The following services are covered by the Indiana Care Select Program. Dual-eligible members, those members eligible for both IHCP and Medicare, will not receive any benefits under Indiana Care Select, since they will be covered via Special Needs Plans. Abortion s (405 IAC 5-28-7) Case Management for Persons with HIV/AIDS (IHCP Provider Manual pg. 8-138) Case Management for Mentally Ill or Emotionally Disturbed (405 IAC 5-21) Case Management for Pregnant Women** (405 IAC 5-11) Chiropractors* (405 IAC 5-12) Abortions may be provided only in the following situations: If the pregnancy is the result of an act of rape or incest; or In the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed. No other abortions, regardless of funding, can be provided as a benefit under the CMO s contract. Targeted case management services limited to no more than 60 hours per quarter. Targeted case management services limited to those provided by or under supervision of qualified mental health professionals who are employees of a provider agency (CMHC) approved by the Department of Mental Health. Limited to one initial assessment, one reassessment per trimester, and one postpartum assessment. Coverage is available for covered services provided by a licensed chiropractor when rendered within the scope of the practice of chiropractic. Limited to five visits and 50 therapeutic physical medicine treatments per member per year. Dental s (405 IAC 5-14) Disease Management Diabetes Self Management Training s* (405-IAC 5-36) Drugs -Prescribed (Legend) Drugs (405 IAC 5-24) Drugs -Over-the-counter (Non-legend) Eligible members will be enrolled in disease management program. Limited to 16 units per member per year. Additional units may be prior authorized. Medicaid covers legend drugs if the drug is: approved by the United States Food and Drug Administration; not designated by CMS as less than effective or identical, related, or similar to less than effective drug; and not specifically excluded from coverage by Indiana Medicaid Medicaid covers non-legend (over-the-counter) drugs on its formulary. This is available at: http://www.indianapbm.com E-1
Early Intervention s (Early Periodic Screening, Diagnosis and Treatment [EPSDT]) (405 IAC 5-15) Emergency s (IC 12-15-12-15 & -17) Eye Care, Eyeglasses and Vision s (405 IAC 5-23) Family Planning s and Supplies (IHCP Provider Manual pg. 8-178) Federally Qualified Health Centers (FQHCs) (405 IAC 5-16-5) Food Supplements, Nutritional Supplements, and Infant Formulas** (405 IAC 5-24-9) Hospital s - Inpatient* (405-IAC 5-17) Hospital s - Outpatient* (405-IAC 5-17) Home Health s** (405 IAC 5-16) Hospice care** (405 IAC 5-34) Laboratory and Radiology s (405 IAC 5-18; 405 IAC 5-27) Covers comprehensive health and development history, comprehensive physical exam, appropriate immunizations, laboratory tests, health education, vision services, dental services, hearing services, and other necessary health care services in accordance with the HealthWatch EPSDT periodicity and screening schedule. Emergency services are covered subject to the prudent layperson standard of an emergency medical condition. All medically necessary screening services provided to an individual who presents to an emergency department with an emergency medical condition are covered. Coverage for the initial vision care examination will be limited to one examination per year for a member under 19 years of age and one examination every two years for a recipient 19 years of age or older unless more frequent care is medically necessary. Coverage for eyeglasses, including frames and lenses, will be limited to a maximum of one pair per year for members under 19 years of age and one pair every two years for members 19 years and older. Family planning services include: limited history and physical examination; pregnancy testing and counseling; provision of contraceptive pills, devices, and supplies; education and counseling on contraceptive methods; laboratory tests, if medically indicated as part of the decision- making process for choice of contraception; initial diagnosis and treatment (no on-going treatment) of sexually transmitted diseases (STDs); screening, and counseling of members at risk for HIV and referral and treatment; tubal ligation; vasectomies. Pap smears are included as a family planning service if performed according to the United States Preventative s Task Force Guidelines. Coverage is available for medically necessary services provided by licensed health care practitioners. Coverage is available only when no other means of nutrition is feasible or reasonable. Not available in cases of routine or ordinary nutritional needs. Inpatient services are covered when such services are provided or prescribed by a physician and when the services are medically necessary for the diagnosis or treatment of the member's condition. Outpatient services are covered when such services are provided or prescribed by a physician and when the services are medically necessary for the diagnosis or treatment of the member's condition. Coverage is available to home health agencies for medically necessary skilled nursing services provided by a registered nurse or licensed practical nurse; home health aide services; physical, occupational, and respiratory therapy services; speech pathology services; and renal dialysis for home-bound individuals. s must be ordered by a physician. E-2
Long Term Acute Care Hospitalization (IHCP Provider Manual Chapter 14-33) Medical supplies and equipment (includes prosthetic devices, implants, hearing aids, dentures, etc.)** (405 IAC 5-19) Mental health services-inpatient** (State Psychiatric Hospital) (405 IAC 5-20-1) Mental health services-inpatient** (Free-standing Psychiatric Facility) (405 IAC 5-20) Mental health services-outpatient (405 IAC 5-20-8) Medicaid Rehabilitation Option (MRO) - Community Mental Health Centers (405 IAC 5-21) Mentally Retarded s- Intermediate Care Facilities ** (405 IAC 5-13-2, IHCP Provider Manual, Chapter 14) Nurse-midwife services (405 IAC 5-22-3) Nurse Practitioners (405 IAC 5-22-4) Nursing Facility s** (Long-term) (405 IAC 5-31-1, IHCP Provider Manual, Chapter 14) Nursing Facility s (Short-term) (405 IAC 5-31-1) Long term acute care services are covered. Prior authorization is required. An all inclusive per diem rate is paid based on level of care. Coverage is available for medical supplies, equipment, and appliances suitable for use in the home when medically necessary. Medicaid reimbursement is available for inpatient psychiatric services provided to an individual between 22 and 65 years of age in a certified psychiatric hospital of 16 beds or less. Coverage includes mental health services provided by physicians, psychiatric wings of acute care hospitals, outpatient mental health facilities and psychologists endorsed as Health s Providers in Psychology. Coverage includes outpatient mental health services, partial hospitalization (group activity program) and case management. The codes for MRO services are: H0031-HW; H0004-HW, - HS, -HR, or -HQ; H2011-HW; H0033-HW; H2014-HW; H0035-HW; T01016-HW or -TG; 97535-HW or -HQ; 97537 -HW or -HQ. Coverage is available for services rendered by a certified nurse-midwife when referred by a PMP. Coverage of certified nursemidwife services is restricted to services that the nurse-midwife is legally authorized to perform. Coverage is available for medically necessary services or preventative health care services provided by a licensed, certified nurse practitioner within the scope of the applicable license and certification. The MCO may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than 30 calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The MCO can negotiate rates for reimbursing the nursing facilities for these short-term stays. E-3
Occupational Therapy** (405 IAC 5-22-6) Organ Transplants (405 IAC 5-3-13) Orthodontics** (IHCP Provider Manual, pg. 8-282) Out-of-state Medical s** (405 IAC 5-5) Physicians' Surgical and Medical s* (405-IAC 5-25) Physical Therapy** (405 IAC 5-22-10) Podiatrists (405 IAC 5-26) Psychiatric Residential Treatment Facility (PRTF) (405 IAC 5-20-3.1) Rehabilitative Unit s - Inpatient** (405 IAC 5-32) Respiratory Therapy* (405 IAC 5-22-8) Rural Health Clinics (405 IAC 5-16-5) Smoking Cessation s (405 IAC 5-37) Substance Abuse s-inpatient** (Free-standing Psychiatric Facility) (405 IAC 5-20-3) s must be ordered by a M.D. or D.O. and provided by qualified therapist or assistant. Prior authorization is not required for initial evaluations, or for services provided within 30 calendar days following discharge from a hospital when ordered by a physician prior to discharge. Cannot exceed 12 hours, sessions or visits in 30 calendar days. Coverage is in accordance with prevailing standards of medical care. Similarly situated individuals are treated alike. Medicaid reimbursement is available for the following services provided outside Indiana: acute hospital care; physician services; behavioral health services, dental services; pharmacy services; transportation services; therapy services; podiatry services; chiropractic services; and durable medical equipment and supplies. All out-of-state services are subject to the same limitations as instate services. Coverage includes reasonable services provided by a M.D. or D.O. for diagnostic, preventive, therapeutic, rehabilitative or palliative services provided within scope of practice. PMP office visits limited to a maximum of 4 per month or 20 per year per member per provider without prior authorization. s must be ordered by a M.D. or D.O. and provided by qualified therapist or assistant. Prior authorization is not required for initial evaluations, or for services provided within 30 calendar days following discharge from a hospital when ordered by a physician prior to discharge. Cannot exceed 12 hours, sessions or visits in 30 calendar days. Surgical procedures involving the foot, laboratory or x-ray services, and hospital stays are covered when medically necessary. No more than six routine foot care visits per year are covered. The following criteria shall demonstrate the inability to function independently with demonstrated impairment: cognitive function, communication, continence, mobility, pain management, perceptual motor function, or self-care activities. s must be ordered by a M.D. or D.O. and provided by qualified therapist or assistant. Prior authorization is not required for inpatient or outpatient hospital, emergency, and oxygen in a nursing facility, 30 calendar days following discharge from hospital when ordered by physician prior to discharge. Coverage is available for services provided by a physician, nurse practitioner, or appropriately licensed, certified, or registered therapist employed by the rural health clinic. Reimbursement is available for one 12-week course of treatment per member per calendar year. One or more modalities may be prescribed and counseling may be included in any combination of treatment. Medicaid reimbursement is available for inpatient psychiatric services provided to an individual between 22 and 65 years of age in a certified psychiatric hospital of 16 beds or less. E-4
Substance Abuse s-outpatient (405 IAC 5-20-8) Substance Abuse s-inpatient** (State Psychiatric Hospital) (405 IAC 5-20) Speech, Hearing and Language Disorders* (405 IAC 5-22-9) Transportation Emergency* (405 IAC 5-30) Transportation Non-emergent (405 IAC 5-30) Coverage includes mental health services provided by physicians, psychiatric wings of acute care hospitals, outpatient mental health facilities and psychologists endorsed as Health s Providers in Psychology. s must be ordered by a M.D. or D.O. and provided by qualified therapist or assistant. Prior authorization is not required for initial evaluations, or for services provided within 30 calendar days following discharge from a hospital when ordered by physician prior to discharge. Coverage has no limit or prior approval for emergency ambulance or trips to/from hospital for inpatient admission/discharge, subject to the prudent layperson standard Non-emergency travel is available for up to 20 one-way trips of less than 50 miles per year without prior authorization. E-5