Benefits and Services

What is covered

• Doctor visits
• Hospital care
• Prescription drugs are covered by Medi-Cal Rx
• Physician Administered Drugs (PADs) - drugs administered in an office or clinic setting
• Diabetes supplies
• Eye and hearing tests
• Skilled nursing care
• Community-Based Adult Services (CBAS)
• Care Planning and Management Benefit
• Preventive care – such as health exams, screenings, tests, immunizations and other office visits with a primary care doctor
• Dental care is covered through HPSM Dental
• Mental health care
• Doula services

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

Learn more about prior authorization.

Telemedicine

Doctor's visits by phone or video anytime

Many providers can give you advice over the phone or see you by video.  Telephone and video visits are fully covered by HPSM. Call your primary care provider (PCP)  to check if they provide telephone or video visits. 

If your do not have PCP, or if your PCP does not offer phone or video appointments, you may be able to use Teladoc®, one of HPSM's newest service partners.  Learn more. 

Ride Benefit

No-cost transportation to approved health care visits 

Medi-Cal members can get an unlimited number of rides to approved health care visits at no cost. These include medical, pharmacy, dental, mental health and other health care visits. Rules and restrictions apply:

• You must have no other way to get to your visit
  
• Call at least two business days before your appointment (for urgent care, call as soon as you can)
  
• Rides to non-healthcare services are not covered
  

Learn more.

Vision Benefits

• 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 

Mental Health and Substance Use Disorder Benefits

For help getting mental health or substance use services under your Medi-Cal benefit, call the San Mateo County Behavioral Health and Recovery Services (BHRS) Access Call Center (toll-free) at 1-800-686-0101 (TTY: 7-1-1). 

Mental health services

• BHRS provides specialty mental health services to Medi-Cal members who meet medical necessity rules for serious mental health issues. For information about specific services, call the BHRS ACCESS Call Center at 1-800-686-0101 (TTY: 7-1-1).
• HPSM's plan covers outpatient treatment services for mild and moderate mental health conditions.

Substance use disorder services

• BHRS provides substance use disorder services to Medi-Cal members who meet medical necessity rules. For information about treatment or a referral for substance use disorders, please call the BHRS ACCESS Call Center at 1-800-686-0101 (TTY: 7-1-1).
• HPSM's plan covers primary care alcohol use screening and referral. These include primary care screening services to identify and discuss risky alcohol use. Members ages 18 and older with an alcohol use disorder may be referred to BHRS for treatment. 
• HPSM's plan does not cover treatment for severe alcohol use disorder. Your PCP may refer you to BHRS.

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. Learn more about prior authorization.