For 2022 Important Plan Information - CareSource
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P.O. Box 8738
Dayton, Ohio 45401-8738
Important
Plan Information
for 2022
CareSource.com
Complete your You can earn a $30 Walmart® gift card. It’s easy to do!
IN-MED-M-755900; FIRST USE: 11/30/2021 OMPP APPROVED: 11/30/2021 © 2022 CareSource. All Rights Reserved.
Health Needs Screening Just call 1-833-230-2011 (TTY: 711) Monday - Friday between 7 a.m. to 6 p.m. Eastern Time
DECEMBER 2021
REVIEW YOUR CARESOURCE ID CARD(S) Member Name: Member Name:
Member RID: Member RID:
FPO FPO
Member Services: RxBIN - 003858 Member Services: RxBIN - 003858
1-844-607-2829 (TTY 1-800-743-3333 or 711) RxPCN - MA 1-844-607-2829 (TTY 1-800-743-3333 or 711) RxPCN - MA
Member Services Hours: RxGRP - RXINN01 Member Services Hours: RxGRP - RXINN01
8 a.m. – 8 p.m. Monday – Friday 8 a.m. – 8 p.m. Monday – Friday
Deductible - $2500 Deductible - $2500
Log on to MyCareSource.com to check for Log on to MyCareSource.com to check for
eligibility and Primary Medical Provider (PMP). eligibility and Primary Medical Provider (PMP).
This ID card identifies you as a CareSource member. CareSource24® Nurse Advice Line: 1-844-206-5947 (TTY: 711) CareSource24® Nurse Advice Line: 1-844-206-5947 (TTY: 711)
Always show your card to health care providers before you get care.
Questions? Or is your name incorrect on the card? Please call Member Services at
1-844-607-2829 (TTY: 1-800-743-3333 or 711). A representative can be reached
Member Name: Member Name:
Monday through Friday from 8 a.m. to 8 p.m. Eastern Time. Member RID: Member RID:
FPO
Member Services: RxBIN - 003858 Member Services: RxBIN - 003858
1-844-607-2829 (TTY 1-800-743-3333 or 711)
Member Services Hours:
8 a.m. – 8 p.m. Monday – Friday
RxPCN - MA
RxGRP - RXINN01
Deductible - $2500
Member Services Hours: FPO
1-844-607-2829 (TTY 1-800-743-3333 or 711)
8 a.m. – 8 p.m. Monday – Friday
RxPCN - MA
RxGRP - RXINN01
Deductible - $2500
Log on to MyCareSource.com to check for Log on to MyCareSource.com to check for
eligibility and Primary Medical Provider (PMP). eligibility and Primary Medical Provider (PMP).
CareSource24® Nurse Advice Line: 1-844-206-5947 (TTY: 711) CareSource24® Nurse Advice Line: 1-844-206-5947 (TTY: 711)
1
EMERGENCIES: EMERGENCIES:
FOR EMERGENCIES CALL 911 OR GO TO THE FOR EMERGENCIES CALL 911 OR GO TO THE
NEAREST EMERGENCY ROOM (ER) NEAREST EMERGENCY ROOM (ER)
For non-emergency visits to the ER, a copay may apply. If your For non-emergency visits to the ER, a copay may apply. If your
health event is not life-threatening and you are not sure about health event is not life-threatening and you are not sure about Member Name: Member Name:
FPO FPO
going to the ER, call the RNs at CareSource24®, Nurse Advice going to the ER, call the RNs at CareSource24®, Nurse Advice Member RID: Member RID:
Line for help at 1-844-206-5947 (TTY: 1-800-743-3333 or 711). Line for help at 1-844-206-5947 (TTY: 1-800-743-3333 or 711).
FPO FPO
Member Services: RxBIN - 003858 Member Services: RxBIN - 003858
1-844-607-2829 (TTY 1-800-743-3333 or 711) RxPCN - MA 1-844-607-2829 (TTY 1-800-743-3333 or 711) RxPCN - MA
PHARMACIST: 1-800-440-0474 PHARMACIST: 1-800-440-0474 Member Services Hours: RxGRP - RXINN01 Member Services Hours: RxGRP - RXINN01
MEMBER PHARMACY SERVICES: 1-844-607-2831 MEMBER PHARMACY SERVICES: 1-844-607-2831 8 a.m. – 8 p.m. Monday – Friday 8 a.m. – 8 p.m. Monday – Friday
Deductible - $2500 Deductible - $2500
PROVIDER SERVICES: 1-844-607-2831 PROVIDER SERVICES: 1-844-607-2831 Log on to MyCareSource.com to check for Log on to MyCareSource.com to check for
eligibility and Primary Medical Provider (PMP). eligibility and Primary Medical Provider (PMP).
IN-MMED-3278 IN-MMED-3278 CareSource24® Nurse Advice Line: 1-844-206-5947 (TTY: 711) CareSource24® Nurse Advice Line: 1-844-206-5947 (TTY: 711)
EMERGENCIES: EMERGENCIES:
FOR EMERGENCIES CALL 911 OR GO TO THE FOR EMERGENCIES CALL 911 OR GO TO THE
NEAREST EMERGENCY ROOM (ER) NEAREST EMERGENCY ROOM (ER)
For non-emergency visits to the ER, a copay may apply. If your For non-emergency visits to the ER, a copay may apply. If your
health event is not life-threatening and you are not sure about health event is not life-threatening and you are not sure about Member Name: Member Name:
FPO
going to the ER, call the RNs at CareSource24®, Nurse Advice
Line for help at 1-844-206-5947 (TTY: 1-800-743-3333 or 711).
FPO
going to the ER, call the RNs at CareSource24®, Nurse Advice
Line for help at 1-844-206-5947 (TTY: 1-800-743-3333 or 711).
Member RID: Member RID:
FPO
Member Services: RxBIN - 003858 Member Services: RxBIN - 003858
PHARMACIST: 1-800-440-0474
MEMBER PHARMACY SERVICES: 1-844-607-2831
PHARMACIST: 1-800-440-0474
MEMBER PHARMACY SERVICES: 1-844-607-2831
1-844-607-2829 (TTY 1-800-743-3333 or 711)
Member Services Hours:
8 a.m. – 8 p.m. Monday – Friday
RxPCN - MA
RxGRP - RXINN01
Deductible - $2500
Member Services Hours: FPO
1-844-607-2829 (TTY 1-800-743-3333 or 711)
8 a.m. – 8 p.m. Monday – Friday
RxPCN - MA
RxGRP - RXINN01
Deductible - $2500
PROVIDER SERVICES: 1-844-607-2831 PROVIDER SERVICES: 1-844-607-2831 Log on to MyCareSource.com to check for Log on to MyCareSource.com to check for
eligibility and Primary Medical Provider (PMP). eligibility and Primary Medical Provider (PMP).
IN-MMED-3278 IN-MMED-3278 CareSource24® Nurse Advice Line: 1-844-206-5947 (TTY: 711) CareSource24® Nurse Advice Line: 1-844-206-5947 (TTY: 711)
WELCOME TO CARESOURCE WHAT’S IN YOUR
EMERGENCIES: EMERGENCIES: NEW MEMBER BOOKLET
FOR EMERGENCIES CALL 911 OR GO TO THE FOR EMERGENCIES CALL 911 OR GO TO THE
NEAREST EMERGENCY ROOM (ER) NEAREST EMERGENCY ROOM (ER)
For non-emergency visits to the ER, a copay may apply. If your For non-emergency visits to the ER, a copay may apply. If your Review Your CareSource ID Cards
health event is not life-threatening and you are not sure about health event is not life-threatening and you are not sure about Each CareSource member in your family will have their own ID card.................................................... 1
FPO FPO
going to the ER, call the RNs at CareSource24®, Nurse Advice going to the ER, call the RNs at CareSource24®, Nurse Advice
Line for help at 1-844-206-5947 (TTY: 1-800-743-3333 or 711). Line for help at 1-844-206-5947 (TTY: 1-800-743-3333 or 711). Welcome to CareSource ...................................................................................................................... 8
PHARMACIST: 1-800-440-0474 PHARMACIST: 1-800-440-0474 Contact Us
MEMBER PHARMACY SERVICES: 1-844-607-2831 MEMBER PHARMACY SERVICES: 1-844-607-2831 Member Services is here to help............................................................................................................ 9
PROVIDER SERVICES: 1-844-607-2831 PROVIDER SERVICES: 1-844-607-2831 Quick Start Steps
What steps to take first as a new CareSource member....................................................................... 10
IN-MMED-3278 IN-MMED-3278
Make the Most of Your Plan
EMERGENCIES: EMERGENCIES: Get the care you need quickly and easily ............................................................................................ 13
FOR EMERGENCIES CALL 911 OR GO TO THE FOR EMERGENCIES CALL 911 OR GO TO THE Transportation
NEAREST EMERGENCY ROOM (ER) NEAREST EMERGENCY ROOM (ER)
For non-emergency visits to the ER, a copay may apply. If your
Get a ride to a doctor, pharmacy and other places at no cost if you don’t have transportation ......... 15
For non-emergency visits to the ER, a copay may apply. If your
health event is not life-threatening and you are not sure about health event is not life-threatening and you are not sure about Choosing or Changing Your Primary Medical Provider (PMP)
FPO FPO
going to the ER, call the RNs at CareSource24®, Nurse Advice going to the ER, call the RNs at CareSource24®, Nurse Advice Choose the physician you want to see most often .............................................................................. 17
Line for help at 1-844-206-5947 (TTY: 1-800-743-3333 or 711). Line for help at 1-844-206-5947 (TTY: 1-800-743-3333 or 711).
Where to Go for Care
PHARMACIST: 1-800-440-0474 PHARMACIST: 1-800-440-0474 You have options if you aren’t sure where to go to get care ................................................................ 18
MEMBER PHARMACY SERVICES: 1-844-607-2831 MEMBER PHARMACY SERVICES: 1-844-607-2831
PROVIDER SERVICES: 1-844-607-2831 PROVIDER SERVICES: 1-844-607-2831 Incentives and Rewards
CareSource rewards you and your family for getting and staying healthy........................................... 19
IN-MMED-3278 IN-MMED-3278 Healthy Indiana Plan (HIP) Personal Wellness and Responsibility (POWER) Account
Understand your POWER Account and its incentive for members...................................................... 20
6
Medically Frail and Healthy Indiana Plan (HIP) Benefits
Members who are medically frail get enhanced benefits..................................................................... 23
Make Sure Your Medical Services Are Covered by CareSource
Understand prior authorization requirements....................................................................................... 24
Welcome to CareSource!
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)/HealthWatch
Understand the special services and rewards for babies and children .............................................. 26
CareSource Life Services®
CareSource can help you find a good job, community support, and education or training ................ 28
CareSource JobConnect™
Get help finding a rewarding career ..................................................................................................... 28 We are glad to have you as a member! We are excited to serve you and other Healthy Indiana Plan (HIP)
MyResources members. At CareSource, our mission is to make a lasting difference in our members’ lives by improving
Use our search tool to help you find food, shelter, and more .............................................................. 29 their health and well-being. We know life is busy. We are here to make things easier to start your health
journey with us. We believe you deserve more than high quality health care. You deserve health care with
myStrengthSM
heart.
Use our online tool to take charge of your mental health .................................................................... 29
HIP is an insurance program offered by the state of Indiana. HIP gives health care to low-income
Renewing Your Benefits
adults. It covers all essential health benefits. HIP has a Personal Wellness and Responsibility (POWER)
Renew your Medicaid benefits each year ............................................................................................ 30
Account. Some plans may have extra benefits. You may also have low-cost monthly POWER Account
Benefits At-a-Glance Contributions (PAC) or copays. Pregnant women and American Indian / Alaska Native members do not
A guide that lists the benefits you have as a CareSource member ..................................................... 31 pay any copays or PAC.
Request Member Handbook and Provider Directory CareSource is here to help you. Let us know if you have questions or concerns about your health care.
Tear out the request cards to get a printed copy of your member handbook or provider directory.... 37 Please call Member Services toll free at 1-844-607-2829 (TTY: 1-800-743-3333 or 711). We are open
Notice of Privacy Practices Monday through Friday from 8 a.m. to 8 p.m. Eastern Time.
Understand your privacy rights related to your health information................................................ Insert
Member Consent/HIPAA Authorization Form
Consent to share your health information with your health care providers and/or someone else.. Insert
7 8
Contact Us Quick Start Steps
HAVE QUESTIONS? WHAT SHOULD YOU DO FIRST?
1. Review your ID Card(s) and the ID Cards of your family members. Included in this
booklet is your member ID card. You will show this card anytime you visit a health
Call Member Services at 1-844-607-2829 (TTY: 1-800-743-3333 or 711) Monday through Friday from care provider.
8 a.m. to 8 p.m. Eastern Time. We are ready to help you:
2. Set up a My CareSource.com account. You can use your account to change
• Get a new ID card • Arrange transportation
your PMP, ask for a new ID card, view claims and plan details, update your contact
• Choose or change your Primary Medical • Get a printed copy of your member handbook information and choose how you would like to hear from us. It’s easy to do:
Provider (PMP) or provider directory
• Go to MyCareSource.com • Click Register
• Make appointments with your health • Answer any questions you may have
• Click Sign Up at the bottom of • Download the CareSource app to
care providers
the page access on your mobile phone
• Answer the questions
3. Make sure the health care providers you plan to use are in the CareSource
Problems Reading or Understanding This Information? network. Visit findadoctor.CareSource.com to view the most up-to-date list of
We want you to be a healthy and happy CareSource member. Call health care providers in the CareSource network. You can also use the Find a Doctor
Member Services at 1-844-607-2829 (TTY: 1-800-743-3333 or 711). tool on the CareSource mobile app. Health care providers in the CareSource network
We can explain this information in English or in another language. If you are those who accept your CareSource insurance plan. In most cases, CareSource
have problems seeing or hearing, we can provide special help like large does not pay for charges from health care providers that are not part of our network.
print or braille. This is all at no cost to you. If you had appointments scheduled before joining CareSource, tell us right away.
We may be able to help you keep your out-of-network services until you get an in-
network health care provider.
9 10
4. Make sure your prescriptions are on the CareSource drug list. You can use 7. Earn rewards*† by filling out your Health Needs Screening (HNS). The HNS is a
the Find My Prescriptions search tool to see what drugs and medical supplies questionnaire. It asks about your health history and helps us identify health issues
are covered. We will let you know if you need prior approval for your prescriptions. or concerns. CareSource wants you to stay healthy. Using a few questions about
Just go to CareSource.com/Indiana, click Tools and Resources, and then click Find your health and lifestyle, CareSource can help your health care providers coordinate
My Prescriptions. your care. You can earn a $30 Walmart® gift card when you take the HNS. It only
5. Request a member handbook and/or provider directory. If you would like printed takes a few minutes.
copies of either document, follow the steps on the enclosed request postcards. There You can take the HNS in one of these ways:
is no postage necessary. You can also call Member Services and ask for copies at • Online: Just log into your secure MyCareSource.com account and click on the
1-844-607-2829 (TTY: 1-800-743-3333 or 711). We are open Monday through Friday Health tab
from 8 a.m. to 8 p.m. Eastern Time. • Phone: 1-833-230-2011 (TTY: 711) Monday through Friday from 7 a.m. to
6. Review your member handbook at www.caresource.com/in/plans/medicaid/ 6 p.m. Eastern Time
plan-documents/. It has information on: • At a health kiosk: In your local Walmart pharmacy
• Your benefits (including limitations) • By paper copy: Mailed separately
• Plan descriptions (and how to keep your benefits) *You must complete the HNS within your first 90 days with CareSource to get the reward.
• Important phone numbers and webpages †Rewards are subject to change.
• Pharmacy tools like Find My Prescriptions
• How to get care HAVE OTHER QUESTIONS?
• Full list of rewards and incentives
We look forward to helping you achieve your health and wellness goals.
• Care (and disease) management information If you have questions, please call Member Services at 1-844-607-2829
• Additional CareSource programs (TTY: 1-800-743-3333 or 711) Monday through Friday from 8 a.m. to
• And much more! 8 p.m. Eastern Time.
11 12To learn about addiction or what to expect when calling, visit Are you ready to quit using tobacco?
Make the Most of Your Plan https://www.caresource.com/in/members/education/ CareSource is here to help! Using tobacco in any form can
behavioral-health/addiction-help/medicaid/ harm your health. It can even cause diseases that can lead
Visit CareSource.com to: Need Medical Advice?
Knowing you need help takes courage and strength. Please to death. CareSource helps members stop using tobacco
• Learn about covered services and how to get them. Call CareSource24®, our Nurse Advice Line at do not do it alone. Treatment is more than focusing on your and offers rewards for participating in Quit Now Indiana.
• See the list of covered prescription drugs. 1-844-206-5947 (TTY: 1-800-743-3333 or 711) and habit. It is your day-to-day challenges. These can be things Just call 1-800-784-8669.
speak to a registered nurse to: like medical needs and mental and social challenges. It can
• Use the Find a Doctor tool at
findadoctor.caresource.com to find an • Get help with how to care for an illness also be family history.
in-network health care provider. or injury. You can call 24 hours a day, 7 days a week. We are here
• Learn about your membership rights • Find out about prescriptions or over-the-counter (OTC) to help you when you are going through a mental health
and responsibilities. medications. or substance use crisis. We want to make sure you get the
• Learn how you can earn rewards. • Decide whether you need self-care, a doctor visit or right services as soon as possible.
the Emergency Room (ER). Give us a call if you are:
• See an online copy of the member handbook. Need Glasses, a Dental Check-Up or
• Know more about a medical issue, recent doctor’s visit • Feeling hopeless
Use the Free CareSource Mobile App to: Chiropractic Check?
or a test.
• View and share your digital ID card • Feeling overwhelmed Chiropractic, dental and vision benefits are covered under
• Learn about healthy eating or staying well.
• Access your secure My CareSource.com account • Feeling anxious these plans:
• Know more about a dental issue or concern and after
• Find a doctor, hospital, clinic, or urgent care near you • Feeling alone • HIP Plus
hour care options.
• View your claims • Feeling depressed • HIP State Plan Plus
Addiction Help
• Check your POWER Account balance • Feeling like there is no reason for living • HIP State Plan Basic
Call our Behavioral Health Crisis line at 1-833-227-3464
• Make a payment and speak to a licensed mental health professional. Or call • Using or abusing drugs or alcohol Contact Member Services for help making your POWER
• Call and speak with Member Services with a touch the Addiction Hotline at 1-833-674-6437 (TTY: 1-800-743- • Having dramatic mood changes Account Contribution or to see if you qualify for State
3333 or 711). Plan Benefits.
• Connect with RelyMD®, our telehealth provider
13 14Transportation No-Shows
If you are not ready when your driver comes, they
NEED A RIDE? can only wait 10 minutes. You will be deemed a
HIP Plus, HIP State Plans, and HIP Maternity Plans include unlimited ride benefits. Trips can be: no-show after 10 minutes.
• A ride to any covered doctor visit or health care visit When Should I Set up my Ride?
• A ride to the pharmacy after your visit with the doctor You can ask for a ride up to 30 days before a
• A ride to the local Women, Infants and Children (WIC) office medical visit. Call Member Services to arrange
a ride at least two business days before
• A ride to service redetermination appointments with the State your appointment.
• A ride to CareSource events
How do I Cancel a Ride?
• A ride to pick up food from a food pantry or curb-side food pick up from a grocery store
Please let us know if you cannot keep your
• A ride to and from a Neonatal Intensive Care Unit (NICU) appointment or if it changes. Call Member
HIP Basic members do not get rides to dental or vision appointments since those services are Services to cancel at least two hours before
not covered. pick-up time.
How do I Set up a Ride? Can a Friend or Family Member Get Paid to
Take Me?
Please call Member Services at 1-844-607-2829 (TTY: 1-800-743-3333 or 711) to set up a ride. Please
call at least two business days before your visit. When you call, tell the person helping you: A family member or other person close to you
may be able to enroll with Indiana Medicaid to
• Your pick-up address - Wheelchair get gas mileage reimbursement for these trips.
• Your appointment address and name - Wheelchair size and weight They need to complete the application process at
• Any special needs you have, such as: - Help getting into or out of the vehicle www.in.gov/medicaid/members/540.htm.
- Oxygen
15 16Choosing Or Changing Your Primary Where to Go for Care
Medical Provider (PMP) You can call our CareSource24 Nurse Advice Line 24 hours a day 365 days, a year. Talk to a nurse for advice on how to treat
your symptoms, illness, or injury. Our nurses can let you know where to get care when your doctor’s office is closed. This
Choose your PMP as soon as possible. It will The CareSource mobile app can make it even could be telehealth, a clinic, a doctor’s visit or the ER. The CareSource24 telephone number is 1-844-206-5947. It is also on
speed up making appointments when you or your easier for you to choose your PMP. It is free! You the back of your ID card.
family members are sick and need to see them. can download it for both iPhone® and Android® Call the Behavioral Health Crisis line at 1-833-227-3464 and speak to a licensed behavioral health (mental health)
It helps you and your family get care from a PMP phones through the Apple App Store® or through professional. You can call 24 hours a day, 7 days a week. We are here to help you when you are going through a mental
who knows you and sees you and your family Google Play®. health or substance use crisis. We want to make sure you get the right services as soon as possible.
regularly. It also ensures that you have a PMP you MyCareSource® will allow you to create
trust who can direct your care with specialists or RelyMD® is a great choice for things that might get worse without quick attention. You can call 24 hours a day, 7 days
your personal online account. Visit a week. They can help with things like infections, rashes, allergies, coughs and more. Talk with a health care provider in
other medical professionals. MyCareSource.com to: about 15 minutes. Call 1-855-879-4332 or visit https://patient.relymd.app/
If you do not choose a PMP, CareSource will • Register/login to change your health Walk-in convenience clinics are great for quick care. Their doctors can see you when your PMP office is closed. They
choose one for you. We will choose a PMP for care provider can also help when your PMP can’t see you soon enough. You can often find these clinics in your local pharmacy or
you based on where you live and if the PMP is
• Ask for a new ID card grocery store. They are usually open evenings and weekends. You do not need an appointment.
taking new patients.
• See claims and plan detail Urgent care clinics are for injuries or illnesses and non-traumatic dental concerns. You can get shots or x-rays if needed.
Change or choose a new PMP by logging into They can handle many of the reasons people go to an ER. These are things like help with minor broken bones and wound
your MyCareSource.com account and choosing • Update your contact information
care. Urgent care clinics are normally open evenings and weekends.
one from the health care providers in the
Remember, once you have a My CareSource Emergency Rooms are for true emergencies like heart attacks, strokes, trouble breathing, and serious injuries.
CareSource network.
account you can also get a free digital picture of
What if I can’t find a health care provider? your ID card. The CareSource mobile app can help you find the nearest in-network health care provider. It can also link you right to
Call Member Services at 1-844-607-2829 (TTY: RelyMD® at https://patient.relymd.app/. You can download the CareSource mobile app from the Apple® or Android® app stores.
1-800-743-3333 or 711). We are here to help you
find a health care provider to meet your needs. You can get quick care when you need it if you choose the best place for it.
17 18Incentives and Rewards* MAKE LIFE MORE REWARDING
One of your benefits is our rewards programs. Go to caresource.com/in/plans/medicaid/benefits-services/rewards/ for
a complete list of rewards and to register. You can also register by calling Member Services.
BABIES FIRST® REWARDS
Healthy Indiana Plan (HIP)
Going to the doctor is healthy for you and your baby. The Babies First program helps you earn up to $200
in rewards. Earn rewards for seeing your doctor while pregnant. Earn them also when you complete visits
POWER Account
with your baby after they are born. You must register for Babies First to earn the rewards.
KIDS FIRST REWARDS
CareSource wants to make sure kids have what they need to be healthy. The Kids First program helps your
child earn rewards. You earn rewards by going to yearly checkups, dental visits, flu shots and more. Kids
aged 16 months through 17 years can earn rewards up to $50 in the program. You must register each of
your children in Kids First to earn rewards. POWER (PERSONAL WELLNESS AND RESPONSIBILITY) ACCOUNT
The POWER Account is a special savings account to give incentives for members. This is to help
MYHEALTH REWARDS
We automatically enroll adults 18 and over in the MyHealth rewards program. You may be earning rewards you stay healthy and keep track of the funds used. Every HIP member starts with $2,500 in their
right now! You can earn up to $300 in rewards for getting: POWER Account.
• Regular physical exams • Dental exams • Other preventive screenings MEMBER COST-SHARING
You also earn rewards for taking part in smoking cessation and other wellness programs. You can redeem
Most HIP members pay part of their coverage cost. HIP Basic members will have copays for each
rewards at a variety of retailers.
service (such as going to see the doctor or filling a prescription). HIP Plus members will make a
PLEASE NOTE: If you are no longer a CareSource member, the Rewards Portal will be deactivated and any unused rewards monthly payment. This payment is called a POWER Account Contribution (PAC).
may be no longer available. HIP Plus members will get an invoice for their PAC payment each month. The monthly amount is
*Rewards subject to change. Rewards for Babies First, Kids First and MyHealth may vary by age, gender and health needs. based on income and family size. Be sure to pay the invoice by the due date.
Log in to your MyCareSource.com account to sign up for the reward programs. Learn more about the benefits CareSource
offers. Call Member Services at 1-844-607-2829 (TTY: 1-800-743-3333 or 711) or visit CareSource.com.
19 20NON-PAYMENT PENALTIES
Not paying may result in lowering your coverage to HIP Basic or losing coverage. HIP Plus members
will have no other costs if they pay their PAC on time. The only exception is an $8 copay for a non-
emergency visit to the ER.
All HIP members will get a POWER Account statement each month. The statement is also on your
My CareSource account. Sign up at MyCareSource.com. You can keep track of funds used for health
services received. It will show you funds remaining. HIP Plus members will have a record of PAC
payments made.
Use the bar code above to make your PAC in cash at any CVS®, Dollar General®, Family Dollar® or
POWER ACCOUNT ROLLOVER Speedway®. Be sure to:
Managing your account well and getting preventive care can lower your future costs. If your expenses • Keep this booklet. You will need the bar code to pay in cash.
are less than $2,500 per year, you may rollover your extra contributions. This will lower your monthly • Keep all receipts for your records.
payment for the next year. • Call us with any questions at 1-844-607-2829 (TTY: 1-800-743-3333 or 711).
• Get a receipt.
MAKING PAYMENTS
There are many ways you can pay your PAC. You can: EMPLOYER POWER ACCOUNT CONTRIBUTIONS
• Send a check in an envelope with your invoice. Ask your employer if they offer payroll deduction for health insurance contributions. Visit
• Sign onto your member account at MyCareSource.com to pay online. https://www.caresource.com/documents/in-hip-employer-payroll-deduction-authorization-
form-508/ to get the Employer Payroll Deduction Form. You may also call Member Services to ask for
• Call Member Services to pay by phone.
a copy of the form. Please fill out the form and send it to CareSource. If your employer offers payroll
• Pay with cash and use the bar code below. You can pay with cash at any: CVS®, Dollar General®, deduction, CareSource will work with them to set it up. Please note that this form lets CareSource
Family Dollar® or Speedway®. coordinate with your employer. It does not automatically enroll you in Employer Payroll Deduction.
21 22Medically Frail and Healthy Indiana Plan (HIP) Benefits Make Sure Your Medical Services are
Enhanced benefits are here for those who qualify
as medically frail. Members who are medically
You must contact us to confirm your health
condition. CareSource needs to determine if
Covered by CareSource
frail will get HIP State Plan benefits. Go to you qualify for enhanced benefits. WHAT IS PRIOR AUTHORIZATION?
www.in.gov/fssa/hip/am-i-eligible/conditions- CareSource will have 30 days to talk to
that-may-qualify-you-as-medically-frail/ to Prior authorization is permission you need for your health care provider to provide a service. Some
you about: services will not be paid for by CareSource if your health care provider does not ask for a prior
learn more. Or call Member Services. Someone
may be medically frail if they have one or more of • Your health and non-health care needs authorization first. CareSource will decide prior authorization requests based on medical necessity,
these conditions: • Look at claims medical appropriateness and your benefit limit.
• Disabling mental disorder • Talk to your health care provider Prior authorization requirements for our covered services can be found online in the member
handbook at www.caresource.com/in/plans/medicaid/plan-documents/. You may also ask for a
• Chronic substance use disorder You will continue with the same benefits if
paper copy by calling Member Services at 1-844-607-2829 (TTY: 1-800-743-3333 or 711).
• Serious and complex medical condition CareSource does not conclude that you are
medically frail. Examples of preventive care that DO NOT need a prior authorization:
• Physical, intellectual, or developmental
disability which greatly impairs your ability to • Annual physical exam
do one or more daily living activities (such as Completing the Health • Early Periodic Screening, Diagnostic and Treatment (EPSDT) for ages up to 21
bathing, dressing or eating) Needs Screening • Dental and eye exams (not covered for HIP Basic plans except under EPSDT)
• Disability determination from the Social It is important to complete your • Breast, cervical or colon cancer screenings (dependent upon age)
Security Administration Health Needs Screening if we
• Cholesterol and diabetes (A1c) screenings
conclude that you are medically frail.
• Vaccines
23 24Examples of benefits that MAY need a prior authorization:
• Certain prescription medications
EPSDT/HealthWatch®
• Dental care (in hospitals and ambulatory surgery centers)
• Inpatient hospital care
• Some medical supplies and equipment
• Inpatient services (mental health and
addiction services) EPSDT stands for: Babies and children need to have regular doctor visits and well-
child exams. Be sure to ask for an EPSDT exam when calling
• Rehabilitation services E = EARLY your doctor.
The examples above are not complete lists of covered services for prior authorization. so problems are treated soon
Members under the age of 21 can get care management services
CareSource should give you permission with a prior authorization before you get a medical P = PERIODIC as part of HealthWatch. The program is for those who have special
service. CareSource will not pay claims for services in which you needed a prior authorization but did to set up regular visits health care needs or any member who wants more support.
not get one through your medical provider first.
Getting screenings and shots can help your child/teen stay
REMINDER: It is important for you or your health care provider to contact CareSource to make S = SCREENING
well. Use the chart below to know when to make appointments.
sure that any prescriptions or services you have already scheduled will be covered by CareSource. to check for a health problem
CareSource can also help you choose different options if your prescription or service is not covered. What’s Who’s When to Have Cost
D = DIAGNOSTIC Covered? Covered? First Exam
Your PMP or specialist has tools to help them ask for a prior authorization. They can also check to find a health problem
Visits to the HIP under 21 Within the first $0
online or through a written request to see if we approved your prior authorization. CareSource has
T = TREATMENT doctor and any members that 90 days of being
Provider Services representatives ready to help your health care provider’s office through this process.
to care for a problem shots and lead meet eligibility a CareSource
Do emergency services need a prior authorization? No. Emergency services do not need this. An testing needed requirements. member, if needed.
emergency is a medical condition that may cause serious harm to a person’s health. at that time
25 26When to have a well-child or EPSDT/HealthWatch Exam
Baby Children/Teen/Young Adults CareSource Life Services®
At birth 12 months old
3-5 days old 15 months
By 1 month old 18 months Good health requires more than just quality health care. Having a good job, community support, and
2 months old 24 months access to education or training impacts your overall health and well-being. That’s why CareSource Life
Services is here for you. We can help remove barriers that stand in the way of reaching your goals. Life
4 months old 30 months Services can help pave the way from where you are to where you want to be. You can be part of Life
6 months old Each year from age 3 to 21 Services if you are a CareSource member or parent or guardian of a CareSource member and at least
9 months old 14 years old. We can link you to services and support for:
• Transportation • Housing
• Access to food • Childcare
• Budgeting and financial assistance • Employment opportunities
• Legal assistance (CareSource JobConnect™)
Your child can earn rewards for completing some
EPSDT activities! CareSource JobConnect
Learn more at CareSource.com/in/plans/medicaid/benefits-services/
CareSource JobConnect helps you get new skills, links you with local services, and helps you find
additional-services/rewards/. Enroll in our Babies First or Kids
a job. We will pair you with a Life Coach who can help set you up for success. Life Coaches provide
First programs.
one-on-one coaching for up to 24 months. CareSource JobConnect partners with employers to
help you in your job search. There is no cost to you for this service. Please fill out our online form at
https://secureforms.caresource.com/en/LSRInfo/IN to learn more. You can also call us at
1-844-607-2832 or email LifeServicesIndiana@CareSource.com.
27 28MyResources Renewing Your Benefits
Sometimes you just need a little extra help. We have a search tool
called MyResources that helps you find free or low-cost programs When it’s time to renew your benefits, you will get a renewal form from the state. The form will tell
and support for: you what action is required. If you are unsure, visit the Indiana Family & Social Services Benefits
Administration Portal at: www.fssabenefits.in.gov or call 1-800-403-0864 and select option 1.
• Food • Work
You can renew your benefits:
• Shelter • Financial support
• By Mail. Fill out the renewal form.
• School • And more!
• In Person. Visit your local Division of Family Resources (DFR). Find the office nearest you at
We have programs across the U.S. from small towns to large cities. Log in
www.in.gov/fssa/dfr/ebt-hoosier-works-card/find-my-local-dfr-office/.
to your MyCareSource.com account to access the tool. You can also call
Member Services to find support near you. Please note that CareSource cannot renew your benefits. You must do it through Indiana’s DFR by one
of the ways listed above. Have questions? Call DFR at 1-800-403-0864.
myStrengthSM Remember, we will give you a ride to your redetermination appointment.
Take charge of your mental health. Try our online wellness tool called We provide trips to any non-emergency health care, WIC or redetermination visits.
myStrength. This online learning platform has: You can also schedule a ride to CareSource events. Please call 1-844-607-2829
(TTY: 1-800-743-3333 or 711) to arrange a ride at least two business days before
• Self-help tools • Inspirational reading
your appointment.
• Wellness help
Be sure to be at your pick-up location on time. If you have to cancel, please call at
This is a safe tool designed to help with your mind, body and spirit. least two hours before the pick-up time.
Go to bh.mystrength.com/caresource to sign up, create a profile,
and learn more. You can also find myStrength on our member portal at
MyCareSource.com. Or download the free app on your mobile device. If you have questions, call Member Services at 1-844-607-2829 (TTY: 1-800-743-3333 or 711). We are
You can get the myStrength app for Apple and Android devices at open Monday through Friday from 8 a.m. to 8 p.m. Eastern Time.
mystrength.com/mobile. Sign in in using your login email and password.
29 30Health Care Visits • Diabetes Tests • Developmental/Behavioral Test Heart
• Chiropractor† • Disease Tests and Treatments, • Health Education • Abdominal Aortic Aneurysm Tests
• Community Mental Health Center (CMHC) e.g., Hepatitis, human • Hearing Tests • Cardiac Rehabilitation Services*
immunodeficiency virus (HIV) and
• Convenience Care Clinics inside of stores like CVS®, • Immunizations (Shots) • Heart Disease Risk Reduction
sexually transmitted infection/
Kroger® and Walmart® sexually transmitted disease • Lab Tests Visit* (Therapy for Heart
• Emergency Room (ER) (STI/STD) • Lead Screenings (Blood Test) Disease)†
• Federally Qualified Health Center (FQHC) and Rural • Immunizations (Shots) • Nutritional Assessment • Heart Disease Testing
Health Clinic (RHC) • Lung Cancer Screening • Vision Exams • Electrocardiogram (ECG/EKG)
• Free-Standing Birth Centers • Breast Cancer Screening Health Condition Management Behavioral Health
• Hospital (Inpatient* and Outpatient) (Mammogram) • All Inpatient Services*
• Chemotherapy and Radiation
• RelyMD® (Virtual doctor visit over the phone or online) • Nutritional Assessment • Partial Hospitalization Program
• Diabetes Screening
Benefits At-a-Glance • Primary Medical Providers (PMPs) like doctors, OB/
GYNs, Physician Assistants and Nurse Practitioners
• Obesity/body mass index (BMI)
Screening and Dietary Counseling
• Diabetes Self-Management
Training
(PHP) Services*
• Psychiatric Diagnostic Evaluation*
At CareSource, we care about you. We know that there • Specialists (e.g., Podiatrist, Neurologist and Oncologist) • Cervical and Vaginal Cancer Test • Psychological Testing
• Diabetic Services and Supplies
is more to health and well-being than just great health • Telehealth (Pap smear) • Intensive Outpatient Program/
care. That’s why CareSource offers benefits and services • Dialysis
• Urgent Care • Physical Exams Treatment (IOP/IOT) Services*
that go beyond basic care. This guide lists the benefits • Kidney Disease Services and
Preventive and Early Detection Care/Screenings • Prostate Cancer Screening Supplies* • Transcranial Magnetic
you have as a CareSource member. Use it to put your
HealthWatch/EPSDT Program (Early Stimulation (TMS)*
benefits to work for you! • Annual Well Visit • Pulmonary Rehabilitation
and Periodic Screening, Diagnostic Services* • Individual Psychotherapy*
Please refer to your member handbook online at • Autism Spectrum Disorder Screening
and Treatment) (Under age 21) • Family Psychotherapy*
CareSource.com or call Member Services to learn • Blood Pressure Screening Diagnostics
more about how to use your benefits. We’re here • Comprehensive Health and • Group Psychotherapy
• Bone Mass Measurements Developmental Exam • Blood Work/Lab Testing*
to help. • Substance Use Disorder (SUD)
• Cholesterol Screening • Dental Screening • Scans (e.g., CT, MRI and PET)* Residential*
• Colorectal Cancer Screening† • X-Rays
31 32• Electroconvulsive Therapy (ECT)* Family Planning and • Physical, Occupational and • Transportation to and from • Surgeries (e.g., General, Bariatric, • Personal Wellness and
• Medication Assisted Treatment Maternity Services Speech Therapy* Neonatal Intensive Care Unit Reconstructive and Transplant) Responsibility Account (POWER
(MAT) • Birth Control Vision/Eye Care† (NICU) • TMJ treatment (Jaw pain or Account)҂
• Pharmacological Management • Breast Pumps • Contacts* Other Care problems with jaw movement) • Rewards for Wellness
• Opioid Treatment Program (OTP) • Family Planning Exams • Glasses • Anesthesia Additional Programs, Services and
Services • Adaptive Behavior Treatment* Rewards ҂ Available only for certain HIP plans
• Nurse Midwife Services • Eye Exams
Pharmacy and Medications† • Parent Education • Allergy Testing and Treatment • Babies First (Rewards Program) † Available only for certain HIP plans.
Dental†
• Brand and Generic Drugs • Lung Cancer Screening† • Kids First (Rewards Program) Prior authorization may be required.
• Prenatal and Postnatal Doctor • Exams and Cleanings†
• Mail Order Drugs and Home Visits • Counseling/Interventions to • Text4Baby (Pregnancy * Prior authorization may be required as
• X-Rays Education Texts) medically necessary for services that are
• Over-the-Counter (OTC) Items • Sexually Transmitted Disease/ Quit Smoking/Using Tobacco
• Dentures (Smoking Cessation) • Care Management not routine. This means that CareSource
(Prescription from your doctor is Sexually Transmitted Infection
required) (STD/STI) Screenings and • Fluoride Treatments (For ages • Hearing (Audiology) (e.g., Exams, • CareSource24 – 24-Hour Nurse must approve the service before you
Treatment 0-20) Hearing Aids* and Cochlear Advice Line receive it. Your PMP will request the
Medical Supplies approval from CareSource. We do this
• Sterilization Surgery (Male and • Orthodontics* (Covers medically Implant Therapy) • Behavioral Health Crisis Line
• Cochlear Implants necessary orthodontic care only, to make sure it is best for you and it is
Female)* • Hospice (Facility and Home) • CareSource Mobile App
• Diabetic Supplies ages 0-20) covered.
• Well-Baby Check-Ups • Inhalation Therapy • Disease Management
• Durable Medical Equipment • Surgeries and Procedures (e.g.,
(DME) and Related Supplies* Home Health Care* Extractions and Restorations) • Medical Nutrition Therapy • Fifth Third Express Banking®
(e.g., Oxygen Tank, Wheelchair/ • Durable Medical Equipment (DME • Nutritional Counseling • Health and Wellness Education
Transportation Services
Walkers, Wound Care and CPAP – see Medical Supplies) • Occupational Therapy Programs
Machine) • Emergency (Ambulance, Air
• Home Infusion Therapy Flights*) • Pain Management* • CareSource JobConnect
• Incontinence Supplies • Home Nursing Services (e.g., • Physical Therapy • Medication Therapy Management
• Non-Emergency (Scheduled Ride,
• Nutritional Supplies Skilled Nursing, Private Duty, Bus, Wheelchair Access)† • Podiatry (Foot) Services • MyHealth Online Tool
• Prosthetic Devices and Related Certified Nurse Aid and Social
Worker) • Speech Therapy • myStrength Online Mental Health
Supplies Tool
33 34If you, or someone you’re helping, have questions about CareSource, you have the right to get help and information in your
language at no cost. Please call the member services number on your member ID card. ITALIAN языке. Для разговора с переводчиком. Пожалуйста,
Se Lei, o qualcuno che Lei sta aiutando, ha domande su позвоните по телефону отдела обслуживания клиентов,
ARABIC DUTCH CareSource, ha il diritto di avere supporto e informazioni указанному на вашей идентификационной карточке
أية استفسارات بخصوص، أو لدى أي شخص تساعده،إذا كان لديك Als u, of iemand die u helpt, vragen heeft over CareSource, nella propria lingua senza alcun costo. Per parlare con un клиента.
فيحق لك الحصول على مساعدة ومعلومات مجانًا وباللغة،CareSource hebt u het recht om kosteloos hulp en informatie te interprete. Chiamare il numero dei servizi ai soci riportato
ُرجى االتصال على، للتحدث إلى أحد المترجمين الفوريين.التي تتحدث بها ontvangen in uw taal. Als u wilt spreken met een tolk. Bel sulla tessera di iscrizione. SPANISH
.رقم خدمة األعضاء الموجود على بطاقة تعريف العضو الخاصة بك naar het nummer voor ledendiensten op uw lidkaart Si usted o alguien a quien ayuda tienen preguntas sobre
JAPANESE CareSource, tiene derecho a recibir esta información y ayuda
AMHARIC FRENCH (CANADA) ご本人様、または身の回りの方で、CareSource に関するご en su propio idioma sin costo. Para hablar con un intérprete.
እርስዎ፣ ወይም እርስዎ የሚያግዙት ግለሰብ፣ ስለ CareSource ጥያቄ ካላችሁ፣ ያለ Des questions au sujet de CareSource? Vous ou la personne 質問がございましたら、ご希望の言語でサポートを受けた Por favor, llame al número de Servicios para Afiliados que
ምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት አላችሁ። ከአስተርጓሚ ጋር que vous aidez avez le droit d’obtenir gratuitement du り、情報を入手したりすることができます（無償）。 通訳を figura en su tarjeta de identificación.
እባክዎን በመታወቂያ ካርዱ ላይ ባለው የአገልግሎቶች ቁጥር ይደውሉ፡፡ soutien et de l’information dans votre langue. Pour parler à ご利用の場合は、お持ちの会員IDカードにある、会員サービ
un interprète. Veuillez communiquer avec les services aux スの電話番号までお問い合わせ下さい。 UKRAINIAN
BURMESE membres au numéro indiqué sur votre carte de membre. Якщо у вас, чи в особи, котрій ви допомагаєте, виникнуть
CareSource အေၾကာင္း သင္ သို႔မဟုတ္ သင္အကူအညီေပးေနသူ တစ္ KOREAN запитання щодо CareSource, ви маєте право безкоштовно
GERMAN 귀하 본인이나 귀하께서 돕고 계신 분이 CareSource에 대해 отримати допомогу та інформацію вашою мовою. Щоб
စံုတစ္ေယာက္က ေမးျမန္းလာပါက သင္ေျပာဆိုေသာ ဘာသာစကားျဖင့္ 궁금한 점이 있으시면, 원하는 언어로 별도 비용 없이 도움을 замовити перекладача, Зателефонуйте за номером
Wenn Sie, oder jemand dem Sie helfen, eine Frage zu
အကူအညီႏွင့္ အခ်က္အလက္မ်ားအား အခမဲ့ ရယူႏိင္ရန္ အခြင့္အေရး႐ွိ CareSource haben, haben Sie das Recht, kostenfrei in Ihrer 받으실 수 있습니다. 통역사가 필요하시면 다음 번호로 обслуговування учасників, який вказано на вашому
ပါသည္။ ဘာသာျပန္တစ္ဦးအား ေၾခ်းဇ်ကဳ ပဳၿပ် သျက္၏ အသျက္် ျက္ၾ eigenen Sprache Hilfe und Information zu bekommen. Um 전화해 귀하의 회원 ID 카드에 적힌 회원 서비스 팀 번호로 посвідченні учасника
ကက္ေဳေပၚရွိ အသျက္် ျက္ ဝက္ေ ငျက္င္မႈဝက္်ဝ္ဳနံက္သွိႈသို႔ ောေ ွိႈဳနါ။ mit einem Dolmetscher zu sprechen, Bitte rufen Sie die 전화하십시오.
Mitglieder-Servicenummer auf Ihrer Mitglieder-ID-Karte an VIETNAMESE
CHINESE PENNSYLVANIA DUTCH Nếu bạn hoặc ai đó bạn đang giúp đỡ, có thắc mắc về
如果您或者您在帮助的人对 CareSource 存有疑问，您有权免 GUJARATI જો તમે અથવા તમે કોઇને મદદ કરી રહ્ ાાં તેમ ાંથી કોઇને Wann du hoscht en Froog, odder ebber, wu du helfscht, hot CareSource, bạn có quyền được nhận trợ giúp và thông tin
费获得以您的语言提供的帮助和信息。 如果您需要与一位翻译 CareSource વવશે પ્રશનો હોર્ તો તમને મદદ અને મ હહતી મેવિવ નો અવવક ર en Froog baut CareSource, hoscht du es Recht fer Hilf un bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một
交谈，请拨打您的会员 ID 卡上的会员服务电话号码。 છે . તે ખર્ય વવન તમ રી ભ ષ મ ાં પ્ર પત કરી શક ર્ છે . દ ભ વષર્ો વ ત કરર મ ટે,કૃપા Information in deinre eegne Schprooch griege, un die Hilf thông dịch viên. Vui lòng gọi số dịch vụ thành viên trên thẻ ID
કરીને તમારા સભર આઈડી કાડ્ય પર સભર સેવા માટે ના નંબર પર ફોન કરો. koschtet nix. Wann du mit me Interpreter schwetze witt, Bel thành viên của bạn.
CUSHITE – OROMO alstublieft met het Ledenservice nummer op uw lid ID -kaart.
Isin yookan namni biraa isin deeggartan CareSource irratti HINDI
gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan यदि आपके , या आप जिसकी मिि कर रहे हैं उसके CareSource के बारे में RUSSIAN
keessaniin odeeffannoo argachuu fi deeggarsa argachuuf कोई सवाल हैं तो आपके पास बगैर दकसी लागत के अपनी भाषा में सहायता Если у Вас или у кого-то, кому Вы помогаете, есть
mirga ni qabdu. Nama isiniif ibsu argachuuf, Maaloo और िानकारी प्ाप्त करने का अजिकार है। एक िभाजषए
ु से बात करने के вопросы относительно CareSource, Вы имеете право
lakkoofsa bilbilaa isa waraqaa eenyummaa keessan irra जलए कॉल करें , कृ पया अपने सिसय आईडी काड्ड पर दिये सिसय सेवा नंबर бесплатно получить помощь и информацию на Вашем
jiruun tajaajila miseensaatiif bilbilaa. पर कॉल करें ।
35 36Request a Member Handbook or
Provider Directory
You’ve got options! It’s easy!
1. Online: For the member handbook, visit www.caresource.
com/in/plans/medicaid/plan-documents/ and click on
the member handbook link. For the provider directory, visit
findadoctor.CareSource.com.
2. Phone: Call Member Services at 1-844-607-2829
(TTY: 1-800-743-3333 or 711) Monday through Friday
PLEASE TEAR OFF THIS CARD AND DROP IN THE
from 8 a.m. to 8 p.m. Eastern Time. We are happy to MAIL FOR A PRINTED MEMBER HANDBOOK.
answer your questions or send you materials.
3. Scan the code below to see the member handbook:
4. Print: Tear off the card(s) and drop in the mail. You do
not need to address or add postage. We will mail you a
member handbook or a provider directory.
Thank you for your request.
FOR CARESOURCE
37 USE ONLYNO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
PLEASE TEAR OFF THIS CARD AND DROP IN THE
BUSINESS REPLY MAIL MAIL FOR A PRINTED PROVIDER DIRECTORY.
FIRST-CLASS MAIL PERMIT NO.91 PLANO TX
POSTAGE WILL BE PAID BY ADDRESSEE
CARE SOURCE
PO BOX 940569
PLANO TX 75094-9818
Thank you for your request.
FOR CARESOURCE
USE ONLYNotice of Non-Discrimination
CareSource complies with applicable state and federal civil CareSource
rights laws and does not discriminate on the basis of age, Attn: Civil Rights Coordinator
gender, gender identity, color, race, disability, national origin, P.O. Box 1947, Dayton, Ohio 45401
marital status, sexual preference, religious affiliation, health 1-844-539-1732, TTY: 711
status, or public assistance status. CareSource does not Fax: 1-844-417-6254
NO POSTAGE exclude people or treat them differently because of age, CivilRightsCoordinator@CareSource.com
NECESSARY gender, gender identity, color, race, disability, national origin,
IF MAILED You can file a grievance by mail, fax, or email. If you need help
IN THE marital status, sexual preference, religious affiliation, health
UNITED STATES status, or public assistance status. filing a grievance, the Civil Rights Coordinator is available to
help you.
CareSource provides free aids and services to people with
You may also file a civil rights complaint with the U.S.
BUSINESS REPLY MAIL
FIRST-CLASS MAIL PERMIT NO.91 PLANO TX
disabilities to communicate effectively with us, such as: (1)
qualified sign language interpreters, and (2) written information Department of Health and Human Services, Office for Civil
in other formats (large print, audio, accessible electronic Rights, electronically through the Office of Civil Rights
POSTAGE WILL BE PAID BY ADDRESSEE formats, other formats). In addition, CareSource provides free Complaint Portal, available at https://ocrportal.hhs.gov/ocr/
language services to people whose primary language is not portal/lobby.jsf, or by mail or phone at:
English, such as: (1) qualified interpreters, and (2) information U.S. Department of Health and Human Services
CARE SOURCE written in other languages. If you need these services, please 200 Independence Avenue, SW Room 509F
PO BOX 940569 call the member services number on your member ID card. HHH Building Washington, D.C. 20201
PLANO TX 75094-9818 If you believe that CareSource has failed to provide the above 1-800-368-1019, 800-537-7697 (TDD)
mentioned services to you or discriminated in another way on Complaint forms are available at
the basis of age, gender, gender identity, color, race, disability,
http://www.hhs.gov/ocr/office/file/index.html.
national origin, marital status, sexual preference, religious
affiliation, health status, or public assistance status, you may
file a grievance, with:
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