Medicaid, known in Indiana as the Indiana Health Coverage Programs (IHCP), provides medical coverage to eligible low-income residents, children, pregnant individuals, and people with disabilities. The specific services an enrollee receives depend heavily on the program they qualify for. Indiana manages its Medicaid through various distinct programs, including Hoosier Healthwise (for children and pregnant individuals), the Healthy Indiana Plan (HIP) (for most adults), Hoosier Care Connect (for certain disabled or low-income adults), and Indiana PathWays for Aging (for seniors). These programs are largely administered through Managed Care Entities (MCEs) which coordinate the delivery of care and benefits.
Core Medical Coverage
The foundation of Indiana Medicaid coverage consists of mandatory services required by federal law, which focus on acute and primary care. These services are delivered through a network of providers, ensuring access to necessary medical intervention for enrollees. Inpatient hospital services, which cover acute care stays, are reimbursed using a prospective system. Outpatient services, including visits to primary care physicians and specialists, are covered when medically necessary for diagnosis or treatment.
Prescription drug coverage is a standard benefit, subject to the Indiana Health Coverage Programs’ preferred drug list (PDL) and generic substitution requirements. Pharmacists must substitute a generically equivalent drug product if it results in a lower price, unless the prescriber explicitly indicates “Brand Medically Necessary.” Laboratory and X-ray services are covered when ordered by a licensed practitioner. Federally Qualified Health Centers (FQHCs) also receive reimbursement for covered services, ensuring that comprehensive primary care is available in medically underserved urban and rural communities.
Specialized Health Services
Indiana Medicaid covers several services that may be optional under federal law or come with specific limitations, particularly for adult enrollees. Behavioral health and substance use disorder (SUD) treatment are covered, including mental health counseling, therapy, and both inpatient and outpatient SUD services.
Adult dental and vision coverage often represent the most significant limitations outside of specialized or enhanced plans. While adults may receive one oral exam every twelve months, extensive services like crowns, root canals, or full dentures may be restricted or only available under specific programs like HIP Plus. Routine vision coverage for adults is often limited to one eye exam every two years, with eyeglasses typically covered only if medically necessary. Non-Emergency Medical Transportation (NEMT) is provided to all managed care enrollees, ensuring that individuals without means can get rides to and from covered medical appointments.
Long-Term Services and Supports
Medicaid is the primary payer for long-term services and supports (LTSS) for individuals with chronic illness, disability, and aging-related needs. Institutional care, specifically nursing facility services, is covered when an individual meets the “nursing facility level of care” (NF LOC) criteria, which involves a functional assessment. This coverage is available to those who meet strict financial and medical eligibility requirements.
Indiana utilizes Home and Community-Based Services (HCBS) waivers to allow eligible individuals to receive necessary care in their homes or community settings rather than in a nursing facility. The Aged & Disabled Waiver transitioned into two separate programs: the Health & Wellness Waiver (for individuals under age 60) and the Indiana PathWays for Aging program (for those aged 60 and older). These waivers cover services designed to assist with Activities of Daily Living (ADLs) and instrumental ADLs, including:
- Personal care assistance
- Adult day services
- Respite care for caregivers
- Home modifications for accessibility
- Specialized medical equipment
Coverage for Children and Youth
Coverage for children and youth under age 21 is significantly more comprehensive than for adults, due to the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) mandate. Indiana refers to its EPSDT program as HealthWatch, which emphasizes preventive care and early intervention. The mandate requires comprehensive health and developmental screenings at specific intervals, ensuring that potential physical and mental health issues are identified early.
EPSDT ensures that all medically necessary diagnostic and treatment services are covered to “correct or ameliorate” any physical or mental illness or condition discovered during a screening. This means that if a service is necessary to treat a child’s condition, it must be covered, even if that specific service would not be covered for an adult under the state’s plan. This broad requirement covers a wide range of services, including enhanced dental, vision, hearing, and developmental therapies, extending beyond the limitations placed on general adult coverage.