CareSource is a nonprofit managed care organization, founded in 1989 and based in Dayton, Ohio, that sells health coverage to more than two million people across 14 states. If you are asking what CareSource insurance is, the short answer is that it is not a single product but three: Medicaid plans for low-income residents, individual plans through the Affordable Care Act Marketplace, and Medicare Advantage plans for people on Medicare. The plans available depend on where you live, and not every state where CareSource operates offers all three.
The company focuses heavily on affordable coverage for low- and moderate-income households, with an emphasis on preventive care and extras like transportation to medical appointments and chronic disease support. Its Medicare Advantage and Medicaid contracts are overseen by the Centers for Medicare & Medicaid Services (CMS), and state insurance departments handle licensing and consumer protection.1CareSource. About Us: The CareSource Difference
The Three Types of CareSource Plans
Medicaid
Medicaid is a joint federal-state program for people with limited income. In the states where CareSource holds a Medicaid contract, it acts as a managed care organization: the state pays CareSource a per-member amount, and CareSource coordinates your care through its provider network. Benefits are broad and out-of-pocket costs are minimal. Preventive care, doctor visits, hospital stays, prescription drugs, maternity care, and mental health services are all typically covered with little or no charge.
Marketplace
CareSource sells individual coverage through the ACA Marketplace in Bronze, Silver, and Gold tiers.2CareSource. Marketplace – CareSource Bronze plans have the lowest monthly premiums and the highest costs when you actually use care. Silver plans sit in the middle and are the only tier that qualifies for cost-sharing reductions if your income is low enough. Gold plans cost more each month but less at the doctor’s office, which suits people who expect regular care.
CareSource also offers specialty Marketplace plans built around chronic conditions. Its diabetes plans include zero-cost chronic care drugs and self-management supplies, and its heart-condition plans cover blood pressure cuffs and cardiac medications at no additional charge.2CareSource. Marketplace – CareSource
Medicare Advantage
Medicare Advantage (Part C) bundles hospital coverage (Part A) and medical coverage (Part B) into a single plan, and most CareSource Medicare Advantage options include prescription drug coverage (Part D) as well.3Medicare. Your Coverage Options These plans often add benefits Original Medicare does not cover, such as routine dental, vision, hearing services, and fitness programs.4Medicare.gov. Understanding Medicare Advantage Plans
What CareSource Plans Cover
Every CareSource Marketplace plan must include the ten categories of essential health benefits required by the Affordable Care Act: doctor and hospital services, prescription drugs, maternity and newborn care, mental health and substance use treatment, rehabilitative services, lab work, preventive care, and pediatric services including dental and vision for children.5HealthCare.gov. Essential Health Benefits – Glossary Medicaid plans cover a similarly broad range of services, and Medicare Advantage plans must cover at least everything Original Medicare covers.
Preventive services like vaccinations, cancer screenings, and annual wellness exams are included at no extra cost across all plan types. Some plans add non-medical benefits. Transportation to medical appointments is available for Medicaid members who live 30 miles or more from their provider, and dual-eligible members (those with both Medicare and Medicaid) can get rides to pharmacies, grocery stores, and community wellness events.6CareSource. Transportation – CareSource
Prescription Drugs
Prescription coverage follows a tiered formulary. Generics sit on the lowest-cost tiers. Brand-name and specialty medications carry higher copays and may require prior authorization or step therapy, where you try a less expensive drug first. If your doctor believes a non-formulary drug is medically necessary because the alternatives would fail or cause harm, you or your prescriber can request a formulary exception, and the prescriber must submit a supporting statement.7eCFR. 42 CFR 423.578 – Exceptions Process
Networks and Emergencies
CareSource is a managed care plan, so you generally need to use in-network providers to get full coverage. Going out of network without approval usually means paying the entire bill. Emergencies are the major exception: federal law bars insurers from charging higher cost-sharing for emergency care just because the hospital was out of network.8HealthCare.gov. Getting Emergency Care The No Surprises Act goes further, banning surprise bills for most emergency services and requiring out-of-network providers at in-network facilities to get your written consent before charging above in-network rates.9Centers for Medicare & Medicaid Services. No Surprises: Understand Your Rights Against Surprise Medical Bills
Out-of-Pocket Ceilings
For the 2026 plan year, federal rules cap out-of-pocket spending on Marketplace plans at $10,600 for an individual and $21,200 for a family.10HealthCare.gov. Out-of-Pocket Maximum/Limit Once you hit that ceiling, the plan pays 100 percent of covered services for the rest of the year. Adult dental and vision benefits vary: Medicaid typically covers routine services, while Marketplace and Medicare Advantage members may need to add optional coverage.
Who Qualifies
Medicaid
Medicaid eligibility depends mostly on income and household size. In the 41 states (including D.C.) that have expanded Medicaid, most adults with household income up to 138 percent of the federal poverty level qualify.11HealthCare.gov. Medicaid Expansion and What It Means for You For 2026, that works out to roughly $22,025 for an individual or $45,540 for a family of four, based on 2026 federal poverty guidelines of $15,960 and $33,000.12U.S. Department of Health and Human Services. 2026 Poverty Guidelines: 48 Contiguous States States that have not expanded Medicaid use stricter thresholds and may limit coverage to specific groups such as pregnant women, children, and people with disabilities. Applicants must be state residents and either U.S. citizens or qualified non-citizens. Federal rules require states to process most Medicaid applications within 45 days, or 90 days when disability is the basis for eligibility.13eCFR. 42 CFR 435.912 – Timely Determination of Eligibility
Marketplace
CareSource Marketplace plans are open to anyone who lives in the plan’s service area, is a U.S. citizen or lawfully present, and is not currently incarcerated. Enrollment runs during the annual Open Enrollment Period. For the 2026 plan year, that window ran from November 1, 2025 through January 15, 2026.14Centers for Medicare & Medicaid Services. Marketplace 2026 Open Enrollment Fact Sheet Outside that window, you can only enroll if you qualify for a Special Enrollment Period after a life event such as losing other coverage, marrying, or having a child.
Premium tax credits are available to households earning between 100 and 400 percent of the federal poverty level. This is a real change for 2026: the enhanced subsidies that had temporarily removed the 400 percent income cap expired on January 1, 2026, and Congress did not extend them.15Congress.gov. Enhanced Premium Tax Credit and 2026 Exchange Premiums A single person earning above roughly $63,840 no longer qualifies for any premium subsidy, and people below the cap will receive smaller subsidies than they did in 2024 or 2025. Cost-sharing reductions that lower deductibles and copays remain available for Silver plan enrollees with income between 100 and 250 percent of FPL.16HealthCare.gov. Federal Poverty Level (FPL) – Glossary
Medicare Advantage
CareSource Medicare Advantage plans are open to people 65 or older, and to younger people who have received Social Security disability benefits for at least 24 months.17Medicare.gov. Getting Medicare Before 65 You need Medicare Part A and Part B already, and you must live in the plan’s service area. Low-income Medicare beneficiaries who also qualify for Medicaid can get extra help covering premiums and out-of-pocket costs.
How Coverage Ends and How to Keep It
CareSource coverage can end for several reasons, and the protections you have depend on the plan.
If you fall behind on premiums for a Marketplace plan and you receive advance premium tax credits, federal rules give you a three-month grace period to catch up.18HealthCare.gov. Premium Payments, Grace Periods, and Losing Coverage During the first month, the insurer keeps paying claims normally. In months two and three, the insurer may hold claims until you pay. Never paying means coverage is canceled back to the end of the first month. If you do not receive premium tax credits, the grace period length varies by state.
Medicaid eligibility is reviewed annually. If a change in income or household size makes you ineligible, the state must give you advance written notice. You then have a Special Enrollment Period of up to 60 days to move to a Marketplace plan, and in some cases up to 90 days if you are reporting a recent loss of Medicaid.19Centers for Medicare & Medicaid Services. Understanding Special Enrollment Periods Miss that window and you may have to wait for the next Open Enrollment Period.
Reporting income and household changes promptly matters for two reasons. It keeps your Medicaid or Marketplace eligibility accurate, and for Marketplace enrollees it lets the Marketplace adjust your advance premium tax credits during the year rather than leaving you with a large repayment at tax time.20HealthCare.gov. Reporting Income, Household, and Other Changes
Appeals When a Claim Is Denied
If CareSource denies a claim, refuses prior authorization, or makes a coverage decision you disagree with, you have the right to appeal. There are two stages: an internal appeal handled by CareSource, and, if that fails, an external review by an independent third party.
For Marketplace plans, you have 180 days from the date of a denial notice to file an internal appeal. Include supporting documentation such as a letter of medical necessity from your doctor, medical records, or test results.21HealthCare.gov. Appealing a Health Plan Decision – Internal Appeals CareSource must decide within 30 days for services you have not yet received and 60 days for services already provided. For urgent situations, the decision is due within 72 hours, or faster depending on your condition.22Centers for Medicare & Medicaid Services. Has Your Health Insurer Denied Payment for a Medical Service – You Have a Right to Appeal
Medicaid members have an additional option: a state fair hearing, an administrative proceeding where you can challenge the state agency’s eligibility or coverage decision directly.23Medicaid.gov. Understanding Medicaid Fair Hearings Factsheet Grievances are different from appeals. A grievance is a complaint about customer service, wait times, or provider behavior rather than about a specific claim. For Medicare Advantage plans, CareSource must resolve grievances within 30 days, with an extension of up to 14 additional calendar days when doing so serves the member’s interest.24Centers for Medicare & Medicaid Services. Grievances