Benefits Grid
Preventive Services
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Affordable Care Act (ACA) Preventive Services | Covered | Covered | Covered |
| Routine Check-Ups | Covered | Covered, limitations may apply | Covered |
| Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) | Covered, up to age 21 | Covered, up to age 21 | Not Covered |
| Immunizations | Covered | Covered, limitations may apply | Covered, limitations may apply |
Professional Office Services
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Primary Care Provider | Covered | Covered | Covered |
| Office Visit | Covered | Covered | Covered |
| Allergy Testing | Covered | Covered | Covered |
| Allergy Serum and Injections | Covered | Covered | Covered |
| Certified Nurse Midwife Services | Covered | Covered | Covered |
| Chiropractor | Covered, limitations may apply | Covered, limitations may apply | Covered, limitations may apply |
| Contraceptive Devices | Covered | Covered | Covered |
| Family Planning and Family Planning Related Services | Covered | Covered | Covered |
| Injections | Covered, limitations may apply | Covered, limitations may apply | Covered, limitations may apply |
| Laboratory Tests | Covered | Covered | Covered |
| Child Care Medical Services | Covered, up to age 21 under EPSDT | Not Covered | Not Covered |
| Newborn Child - Office Visits | Covered | Covered | Covered |
| Podiatry | Covered Routine foor care is not covered unless it is part of a Member's overall treatment related to certain health care conditions. |
Covered Routine foor care is not covered unless it is part of a Member's overall treatment related to certain health care conditions. |
Covered |
| Routine Eye Exam One routine vision exam per calendar year |
Covered | Covered | Covered |
| Routine Hearing Exam One routine hearing exam per calendar year |
Covered | Covered | Covered |
| Specialist Office Visit | Covered, PCP referral may be required | Covered, PCP referral may be required | Covered, PCP referral may be required |
Inpatient Hospital Services
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Preapproval of Inpatient Admissions | Covered, required for non-emergent admissions | Covered, required for non-emergent admissions | Covered, required for non-emergent admissions |
| Room and Board | Covered | Covered | Covered |
| Inpatient Physician Services | Covered, includes anesthesia | Covered, includes anesthesia | Covered |
| Inpatient Supplies | Covered | Covered | Covered |
| Inpatient Surgery | Covered | Covered | Covered |
| Bariatric Surgery for Morbid Obesity | Covered | Not Covered | Covered, limitations may apply |
| Breast Reconstruction, following breast cancer and masectomy | Covered | Covered | Covered, limitations may apply |
| Organ/Bone Marrow Transplants | Covered, limitations may apply | Covered, limitations apply | Covered, limitations may apply |
Outpatient Hospital Services
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Ambulance | Covered | Covered | Covered |
| Urgent Care Center | Covered | Covered | Covered |
| Hospital Emergency Room | Covered | Covered, $8.00 per visit for non-emergent medical services | Covered, emergency services for non-emergent conditions are subject to a $25 copay if the family pays a premium for the Hawki program |
| Non-Emergency Medical Transportation (NEMT) | Covered | Not Covered | Not Covered |
Behavioral Health Services
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Assertive Community Treatment (ACT) | Covered | Covered when the member has been determined to be medically exempt pursuant to 441 IAC subrule 74.12(3) | Not Covered |
| Behavioral Health Intervention Services (BHIS), including applied behavior analysis | Covered | Covered, residential treatment is covered when the member has been determined to be medically exempt pursuant to 441 IAC subrule 74.12(3) | Not Covered |
| (b)(3) services (intensive psychiatric rehabilitation, community support services, peer support, and residential substance use treatment) | Covered (MCO Members only) | Covered when the member has been determined to be medically exempt pursuant to 441 IAC subrule 74.12(3) | Not Covered |
| Inpatient Mental Health and Substance Abuse Treatment | Covered | Covered, limitations may apply | Covered |
| Office Visit | Covered | Covered | Covered |
| Outpatient Mental Health and Substance Abuse | Covered | Covered | Covered |
| Psychiatric Medical Institutions for Children (PMC) | Covered | Covered, for 19 to 20 year olds. Limitations may apply | Not Covered |
| Crisis Response and Subacute Mental Health Services | Covered | Covered | Covered |
Outpatient Therapy Services
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Cardiac Rehabilitation | Covered | Covered | Covered |
| Occupational Therapy | Covered | Covered, limited to 60 visits per year | Covered |
| Oxygen Therapy | Covered | Covered, limited to 60 visits in a 12-month period | Covered |
| Physical Therapy | Covered | Covered, limited to 60 visits per year | Covered |
| Pulmonary Therapy | Covered | Covered, limited to 60 visits per year | Covered |
| Respiratory Therapy | Covered | Covered, limited to 60 visits per year | Covered |
| Speech Therapy | Covered | Covered, limited to 60 visits per year | Covered |
Radiology Services
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Mammography | Covered | Covered | Covered |
| Routine Radiology Screening and Diagnostic Services | Covered | Covered | Covered |
| Sleep Study Testing | Covered | Covered, sleep apnea diagnostic services only | Covered |
Laboratory Services
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Colorectal Cancer Screening | Covered | Covered | Covered |
| Diagnostic Genetic Testing | Covered | Covered | Covered |
| Pap Smears | Covered | Covered | Covered |
| Pathology Tests | Covered | Covered | Covered |
| Routine Laboratory Screening and Diagnostic Services | Covered | Covered | Covered |
| Sexually Transmitted Infection (STI) and Sexually Transmitted Disease (STD) Testing | Covered | Covered | Covered |
Durable Medical Equipment
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Medical Equiipment and Supplies | Covered | Covered | Covered |
| Diabetes Equipment and Supplies | Covered | Covered, limitations may apply | Covered |
| Eye Glasses | Covered, limitations may apply | Covered, for ages 19 and 20, limitations may apply | Covered, limitations may apply |
| Hearing Aids | Covered | Covered, for ages 19 to 20, limitations may apply | Covered, limitations may apply |
| Orthotics | Covered, limitations may apply | Not Covered | Covered, limitations may apply |
Long Term Support Services (LTSS) - Community Based
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Care Management - HCBS Waiver and HCBS Habitation Populations Only | Covered | Not Covered | Not Covered |
| Section 1915(C) Home-and-Community-Based Services (HCBS) | Covered | Not Covered | Not Covered |
| Section 1915(I) Habitation Services | Covered | Not Covered | Covered |
Long Term Support Services (LTSS) - Institutional
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| ICF/ID (Intermediate Care Facility for Individuals with Intellectual Disabilities) | Covered, limitations apply | Not Covered | Not Covered |
| Nursing Facility (NF) | Covered | Not Covered | Not Covered |
| Nursing Facility for the Mentally Ill (NF/MI) | Covered | Not Covered | Not Covered |
| Skilled Nursing Facility (SNF) | Covered | Covered, limitations apply, limited to a 120 days stay | Not Covered |
| Skilled Nursing Facility Out of State (Skilled Preapproval) | Covered, limitations apply | Not Covered | Not Covered |
| Community-Based Neurobehavioral Rehabilitation Services | Covered | Not Covered | Not Covered |
Hospice
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Hospice | Covered | Covered, limitations apply | Covered |
Health Homes
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Chronic Conditions Health Homes | Covered | Not Covered | Not Covered |
| Integrated Health Homes | Covered | Not Covered | Not Covered |
Home Health
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Private Duty Nursing / Personal Cares per EPSDT Authority | Covered, up to age 21 under EPSDT | Covered, up to age 21 under EPSDT | Not Covered |
Vision Services
| Services | IA Health Link | IA Health & Wellness Plan - IA Wellness Plan | HAWKI |
|---|---|---|---|
| Exams (Every 12 Months): Additional coverage for exams are covered following eye surgeries or for monitoring of certain medical conditions may be covered. | Covered | Covered | Covered |
| Eyewear | Covered Eyeglasses (frames and lenses) are covered as follows: Under 1 year of age: 3 pairs every 12 months Age 1-3: 4 pairs every 12 months Age 4-7: 1 pair every 12 months Age 8 and over: 1 pair every 24 months |
Covered Eyeglasses (frames and lenses) are covered as follows: Age 19-21: 1 pair every 24 months |
Covered $100 each year towards frames and contact lenses |
| Repairs: Under 21: Covered for lost or damaged glasses. Over 21: Lost or damaged glasses beyond repair are covered once every 12 months |
Covered | Covered Ages 19-20: Coverage for lost or damaged glasses |
Not Covered |
Excluded Services
Services not covered include the following:
- Services or items used for cosmetic purposes only
- Acupuncture
- Infertility Services
- Dental Services
Iowa Total Care does not pay for services not covered. This is not a complete list of excluded services. If you wish to know if a service is covered, please call Member Services at 1-833-404-1061 (TTY 711).