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 Members
West Virginia
West Virginia

Health insurance you can afford, understand and use

CareSource plans provide comprehensive, quality coverage that you can afford, understand and use. We offer individual and family plans with optional dental and vision coverage for adults.

CareSource is a Qualified Health Plan issuer on the Health Insurance Marketplace.

Benefits

In 2018, you get:

  • Low copays for most in-network primary care office visits (CareSource Gold and Silver plans). You see, at CareSource we actually want you to be able to see your doctor. Not only when you need to, but regularly. That’s because we believe that’s the best way for you to stay healthy and worry free. So, we make sure it’s easy to afford. Your Summary of Benefits and Coverage shows details for your costs.
  • Low copays for generic medications included on our formulary and no deductible required for many covered prescriptions.
  • NEW Dental and Vision plans For 2018, CareSource Low Premium and Federal Simple Choice plans are offering optional adult Dental and Vision Benefits, because your dental and eye health are important to your overall health and wellness.
  • As an added bonus, all optional Dental and Vision plan members over the age of 18 are eligible for the Active&Fit® program. A The Active&Fit program offers low-cost fitness center memberships or home fitness kits. Members can join a contracted network of fitness centers in their area for an annual $100 fee or choose two home fitness kits for an annual $10 fee. Active&Fit also offers no cost fitness information and personal fitness tracking on their website. To get more information about the Active&Fit program, visit www.ActiveandFit.com.

Services

We are here to help you. Your services include:

  • Member Services – Our Member Services representatives answer your questions and provide assistance Monday through Friday, from 7 a.m. to 7 p.m. Eastern Standard Time (EST). We also provide TTY access for members who are deaf or hearing impaired. Please call us at 1-855-202-0622 (TTY: 1-800-982-8771 or 711).
  • CareSource24® Nurse Advice Line – Members may call any time of the day or night to speak to a registered nurse about health and medical concerns. Call the number on your member ID card 24 hours a day, 7 days a week.
  • Care Management Services – CareSource offers care management services to children and adults with special health care needs. Registered nurses, social workers and outreach workers can work with you one-on-one to help coordinate your care.

For more specific information about your benefits and services, please see your Evidence of Coverage and Member Handbook, found on the Plan Documents & Resources page. You can also contact us directly. We are happy to help.

Network Providers

In order to have your health care services covered by CareSource, you must get them from a network provider. The only exceptions are:

  • In cases of emergency; or
  • If you need medically necessary, covered urgent care services when traveling out of our service area; or when specifically authorized by CareSource.

In 2017 and 2018, our service area includes the following West Virginia counties: Barbour, Boone, Brooke, Cabell, Calhoun, Clay, Doddridge, Fayette, Gilmer, Hancock, Harrison, Jackson, Kanawha, Lincoln, Logan, Marion, Marshall, Mason, Monongalia, Ohio, Pleasants, Preston, Putnam, Raleigh, Ritchie, Roane, Taylor, Tyler, Wayne, Wetzel, Wirt and Wood.

For more information, please see your Member Handbook or Evidence of Coverage on the Plan Documents & Resources page.

Services that Require a Prior Authorization

CareSource keeps track of the services you get from health care providers. We discuss some services with your providers before you get them. We do this to make sure the services are appropriate and necessary.

Your doctor will assist you in getting a prior authorization from us for services that need one. For example, some procedures and most inpatient hospital stays require prior authorization.

Many other services do not need a prior authorization. You do not need one to see your PCP or most specialists. You don’t need one for lab work, x-rays or many outpatient services either. Your doctor will tell you when you need these types of care.

Your evidence of coverage includes a detailed list of covered services and requirements. Check this document if you have questions about a specific service.

Utilization Management

Our Utilization Management (UM) staff evaluates, according to established criteria or guidelines, the health care services you receive. We do this to make sure it is the best care for your needs.

Access to UM Staff

  • Staff are available from 8 a.m. to 5 p.m. Eastern Standard Time (EST) during normal business hours for inbound calls regarding UM issues.
  • Staff can receive inbound communication regarding UM issues after normal business hours.
  • Staff can send outbound communication regarding UM inquiries during normal business hours, unless otherwise agreed upon.
  • Staff are identified by name, title and organization name when initiating or returning calls regarding UM issues.
  • Staff are available to accept collect calls regarding UM issues.
  • Staff are accessible to callers who have questions about the UM process.

You can contact us anytime about UM or prior authorization requests. We also provide members with interpreter services for language assistance to discuss UM issues. Just call Member Services at 1-855-202-0622 (TTY: 1-800-982-8771 or 711).

Any decisions we make with your providers about the medical necessity of your health care are based only on how appropriate the care setting or services are. CareSource does not award providers or our own staff for denying coverage or services. We do not offer financial incentives to our staff that encourage them to make decisions that result in under-utilization. 

Review of New Health Care Services

We will review requests for newly developed health care services that are not currently covered by CareSource. This includes newly developed health care services, medical devices, therapies and treatment options. Coverage and approval will be based upon Health Insurance Marketplace rules, external technology assessment guidelines, Food and Drug Administration (FDA) approval, CareSource policies and procedures, federal and state law, medical necessity criteria, CareSource Evidence of Coverage(s), and medical literature recommendations.