Benefits and Services
What is covered
- Doctor visits
- Hospital care
- Prescription drugs
- Diabetes supplies
- Eye and hearing tests
- Mental health care
- Skilled nursing care
- Community-Based Adult Services (CBAS)
- Care Planning and Management Benefit
- Preventive care – such as health exams, screenings, tests, immunizations and other office visits with a primary care doctor
- Dental care is covered through the Denti-Cal Program
Services that require prior authorization
- Services received from a doctor who is not an HPSM Medi-Cal provider without a prior authorization for coverage
- Services from a non-contracted specialist without a referral from a primary care doctor and prior authorization
Doctor's visits by phone or video anytime
Many providers can give you advice over the phone or see you by video. Telephone and video visits are fully covered by HPSM. Call your primary care provider (PCP) to check if they provide telephone or video visits.
If your do not have PCP, or if your PCP does not offer phone or video appointments, you may be able to use Teladoc®, one of HPSM's newest service partners. Learn more.
No-cost transportation to approved health care visits
Medi-Cal members can get an unlimited number of rides to approved health care visits at no cost. These include medical, pharmacy, dental, mental health and other health care visits. Rules and restrictions apply:
- You must have no other way to get to your visit
- Call at least two business days before your appointment (for urgent care, call as soon as you can)
- Rides to non-healthcare services are not covered
- One routine eye examination every two years
- Services from a specialist to treat serious eye conditions require a referral from your PCP
- One pair of eyeglasses every two years
Mental Health and Substance Use Disorder Benefits
Mental health services
BHRS provides mental health services to Medi-Cal members who meet medical necessity rules. Mental health providers must be contracted with San Mateo County Behavioral Health and Recovery Services (BHRS). For information about mental health providers and specific services, call the BHRS ACCESS Call Center at 1-800-686-0101.
HPSM's plan covers:
- Outpatient treatment services for mild, moderate and serious mental health conditions
- Inpatient treatment and services for serious mental illness
Substance use disorder services
BHRS provides substance use disorder services to Medi-Cal members who meet medical necessity rules. For information about treatment or a referral for substance use disorders, please call the BHRS ACCESS call center (toll free) at 1-800-686-0101 (TTY 7-1-1). Members who are identified for substance use disorder treatment services are referred to their county department for treatment. Consult the list of Substance Use Disorder County Access Lines to find the correct department to call for treatment.
HPSM's plan covers:
- Outpatient substance use disorder services Treatments for substance use include outpatient services, medication assisted treatment, withdrawal management and residential treatment based on member need.
- Primary care alcohol use screening and referral These include primary care screening services to identify and discuss risky alcohol use. Members age 18 and older with an alcohol misuse problem may be referred to BHRS for treatment.
Mental health and substance use services not covered:
- Counseling for couples and families (family therapy)
- Treatment for major alcohol problems (your PCP may refer you to BHRS)
For some types of care, your PCP or specialist will need to ask HPSM for permission before you get the care. This is called asking for prior authorization, prior approval, or pre-approval. It means that HPSM must make sure that the care is medically necessary or needed. Learn more about prior authorization.
Medi-Cal offers free or low-cost health care for eligible California residents including dental benefits. Dental benefits are provided through Denti-Cal. You will need to provide your Medi-Cal Benefits Identification Card (BIC) to your dental provider to receive dental services.
For more information about covered dental services and costs, contact Denti-Cal at 1-800-322-6384 or visit denti-cal.ca.gov.