There are some health services that are not covered by the Hoosier Healthwise program. For a complete list of these services, see the Hoosier Healthwise section of the member handbook. There are some network, service or benefit restrictions, see the Hoosier Healthwise section of the member handbook for more information.
Hoosier Healthwise Member Handbook (English) | Hoosier Healthwise Member Handbook (Spanish)
Hoosier Healthwise Covered Medical Services
MDwise wants to help you stay healthy. That is why we cover preventive care as well as sick care. If there are changes to your benefits, we will let you know by mail. If you have any questions about your benefits, please talk to your doctor or call MDwise customer service.
Preventive Care
Getting regular preventive care is the key to better health. You get preventive care when you go to the doctor for check-ups and other well care. MDwise covers preventive care because it keeps you healthy and checks for problems before they become serious. Examples include:
- Check-ups and shots for adults and children.
- Care for pregnant women.
- Well-baby care.
- Physical exams.
- Mammograms and Pap smears.
Necessary Care
Care must be “medically necessary.” This means it is:
- Needed to diagnose or treat you.
- Proper based on current medical standards.
- Not more than what is needed.
Prior Authorization
Some services need approval from MDwise before you get them. This is called prior authorization. If your doctor does not get prior authorization when it is needed, MDwise will not pay for the services. Prior authorization decisions are based only on the appropriateness of care and services. These decisions are also based on whether or not you have coverage. Doctors and staff who make prior authorization decisions do not get incentives or rewards for making these decisions. They do not get payment for deciding to deny a service or for making decisions that may make it harder to get care and services.
Your health care provider will call the prior authorization department for you to ask questions about prior authorization requests or to request a prior authorization. You can also call the prior authorization department with questions about prior authorization requests from your health care provider and in general. You can reach them via a toll-free number at 1-800-788-2949 Monday–Friday from 8 a.m. to 5 p.m. This does not include holidays. The language line can assist non-English speaking callers. If you call the toll-free number after hours, on a holiday or on a weekend, you can leave a voicemail and the department will call you back the next business day.
Services From Other Providers for Hoosier Healthwise Members
Sometimes, you may need to see a provider other than your regular doctor.
Seeing a Specialist
A specialist is a doctor who treats one part of the body, like the heart, skin or bones. Your regular doctor will write you a referral if you need to see a specialist.
Self-Referral Services
MDwise covers these services. Your doctor can help you get these services, but you do not have to go through your doctor to get them. You can go to any Hoosier Healthwise provider to get these services. Self-referral providers must get an okay from MDwise before giving you some services.
Remember, your doctor can best take care of you if you talk to the doctor before getting any kind of health care.
The following services are “self-referral” services within the MDwise network:
- Eye care.
- Foot care.
- Mental health and substance abuse services.
- Chiropractor services.
- Emergency services.
- Urgent care services.
- HIV case management.
- Family planning (If your family planning provider prescribes birth control pills, you can get a 90 day supply).
- Immunizations (for example, at health department, school).
- Diabetes self-management training (if given by a self-referral provider).
- Services from a psychiatrist.
- School-based health services. (Immunizations, sick visit)
- School based health services help meet the needs of a student or family member. Services can include mental or behavioral services, healthy habit education plus injury prevention. Talk with your child’s school or call MDwise Customer Service at 1-800-356-1204.
Services Outside MDwise
For most services you need to go to a MDwise provider. For some services, you can go to any Hoosier Healthwise provider who is registered with IHCP. If you get these services, please let your doctor know. This helps them take care of you. You do not have to get all of your maternity services from MDwise.
For questions, call customer service or contact your doctor.
- Services for a student’s individualized education program (IEP).
- Medicaid Rehabilitation Option (MRO) services.
Services Not Covered By MDwise
The following services are not covered by MDwise under Package A:
- Services provided in a nursing home (long-term facility).
- Services provided in an intermediate care facility
for individuals with intellectual disabilities (ICF/IID).
- Hospice care.
- Services under the home and community-based services (HCBS) waiver.
- Psychiatric treatment in a State hospital.
- Psychiatric Residential Treatment Facility (PRTF) services.
If you need these services, there may be programs outside of Hoosier Healthwise that can help cover these services. To learn more, call Hoosier Healthwise at 1-800-889-9949.
The following services are not covered by MDwise under Package C:
- Services provided in a nursing home (long-term facility).
- Services provided in a nursing home (short term facility).
- Services provided in an intermediate care facility for the mentally retarded (ICF/MR).
- Hospice care.
- Services under the home and community-based services (HCBS) waiver.