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Michigan
Michigan

Covered Services

CareSource Advantage® (HMO SNP) ) covers the same services as traditional fee-for-service Medicare as well as prescription drug coverage. Our members do not have co-payments for medical services.

Members can get many services with no referral required from their Primary Care Provider (PCP). They can simply call for an appointment.

Some services require a referral from the Primary Care Provider, Prior Authorization from CareSource, or both.

CareSource Advantage members also receive many other benefits. These include a service center, a 24-hour nurse triage line, and transportation to medical appointments. For more information about referral procedures, Prior Authorizations, and covered services, please visit the Prior Authorization section or the Covered Services Grid.

CareSource uses a Pharmacy Benefits Manager. With pharmacy coordinators on staff to help facilitate services, we pair a clinically sound Preferred Drug List (PDL) with a wide network of participating pharmacies.

For more information, please call Provider Services at 1-800-390-7102.

Referrals

CareSource offers a no-hassle referral process. No forms or referral numbers are needed. The Member’s Primary Care Provider (PCP) simply documents the referral in the patient’s medical chart and notifies the specialist. PCPs are asked to assist Members in obtaining specialty services if needed.

If you have difficulty finding a specialist for your CareSource Advantage Member, please call Provider Services at 1-800-390-7102.

If you have questions about referrals and prior authorizations, please call Medical Management at 1-800-390-7102.

Members may go to Non-Participating Providers for:

  • Emergency care
  • Out of area dialysis care 
  • Out of area urgently needed care 

For more information, please call Provider Services at 1-800-390-7102 or visit the Provider Manual.

Services Rendered by Out-of-plan Providers

A Member may be sent to out-of-plan Providers if the Member needs medical care that can only be received from a doctor or other health care Provider who is not participating with our health plan. PCPs must get prior authorization from our health plan before sending a Member to an out-of-plan Provider. You can request a prior authorization by calling our Medical Management Department at 1-800-390-7102, and select the prompt to request prior authorization.

Second Opinion

A second opinion is not required for surgery or other medical services. However, health care Providers or Members may request a second opinion at no cost to the Member other than applicable co-payments, co-insurance and deductibles. The following criteria should be used when selecting a Provider for a second opinion:

  • The Provider must be a participating Provider.
  • If not, a prior authorization must be obtained to send the patient to a non-participating Provider.
  • The Provider must not be affiliated with the Member’s PCP or the specialist practice group from which the first opinion was obtained.
  • The Provider must be in an appropriate specialty area.
  • Results of laboratory tests and other diagnostic procedures must be made available to the Provider giving the second opinion.

Additional Services

CareSource offers its members many benefits and support services. For additional questions regarding benefits, call 1-800-390-7102 from 8 a.m. to 5:30 p.m. These include:

CareSource 24

CareSource offers an in-house, 24-hour nurse triage line for Members to call with medical questions and concerns 24 hours a day, 7 days a week. Our nurses can assess a Member's condition and direct the Member to the most appropriate place for care, whether that is the doctor's office, urgent treatment center or the emergency room. Members can call CareSource 24 at 1-866-206-0488.

Transportation

Transportation can be provided for member medical appointments with participating providers through CareSource's Transportation Services. Members can request transportation by calling 1-800-390-7102.

Case Management

CareSource has nurse case managers who assist members with conditions such as asthma, diabetes, congestive heart failure, obesity and high-risk pregnancy in coordinating appropriate medical and support services. If you know of any CareSource member who may benefit from case management, please call Member Services at 1-800-390-7102.

Interpreter Services

CareSource offers sign and language interpreters for members who are hearing impaired, visually impaired, do not speak English, or have limited English-speaking ability. These services are available at no cost to members or health care providers.

As a provider for Medicare consumers, you are required to identify the need for interpreter services for your CareSource patients and offer assistance to them appropriately. To arrange services, please contact Member Services at 1-800-390-7102.

Vision Services

CareSource Advantage covers all Medicare covered vision care and a $125 limit for eye wear every year.

Mental Health Services

For all mental health services including routine, urgent and emergency care, CareSource members should call Comprehensive Behavioral Care at 1-800-435-5348. They will be referred to an appropriate mental health care provider.

For more information, please call Member Services at 1-800-390-7102 or visit the Provider Manual.

Services Outside CareSource

CareSource does not cover some services, but Members can still receive them through Michigan Medicaid or another agency.

Examples of these services are:

  • Dental care - Dental care is covered by Medicaid Fee-For-Service
  • Pharmacy/Prescriptions not covered by Medicare Part D
  • Routine Podiatry services
  • WIC services - This is a food and nutrition program for women, infants and children. Call your local health department
  • Services for people with developmental disabilities - Call your local community mental health agency
  • Drug and alcohol abuse services not covered by Medicare - Call your local substance abuse coordinating agency

For help in locating an agency, please call Provider Services at 1-800-390-7102.

Services Not Covered

If you have questions regarding services not covered, please call Provider Services at 1-800-390-7102.