Your HEALTHmatters

Comprehensive coverage is an essential component of high-quality health care because it ensures that people can get specialized health services. That means people with diagnosed medical conditions can get treated by licensed medical specialists who have advanced expertise in those particular conditions. This produces better health outcomes by ensuring that people get the specific type of care they need when they need it.

That’s why Health Plan of San Mateo (HPSM) covers a full range of specialized health services for our members living in San Mateo County. Some of the specialized providers in HPSM’s network include:

• Allergist/Immunologist – Treats allergies (including asthma) and autoimmune conditions (e.g., type 1 diabetes, celiac disease, multiple sclerosis).
• Cardiologist – Treats disorders of the heart and parts of the circulatory system.
• Dermatologist – Concerned with problems affecting the skin (e.g., acne, eczema, psoriasis).
• Dentist – Specializes in oral health (e.g., teeth, gums, mouth). 
• Gastroenterologist – Focuses on the gastrointestinal system (e.g., stomach, intestines, colon, liver).
• Neurologist – Treats disorders of the nerves and nervous system.
• Orthopedist – Focuses on the musculoskeletal system.
• Obstetrician/Gynecologist – Specializes in reproductive issues (e.g., pregnancy, childbirth, postpartum health).
• Urologist – Concerned with urinary system functions and disorders. 

The advantage of comprehensive specialized health services coverage

All physicians – from primary care providers (PCPs) to specialized providers – spend many years learning and earning the medical degrees they need to become licensed physicians. PCPs study medicine more generally, which enables them to diagnose and treat a wide range of common conditions. They also provide preventive care that helps people stay healthy. Specialists, in contrast, spend most of their training focused on one particular area of medicine to become experts in treating the conditions associated with it. 

When a PCP identifies a potential health issue that would be best treated by someone with expertise in that condition, they may refer the patient to a specialist. That is one reason why seeing a PCP at least once a year is important: because the sooner a condition is diagnosed, the less advanced it will be. That often makes treatment interventions simpler and more successful, which leads to better overall health outcomes. This is especially true when someone has more than one health condition simultaneously. 

Specialists know which specific treatments are most likely to cure or manage the particular conditions they specialize in, no matter how complex the disorder or how far it has progressed. People with diseases or injuries requiring a specialist’s expertise therefore need comprehensive health care coverage to ensure they get the specialized services they need when they need them. 

Benefits of HPSM's comprehensive coverage

HPSM is one of two health care plans covering San Mateo County residents who qualify for Medi-Cal (i.e., California’s version of the federal Medicaid program). That means our Medi-Cal and CareAdvantage members have access to a robust network of over thousands of specialty providers and a comprehensive set of health benefits. 

These benefits include comprehensive dental care through HPSM Dental – California’s first and only dental plan for Medi-Cal recipients that is fully integrated with medical and behavioral health care benefits. This all-in-one care improves our members’ oral health and overall wellness through enhanced care coordination between HPSM, our dental specialists and our medical providers. 

While our HealthWorx HMO and Access and Care for Everyone (ACE) programs offer more basic benefits, they do cover some specialized health services. Plus, all HPSM members can join our Complex Care Management program to get an assigned Care Manager who works with the member and all of their providers (PCP and specialists) to meet identified health goals. 

How HPSM members can get specialized health services

HPSM members who need non-emergency specialized health services may first need ask their PCP for a referral. Their PCP may also need to ask HPSM for prior authorization before specialized health services can be provided. These processes ensure that the member sees the right kind of specialist and that the services are covered before they are provided. 

In April 2023, for the first time in three years, California counties started checking if Medi-Cal members are still eligible. Now many eligible HPSM members are at risk of losing their Medi-Cal. That is because they have not sent their renewal packets to the Human Services Agency (HSA).

That is why HPSM is reaching out to these members with:

• Robocalls: Since June, our automated system has made thousands of calls: two per household each month until we get a call back.
• Text messages: We send renewal messages and work with clinics to help reach more members.
• Social media: Posts to our Facebook and Instagram accounts (right) get the word out to all our followers.
• Member newsletter articles: This is the third HEALTHmatters article urging members to return their renewal packets.

If you get a robocall or text message from HPSM, send your renewal packet to HSA

• Check your mail for a white envelope with a yellow strip from HSA.
• Fill out and return the packet as soon as you can. If you do not have all your supporting documents ready, return it with what you have.
• If you have questions or need renewal help, call HSA at 1-800-223-8383.
• You can also use your account on the MyBenefits CalWIN website to:
  • Get online help and instructions on how to apply.
  • Report changes in your information.
  • Renew your Medi-Cal benefits.
  • Order a Medi-Cal Benefits Identification Card (BIC).

It is hard to imagine that 10 years ago this month, the Affordable Care Act (ACA) expanded Medicaid to more low-income adults. It seems like only yesterday. Prior to the ACA, 42 out of 50 states had uninsured rates of more than 10%. More than 17% of California residents had no health insurance coverage. 

In 2014, I was working at another safety net health plan much like HPSM. I will never forget one conversation I had with a man who told me that because he and his wife had health coverage for the first time, he could start saving for his children’s education. That’s how important health coverage is for people. 

It is fitting then, that as we celebrate this 10-year anniversary of the ACA Medicaid expansion, the state of California is taking another bold step. Starting this month, HPSM will begin enrolling thousands of new members. It is not unusual for us to do so, but what is notable is that California will become the first state to cover all residents regardless of documentation status. Locally, this means that many of the 20,000 individuals currently enrolled in Access to Care for Everyone (ACE), which HPSM administers for San Mateo County, are being transitioned to our Medi-Cal plan, which will provide expanded benefits (including dental) and a broader network of providers, all at no cost to the individual.

With this transition, we expect that the number of uninsured in California and San Mateo County will drop to less than 4%. While we celebrate this tremendous step forward in coverage, moving from 17% to 4% uninsured in the last decade, we know that it is only the first step. Health insurance coverage provides a safety net, both emotionally and financially, as it did for the man with whom I spoke 10 years ago. To truly attain our vision that healthy is for everyone means that not only do our members have health coverage, but they also have the same access to health care services for themselves and their families, and that they have the same opportunity to attain their best possible health.

This month we celebrate this expanded Medi-Cal coverage to more San Mateo County residents, and we continue to do the important work to make our vision a reality.