Starting January 1, 2026, the Health Plan of San Mateo (HPSM) removed all frequency limits for pediatric well visits for Medi-Cal members aged 0-21 years old. This is in reference to Preventive Medicine Service codes 993981-5 and 99391-5.
Previously, HPSM denied claims if frequency exceeded a maximum threshold by member age. By removing restrictions on payments based on periodicity schedules, HPSM hopes to offer providers increased flexibility and completion of well visits among pediatric members.
While the codes 993981-5 and 99391-5 are included in the scope of HPSM’s primary care partial capitation, claims will now be paid at the allowable amount under either of the following scenarios:
- Primary care provider receiving HPSM primary care partial capitation has billed for Preventive Medicine Services rendered to HPSM Medi-Cal members who are not assigned to their group for primary care
- Primary care provider not eligible for or opted-in to partial capitation has billed for Preventive Medicine Services rendered to any HPSM Medi-Cal member
Under our primary care incentive programs, Care Gap Pay-for-Performance (P4P) and Benchmark P4P, HPSM pays providers additional incentive dollars for completing a minimum number of well visits for children and adolescents according to the following schedules:
- Well Child Visits in the First 30 Months of Life (W30 Rate 1): Members 0–15 months require six visits in the first 15 months of life
- Well Child Visits in the First 30 Months of Life (W30 Rate 2): Members 15–30 months require two visits between the 15th month birthday plus one day and the 30th month birthday
- Child and Adolescent Well-Care Visits (WCV): Members 3–21 years require one visit per calendar year
For more information, email HPSM Provider Services.
