What Benefits Does HPSM Medi-Cal Cover?
HPSM Medi-Cal members have access to a full range of covered healthcare benefits, programs and services at no cost. Some key benefits are highlighted on this page.
Member Services team
Not Sure What to Do Next? HPSM Member Services is here to help – whether you need help finding a doctor, understanding your benefits or getting connected to services. Our team takes the time to answer your questions and guide you to the right resources. Get Call Center contact information.
Doctor and other healthcare provider visits – including specialist care
HPSM covers primary and specialty care services given by a network of providers in San Mateo, San Francisco and Santa Clara Counties (our service area). Most services are provided in an office setting. HPSM also covers telephone and video visits (known as telemedicine). Ask your providers if they offer this service.
Well visits – including health exams, screenings, tests, immunizations and other office visits with a primary care provider (PCP). PCPs can also refer members for specialist care. Learn more about well visits and other preventive care.
Services are covered outside of our service area only for urgent care or when HPSM pre-approves coverage for a visit to a non-network provider. Services may be given by an out-of-network provider at no cost as long as they are medically necessary and not available in HPSM’s network.
When non-emergency care is needed outside of HPSM’s service area, members should:
- Call their PCP right away to get authorization for treatment
- Call HPSM Member Services at 1-800-750-4776 (TTY 1-800-735-2929 or dial 7-1-1)
Does Medi-Cal cover emergency services?
In California
Call 9-1-1 or go to the nearest emergency room (ER). You do not need pre-approval (prior authorization) for emergency care. If emergency care is needed outside of Canada, Mexico or another state or U.S. territory, HPSM will not cover it in most cases.
Outside of California
Including U.S. territories (American Samoa, Guam, Northern Mariana Islands, Puerto Rico and the Virgin Islands)
Tell the hospital or emergency room doctor as soon as possible that you have Medi-Cal and are an HPSM member. Not all hospitals and providers accept Medicaid.
Can I continue seeing my current provider after becoming an HPSM Medi-Cal member?
New members, or those who need to find a new provider because the provider's office closed or their contract with HPSM ended, may qualify for continuity of care for up to 12 months – even if the provider does not accept Medi-Cal. Learn more about continuity of care.
Prescription medicines
Medicine coverage is primarily managed by the California Department of Health Care Services through a program called Medi-Cal Rx. Learn more about prescription medicine coverage.
Vision care
Includes:
- 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 or contact lenses every two years (if medically necessary)
Maternity care
Get the support and care you need through each stage of your pregnancy.
- Pregnancy, maternity and newborn care
- Delivery and postpartum care
- Doula services
Learn more about maternity care.
Dental care
Access to high quality dental care is offered through HPSM Dental. Covered services include checkups, x-rays, cleanings, crowns and other services for most members. Learn more about dental coverage.
Mental health care
Mild to moderate issues are covered at no cost with treatments such as psychotherapy and medication therapy. More serious mental health and substance use issues are covered by Behavioral Health and Recovery Services (BHRS). Learn how to access mental health care.
Doula services
Emotional and physical support during pregnancy, childbirth and after the end of a pregnancy with in-person and online visits. Learn more about doula services.
No-cost transportation
The HPSM Ride Benefit is available for HPSM members who have no other transportation to approved healthcare visits and back home. Learn how to use the Ride Benefit.
Enhanced Care Management
Extra personal support services that can help meet your healthcare needs for $0 cost with a care manager to lead your care team. Learn more about Enhanced Care Management.
Nurse Advice Line
Call anytime you have an urgent health question and your provider is not available. Learn how to call the Nurse Advice Line.
For complete and detailed information, see the Medi-Cal Member Handbook (Evidence of Coverage) or contact HPSM Member Services.