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).