Hoosier Healthwise (HHW)

Click on any of the links below to learn more.
 

HOOSIER HEALTHWISE COVERED MEDICAL SERVICES AND COSTS


HHW-Logo-Crayons.jpgMDwise 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.
 


How to Know What Medical Services Cost


It is important to know what your medical services cost. If you want to know costs before you get a medical service, please visit MDwise.org. We have posted a list of common medical services and their costs. You can also call MDwise customer service. We can mail you a list of these common services and their costs. If you have a specific service that is not listed, please call MDwise customer service and we will research it for you. We will call you back to let you know the cost for that 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.

The prior authorization departments are available via a toll-free number from 8 a.m. to 5 p.m. Monday through Friday excluding holidays. The language line is available to assist non-English speaking callers. The prior authorization department is available to answer any questions regarding a specific prior authorization request. They can also answer general questions regarding prior authorization. Your health care provider will contact the prior authorization department on your behalf to ask questions regarding prior authorization or request a prior authorization. If you call the toll-free number after hours or on a holiday or weekend, a voice recording is available and all messages are returned the following business day.


Services Your Doctor Must Approve First


Package A members can get the full list of services on the following page. Your doctor must approve all these services.

Package C is for children. Package C members can get the full list of health care services shown on the following page. Your child must get these services from his or her doctor or through a referral from the doctor. Please read the list carefully. Some types of services have limits on how many visits your child’s benefits will cover.

Package P is for members who are “presumptively eligible” for services due to their pregnancy. This means that some health services are covered while you wait for your Hoosier Healthwise application to be approved. Package P covers pregnancy related services and prescriptions. However, Package P does not cover the delivery of your baby or “inpatient hospital care.” Hoosier Healthwise Package A covers inpatient care such as the delivery of your baby.

If you are not sure which benefit package you have, please call MDwise customer service.

To get the following services, you must call or go to your doctor first. The doctor will refer you for any treatments you need.

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MDwise looks at new medical and behavioral health procedures. MDwise also looks at new drugs and equipment. To help us do this we use:
  • Experts.
  • Research.
  • Government decisions.

This helps to decide if they are safe and should be provided for our members.

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SERVICES FROM OTHER PROVIDERS FOR HOOSIER HEALTHWISE MEMBERS


Sometimes, you may need to see a provider other than your regular doctor. The next few pages explain how to do that.


Seeing a Specialist


hip-basic-icon.pngA 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. You must get a referral from your doctor before going to a specialist.

MDwise will not cover specialist care unless you have a referral from your doctor. Your doctor will tell you how to get specialist care.


Self-Referral Services


The following services are “self-referral” services:
  • Eye care.
  • Foot care.
  • Mental health and substance abuse services (See page 9 for behavioral health information).
  • 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.

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.


Services Outside MDwise


You do not have to get all of your Hoosier Healthwise services from MDwise. For some services, you can go to any Hoosier Healthwise provider. If you get these services, please let your doctor know. This helps them take care of you. The services that you may get outside of MDwise are:
  • Dental services (See page 41 for dental information).
  • Services for a student’s individualized education program (IEP).
  • Medicaid Rehabilitation Option (MRO) services.
  • Pharmacy services (See page 40 for more information).
  • Services for an Individualized Family Services Plan (IFSP) or the First Steps program. You do not need your doctor’s okay for these services. But if you want, your doctor can help you find these 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 the mentally retarded (ICF/MR).
  • 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.
  • Case management for the following:
    1. Persons with HIV/AIDS.
    2. Pregnant women.
  • Psychiatric treatment in a State hospital.
  • Organ transplants.
  • Over-the-counter drugs (except insulin when prescribed).
  • Psychiatric Residential Treatment Facility (PRTF) services.

If your child needs 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.

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HOOSIER HEALTHWISE PHARMACY SERVICES


Medicines for MDwise Hoosier Healthwise (HHW) members are covered. You can go to any MDwise participating pharmacy that accepts Indiana Medicaid. If you have pharmacy questions or problems, please call 1-844-336-2677.

When you or your child needs medicine or over-the-counter items, your doctor will write a prescription. You can take that prescription to a participating pharmacy.


Hoosier Healthwise Members


Members who have Internet access, can go to MDwise.org/members and choose your plan, to look up a medication on the formulary. The formulary also tells you some over-the-counter medicines and vitamins that are covered.

You can also visit MDwise.org/findadoctor, then choose “Find a Pharmacy” to see a list of participating pharmacies. If you need help, you can call MDwise customer service at 1-800-356-1204.


Prescription Medicine


MDwise Hoosier Healthwise covers necessary medicines. Your doctor must prescribe these medicines. The medicine must be approved by the Food and Drug Administration (FDA). You can go to any MDwise participating pharmacy that accepts Indiana Medicaid. If you have pharmacy questions or problems, please call MDwise customer service and choose the pharmacy option. The phone number is located on the back of your ID card.

When you need medicine, your doctor will write a prescription. You can take that prescription to any MDwise participating pharmacy.

MDwise Hoosier Healthwise Package C members will have copays of $3.00 for each generic medication and $10.00 for each brand medication.

phone-icon.pngTIP: If you need help finding a pharmacy, call MDwise customer service.

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HOOSIER HEALTHWISE DENTAL SERVICES


dental-icon.pngMDwise uses a company called DentaQuest to provide your dental services under Hoosier Healthwise. Dental care is very important for your health and well-being. You need to have regular check-ups every six months at your dentist’s office.


Contact DentaQuest


For any questions regarding eligibility, finding a dentist, benefits or other questions call DentaQuest toll-free at 844-231-8310. Hours are Monday through Friday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-800-743-3333.

Below are the dental services that are covered under Hoosier Healthwise.

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What’s Not Covered?


Your dentist can tell you the full list of services covered by Hoosier Healthwise.


Find a Dentist


To find a participating dentist with DentaQuest, please call 844-231-8310 or visit DentaQuest.com. Have your member ID card ready when you call. You may also call MDwise customer service if you need assistance.


Emergency Dental Care


If you experience dental pain, call your dentist right away. Your dentist will arrange to see you as soon as possible.


Dental Questions?


For any questions regarding eligibility, finding a dentist, benefits or other questions, call MDwise at 1-800-356-1204, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-743-3333.

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HOOSIER HEALTHWISE EYE CARE


Eye care benefits are available for Hoosier Healthwise members.


Getting Eye Care Services


To get eye care services, you can call an eye doctor (either an optometrist or ophthalmologist). Eye care exams count as a preventive service. The eye doctor must be contracted with the state of Indiana. When making an appointment be sure to ask if the office is contracted with the state of Indiana. You can search for eye care providers at MDwise.org/findadoctor. You can also call MDwise customer service and we can help.


Benefit Summary


Eye Exams
  • One eye exam per year.
  • One eye exam every two years.
  • Additional examinations must be medically necessary.

Eyeglasses (including frames and lenses)
  • One pair of eyeglasses a year.
  • Repairs or replacements of eyeglasses for reasons that are beyond your control. Examples include fire, theft or a car accident.

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HOOSIER HEALTHWISE TRANSPORTATION


Rides to Your Doctor


car-icon.pngMDwise covers transportation to doctor and dentist appointments for Hoosier Healthwise Package A and in the Hoosier Healthwise plan, pregnant presumptively eligible members. You can always get transportation if you are a pregnant Hoosier Healthwise member.

MDwise covers 20 one-way rides to and from your doctor or clinic each year. You should save your trips for when you cannot get a ride any other way. If available in your area, MDwise may give you a bus pass for your trip to the doctor. A bus pass counts as two trips towards your trip limit. If there are any extra trips on the buss pass, you can use them to go to other important appointments.

You should only take an ambulance when it is a true emergency. If you think your problem could cause lasting harm or loss of life, call 911. Hoosier Healthwise Package C members can get ambulance transportation for true emergencies only, at a reduced price. The copay for each ambulance trip is $10.00.

MDwise does not cover trips to the pharmacy.


Scheduling a Ride (non-emergency)


You should call MDwise to arrange a ride the same day you make your doctor’s appointment. If you forget, you must call at least two business days before the doctor’s appointment to get a ride. For example, if your appointment is on Wednesday, you must call by Monday at the latest. Weekend days and holidays do not count. If you need an urgent trip, let us know.

phone-icon.pngTIP: Don’t forget to call for your ride as soon as you set up your doctor appointment. If you cancel or change your appointment, call MDwise right away to cancel or change your ride.


If you have used your 20 one-way rides, or if you need transportation further than 50 miles from your home or outside of Indiana, you will need to call MDwise for prior approval for the trip. This means a nurse will need to approve the trip based on medical necessity. If this is the case, call at least three days before your appointment to schedule your transportation. That allows MDwise time to get your trip approved.

When you call for a ride, you should:
  1. Schedule your appointment with your doctor or dentist before you call to schedule a ride.
  2. Have your MDwise member ID card ready. You will also need to know:
    • Your address and phone number.
    • Date the ride is needed.
    • Time of the doctor appointment.
    • Name, address and phone number of the doctor or clinic.
    • Total number of passengers.
    • Time you think the visit will end.
  3. Call MDwise customer service to reserve your ride. Listen carefully and pick the transportation option. You must call between 8:00 a.m.–8:00 p.m., Monday through Friday.
  4. Members must call the MDwise customer service transportation line for a return ride from their appointment, NOT the transportation company.

WHO CAN GET TRANSPORTATION?
The following members can get rides:
  • Any pregnant Hoosier Healthwise Member.
  • Any member in Hoosier Healthwise Package A or Package P Plan.

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CHANGES YOU MUST REPORT AND DOCTOR AND PLAN CHANGES FOR HOOSIER HEALTHWISE MEMBERS


New Address, Phone Number, Change in Income or Change in Family Size


If you move, change your phone number, have a change in your income or a change in your family size, you must let the Division of Family Resources (DFR) know. Go to www.in.gov/fssa/dfr/2999.htm. Click on “Manage Current Benefits.” Log in to the system to make your change. You can also call MDwise customer service for help.

phone-icon.pngTIP: Please call MDwise as soon as you know your new address or phone number. This helps us tell you about special programs and important health care information.
 


Changing Your Plan


You can ask to change your health plan at any time if you have “just cause.” Just cause reasons are listed below.
• The health plan does not have access to medically necessary services covered.
• The health plan does not, for moral or religious reasons, cover the service that you need.
• You need related services to be performed at the same time; not all related services are available within the health plan network; and your primary medical provider or another provider believes that getting the services separately would subject you to unnecessary risk.
• The health plan is disciplined by the Office of Medicaid Policy and Planning.
• The health plan does not have providers experienced in dealing with your health care needs.
• Poor quality of care. Poor quality of care includes failing to meet established standards of medical care and significant language or cultural barriers.
• The member’s primary care provider (PMP) leaves the health plan, and the health plan cannot choose a new PMP suitable for the member’s needs.
• The health plan provides limited access to a primary care clinic or other health services within reasonable proximity to the member’s home.

If you think you have a “just cause” reason, you must first contact MDwise so that we can try to resolve your concern. If you are still unhappy after contacting us, you can contact the Hoosier Healthwise Helpline by phone at 1-800-889-9949 or by mail at:

Hoosier Healthwise
PO Box 441410
Indianapolis, IN 46244


The Hoosier Healthwise Helpline will review your request and help you obtain the form to submit the change.

If you or your family members want to stay with MDwise, you do not need to do anything. You will stay enrolled with the MDwise health plan. If you do not want to stay with the MDwise health plan, please call the Hoosier Healthwise Helpline at 1-800-889-9949 to make that change. If you do not request a change in the first 90 days, you will stay with MDwise. If you have any questions, please call MDwise customer service.


Other Insurance Plans


If you or your child has other health insurance, you must let us know. You can call MDwise or your caseworker. You must also tell us (or your caseworker) if:
  • You have changes in your insurance.
  • You get hurt in a car wreck.
  • You get hurt at work.
  • You get hurt and someone else may have to pay.

The other insurance plans are supposed to help pay for your care. By letting us know about them, you can help make sure they do. Telling us about your other insurance will not reduce your MDwise benefits.


Changing Your Doctor


If you are not happy with your health care or doctor, please call MDwise. We hope you do not want to leave MDwise. We will work with you to fix any problems you have.

We can help you change doctors. You may need to change your doctor when:
  • You have moved.
  • Your doctor has moved or no longer belongs to MDwise.
  • You are not happy with the care you get from MDwise.
  • Someone in MDwise treated you rudely.
  • Your doctor does not return your calls.
  • You have trouble getting the care you want or your doctor says you need.
  • Other reasons - call for more information.

To change your doctor or your child’s doctor, or to ask for a list of doctors in your area, please call MDwise customer service. You can also go to MDwise.org/findadoctor to get a list of MDwise doctors.


Important Information About MDwise Doctors


You can find information about MDwise doctors at MDwise.org/findadoctor. This will tell you many things about doctors and other providers including practice location, phone number, if they are on a bus line, languages they speak, and more.

If you have questions about the quality of MDwise providers please ask us. You can call MDwise customer service and we can research specific doctors for you. The information we give you might include credentialing status and board certifications, licensure and accreditation information, and complaint history. You can also find quality information on facilities, such as hospitals, in the MDwise network. Go to MDwise.org/findadoctor where we have links to information about hospitals. This information is collected nationally by the Department of Health and Human Services. Remember, it is better for you or your child’s health to stay with one doctor, rather than to change doctors often.

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HOOSIER HEALTHWISE REDETERMINATION


Hoosier Healthwise members remain enrolled in their chosen health plan for a one-year period. You are in the MDwise health plan. New members get 90 days to decide if they want to stay in the MDwise plan. After that, you will have an open enrollment period once a year. During this time you will have another chance to choose a new health plan. Once the redetermination period ends, you will stay enrolled in your chosen health plan for the rest of the 12 month period unless you lose your Hoosier Healthwise eligibility.

You can still change your health plan doctor at any time. Please see page 28 on how to change doctors. Please remember that it is better for your health to stay with one doctor than to change often.

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HOOSIER HEALTHWISE CHILDREN WITH SPECIAL NEEDS


Health Needs Screening


If you believe your child has special needs, MDwise can help. You can complete our Health Needs Screening survey. To complete the screening you answer questions about your child’s health. When you complete the survey you earn MDwiseREWARDS points.

You can also call MDwise customer service. Your representative will help you identify your child’s special needs. Children with special needs may be able to get other services.


First Steps Program


1-800-441-7837 (STEP)
The First Steps Program program provides services for children up to age three. The children must be developmentally vulnerable or have a disability. The services include:
  • Screenings and assessments.
  • Help accessing medical care and other resources.
  • Coverage for some health care services that are not covered by Hoosier Healthwise.
  • Support services.
  • Family education and special training.


Children’s Special Health Care Services (CSHCS) Program


1-800-475-1355
This program provides health care services for children through age 21. The child must have a severe, chronic medical condition that does at least one of the following:
  • Has lasted or is expected to last at least two years.
  • OR will produce disability, disfigurement, or limits on function.
  • OR requires special diet or devices.
  • OR without treatment, would produce a chronic disabling condition.

A care coordinator will help you get any medical services you need. For children under three years old, they will help work with First Steps too.

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