Effective January 1, 2027, Health Plan of San Mateo (HPSM) members with unsatisfactory immigration status (UIS) will transition to the Medi-Cal Fee-for-Service (FFS) delivery system. This change is due to changes in Medi-Cal eligibility requirements.
Many HPSM members and their families will be impacted by this change. As a Medi-Cal provider, HPSM wants to make sure you have the information you need to minimize harm to HPSM members and their families and help avoid disruptions in their care. Here are three important ways you can support HPSM members:
Encourage members to check their mail and voicemail regularly and respond to communications promptly. Members affected by this change may have already been contacted via mail and automated phone calls with critical information about their health benefits. If they have not been contacted yet, encourage them to continue checking.
Support your patients with any necessary referrals. HPSM members transitioning to FFS Medi-Cal will need transitional care plans. Schedule needed specialty care visits before January 1, 2027. Members with complex specialty needs, members currently using the Enhanced Care Management benefit, or those using Community Supports may especially be impacted by this transition.
Refill prescriptions ahead of January 1. HPSM members transitioning to FFS Medi-Cal may not have access to a provider who can prescribe their medications. HPSM recommends providers write 90-day prescriptions with four refills, which will last a member one year, when clinically appropriate. Please note: members transitioning to Medi-Cal FFS will continue to have Medi-Cal Rx for medication coverage.
Primary care providers: please contact HPSM if you have specific questions about your assigned panel and how you can best support them. You may reach us at PSInquiries@hpsm.org.
To learn more about immigration status and changes to eligibility please visit the Department of Health Care Services’ (DHCS’) website here: https://www.dhcs.ca.gov/immigration-status-and-changes-to-medi-cal-eligibility/
Here is additional information from DHCS regarding provider enrollment, billing, and ongoing care responsibilities.
1. Medi-Cal FFS Enrollment Requirements
Providers must be enrolled in Medi-Cal FFS to continue to serve Medi-Cal members transitioning to Medi-Cal FFS. To enroll, providers must complete a provider enrollment application with the DHCS Provider Enrollment Division (PED). Although members will no longer be assigned a primary care provider under Medi-Cal FFS, you may continue to see your patients if you are enrolled in Medi-Cal FFS.
If you are already enrolled in Medi-Cal through PED via Provider Application and Validation for Enrollment (PAVE), you may continue to provide services to your members that have transitioned to Medi-Cal FFS and be eligible for reimbursement under Medi-Cal FFS.
If you are not currently enrolled through PAVE, you must apply and be approved to enroll by January 1, 2027, to receive reimbursement at FFS rates. For more information on PAVE enrollment, please visit https://www.dhcs.ca.gov/providers-partners/provider-application-and-validation-for-enrollment/
Please ensure that a hand off with appropriate records is shared with any providers who will continue to care for these patients. A list of providers who are enrolled in Medi-Cal FFS can be found here: https://data.chhs.ca.gov/dataset/profile-of-enrolled-medi-cal-fee-for-service-ffs-providers
2. Preparing for FFS Billing
DHCS strongly encourages all providers to familiarize themselves with Medi-Cal FFS billing processes to prepare for billing Medi-Cal FFS after January 1, 2027.
This includes:
Understanding FFS billing requirements: https://www.dhcs.ca.gov/providers-partners/tar-billing/
Reviewing FFS rates: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/rates?page=1&tab=rates
Accessing the Medi-Cal Provider Manual and Provider Bulletins: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/publications
Medi-Cal providers have access to billing and claims assistance through DHCS’ California Medicaid Management Information System (CA-MMIS) and its contracted Fiscal Intermediary (FI). CA-MMIS and FI staff can assist providers with questions about paper claim submissions, electronic claim submission, and Treatment Authorization Requests (TARs and electronic-TARs, or eTARs).
Medi-Cal providers can also contact the Telephone Service Center (TSC) by phone at 800-541-5555 (outside of California, 916-636-1980), Monday through Friday, except holidays, from 8:00 a.m. to 5:00 p.m. For faster access to TSC resources, Medi-Cal providers can refer to the TSC Main Menu Prompt Options Guide: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/82E2E926-5998-44E3-A478-965E0B59FFE8/provrelfrm1ref.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO
3. Benefit Changes and Support for Transition of Care
Enhanced Care Management and Community Supports are not covered under Medi-Cal FFS. However, certain related services are available for coverage and reimbursement when billed in accordance with Medi-Cal Coverage Policy by eligible providers. Specifically, providers enrolled in Medi-Cal FFS may bill for eligible care management, case management, or care coordination activities when provided in accordance with Medi-Cal FFS coverage and billing requirements.
DHCS plans to provide links and/or a resource document that includes the available codes for billing purposes under FFS. The resource will include lists of potential codes with links to the appropriate provider manual that includes details on billing guidance.
4. Checking Member Eligibility
To check an HPSM member’s eligibility visit the provider portal: https://www.hpsm.org/provider-portal-logi
Under the Office Management tab in the provider portal, you may search by member last name, HPSM Member ID, Medicaid ID, or Medicare ID (if applicable) to check eligibility.
You may also call 650-616-2056 to verify an HPSM member’s eligibility.
5. Questions & Support
HPSM will provide additional information as DHCS finalizes transition updates, including:
Care management applicable billing codes in Medi-Cal FFS
Member support pathways
Contact information for DHCS or MCP support channels
In the interim, please direct any questions to HPSM Provider Services at PSInquiries@hpsm.org.