Covered Medical Services for HIP Members
There are some network, health service or benefit restrictions, see pages 19-20 of the Healthy Indiana Plan member handbook for more information.
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MDwise wants to help you stay healthy. That is why we cover preventive care as well as sick care. We will let you know by mail if there are changes to your benefits. Even if your benefit plan changes, your ID card will still work. The card is good until you are not enrolled with MDwise in the Healthy Indiana Plan. If you have any questions about your benefits, please talk to your doctor or call MDwise customer service.
It is also important to understand your Benefit Year and Eligibility Period (also known as Redetermination Period). Your Benefit Year starts January 1 and ends December 31 each calendar year. Your Eligibility Period (Redetermination Period) is 12 months from when you are approved for coverage. This can be different for each person.
Benefit Year
- IMPORTANT: You must participate in the annual Eligibility (Redetermination) process.
- Your Benefit Year does not change if you leave the HIP program and return during the year.
- Your benefit limits and POWER Account reset every year in January.
- The HIP Health Plan Selection Period is every year from November 1–December 15. During this time, you will have the chance to stay with your current health plan or change your health plan for the next benefit year.
- NOTE: If you like MDwise you do not need to take any action to stay with your current health plan. Your MDwise coverage will automatically continue into the next benefit year. MDwise is committed to serving your health care needs.
- If you want to change your health plan, you can do that during the Health Plan Selection Period that happens every year from November 1–December 15. You will need to contact the enrollment broker at 1-877-438-4479.
- If you get preventive services, your POWER Account payments may be less the next year.
Eligibility (also known as Redetermination) Period:
- You can buy in to HIP Plus during the Eligibility Period.
- Letters for your eligibility will come from the Indiana Family and Social Services Administration (FSSA).
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. In addition, your future POWER Account contributions could be lower if you get any of your preventive care services.
Examples of preventive care include:
- Check-ups and shots.
- Physical exams.
- Mammograms and Pap smears.
- Eye care exams.
- Dental exams.
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. MDwise will not pay for the services if your doctor does not get prior authorization when it is needed. Prior authorization decisions are based on whether the care and services are appropriate. These decisions are also based on whether or not you have coverage.
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 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 HIP 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
The table below outlines the self-referral services for each HIP health plan. You do not need a referral from your doctor to receive these services. You may go out of network for these services unless it states below "in-network only."
| Eye care. |
not covered for age 21+ |
X |
X |
X |
X |
| Dental services (in-network only). |
not covered for age 21+ |
X |
X |
X |
X |
| Psychiatric services. |
X |
X |
X |
X |
X |
| Family planning. |
X |
X |
X |
X |
X |
| Emergency services (including dental emergencies). |
X |
X |
X |
X |
X |
| Immunization. |
X |
X |
X |
X |
X |
| Diabetes self-management (in-network only). |
X |
X |
X |
X |
X |
| Behavioral health services (in-network only). |
X |
X |
X |
X |
X |
| Urgent care. |
X |
X |
X |
X |
X |
| Chiropractic services. |
not covered in HIP Basic |
X |
X |
X |
X |
| Podiatry. |
not covered in HIP Basic except when medically necessary |
not covered in HIP Plus except when medically necessary |
X |
X |
X |
Services Outside MDwise
For most services you need to go to a MDwise provider. For some services, you can go to any HIP 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 Healthy Indiana Plan Maternity services from MDwise. For questions, call customer service or contact your doctor.
Services Not Covered
The following services are not covered under the Healthy Indiana Plan:
- Long-term care services.
- Bariatric surgery (not covered for HIP Basic).
- Services provided in an intermediate care facility for individuals with intellectual disabilities (ICF/IID).
- Psychiatric treatment in a State hospital.
- Services under the home and community based services (HCBS) waiver.
- Services that are not medically necessary.
- Dental services (not covered for HIP Basic members 21 and older except for emergency services).
- Conventional or surgical orthodontics, or any treatment of congenitally missing, malpositioned, or super numerary teeth, even if part of a congenital anomaly.
- Vision services (not covered for HIP Basic for members 21 and older).
- Podiatry (not covered for HIP Basic and HIP Plus members unless medically necessary).
- Elective abortions and abortifacients.
- Chiropractic services, except for those services covered under the plan that are within the scope of practice of a chiropractor (Not covered for HIP Basic).
- Drugs excluded from HIP.
- Experimental and investigative services except for cancer related.
- Day care and foster care.
- Personal comfort or convenience items.
- Cosmetic services, procedures, equipment or supplies, and complications directly relating to cosmetic services, treatment or surgery, with the exception of reconstructive services performed to correct a physical functional impairment of any area caused by disease, trauma, congenital anomalies or a previous medically necessary procedure.
- Safety glasses, athletic glasses and sunglasses.
- LASIK and any surgical eye procedures to correct refractive errors.
- Vitamins, with the exception of vitamins included through the pharmacy benefit.
- Wellness benefits other than tobacco cessation.
- Diagnostic testing or treatment in relation to infertility.
- In vitro fertilization.
- Gamete or zygote intrafallopian transfers.
- Artificial insemination.
- Behavioral and Primary Healthcare Coordination (BPHC) Services
- Reversal of voluntary sterilization.
- Gender reassignment surgery.
- Treatment of sexual dysfunction.
- Body piercing.
- Alternative or complementary medicine including, but not limited to, acupuncture, holistic medicine, homeopathy, hypnosis, aroma therapy, reiki therapy, massage therapy and herbal, vitamin or dietary products or therapies.
- Treatment of hyperhidrosis.
- Court-ordered testing or care, unless medically necessary.
- Travel-related expenses including mileage, lodging and meal costs, except when medically related with a prior authorization (PA).
- Missed or canceled appointments for which there is a charge. Note: IHCP providers are not allowed to charge missed or canceled appointment fees.
- Services and supplies provided by, prescribed by, or ordered by immediate family members, such as spouses, caretaker relatives, siblings, inlaws or self.
- Services and supplies for which an enrollee would have no legal obligation to pay in the absence of coverage under the plan.
- Routine foot care not covered in HIP Basic and Plus unless medically necessary.
- Surgical treatment of the feet to correct flat feet, hyperkeratosis, metatarsalgia, subluxation of the foot and tarsalgia.
- Any injury, condition, disease or ailment arising out of the course of employment if benefits are available under any Worker’s Compensation Act or other similar law.
- Examinations for the purpose of research screening