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Medical Benefits

Many of the health care services and benefits for AmeriHealth Caritas Iowa members are listed below. For some benefits, you have to be a certain age or have a certain need for the service.

You must use an AmeriHealth Caritas Iowa network provider to get these benefits and services, unless:

  • The services are emergency services.
  • You get prior authorization (prior approval) to use a provider who is not in our network.
  • You are a new AmeriHealth Caritas Iowa member, are pregnant, and already get treatment from an OB or midwife who is not in our network. You can keep getting treatment from that provider until your postpartum care for that delivery ends.

To learn more about all of your benefits, see your member handbook. Or call Member Services at 1-855-332-2440 (TTY: 1-844-214-2471) 24 hours a day, 7 days a week.

Your benefits

Which coverage do you have?

IA Health Link
  • 1915(C) home- and community-based services.
    • Must meet level of care.
  • 1915(I) habilitation services.
    • Must meet the needs based criteria.
  • Abortions.
    • Certain circumstances must apply. Contact Member Services.
  • Allergy testing and injections.
  • Anesthesia.
  • (b)(3) services.
    • (intensive psychiatric rehabilitation, community support services, peer support, residential substance use treatment).
  • Bariatric surgery for morbid obesity.
  • Behavioral health intervention services (including applied behavior analysis).
  • Breast reconstruction.
    • Following breast cancer and mastectomy.
  • Cardiac rehabilitation.
  • Certified nurse midwife services.
  • Chemotherapy.
  • Child care medical services.
  • Chiropractic care (limitations apply).  
  • Colorectal cancer screening.
  • Community-based neurobehavioral rehabilitation services.
  • Diabetes equipment and supplies.
  • Diabetic self-management training.
  • Diagnostic genetic testing.
  • Dialysis.
  • Durable medical equipment and supplies (limitations may apply; contact Member Services).
  • Emergency room services.
    • Non-emergent visits will be subject to copay.
  • Early and Periodic Screening, Diagnostic and Treatment (EPSDT).
  • EPSDT home care benefit (private duty nursing/personal care).
  • Emergency medical transportation.
    • Emergency transportation is subject to review for medical necessity.
  • Foot care (podiatry).
    • Must be related to medical condition of the foot and/or ankle. Routine foot care services are not covered.
  • Genetic counseling.
    • Covered with prior authorization.
  • Gynecological exam.
  • Healthy incentives (value-added).
    • AmeriHealth Caritas Iowa Visa® Rewards CARE Card.
  • Healthy resources and services (value-added).
    • Telehealth and tele-monitoring.
    • Mobile health units.
    • Healthy Hoops asthma management program.
    • Wellness centers.
  • Health and wellness (value-added).
    • Weight management program.
    • Lose to Win program.
    • Focus on Fitness gym membership.
    • Family Food program.
    • Health Empowerment Tour health and wellness program.
    • Community health fairs.
  • Hearing aids.
  • Hearing exams.
    • 1 hearing exam per year covered.
  • HiSET program (value-added).
    • (high school diploma equivalency).
  • Home health services.
    • (home health aide, physical therapy [PT], occupational therapy [OT], speech-language therapy [ST]).
  • Hospice.
    • Daily categories: routine care, facility respite or inpatient hospital.
    • Hourly category: continuous care (in home).
    • NF room and board: 95% of NF.
  • Immunizations (shots).
    • Vaccines for Children covers shots children up to age 21.
  • Injections (physician's office and hospital).
  • Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID).
    • Level of care must be met.
  • Lab tests.
  • Maternity and pregnancy services.
  • Medical equipment and supplies (value-added).
    • Free cell phone and service program.
  • Mental health/behavioral health inpatient treatment.
  • Mental health/behavioral health outpatient treatment.
  • Newborn child coverage.
  • Non-emergency medical transportation.
  • Nursing facility.
  • Organ/bone marrow transplants (with limitations).
  • Orthotics (some limitations may apply).
  • Outpatient surgery.
  • Outpatient therapy (physical, occupational, speech, cardiac, pulmonary).
    • Prior authorization is required after 12 visits.
  • Oxygen therapy (inhalation therapy).
  • Pap smears.
  • Pathology.
  • Pelvic exams.
  • Pharmacy.
    • Prior authorization is required as specified in the preferred drug list. Exclusions may apply.
  • Physician services 
    • (office visits, physician emergency room visits, inpatient hospital visits, and consultations).
  • Psychiatric medical institutions for children (PMIC).
    • Must meet the needs-based criteria.
  • Preventive care.
  • Prostate cancer screening.
  • Prosthetics.
  • Radiation therapy.
  • Reconstructive surgery (non-cosmetic).
  • Second surgical option.
  • Sexually transmitted infection (STI) and sexually transmitted disease (STD) testing.
  • Skilled nursing facility.
    • Level of care must be met.
  • Sleep apnea treatment.
  • Sleep study testing.
  • Special Population Nursing Facility (aka Skilled Preapproval).
  • Substance use disorder inpatient treatment.
  • Substance use disorder outpatient treatment.
  • Temporomandibular joints (TMJ) treatment.
  • Tobacco cessation.
  • Urgent care centers/facilities and emergency clinics (non-hospital based).
  • Vision services.
    • 1 visit per year covered. 
  • Vision frames and lenses.
    • Limitations may apply. Contact Member Services for more information.
  • X-rays.
    • (procedures such as MRIs, CAT scans and PET scans require prior authorization).
Iowa Wellness Plan
  • Abortions.
    • Certain circumstances must apply. Contact Member Services.
  • Allergy testing and injections.
  • Anesthesia.
  • Behavioral health intervention services (including applied behavior analysis).
    • Residential not covered.
  • Breast reconstruction.
    • Following breast cancer and mastectomy.
  • Cardiac rehabilitation.
  • Certified nurse midwife services.
  • Chemotherapy.
  • Chiropractic care (limitations apply).
  • Colorectal cancer screening.
  • Diabetes equipment and supplies.
    • Medically necessary equipment and supplies and education services are covered.
  • Diabetic self-management training.
  • Diagnostic and genetic testing.
    • Prior authorization needed.
  • Dialysis.
  • Durable medical equipment and supplies.
    • Limitations may apply. Contact Member Services.
  • Emergency room services.
    • Non-emergent visits will be subject to copay.
  • Early and Periodic Screening, Diagnostic and Treatment (EPSDT).
    • Covered for ages 19-20.
  • EPSDT home care benefit (private duty nursing/personal care).
  • Emergency medical transportation.
    • Emergency transportation is subject to review for medical necessity.
  • Foot care (podiatry).
    • Must be related to medical condition of the foot and/or ankle. Routine foot care services are not covered.
  • Genetic counseling.
    • Covered with prior authorization.
  • Gynecological exams.
    • Includes an annual women’s health and wellness exam in addition to any other medically necessary gynecological exam for a specific medical condition which requires diagnosis and/or treatment.
  • Healthy incentives (value-added).
    • AmeriHealth Caritas Iowa Visa® Rewards CARE Card.
  • Healthy resources and services (value-added).
    • Telehealth and tele-monitoring.
    • Mobile health units.
    • Healthy Hoops asthma management program.
    • Wellness centers.
  • Health and wellness (value-added).
    • Weight management program.
    • Lose to Win program.
    • Focus on Fitness gym membership.
    • Family Food program.
    • Health Empowerment Tour health and wellness program.
    • Community health fairs.
  • Hearing aids.
    • Covered for ages 19–20.
  • Hearing exams.
    • 1 hearing exam per year covered.
  • HiSET program (value-added).
    • (high school diploma equivalency).
  • Home health services.
    • (skilled nursing, home health aide, physical therapy [PT], occupational therapy [OT], speech-language therapy[ST]).
    • The following limitations apply:
      • Skilled Nursing – 5 visits per week.
      • Home Health Aide – Total visits that do not exceed 28 hours per week.
      • Physical, occupational and speech therapies – Visits that do not exceed the authorization in a physician approved home health plan of care.
      • Private duty nursing and personal cares are not covered.
  • Hospice.
    • Daily categories: routine care, facility respite or inpatient hospital.
    • Hourly category: continuous care (in home).
    • NF room and board: 95% of NF.
  • Immunizations (shots).
    • Vaccines for Children covers shots for children up to age 21.
    • Travel immunizations are not covered.
  • Injections (physician's office and hospital).
  • Lab tests.
  • Maternity and pregnancy services.
    • Member is required to report pregnancy and eligibility for consideration of benefits under the Medicaid state plan.
  • Medical equipment and supplies (value-added).
    • Free cell phone and service program.
  • Mental health/behavioral health inpatient treatment.
    • Residential treatment is not covered.
  • Mental health/behavioral health outpatient treatment.
  • Newborn child coverage.
  • Organ/bone marrow transplants (with limitations).
  • Orthotics (some limitations may apply). 
  • Outpatient surgery.
  • Outpatient therapy (physical, occupational, speech, cardiac, pulmonary).
    • Prior authorization is required after 12 visits.
  • Oxygen therapy (inhalation therapy).
    • Limited to 60 visits in a 12-month period.
  • Pap Smears.
  • Pathology.
  • Pelvic exams.
  • Pharmacy.
    • Prior authorization is required as specified in the preferred drug list. Exclusions may apply.
  • Physician services.
    • (office visits, physician emergency room visits, inpatient hospital visits and consultations).
  • Preventive care.
    • Preventive services are covered the same as under Medicaid.
  • Prostate cancer screening.
  • Prosthetics 
  • Radiation therapy.
  • Reconstructive surgery (non-cosmetic).
  • Second surgical option.
  • Sexually transmitted infection (STI) and sexually transmitted disease (STD) testing.
  • Skilled nursing facility.
    • Limited to 120 days.
  • Sleep apnea treatment.
  • Sleep study testing.
    • Treatment for snoring, without a diagnosis of sleep apnea, is not covered. Claims for sleep study testing must be for a diagnosis of sleep apnea.
  • Special Population Nursing Facility (aka Skilled Preapproval).
  • Substance use disorder inpatient treatment.
  • Substance use disorder outpatient treatment.
  • Tobacco cessation.
  • Urgent care centers/facilities and emergency clinics (non-hospital based).
  • Vision services
    • 1 visit per year covered.
  • Vision frames and lenses.
    • Frames and lenses are covered only following cataract surgery. Frames and lenses are covered for individuals between the ages of 19-20.
  • X-rays.
    • (procedures such as MRIs, CAT scans and PET scans require prior authorization).
hawk-i
  • Abortions.
    • Certain circumstances must apply. Contact Member Services.
  • Allergy testing and injections
  • Bariatric surgery for morbid obesity.
  • Certified nurse midwife services.
  • Chemotherapy.
  • Chiropractic care (limitations apply).
  • Contraceptives.
  • Diabetes equipment and supplies.
  • Diabetes self-management training.
  • Diagnostic genetic testing.
  • Dialysis.
  • Durable medical equipment and supplies.
    • (limitations may apply; contact Member Services).
  • Emergency room services.
    • Emergency services for non-emergent conditions are subject to a $25 copay if the family pays a premium for the hawk-i program.
  • Emergency medical transportation.
  • Foot care (podiatry).
    • Limitations may apply.
  • Genetic counseling.
    • Requires prior authorization.
  • Healthy incentives (value-added).
    • AmeriHealth Caritas Iowa Visa® Rewards CARE Card.
  • Healthy resources and services (value-added).
    • Telehealth and tele-monitoring.
    • Mobile health units.
    • Healthy Hoops asthma management program.
    • Wellness centers.
  • Health and wellness (value-added).
    • Weight management program.
    • Lose to Win program.
    • Focus on Fitness gym membership.
    • Family Food program.
    • Health Empowerment Tour health and wellness program.
    • Community health fairs.
  • Hearing aids.
  • Hearing exams.
  • HiSET program (value-added) (high school diploma equivalency)
  • Home health services.
    • (home health agency care, including skilled nursing, home health aides and therapies (PT, OT, ST) are covered benefits).
  • Hospice.
  • Hospital inpatient services.
    • Room and board (semi-private).
    • Miscellaneous.
  • Immunizations (shots).
  • Injections (physician's office and hospital).
  • Lab tests.
  • Maternity and pregnancy services.
  • Medical equipment and supplies (value-added).
    • Free cell phone and service program.
  • Mental/behavioral health inpatient treatment.
  • Mental/behavioral health outpatient treatment.
  • Newborn child coverage.
  • Nursing facility.
  • Organ/bone marrow transplants (with limitations).
  • Orthotics (some limitations may apply).
    • Prior authorization is required.
  • Outpatient surgery.
  • Outpatient therapy (physical, occupational, speech, cardiac, pulmonary).
    • Limitations may apply.
  • Oxygen therapy (inhalation therapy).
    • Limitations may apply.
  • Pap smears.
  • Pathology.
  • Pelvic exams.
  • Pharmacy.
    • Prior authorization is required as specified in the preferred drug list. Exclusions may apply.
  • Physician services.
    • (office visits, physician emergency room visits, inpatient hospital visits, and consultations).
  • Preventive care.
    • Routine preventive physical exams, including well-child care and gynecological exams.
  • Prosthetics.
  • Radiation therapy.
  • Reconstructive surgery (non-cosmetic)
    • (To restore function lost or impaired as the result of illness, injury, or a birth defect, even if there is an incidental improvement in physical appearance).
  • Second surgical option.
  • Sexually transmitted infection (STI) and sexually transmitted disease (STD) testing.
  • Skilled nursing facility.
  • Sleep apnea treatment.
  • Sleep study testing.
  • Special Population Nursing Facility (aka Skilled Preapproval).
  • Substance use disorder inpatient treatment.
  • Substance use disorder outpatient treatment.
  • Temporomandibular joints (TMJ) treatment.
    • Services that are medically necessary. Osteotomy not covered.
  • Urgent care centers/facilities and emergency clinics (non-hospital based).
  • Vision services.
    • 1 visit per year covered.
  • Vision frames and lenses.
    • Limitations may apply. Contact Member Services for more information.
  • X-rays.
    • (procedures such as MRIs, CAT scans and PET scans require prior authorization).

This list does not show all your covered benefits. For more information, call AmeriHealth Caritas Iowa Member Services at 1-855-332-2440 (TTY: 1-844-214-2471).