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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).