Provider Manual | Section 6

Ancillary Services

Ancillary Services

Items in this section are not inclusive of benefit coverage under CareAdvantage.

CareAdvantage members are eligible for both Medicare and Medi-Cal. Medi-Cal benefits will apply to those CareAdvantage members who are full scope Medi-Cal beneficiaries.

For CareAdvantage members coverage requirements and rules for a dual eligible under Title XVII and XIX should be transparent. If you have questions or need to verify benefit coverage for CareAdvantage members, contact the Provider Services Department at 650-616-2106.

Laboratory Testing

HPSM has relationships with recognized vendors of laboratory services, including free standing and hospitalbased laboratories, to ensure member access and the highest quality and consistency of care.

HPSM has relationships with the following vendors:

  • Quest Laboratories (located in Burlingame and Palo Alto).
  • Chinatown Medical Laboratory (located in San Francisco).
  • Satellite Laboratory Services (located in Redwood City, dialysis related).

In addition, all our contracted hospital facilities have outpatient laboratory services available for our members.

We do recognize that some testing is best completed while the patient is in the office, when a provider can most efficiently assess and develop a plan to address the patient's care needs. HPSM also appreciates that as health care systems and groups of providers have progressively integrated; the completion and communication of these diagnostic services are tightly woven into that integration. As a result, HPSM will also support office-based diagnostic testing that adheres to office CLIA certification at provider and member convenience.

Providers of CLIA-certified office-based testing are expected to maintain the necessary certification to ensure quality control and consistency of results. Services will only be covered for members who are otherwise under the care of a provider in that practice. Most of these services are covered under the PCP capitation agreement. Please refer to “Section 4: Claims” for details. Services not on the list will be reimbursed based on the Medicare or Medi-Cal fee schedule depending on the member’s coverage.

Whether you choose to utilize the services of our preferred vendors or perform these services in your own office, our primary goal is to ensure our members receive the diagnostics they require in a manner that facilitates delivering high quality care.

Pharmacy Benefits

Medi-Cal

Pharmacy benefits are covered under the Medi-Cal fee-for-service delivery system effective January 1st, 2022 (collectively referred to as “Medi-Cal Rx”) and is now managed by the Department of Health Care Services (DHCS). As a result, pharmacy claims should be billed to Magellan, DHCS’ delegated pharmacy benefits manager. This includes diabetic medications and supplies, and medically necessary enteral formulas and modified solid food products.

Provider-administered medications in a physician’s office or a clinic (those medications that cannot be selfadministered, generally IM and IV) are generally covered under member’s HPSM medical benefits and are therefore not within the scope of Medi-Cal Rx. These medications can continue to be billed to HPSM rather than Magellan. A Prior Authorization Request (PAR) may be required.

CareAdvantage, HealthWorx, and ACE

Pharmacy benefits for Healthworx, CareAdvantage, and ACE are administered through HPSM. HPSM Pharmacy staff are available to consult with providers about plan benefits and exclusion, drug formularies, the prior authorization process, and other clinical pharmacy issues related to HPSM members. Each program has a detailed description of the pharmacy benefits coverage and exclusions in the member handbook/evidence of coverage (EOC). All pharmacy claims should be billed through HPSM’s pharmacy benefits manager, SS&C.

Diabetic medications and supplies, in accordance with California State Law are administered under the patient’s pharmacy benefits and therefore should be billed through HPSM’s pharmacy benefits manager, SS&C. These supplies and medications may be subject to a co-pay depending on which program the member is eligible for. Diabetic medication and supplies are not subject to any pharmacy benefit cap limitations.

HPSM will cover for medically necessary enteral formulas and for modified solid food products through pharmacy prior authorization, in accordance with California State Law, for the treatment of certain inherited diseases. Claims for enteral formulas and modified solid foods should be billed through HPSM’s pharmacy benefits manager, SS&C. This benefit is subject to any pharmacy benefit cap limitations depending on the program.

Provider-administered medications in a physician’s office or a clinic (those medications that cannot be self-administered, generally IM and IV) are generally covered under the member’s medical benefits.. A Prior Authorization Request (PAR) may be required.

Who to Contact

Medi-Cal

Magellan is primary responsible for processing pharmacy claims and assist with day-to-day pharmacy billing problems and issues. All Prior Authorization (PA) requests are reviewed and processed by Magellan's Pharmacy staff. For billing questions or questions regarding pending or submitted prior authorization requests, please visit the Medi-Cal Rx website at medicalrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

CareAdvantage, HealthWorx, and ACE

HPSM contracts with SS&C Health Solutions (previously known as Argus or DST) as our Pharmacy Benefits Manager to administer the pharmacy benefit through its network of retail, home infusion and long-term care pharmacies. SS&C is primarily responsible for processing pharmacy claims and assist with day-to-day pharmacy billing problems and issues. The SS&C customer service and help desk telephone number is 888-635-8362. You may contact SS&C directly at any time (24 hours a day, 7 days a week).

HPSM pharmacy staff are available to answer your questions regarding pharmacy services, formularies, and prior authorization process. All Prior Authorization (PA) requests are reviewed and processed by HPSM Pharmacy staff. They can be reached at 650-616-2088, from 8:00 AM to 5:00 PM, Monday through Friday. (Please note: On Wednesdays, the Pharmacy Services department is closed from 8:00 AM to 10:00 AM)

Drug Formularies

Medi-Cal

DHCS maintains the formulary for pharmacy services related to Medi-Cal members, called the Medi-Cal Rx Contract Drug List. This list is posted on the Medi-Cal Rx website, available at medicalrx.dhcs.ca.gov/home/.

CareAdvantage, HealthWorx, and ACE

HPSM maintains three separate drug formularies. There is one formulary for HPSM HealthWorx, one for CareAdvantage, and one for the Access and Care for Everyone (ACE) program. The HealthWorx and CareAdvantage formularies are reviewed by the HPSM Pharmacy and Therapeutics Committee. The committee is comprised of pharmacists and physicians within the community and includes representation from various specialties. It meets bi-monthly and systematically reviews the formulary on a periodic basis. HPSM’s formulary management approach is to consider the efficacy, safety, and cost-effectiveness of drugs when making formulary changes. References that inform formulary recommendations include but are not limited to evidence-based clinical practice guidelines, clinical studies, peer-reviewed medical literature, FDA package inserts, clinical compendia, and more. In most situations, this may result in the preference towards formulary coverage of generic medications.

Provider requests for consideration of new drugs to be added to the HPSM formularies must be submitted in writing using the HPSM Request for Formulary Modification form, available online at www.hpsm.org. A copy of this form is included in the Forms section. Completed forms may be sent to:

Fax: 650-829-2045

Mail:

Health Plan of San Mateo
Attn: Pharmacy and Therapeutics Committee
801 Gateway Boulevard., Suite 100
South San Francisco, California 94080

The HPSM formularies are available on the HPSM website. Hard copies of the HPSM formularies are also available from the Provider Services Department. The HPSM formularies list all drugs by either the chemical name, brand name (if one exists), and/or the name of the generic equivalent. The formularies will also have information regarding any restrictions that may apply such as prior authorization, step therapy, or quantity limit. If you have any questions regarding the HPSM drug formularies, please contact the HPSM Pharmacy staff at 650-616-2088.

Non-Formulary Drugs

Medi-Cal

HPSM participating providers and pharmacies are highly encouraged to prescribe drugs that available on the Medi-Cal Rx Contract Drug List. If there is a need to prescribe a drug that is not on this list, a pharmacist may contact the prescribing provider to recommend switching to a formulary alternative, when appropriate. If an alternative is not available or inappropriate for a member’s condition, the provider must submit a prior authorization request to Magellan.

For more information regarding how to submit prior authorization requests, please visit the Medi-Cal Rx website at medi-calrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273

CareAdvantage, HealthWorx, and ACE

HPSM participating providers and pharmacies are highly encouraged to prescribe drugs that are available on HPSM formularies first. If there is a need to prescribe a drug that is not on the formulary, a pharmacist may contact the prescribing provider to recommend switching to a formulary alternative, when appropriate. If an alternative is not available or inappropriate for a member’s condition, the provider should submit a Prescription Drug Prior Authorization or Step Therapy Exception Request Form to HPSM at 650-829-2045. (See Pharmacy Prior Authorization Process for information on submitting a Medication Request Form).

Changes in Drug Formularies

Medi-Cal

Please refer to Medi-Cal Rx website, available at medicalrx.dhcs.ca.gov/home/, for details regarding changes to the Medi-Cal Rx drug list.

CareAdvantage, HealthWorx, and ACE

If a member is on a drug, and HPSM removes the drug from its formulary, the prescriber would need to consider changing their patient to a formulary alternative. If none of the formulary alternatives can be utilized, a Prescription Drug Prior Authorization or Step Therapy Exception Request Form should be submitted to HPSM providing reasons as to why a formulary alternative is not appropriate.

Pharmacy Prior Authorizations (PA)

Medi-Cal

For more information regarding how to submit prior authorization requests, please visit the Medi-Cal Rx website at medi-calrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800- 977-2273.

CareAdvantage, HealthWorx, and ACE

Prior authorization provides access to drugs and/or products that are either non-formulary or are on the formulary with restrictions.

Prior authorization of selected pharmacy services allows HPSM to balance patient care, quality, safety, and cost objectives in a manner, which facilitates the most appropriate use of state and federal resources while resulting in favorable health status outcomes. Please refer to our website for the most current prior authorization requirements at www.hpsm.org.

Completing and Submitting Pharmacy Prior Authorization Requests

Medi-Cal

For more information regarding how to submit a pharmacy prior authorization request to Magellan, please visit the Medi-Cal Rx website at medicalrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273

CareAdvantage, HealthWorx, and ACE

Once the appropriate form has been completed, providers should fax it to HPSM at 650-829-2045. Providers may also call 650-616-2088 with this information. For CareAdvantage, pharmacies must also fill out a CMS Appointment of Representative (AOR) Form and include it with each request submitted. This form is available in the Forms section and is also available online on the HPSM website.

It is important to fill out the prescription request form completely. The following data items are frequently not completed by providers and results in returned request forms.

  • Prescribing Provider’s Name, NPI, Address, Phone Number and Fax Number
  • ICD-10-CM Diagnosis Code
  • Medical Justification (including formulary alternatives tried)
  • Specific Services Requested
  • Specific Directions for Use

Once the prior authorization request form has been received, HPSM Pharmacy staff will review the clinical information submitted to render a decision. The criteria used to make these decisions have been developed and approved by HPSM’s Pharmacy and Therapeutics Committee.

Processing Time for Pharmacy Prior Authorizations

Medi-Cal

Decisions for prior authorization are usually made by Magellan within 24 hours.

CareAdvantage, HealthWorx, and ACE

For standard CareAdvantage, HealthWorx, and ACE requests, decisions for prior authorizations are made within 72 hours of the request for standard requests. For all expedited/urgent CareAdvantage, HealthWorx, and ACE requests, decisions for prior authorization and continuing pharmacy requests are made within 24 hours of the receipt of the information reasonably necessary to decide.

Prescription Deferral Process

Medi-Cal

Deferral process does not apply to Medi-Cal Rx.

CareAdvantage

A decision on a prescription request form may be deferred or “tolled” for up to 14 days if it is submitted with insufficient medical justification or incomplete information. In the event this occurs, HPSM Pharmacy staff will make attempts to contact the provider to obtain the additional medical information needed.

If no additional information is received after the tolling period of 14 days, HPSM staff will make a final determination based on the information available.

ACE and HealthWorx

Deferral process does not apply to ACE or HealthWorx.

Prescription Denial Process

Medi-Cal

For more information regarding the denial process for Medi-Cal pharmacy services, please visit the Medi-Cal Rx website at medi-calrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

CareAdvantage, HealthWorx, and ACE

A licensed clinician reviewer (medical director or clinical pharmacist) may deny certain prior authorization requests when the request is not determined to be medically necessary. Cases reviewed by a clinician reviewer may involve consultation with appropriate specialists as needed prior to denial. If necessary, the clinician reviewer may discuss the determination with the prescribing physician to ensure that appropriate patient care is not delayed.

If a request for a drug is denied, a Denial Letter is sent to the requesting provider and a Denial Notice of Action Letter is sent to the member. The Denial Letter and Notice of Action Letter explain the reason for the denial and provide information on how the member may file an appeal with HPSM regarding the Plan’s decision.

Pharmacy Appeals Process

Medi-Cal

The process for submitting pharmacy related appeals differ depending on whether it is the member or provider that is submitting the appeal.

  • Member must go through the State Fair Hearing Process and usually must submit their request within 90 days from the original denial notification.
  • Providers must submit appeals request to Magellan. For more information regarding the appeals process, please visit the Medi-Cal Rx website at medi-calrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

CareAdvantage, HealthWorx, and ACE

Members and providers may request that HPSM reconsider an initial adverse determination. The request must be made in writing within sixty (60) days of the date of the original adverse determination notice for CareAdvantage appeals, within sixty (180) days for HealthWorx and ACE. See “Pharmacy Appeals for Drugs/Medications Denials” under “Section 3: Member Complaints” for more information on requesting a pharmacy appeal.

Evening and Weekend Pharmacy Prior Authorization Requests

Medi-Cal

For more information regarding how evening and weekend prior authorization requests are handled, please visit the Medi-Cal Rx website at medi-calrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

CareAdvantage, HealthWorx, and ACE

Evening, weekend/holidays prior authorization requests are reviewed by HPSM’s on-call pharmacist within usual processing timeframes.

Emergency Medication Supply

Medi-Cal

For more information regarding how to obtain an emergency medication supply, please visit the Medi-Cal Rx website at medi-calrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

CareAdvantage, HealthWorx, and ACE

For emergency situations, HPSM’s Pharmacy Services department can provide up to at least a 72-hour supply of most medication(s) without restriction. This includes prescriptions awaiting the submission or approval of a prior authorization request. Certain limitations apply. For additional information or assistance, please contact us at one of the following:

  • The Pharmacy Help Desk line at 888-635-8362 any time (24/7).
  • HPSM’s PharmacyServices at 650-616-2088 during business hours (Monday through Friday, 8:00 AM to 5:00 PM).

Pharmacy Network

Medi-Cal

Under Medi-Cal fee-for-service, most California-licensed pharmacies are enrolled in the FFS network. For helping a pharmacy, you can use the Medi-Cal Rx Pharmacy Locator online medi-calrx.dhcs.ca.gov/home/ or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

CareAdvantage and HealthWorx

An extensive network, which includes over 55,000 pharmacies throughout the United States, is available to members through the SS&C network. Covered drugs filled at a participating pharmacy are subject to the patient’s applicable co-pay(s) as defined by their pharmacy coverage.

ACE

Only select pharmacies serve ACE members. For more information regarding which pharmacies are included in the ACE network, please contact the SS&C customer service help desk at 888-635-8362.

Co-Payments and Cost-Sharing

Medi-Cal

For full scope Medi-Cal members, there are no co-pays for pharmacy benefits.

CareAdvantage, HealthWorx, and ACE

HPSM pharmacy benefits for some programs may require member co-payments/cost-sharing for prescriptions. The co-pay may also vary depending on whether the prescription is for a generic or brand name drug and whether it is a preferred drug on the HPSM formulary. Programs may have annual drug cap amounts as well. For questions on eligibility, pharmacy benefits, or co-pays, call SS&C’s Customer Service at 888-635-8362, available 24 hours per day, seven days per week.

Important Reminder on Charging Cash to HPSM Members

Never bill member in place of submitting a prior authorization. You will be required to reimburse any money collected from an eligible HPSM member.

Members should never be told that a drug is not covered by Medi-Cal or HPSM unless a specific denied Prior Authorization Request has been obtained. All drugs are potentially covered through the prior authorization process unless it is a specific exclusion of the program.

Safety and Alert Programs

Affected physicians and members will be notified by mail with the appropriate information when a drug is withdrawn from the market due to safety concerns. The names of the physicians' patients may be included in the communication or can be provided upon request.

Mental Health and Substance Abuse Services

Primary care providers are responsible for supporting their patient’s mental health needs within their scope of practice, which may include diagnosis and treatment. All HPSM members in need of behavioral health support should be encouraged to speak with their primary care provider for basic screening and support. Please note: some primary care providers have behavioral health services or providers available in their practices.

If a member has a behavioral health treatment need that cannot be managed through primary care, providers should refer members to the ACCESS Call Center) for additional services.

Members may call the ACCESS Call Center at 800-686-0101 to be screened and routed to the correct benefit and network provider, including for therapy, psychiatry/medication management and/or substance use treatment. A provider referral is not needed to call the ACCESS Call Center: a member may self-refer.

Coverage and services available varies by line of business.

For Medi-Cal members, behavioral health services are covered by three separate plans where the member receives service and coverage depends on severity of symptoms and treatment need and may vary by line of business.

  • Managed Care Plan (HPSM)
  • County Mental Health Plan (BHRS- specialty mental health)
  • Organized Delivery System (BHRS-substance use treatment)

The ACCESS Call Center

The ACCESS Call Center is the San Mateo County community line for mental health services, Reach them toll free at 800-686-0101. Staff is available during normal business hours (Monday through Friday, 8:00 AM to 5:00 PM) to assist you, after hours support is also available. The ACCESS Call Center is an important resource for HPSM members to be screened and routed to the appropriate behavioral health services. Upon a member’s call, or provider referral form being received the ACCESS Call Center will conduct a screening to identify whether the member meets criteria for specialty mental health care, mild to moderate mental health care and/or substance use treatment and will refer the member accordingly. Members should not be directly referred to a mental health clinician; they must first be screened through the ACCESS Call Center to ensure they are routed to appropriate services.

Managed Care Plan

HPSM’s network provides outpatient mild to moderate mental health services for members. HPSM also covers emergency psychiatric services and mental health services provided by a member’s PCP, within the scope of their licensure.

HPSM’s mental health network providers serve members with mild to moderate mental health needs. If a member in this level of treatment has a change in symptoms the mental health provider should use the HPSM Higher Level of Care form to have the member re-screened by the ACCESS Call Center.

For Care Advantage members, HPSM provides coverage for all specialty services while BHRS manages most of the network and services.

San Mateo County Behavioral Health and Recovery Services (BHRS) County Mental Health Plan

BHRS is responsible for services for HPSM members with severe mental health issues and treatment needs. They also have a number of community-based programs. BHRS services are aimed at helping members with mental illness maintain their independence and helping children with serious emotional problems become educated and stay with their families.

BHRS has specialty outpatient service centers in Daly City, San Mateo, the Coastside, Redwood City and East Palo Alto; in school-based locations; and through a network of community agencies and independent providers. BHRS operates the Cordilleras Mental Health Center, a 120-bed skilled nursing facility in Redwood City, through a contract with Telecare Corporation.

How to Refer a Patient to Behavioral Health Services

To refer a patient to behavioral health services, follow these steps:

  1. Complete the Behavioral Health Referral Form and fax it to the ACCESS call center. For hospital discharges only, call BHRS Access Team at 800-686-0101.
    1. If the situation is life-threatening, refer the patient to the nearest emergency room or call 911. If the ACCESS Call center identifies the emergency the patient will be referred immediately to the nearest emergency room.
  2. A clinician will review the referral and may call you for more information to determine the most appropriate treatment setting. Staff will route the member to HPSM (mild to moderate treatment needs,) or BHRS (specialty mental health or substance use treatment) network provider or community resources accordingly.

Your role in the referral process is very important. Your support and encouragement may help your patients approach their treatment with a better outlook, thereby increasing the likelihood of their successful recovery.

Organized Delivery System (BHRS) Substance Use Treatment

Behavioral Health and Recovery Services provides services for substance use treatment ranging from intensive outpatient treatment to residential care and detox. You can refer your patients for treatment by using the Behavioral Health Referral Form and faxing it into the ACCESS Call Center. Members can also self-refer by calling the ACCESS Call Center at 800-686-0101.

Diagnostic Radiology and Advanced Imaging

HPSM members have many contracted facilities from which to choose for their diagnostic radiology and advanced imaging needs. All contracted hospital facilities provide outpatient radiology services. In addition, HPSM has contracted with several free-standing radiology facilities. Please refer to the Provider List to find the most convenient location for your patient.

Please refer to the HPSM website for the most current prior authorization requirements for diagnostic radiology and advanced imaging services. Claims submitted by a participating provider or facility for diagnostic radiology and advanced imaging tests that have not been authorized through HPSM may be denied. The member is held harmless and balance billing is not permitted.

Exceptions

Radiology services provided to an HPSM member during an inpatient hospitalization or in the emergency department do not require a PAR for technical services.

Note: These are general guidelines. Cases are reviewed on an individual basis – the more information that is provided on the PAR, the faster the authorization can be processed. Please remember, a PAR can only be deferred once.

HPSM will determine medical necessity only. Always verify eligibility, benefits, and co-payments for a member directly with HPSM Member Services.

Remember the applicable modifier(s) when submitting PARs for these services.

Chiropractic Care and Acupuncture

HPSM contracts with local chiropractic providers for the provision of chiropractic services for HPSM members. Acupuncture services are available for Medi-Cal and HealthWorx members. In both cases benefits are subject to program coverage and limitations. In general, visits are limited to two per month. These services are provided through contracted providers listed in the Provider Directory.

Both chiropractic and acupuncture services are self-referred and do not require authorization, subject to the limits of the program.

Physical and Occupational Therapy

All HPSM members are provided physical and occupational therapy services through our outpatient, hospital-based physical and occupational therapy units within the contracted hospital network. Initial evaluations do not require a PAR. Please refer to the HPSM website for the most up-to-date information on prior authorization requirements for continuing therapy services.

Speech Therapy

All HPSM members have access to outpatient speech therapy services. Initial evaluations do not require a PAR. Please refer to the HPSM website for the most up-to-date information regarding prior authorization requirements for continuing therapy services.

For patients who may be eligible for a school-based speech therapy program (three years of age and older), an evaluation by the school district will be required for additional therapy sessions. The school district evaluation requirement may be waived if there are extenuating circumstances which prevent the evaluation from taking place on a timely basis. Participation in a school-based speech therapy program, if the member is eligible, is required while school is in session (September through June).

Podiatry (CareAdvantage and Medi-Cal only)

Medi-Cal and HealthWorx

Podiatry benefits are provided for HPSM Medi-Cal and HealthWorx members.

Podiatry services are provided through our contracted providers located throughout San Mateo County. Services are limited to two office visits a month. Please refer to the HPSM website for the most up-to-date information regarding prior authorization requirements for podiatry services.

CareAdvantage

Podiatry services are a covered benefit for the treatment of injuries and disease of the feet (such as hammer toe or heel spurs). Routine foot care is covered for members with certain medical conditions affecting the lower limbs (diabetes).

Dental (Medi-Cal and CareAdvantage only)

Dental services are a covered through HPSM’s Medi-Cal dental benefit. Dental services are provided through our contracted Dental providers located throughout San Mateo County and neighboring counties. Medi-Cal & CareAdvantage members are eligible for certain dental services including cleanings, fillings, and dentures.

All medically necessary dental treatment will be reviewed and authorized by HPSM. Please refer to the HPSM website for the most up-to-date information regarding prior authorization requirements for covered dental services.

Vision

Vision care services are covered through a variety of different methods, depending on the specific program that the member is enrolled in. The section below describes each of the various programs and their associated vision care benefits.

Medi-Cal

Members who need an examination for eyeglasses may go directly to an optometrist for a visit once every two years (without the need for a referral from the PCP*). For other eye problems, members should see their PCP for a referral to an ophthalmologist.

Members are eligible for new eyeglass (frames and lenses) every two years. Lost, stolen, or broken glasses may be replaced under extenuating circumstances. If members repeatedly lose or break their eyeglasses, they may be responsible for replacement eyeglasses.

*Only Willow Clinic optometrists require a referral (RAF), since they do not have their own provider number.

CareAdvantage

Outpatient physician services for eye care is a covered benefit for people who are at high risk of glaucoma, such as people with a history of glaucoma, people with diabetes, and African-American who are age 50 and older are covered for glaucoma screening once per year.

Members are eligible for one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. Corrective lenses/frames (and replacements) needed after a cataract removal without a lens implant.

HealthWorx

Vision Services are covered through the Services Employees International Union (SEIU), Local 715 for those IHSS workers who meet eligibility requirements. For more information about Vision Benefits, Members need to call the SEIU, at 408-954-8715 ext. 186.

Durable Medical Equipment

Durable medical equipment (DME), when prescribed by a licensed practitioner, is covered when medically necessary to preserve bodily function essential to activities of daily living or to prevent significant physical disability. There are program specific limitations which are outlined below. DME may be obtained from any licensed DME provider who has a Medi-Cal provider number. HPSM contracted DME providers are listed in the HPSM provider directory. There are no co-payments required from members for these services. For the most up-to-date information regarding prior authorizations for DME requests, please refer to the HPSM website.

Medi-Cal

Included ItemsExcluded Items
  • Oxygen and oxygen equipment.
  • Blood glucose monitors (must be obtained from a pharmacy).
  • Apnea monitors.
  • Nebulizer machines, tubing and related supplies, and spacer devices for metered dose inhalers.
  • Ostomy bags, urinary catheters, and related supplies.
  • Insulin pumps and related supplies.
  • Other diabetic self-management supplies, as medically necessary (must be obtained from a pharmacy).
  • Comfort and convenience items.
  • Experimental or research equipment.
  • Devices not medical in nature, including modifications to the home or automobile.
  • More than one piece of equipment that serves the same function, unless medically necessary.

CareAdvantage

Included ItemsExcluded Items
  • Crutches
  • Hospital Beds
  • IV Infusion pump
  • Oxygen and oxygen equipment
  • Nebulizers
  • Walker
  • Colostomy bags and supplies directly related to colostomy care
  • Pacemakers
  • Blood glucose monitor, test strips, lancets, lancets devices, and glucose control solution.
  • Orthopedic shoes or supportive devices for the feet (certain exceptions apply).

HealthWorx

Included ItemsExcluded Items
  • Oxygen and oxygen equipment.
  • Blood glucose monitors (must be obtained from a pharmacy).
  • Apnea monitors.
  • Nebulizer machines, tubing and related supplies, and spacer devices for metered dose inhalers.
  • Ostomy bags, urinary catheters, and related supplies.
  • Insulin pumps and all related supplies.
  • Comfort and convenience items.
  • Disposable supplies, except ostomy bags, urinary catheters and supplies consistent with Medicare coverage guidelines.
  • Exercise and hygiene equipment.
  • Experimental or research equipment.
  • Devices not medical in nature, such as sauna baths and elevators, or modifications to the home or automobile.
  • Deluxe equipment.
  • More than one piece of equipment that serves the same purpose, unless medically necessary.

Wheelchairs

Manual and powered wheelchairs are covered (must meet clinical criteria per product line) under all HPSM programs. The requirements for obtaining a wheelchair are:

  1. The wheelchair is prescribed by a licensed medical provider.
  2. HPSM has determined that the proposed wheelchair is medically necessary.
  3. The wheelchair provider has received an authorization via an authorized prior authorization request (PAR) form from the HPSM Health Services Department.

Wheelchairs may be obtained from any licensed DME provider who has a Medi-Cal provider number. HPSM contracted wheelchair providers are listed in the HPSM provider directory.

Please refer to the HPSM website for information regarding prior authorization requirements for wheelchair requests. HPSM generally requires an independent member evaluation when a request for a wheelchair is submitted to Health Services. The HPSM contracted evaluator is a specialist who performs an onsite evaluation of the member. If the HPSM contractor is unable to perform the onsite member evaluation, the request for the wheelchair will be denied for administrative reasons.

HPSM reserves the right to determine whether to rent or purchase the proposed equipment.

Audiology/Hearing Aids

Audiology services, including hearing tests and hearing aids are covered under most of HPSM programs, subject to specific program limitations described below. Please refer to the HPSM website for the most up-to-date information regarding prior authorization requirements for audiology services. Audiology services may be obtained from any licensed provider who has a Medi-Cal provider number. Contracted HPSM audiology specialists and hearing aid dispensers are listed in the HPSM provider directory. There are no copayments required from members for these services.

Medi-Cal

Included ItemsExcluded Items
  • Screenings and examinations.
  • Hearing aids are covered when provided by an HPSM contracted specialist. A referral is required from the PCP if more visits are needed after the initial screening hearing evaluation.
  • Batteries or other ancillary equipment, except those covered under the terms of the initial hearing aid purchase.
  • Charges for a hearing aid which is more than the prescribed correction for the hearing loss. Replacement parts for hearing aids and repair of hearing aids after the covered one-year warranty period.

CareAdvantage

Included ItemsExcluded Items
  • Diagnostic hearing and balance exams.
  • Hearing aids and hearing exam for the purpose of fitting a hearing aid.

HealthWorx

Included ItemsExcluded Items
  • Audiological evaluation to measure the extent of hearing loss.
  • Hearing aid evaluation to determine the most appropriate make and model of hearing aid.
  • Monoaural or binaural hearing aids, including ear mold(s), hearing aid instrument, initial battery, cords, and other medically necessary ancillary equipment.
  • Visits for fitting, counseling, adjustments, repairs, etc., at no charge for a one-year period following the provision of a covered hearing aid.
  • Purchase of batteries or other ancillary equipment, except those covered under the terms of the initial hearing aid purchase and charges for a hearing aid which exceeds specifications prescribed for correction of a hearing loss.
  • Replacement parts for hearing aids and repair of hearing aids after the covered one year warranty period.
  • Replacement of a hearing aid more than once in any 36- month period.
  • Surgically implanted hearing devices.

Prosthetics/Orthotics

Prosthetic and orthotic devices are covered under all HPSM programs when such appliances are medically necessary for the restoration of function or replacement of body parts. Coverage is subject to specific program limitations as outlined below.

Covered items must be prescribed by a licensed physician or podiatrist and dispensed by an HPSM contracted provider. Please refer to the HPSM website for the most up-to-date information regarding prior authorization requirements for prosthetic and orthotic devices.

A list of HPSM contracted prosthetists and orthotists can be found in the HPSM provider manual. HPSM reserves the right to determine whether to replace or repair a requested prosthetic or orthotic device.

There are no co-payments required from members for these services.

Medi-Cal

Included ItemsExcluded Items
  • All requested items must be determined by HPSM to be medically necessary.
  • All requested items must be determined by HPSM to be medically necessary.

CareAdvantage

Included ItemsExcluded Items
  • Prosthetic devices and related supplies (other than dental).
  • Braces, Prosthetic shoes, artificial limbs
  • Therapeutic shoes (includes shoe fitting or inserts) only with diagnosis of severe diabetic foot disease.
  • Breast prosthesis (including surgical brassiere after mastectomy).
  • Repair and replacement of prosthetic devices
  • Orthopedic shoe or supportive devices for the feet (certain exceptions apply).

HealthWorx

Included ItemsExcluded Items
  • Medically necessary replacement prosthetic/orthotic devices as prescribed by a licensed practitioner acting within the scope of his/her licensure.
  • Initial and subsequent prosthetic devices and installation accessories to restore a method of speaking incident to a laryngectomy.
  • Therapeutic footwear for diabetic conditions.
  • Prosthetic devices to restore and achieve symmetry incident to mastectomy.
  • Most over-the-counter items.
  • Corrective shoes, shoe inserts and arch supports, except for therapeutic footwear for diabetics
  • Non-rigid devices, such as elastic knee supports, corsets, elastic stocking, and garter belts.
  • Dental appliances.
  • Electronic voice producing machines.
  • More than one device for the same part of the body, unless medically necessary.

Enhanced Care Management (ECM)

Enhanced Care Management (ECM) for Medi-Cal members is a new statewide benefit effective January 1, 2022. ECM offers a whole-person, interdisciplinary approach to care that addresses the clinical and nonclinical needs of high need and/or high-cost members through systematic coordination of services and comprehensive care management that is community-based, interdisciplinary, high-touch, and person-centered with the overarching goals of:

  • Improving care coordination;
  • Integrating services;
  • Facilitating community resources;
  • Improving health outcomes; and
  • Decreasing inappropriate utilization and duplication of services.

ECM will be offered to specific target populations of focus. An ECM New Benefit Notice will be sent to all HPSM members to learn about ECM and will ensure ECM eligible members and/or authorized support person such as family member(s), guardian, and caregiver will learn about where to obtain information about the ECM benefit, how to make a referral or request ECM, and who to contact regarding any questions regarding ECM and/or the status of their referral. More information about ECM, and an ECM referral can be made, by accessing the referral form via HPSM’s website at www.hpsm.org or made by phone by contacting HPSM’s Care Coordination Unit/Integrated Care Management at 650-616-2060 during Monday through Friday, 8:00 AM – 5:00 PM.

Members who are already enrolled in Whole Person Care (WPC) a five year, federally funded pilot program to test county-based initiatives that coordinate health, behavioral health, and social services for vulnerable Medi-Cal beneficiaries who are high users of multiple systems and have poor outcomes will be automatically eligible for ECM. HPSM has worked with San Mateo County (SMC) Whole Person Care (WPC) to identify eligible members in all programs under Whole Person Care and will continue to work with SMC WPC to reconcile any data discrepancies and align on WPC members eligible for transition to ECM.

HPSM administers this benefit through a partnership with SMC WPC and ECM contracted providers who are community-based entities with experience and expertise providing intensive, in-person care management services to individuals in one or more of the Populations of Focus for ECM.

Community Supports

Community Supports are optional services or settings that are offered to Medi-Cal and CareAdvantage members in place of services or settings covered under Medi-Cal. Community Supports is not a benefit but are medically appropriate and cost-effective alternative services with the goal to improve the health outcomes and quality of life experienced by high risk Medi-Cal recipients by addressing Social Determinants of Health (SDOH). Community Supports services or settings are administered by HPSM contracted Community Support providers.

To learn more about the Community Supports service options offered by HPSM and/or to make a referral for Community Supports, please access HPSM’s website at www.hpsm.org or contact HPSM’s Care Coordination Unit/Integrated Care Management at 650-616-2060 during business hours, Monday through Friday, 8:00 AM to 5:00 PM.

State and County Programs

Whole Child Model (WCM)/California Children’s Services (CCS)

California Children’s Services (CCS) is a statewide program that treats children with certain physical limitations and chronic health conditions or diseases. In San Mateo County, children who are eligible for CCS and HPSM Medi-Cal are enrolled into the Whole Child Model. The WCM program is a partnership between HPSM and San Mateo County CCS.

Except for pharmacy benefits (which are covered through Medi-Cal Rx beginning in 2022), services under the Whole Child Model are covered by the Health Plan of San Mateo. Utilizing the standard MediCal Prior Authorization process, submit any necessary Prior Authorization to HPSM. San Mateo County CCS works closely with HPSM to receive referrals to CCS, authorize services for WCM eligible members, and provide case management services to these children with special health care needs.

Hours: Monday through Friday 8:00 a.m. to 5:00 p.m.

Fax: 650-616-2598

Mail

CCS
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

Website: www.smchealth.org/ccs

Golden Gate Regional Center (GGRC)

Golden Gate Regional Center serves individuals with developmental disabilities and their families who reside in Marin, San Francisco, and San Mateo counties. In addition, GGRC provides early intervention services to infants between birth and three years of age who are developmentally delayed or believed to be at high risk of having a developmental disability, and genetic counseling and testing for individuals at high risk of having a child with a disability.

Regional centers are the hub of a comprehensive network which links people to services, acts as a community focus for individuals with developmental disabilities, their families and service providers. GGRC provides lifelong support for their clients and their families.

Any HPSM member may be referred for GGRC services via telephone or letter. The request goes to the San Mateo County Intake Supervising Social Worker who conducts a basic screening to determine if further assessment and diagnostic services are appropriate. Persons with developmental disabilities may apply for services directly or be referred by others.

Phone: 650-574-9232

Fax: 650-345-2361

Mail

GGRC
3130 La Selva Drive, Suite 202-107
San Mateo, California 94403

Website: www.ggrc.org