What Does Indiana Medicaid Cover? HIP Plus vs. HIP Basic Benefits

Indiana Medicaid covers hospital and doctor care, prescription drugs, mental health and substance use treatment, dental, vision, hearing, therapy, durable medical equipment, emergency and non-emergency transportation, maternity care, family planning, long-term care, and home and community-based services. What any one member actually receives depends on which Indiana Medicaid program they are enrolled in: Hoosier Healthwise for children and pregnant women, the Healthy Indiana Plan (HIP) for adults 19 to 64, Hoosier Care Connect for blind or disabled Hoosiers under 60, Indiana PathWays for Aging for people 60 and older, or Traditional Medicaid.¹

Core Medical Services

Across Hoosier Healthwise Package A (full Medicaid) and Package C (Indiana’s Children’s Health Insurance Program), the covered list runs long: inpatient and outpatient hospital care, doctor and clinic visits, wellness and well-child checkups, prescription and approved over-the-counter drugs, lab and X-ray services, mental health and substance use treatment, medical supplies and equipment, home health, dental, vision, physical, occupational and speech therapy, emergency transportation, chiropractic care, surgical foot care, and family planning.¹

Package A adds four categories that Package C does not include: nursing facility care, hospice, non-emergency medical transportation, and routine foot care.¹

Prescription Drugs

Indiana Medicaid covers most FDA-approved prescription drugs, approved over-the-counter items, self-injectables including insulin and related supplies, and smoking cessation drugs. Medications are organized on a Statewide Uniform Preferred Drug List and classified as preferred, non-preferred, or neutral. Preferred drugs generally don’t require prior authorization. Non-preferred drugs usually do, and a member may need to try a preferred alternative first.²³

All mental health medications, including antidepressants, antipsychotics, and anti-anxiety drugs, are classified as preferred under Indiana law.³

State law requires pharmacies to dispense the generic version of a drug when one exists, unless a physician provides a medical justification for the brand name. Non-maintenance medications are generally limited to a 30- to 34-day supply, while maintenance drugs for chronic conditions like diabetes or hypertension can be dispensed in larger quantities.²

Several categories of drugs are not covered: medications from non-participating manufacturers, drugs without FDA-approved uses, experimental or investigational drugs, fertility medications, weight-loss drugs, cosmetic or hair-growth medications, and over-the-counter items that are not on the approved formulary.²

When a prescription needs prior authorization, the decision must be made within 24 hours. While a member waits, a pharmacist may dispense a 72-hour emergency supply. Prescription copays are waived for members under 18, for pregnancy or family planning prescriptions, and for drugs given during an emergency room visit, hospital stay, or nursing home stay.²

Mental Health and Substance Use Treatment

Members enrolled in HIP, Hoosier Care Connect, or Hoosier Healthwise can see a behavioral health provider without a referral from their primary care doctor. For psychiatric services, members can self-refer to any enrolled licensed provider; for other outpatient mental health care, the self-referral must be to an in-network provider.⁴

Outpatient coverage includes individual, family, couple, and group counseling, psychiatric evaluations, psychological and neuropsychological testing, Applied Behavior Analysis therapy, crisis intervention and mobile crisis response, intensive outpatient treatment, medication-assisted treatment for opioid use disorder, peer recovery services, annual depression screening, tobacco dependence treatment, and transcranial magnetic stimulation.⁵

Inpatient care is covered in psychiatric hospitals, general hospital psychiatric units, and psychiatric residential treatment facilities for people under 21. Residential substance use disorder treatment and inpatient detoxification are also covered, subject to prior authorization and admission criteria.⁵

Outpatient mental health visits need prior authorization after 20 visits per provider in a rolling 12-month period. Package C (CHIP) members are covered for 30 office visits per year, with the possibility of 20 more through prior authorization, for a total of 50.⁴

Dental Coverage

Indiana Medicaid pays for diagnostic, preventive, and corrective dental services for both children and adults, with limits that vary by age and program.

Adults 21 and older in Hoosier Healthwise can get one oral exam every 12 months, one cleaning every six months, bitewing X-rays once every 12 months, and full-mouth or panoramic X-rays once every three years. Fillings, crowns, periodontal services such as scaling and root planing, medically necessary extractions, dentures and partials, and dental surgery are covered with applicable limits. Dentures and dental surgery require prior authorization.⁶

For adults in fee-for-service Medicaid, prophylaxis is limited to once every 12 months for non-institutionalized adults, and periodontal scaling and root planing is limited to four treatments per lifetime. Dentures can be replaced once every six years. Sealants, fluoride, and orthodontics are generally restricted to members 20 and younger.⁷

Within HIP, dental coverage is available only to HIP Plus members; HIP Basic does not include dental.⁸

Vision Coverage

Under fee-for-service Medicaid, children under 21 are eligible for one eye exam and one pair of eyeglasses per year. Adults 21 and older get one eye exam every two years and one pair of eyeglasses every five years. Glasses are covered only when there is a minimum prescription threshold or a significant change in vision. Contact lenses are covered only when medically necessary, such as for severe facial deformity or allergies to all frame materials.⁹

In HIP, vision is a HIP Plus benefit. HIP Basic does not include routine vision. HIP Plus members 21 and older get one routine eye exam every two years and new eyeglasses when their vision has changed significantly. Members may alternatively opt out of the standard eyewear benefit and receive a $75 credit toward eyewear, contacts, or a contact lens fitting.¹⁰

Hearing Services

Audiological assessments, hearing aids, and cochlear implants are covered. Hearing evaluations are limited to one assessment every three years without prior authorization. Hearing aids are available for members with a pure-tone average hearing loss greater than 30 decibels and require prior authorization. The dispensing fee is covered once every five years, and replacement is also limited to once every five years. For members under 21, more frequent replacement can be authorized with documentation. Canal hearing aids are not covered.¹¹

Cochlear implant surgery is covered with prior authorization, and replacement of an implant is limited to once every five years. Hearing aid repairs are allowed once every 12 months without prior authorization, and accessories such as batteries, tubing, and cords don’t require authorization.¹¹

Therapy, Rehabilitation, and Chiropractic Care

Physical therapy, occupational therapy, speech-language pathology, and respiratory therapy are all covered. Most require prior authorization, with exceptions for initial evaluations (one per 12-month period), emergency respiratory therapy, and short post-hospital transitions. Reimbursement is limited to one hour per day per therapy type, and one billed hour must include at least 45 minutes of direct patient care.¹²

For adults 21 and older, rehabilitative therapy is covered for up to two years from the start of treatment, unless a significant medical change justifies a longer course. Habilitative therapy, which addresses conditions a person has had since birth or childhood, is covered for members under 21 on a case-by-case basis and is not available for adults.¹²

Chiropractic services are limited to 50 combined office visits, spinal manipulations, and physical medicine treatments per rolling 12-month period. Only five of those may be standard office visits.¹³

Durable Medical Equipment and Supplies

Medically necessary durable medical equipment, home medical equipment, and complex rehabilitation technology are covered. That includes items like wheelchairs, hospital beds, oxygen equipment, and prosthetic devices. Comfort or convenience items and luxury features are excluded. All DME needs a written order from an enrolled practitioner, and most items require prior authorization.¹⁴

Wheelchairs, hospital beds, and oxygen equipment require a face-to-face encounter with a qualified practitioner within six months before services begin. Large equipment generally cannot be replaced more than once every five years, though exceptions are allowed when medical needs change. The program decides between rental and purchase based on whichever is less expensive over the expected period of need. Repairs of purchased equipment all require prior authorization.¹⁴

Transportation

Emergency ambulance transportation, by ground or air, is covered. All 911-dispatched trips to an emergency room are treated as emergency transports. Air ambulance is covered with prior authorization and documentation of medical necessity. Emergency services are billed at the level of care actually provided, whether Advanced Life Support or Basic Life Support.¹⁵

Non-emergency medical transportation is also covered. Traditional Medicaid (fee-for-service) members book through Verida at least two business days in advance. Medicaid covers 20 one-way trips per rolling 12-month period, with more available if a doctor requests them. Rides are for medical appointments only and should be used when no other transportation is available. Family members who drive may qualify for mileage reimbursement.¹⁶

Managed care members arrange non-emergency transportation through their health plan’s designated contractor. Anthem members, for example, book through WellTrans and can schedule rides up to 45 days in advance.¹⁷

Maternity and Postpartum Care

Pregnant women receive Medicaid coverage through Hoosier Healthwise or HIP, depending on eligibility category. Both pay for prenatal care at little or no cost. People who don’t meet citizenship or immigration requirements can apply for emergency-only coverage with pregnancy benefits, which covers prenatal care, labor and delivery, and postpartum services.¹⁸

Indiana has extended postpartum Medicaid coverage to a full 12 months after giving birth, up from the previous 60-day limit. Coverage during the postpartum year applies to all health needs, not just pregnancy-related care, and women remain enrolled for the full year regardless of changes in income. Federal approval for the extension runs through March 31, 2027.¹⁹

Family Planning

Family planning is covered within standard Medicaid programs and through a standalone Family Planning Eligibility Program for men and women with income up to 141% of the federal poverty level who don’t qualify for other categories. Covered services include annual exams with Pap tests and cervical cancer screening, FDA-approved contraceptives (pills, IUDs, implants, patches, rings, injectables, condoms, diaphragms, emergency contraceptives), sterilization procedures such as tubal ligation and vasectomy, initial diagnosis and treatment of sexually transmitted infections including HIV screening, and follow-up care for complications from a contraceptive method.²⁰

The Family Planning Eligibility Program does not cover abortion, fertility treatments, in vitro fertilization, reversal of sterilization, inpatient hospital stays, or emergency room visits.²⁰

Children’s Expanded Coverage Through EPSDT

Children on Indiana Medicaid are covered by the Early and Periodic Screening, Diagnostic, and Treatment program (EPSDT), which Indiana calls HealthWatch. The federal benefit runs from birth through age 20 and expands what’s available to children well beyond the adult benefit set.²¹

EPSDT requires comprehensive well-child screenings on the American Academy of Pediatrics schedule: multiple visits during the first two and a half years of life, then annually from age 3 through 20. Each screening includes a physical exam, developmental and behavioral assessments, vision and hearing checks, immunizations, and age-appropriate lab tests.²¹

The key feature: if a screening detects a health problem, Indiana Medicaid must pay for any medically necessary treatment to correct or improve the condition, even when the treatment isn’t normally covered under the state’s standard plan. Coverage extends to services that maintain a child’s condition or make it easier to live with, not only to curative care.²²

Telehealth

Indiana Medicaid pays for telehealth visits delivered via real-time audio and video, and certain services can be delivered by audio only. Virtual check-ins and asynchronous e-visits are not covered. Eligible services include doctor visits, psychotherapy, speech therapy, physical therapy evaluations, prenatal and postpartum care, dental consultations, and health behavior interventions, among others.²³²⁴

The standard of care for telehealth visits must match in-person standards, and providers must document the service, the locations of both provider and patient, and participant consent.²⁵

Long-Term Care and Home and Community-Based Services

Nursing facility care, intermediate care facilities for individuals with intellectual disabilities, and hospice are covered. For people who want to remain in their communities, Indiana runs several home and community-based services (HCBS) waivers as alternatives to institutional care.

The main waiver programs and examples of services:

Community Integration and Habilitation (CIH) Waiver: day habilitation, residential support, behavioral support, respite, home modifications, vehicle modifications, music therapy, recreational therapy, remote supports, transportation, and specialized medical equipment.
Family Supports Waiver: respite, day habilitation, behavioral support, home modifications, therapies, transportation, and participant assistance and care.
Health and Wellness Waiver: attendant care, adult day services, adult family care, assisted living, home-delivered meals, pest control, nutritional supplements, home modifications, and structured family caregiving.
Traumatic Brain Injury (TBI) Waiver: attendant care, behavior management, residential habilitation, structured day programs, home-delivered meals, and transportation.

All four waivers also cover case management, specialized medical equipment and supplies, and benefits counseling.²⁶

Standard home health, separate from the waivers, covers skilled nursing, home health aide services, and physical, occupational, and speech therapy provided on a part-time and intermittent basis in the member’s home. Homemaker, sitter, and respite services are not covered under standard home health, though they may be available through a waiver.²⁷

As of early 2026, the Family Supports and CIH waivers have reached capacity. New applicants invited to begin the process as of February 2026 have been placed on a waiting list until additional slots open.²⁸

For members 60 and older, the Indiana PathWays for Aging program (launched July 1, 2024) coordinates existing benefits through managed care. Members who meet functional eligibility, defined as needing help with at least three activities of daily living, can access adult day care, assisted living, attendant care, home modifications, home-delivered meals, nutritional supplements, personal emergency response systems, respite, specialized medical equipment, structured family care, transportation, and vehicle modifications. PathWays members have no copayments for covered services.²⁹

What HIP Plus Covers That HIP Basic Doesn’t

If you’re on the Healthy Indiana Plan, your benefit set depends on whether you keep up with your POWER account contributions. HIP Plus members, who make the monthly contribution of $1 to $20 based on income, get vision, dental, and chiropractic services and pay no copays, with one exception: an $8 fee for using the emergency room for a non-emergency condition.⁸³⁰

Members who stop contributing face different outcomes depending on income. Those above the federal poverty level are removed from HIP. Those at or below it are moved to HIP Basic, which does not cover vision, dental, or chiropractic services. HIP Basic members also pay copays: $4 for outpatient visits and preferred drugs, $8 for non-preferred drugs and non-emergency ER visits, and up to $75 per hospital stay. Preventive care and family planning are exempt.³¹⁸

Quarterly cost-sharing for any HIP member is capped at 5% of family income. Once that cap is reached, HIP Basic members stop paying copays for the rest of the quarter, and HIP Plus members see their monthly contribution drop to $1.³¹

What Indiana Medicaid Will Not Pay For

Some categories sit outside Indiana Medicaid coverage no matter which program you’re on. On the pharmacy side, that includes fertility medications, weight-loss drugs, cosmetic or hair-growth drugs, experimental or investigational drugs, drugs without FDA-approved uses, and over-the-counter items not on the approved formulary.²¹²¹¹¹⁴ The Family Planning Eligibility Program does not cover abortion, fertility treatments, in vitro fertilization, reversal of sterilization, inpatient hospital stays, or emergency room visits.²⁰ And many adult services carry frequency limits (one cleaning every six months, one eye exam every two years, one pair of glasses every five years) that affect what’s covered in a given year even when the service type is on the benefit list.

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