Overview and General Information
Third-Party Administrator Services
HPSM will provide the following services for the San Mateo ACE Program:
- Claim processing and data management
- Outpatient pharmacy benefit management
- Provider contracting and payment
- Utilization and medical management
- Collection of annual participation fee
|
- Customer service
- Grievance and appeals
- Quality assessment and improvement
- Provision of participant informing materials
- Reporting
|
These services are designed to create a coordinated and participant-centered system of care that emphasizes primary and preventive care and management
of chronic conditions. Participants will be assigned to a primary care clinic that will serve as a medical home. Services may also be available through
other San Mateo ACE Providers, as well as through designated non-ACE providers with referral and authorization.
An estimated 12,000 to 15,000 participants are expected in the expanded ACE Program. All participants will be issued a participant identification card by the HPSM.
San Mateo ACE is Not Insurance
The San Mateo ACE Program covers a wide range of health care and pharmacy benefits under a coordinated system of care,
but it is not an insurance product subject to state insurance requirements. It is a payer of last resort, which means
it pays only for certain services that are not covered by other existing coverage programs.
Examples of other coverage programs that are primary to the San Mateo ACE Program include:
- Medi-Cal, which provides comprehensive health care services for low-income individuals who become
eligible due reason that may include pregnancy, disability, and long-term placement in a nursing facility
- Family PACT, which provides coverage of family planning services to eligible men and women of
reproductive age
- Cancer Detection Program, which provides coverage of breast and cervical cancer screening
services to eligible women 40 years old or older
Emergency services are also excluded under the San Mateo ACE Program. Hospitals are required to provide
these services under their charity care and SB 12 requirements.
Covered Services
The San Mateo ACE Program provides access to a wide range of benefits, including but not limited to:
- Outpatient services
- Inpatient hospital services
- Ancillary care services
|
- Durable medical equipment
- Orthotics and prosthetics
- Prescription drugs
|
See the
San Mateo ACE Participant Handbook (en español)
for a full list of covered benefits, exclusions, and limitations.