HPSM Medi-Cal

Member Benefits

Medical Benefits

Medical services from a licensed medical professional received for reasons related to treatment and diagnosis of a medical condition are covered.

Not covered

  • 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

Vision Benefits

Adults

  • One eye examination every two years
  • Services from a specialist to treat serious eye conditions require a referral from your PCP

Children, adults under 21 and nursing home residents

  • One eye examination and one pair of eyeglasses every two years
  • Services from a specialist to treat serious eye conditions require a referral from your PCP

Mental Health Benefits

  • Outpatient treatment services for mild, moderate and serious mental health conditions
  • Inpatient treatment and services for serious mental illness

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.

Alcohol abuse screening and referral (primary care)

  • Primary care screening services to identify and discuss risky alcohol use are covered.
  • Members age 18 and older with an alcohol misuse problem may be referred to BHRS for treatment
Not covered
  • Counseling for couples and families (family therapy)
  • Treatment for major alcohol problems (your PCP may refer you to San Mateo County Behavioral Health and Recovery Services)

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.

Read more about prior authorization.

Dental Benefits

The Medi-Cal dental program is called Denti-Cal. It covers a variety of dental services such as examinations, x-rays and teeth cleaning to members under the age of 21. Limited coverage is available to adults, including members in a long term care nursing facility.

For more information about covered dental services and costs, contact Denti-Cal at 1-800-322-6384 or visit denti-cal.ca.gov.