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)
- 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
- 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 for children, pregnant women (through postpartum), nursing home residents, and members under the age of 21
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
Mental health services 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.
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.