Using Your Medicaid Coverage
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Managing a medical condition can be challenging. Be prepared by knowing how to use your Medicaid coverage when you need it most. This fact sheet provides tips to make your plan work for you. For more information on insurance coverage, see our Fact Sheet “Insurance Basics”
What Type of Medicaid do I Have?Indiana has several Medicaid categories. Each one works differently, so it is important to know which type you have. These questions serve as a guide:
If you are unsure which type of Medicaid you have, call the Division of Family Resources at 1-800-403-0864 Where do I go for Medical Care?Many plans require you to choose a Primary Care Provider (PCP). This is the doctor who provides non-emergency care, such as well-visits or screenings, acute care for a minor illness, and diagnosis/treatment for a health problem. Your PCP can do an examination, order tests, and/or make a referral to a medical specialty. If a specialist is needed, you can then choose one that accepts your type of Medicaid. For medical advice outside of regular office hours, call your PCP. If you are experiencing a life- threatening medical emergency, call 911 or go to the emergency room.
How do I Find a Provider?Visit https://www.in.gov/medicaid/members/member-resources/provider-directory/ or call the number on your Medicaid card to find a Medicaid provider. If you are new to Medicaid, click on the same link to see if your current doctor participates.
Can I get a Ride to my Doctor?Medicaid participants are eligible to receive transportation services to and from medical and dental appointments. Call the number on your card to find approved transportation in your area. Package C members are not eligible for non-emergency transportation. For more information on Medicaid transportation, see our Fact Sheets: “Medicaid Transportation: Package A and Package C CHIP” and “Medicaid Transportation: Traditional Medicaid”.
What Does my Plan Cover?All Medicaid plans cover Early and Periodic Screening, Diagnosis and Treatment (EPSDT)—pediatric preventative care—for Indiana children and young adults ages 0-21. For more information, see our Fact Sheet: “Medicaid Health Watch Program: EPSDT”. Some covered services include doctor visits, checkups, shots, dental and vision services, inpatient/outpatient hospital services, medical supplies (including diapers with a prescription for ages 3 and up) and equipment, prescription drugs, laboratory and x-ray services, mental health services, emergency room visits, transportation, and more. Most covered services require Medicaid Prior Authorization (PA).
What is Medicaid Prior Authorization (PA)? How does it Work?Prior Approval or Prior Authorization (PA) is required for certain covered services to document the medical necessity for those services. The provider must show proof that you need the service before Medicaid will cover the cost.
Examples that require PA include: wheelchairs, elective inpatient admission, physical/occupational/speech therapy, psychiatric residential treatment facility, transportation, some prescription drugs, hospice, and more. For Medicaid to approve the PA request in a timely manner and avoid denied coverage, the provider must submit all required paperwork correctly. Note that while many services require PA approval before services are provided, requests for PA can also be submitted and approved retroactively as needed for a covered medical service provided on a prior date. For persons on a Medicaid waiver, using PA can optimize services and maximize the waiver budget. For example, if your goal is to improve independent mobility for a child under 21, you can use Medicaid PA instead of your waiver budget to access Physical Therapy (PT). Contact your case manager about utilizing Medicaid PA services. How does my PCP get Medicaid PA to Cover the Services I Need?First, your provider must assess your needs, so share all pertinent information about your condition with your doctor. Note that the provider must also “verify eligibility” to ensure that your Medicaid coverage is active on both the date of service and the date of the PA request. Be sure to bring your insurance card with you to all appointments and take steps to avoid any lapse in coverage.
The PA process varies based on type of Medicaid. The provider must follow the protocol for your particular plan. Prescription PA: All covered prescription drugs require a physician’s order or prescription and may require a special PA form and supporting medical documentation. A pharmacy that participates in your Medicaid plan can help with securing PA. Home Health: Home health services require PA and a detailed plan of care. Medicaid may cover skilled nursing/home health for persons up to age 21 while the primary caregiver does a non-respite activity (work or school). If the participant receives Medicaid waiver services, home health providers and waiver providers must coordinate with the plan of care. For more detailed information on how to use your Medicaid plan, see From Coverage to Care: A Roadmap to Better Care, or contact Indiana Family to Family at 1-844- 323- 4636. |
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Programs and systems change often. It is important to ensure that you are using the most current information. Please check https://www.inf2f.org/fact-sheets.html for the most recent edition.
This fact sheet was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $96,750 with 89% percent financed with nongovernmental sources. The contents are those of INF2F and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
This fact sheet was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $96,750 with 89% percent financed with nongovernmental sources. The contents are those of INF2F and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
