In Indiana:
  • As of July 1, 2011, there were 1,055,779 beneficiaries enrolled in the state’s Medicaid program, 741,744 of whom were enrolled in managed care through one of six commercial managed care organizations (MCOs) or a primary care case management program.
  • Physical and behavioral health benefits are delivered through MCOs. Dental benefits are carved out from managed care and are delivered on a fee-for-service basis.
  • Two home and community-based services waivers can be used to provide services to children:
As of 2013, 765,985 individuals were eligible for Indiana’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT), known in the state as HealthWatch. According to 416 data from 2013, the state achieved an EPSDT screening ratio of 100% and a participant ratio of 77%. 259,465 children received dental services of any kind, with 225,918 receiving preventive dental services.
Last updated September 2014
Medical Necessity
The Indiana Administrative Code (405 IAC 5-2-17) defines medically reasonable and necessary services for Medicaid.
“‘Medically reasonable and necessary service’ as used in this title means a covered service (as defined in section 6 of this rule) that is required for the care or well being of the patient and is provided in accordance with generally accepted standards of medical or professional practice. For a service to be reimbursable by the office, it must:
(1) be medically reasonable and necessary, as determined by the office, which shall, in making that determination, utilize generally accepted standards of medical or professional practice; and
(2) not be listed in this title as a noncovered service, or otherwise excluded from coverage.”
Initiatives to Improve Access
Reporting & Data Collection
Managed care organizations (MCOs) are required to collect quality measurement data on areas that include: EPSDT services, immunization rates, and blood lead testing.
MCOs also offer performance bonuses to providers based on HEDIS measures as part of the Indiana 2014 Performance Bonus Program for Hoosier Healthwatch. Among the measures determining performance bonuses are:
  • Annual well-child visits: 3-6 years of age
  • Annual well-adolescent visits: 12-21 years
Behavioral Health
Managed care entities in Indiana are required to:
  • Develop networks of psychiatrists, psychologists, clinical social workers, and other behavioral health providers capable of delivering a spectrum of behavioral health services;
  • Provide a continuum of inpatient behavioral health services;
  • Train primary care providers and specialists to identify and treat beneficiaries with behavioral health conditions; and
  • Train providers in screening for co-occurring mental health and substance abuse disorders.

Medicaid providers can bill for structured developmental screenings at select well-child visits (at 9 months, 18 months, and 30 months). The state suggests the following tools be used when billing for a developmental screening:

  • Ages and Stages Questionnaire (ASQ)
  • Ages and Stages Questionnaire/Social Emotional (ASQ-SE)
  • Denver DST/Denver II
  • Battelle Developmental Screener
  • Bayley Infant Neurodevelopment Screener (BINS)
  • Parents Evaluation of Development (PEDS)
  • Early Language Accomplishment Profile (ELAP)
  • Brigance Screens II
  • Modified Checklist for Autism in Toddlers (M-CHAT)
  • Vanderbilt Rating Scales
  • Behavior Assessment Scale for Children-Second Edition (BASC-II)
Support to Providers and Families
Support for Providers
Indiana’s Medicaid program operates a provider website that collects a variety of information on the program. This includes claims and billing guidelines, fee schedules, form, provider manuals, and information on each managed care organization in the state. The site also contains virtual provider training on program procedures. The state also produces an EPSDT/Healthwatch provider manual.
Support for Families
A Medicaid member website provides information on the program for enrollees. The site helps beneficiaries to choose a health plan and understand available benefits. It also provides tips for prevention and staying healthy.
Care Coordination
Coordination of physical and behavioral health services for Medicaid beneficiaries with co-morbidities is required of managed care organizations (MCOs). MCOs provide case management for Medicaid beneficiaries receiving behavioral health services, coordinating between physical and behavioral health providers.
Children with special health care needs receive care coordination services through a special program, Care Select. They enroll in special managed care organizations designed to improve communication across provider settings and arrange more holistic, whole-person service delivery (addressing physical, behavioral, and social needs).
Oral Health
Indiana EPSDT provider manual provides information on dental observation and screening as part of well-child visits, as well as guidelines on providing dental anticipatory guidance to parents.