans.

Low premium Silver plans

Get the lowest premium of all of our Silver level plans when you choose a Low Premium Plan.

Federal Standard health plans

Our Simple Choice plan benefits are the same for every health insurer, but the provider networks, monthly premiums, added benefits, and medications covered vary.

More health providers (doctors, hospitals, clinics, etc.)

Getting care from our network providers means better rates for services. Since you get a Managed Care HMO Plan, tapping into our care network helps you make the most of your coverage. We’ve added more providers so you have more choices for care.


Special Enroll marketplace

What do I Pay?

Health insurance costs can be confusing. That’s why it’s important that you understand what you pay and what CareSource pays when you use your benefits. Learn more about how to pay.


Premium

A premium is an amount you pay for your insurance plan each month.

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You pay this amount even if you don't use medical care that month. Your health insurance premium is similar to your auto insurance premium. You pay it monthly so that you are covered when you need it.


Coinsurance & Copayment

Coinsurance & copayments (or copays) are set amounts you pay each time you use some services, such as going to see your primary care provider or specialist.

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When services have a coinsurance or copay, you pay the health care provider that amount, usually at the time of service. CareSource pays the provider the balance of the bill.

  • Coinsurance is typically a percent of a bill.
  • Copayment is typically a set dollar amount.

If...

Your copayment for a primary doctor’s office visit is $20.

You visit your doctor, and the amount is $125.

You pay the doctor the $20 copayment.

CareSource plan pays the doctor $105.

If...

Your coinsurance for a medical procedure is 30 percent.

The amount of the medical procedure is $600.

You pay the provider 30 percent or $180.

CareSource plan pays the remaining 70 percent or $420.


Deductible

An amount of money that insurance plans require you to pay once a year before CareSource starts to pay its share.

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The deductible does not apply to all health care services. For example, doctor’s office visits to your primary care provider do not have an annual deductible. Even if you have not yet met your annual deductible, you can still see your primary care provider. You may have to pay a copay for a primary care visit, depending on your plan.

For some services, CareSource plans pay eligible expenses after you have met your annual deductible. When services have an annual deductible, you pay the health care provider for services until you have met the annual deductible amount. CareSource plans pay the provider for eligible expenses after you have paid this amount. Your annual deductible starts over every January.

If...

Your copay for a primary care (doctor’s office) visit is $20.

You visit your doctor, and the amount is $125.

You pay the doctor the $20 copayment.

CareSource is responsible for the remainder of the amount, $105.

To visit the emergency room (ER), a deductible does apply.

If...

Your plan requires you to pay $300 for an ER visit after you’ve met your deductible.

Your annual deductible is $200, and your ER amount is $2,200.

This means you need to pay $200 to meet your deductible plus the $300 copay for the ER visit.

CareSource is responsible for the remainder of the amount, $1,700.

At this point, you have met your annual deductible of $200 for the year.

This deductible applies to other services too. After you have met your annual deductible (in this example, $200), any service that has a deductible will only require you to pay the copay or coinsurance amount for the rest of the year.

Please note that not all out-of-pocket costs go toward meeting your deductible. Coinsurance, copays and premiums do not count toward your annual deductible.

As in the example above, the $20 copay for the doctor’s office visit did not go toward the $200 deductible amount.


Out-of-Pocket

Out-of-pocket costs are what you pay during the year through deductibles, copays and coinsurance.

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Premiums and services not covered by CareSource plans do not count toward your out-of-pocket maximum. After you meet your annual out-of-pocket maximum, CareSource plans begin to pay 100 percent for covered health benefits. Your out-of-pocket maximum starts over each January.

If...

Your annual out-of-pocket maximum is $650, and your annual deductible is $200.

You visit the ER, and the amount is $2,200.

Your plan requires you to pay $300 for an ER visit after you’ve met your deductible.

This means you need to pay $200 to meet your deductible plus the $300 copay for the ER visit.

CareSource is responsible for the remainder of the amount, $1,700.

At this point, you have paid $500 toward your out-of-pocket maximum and have met your deductible.

Now, your doctor recommends that you have a magnetic resonance imaging (MRI) scan.

If...

Your plan requires you to pay $150 for an MRI after meeting your deductible.

The MRI amount is $2,500.

Because you’ve already met your deductible, you pay the $150 copay and CareSource is responsible for the remaining $2,350.

At this point, you have met your $650 annual out-of-pocket maximum. For the rest of the benefit year, CareSource will pay 100 percent of covered services as defined in the plan’s Summary of Benefits and Coverage or Schedule of Benefits. To find these documents for your CareSource plan, access our Plan Details.

Want to learn more about paying for insurance, enrolling in a plan and coverage and benefits? Access our Frequently Asked Questions for more information.

How Can I Save?

When you enroll, the Health Insurance Marketplace determines your eligibility for cost savings based on your income and family size.

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Two types of cost savings through the Health Insurance Marketplace:

  • Cost sharing reduction (Silver plans only)
  • Advance premium tax credit (or subsidy)

Cost Sharing Reduction

A cost sharing reduction is a discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance and copayments.

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When you enroll through the Marketplace and review the plans you qualify for, this discount will be built into your Silver level plans. This discount is what makes the Silver plans so cost effective.


Advance Premium Tax Credit

An advance premium tax credit is a tax credit or subsidy that can be used in two ways.

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If you use the tax credit to lower your monthly premiums, you get the savings throughout the year. If you apply your tax credit to next year’s tax return, you increase your chance of getting money back at tax time. You decide how to use your tax credit when you enroll through the Health Insurance Marketplace.

  • Right away to lower your monthly premium payments
  • When you file your federal tax return