HPSM Medi-Cal Benefits A Guide on How to Get Your Health Care Health care and insurance benefits can be difficult to understand. This guide introduces you to your basic Medi-Cal benefits, to the Health Plan of San Mateo (HPSM), and explains who to call if you have questions or need help. More information can be found in your HPSM Medi-Cal Member Handbook/ Evidence of Coverage.
Contents You Are a Member of HPSM 1 HPSM Is Here to Help 2 Contact Member Services 3 Visiting Your Doctor 5 Drug Coverage 6 Other Services 6 Your HPSM Medi-Cal Benefits 7 Who to Contact About Continuing Your Medi-Cal Coverage 9 Important Phone Numbers 11 We Speak Your Language 12 HPSM Nurse Advice Line 13 Notes 14 You Are a Member of HPSM The Health Plan of San Mateo (HPSM) is your Medi-Cal managed care insurance plan. You automatically became a member of HPSM when your eligibility for Medi-Cal coverage was approved by the County of San Mateo Human Services Agency, or through the SSI program (Supplemental Security Income). 1
HPSM Is Here to Help HPSM provides you with the resources for staying healthy. We pay for your health care services and drug prescriptions We give you access to a primary care physician (PCP) We provide you with a large network of specialists Provider Directory In your new member packet is a copy of our Provider Directory. Use this to help find a primary care physician (PCP) that suits your needs. 2
Contact Member Services HPSM s Member Services staff is dedicated to responding to your questions about your benefits and your doctors. We can also help you with problems related to getting your medical care covered, or with the quality of service that you received. HPSM Member Services Local: 650-616-2133 Toll-free: 1-800-750-4776 TTY: 1-800-735-2929 or 7-1-1 See Page 12 for Language Services About You If you need a new HPSM ID card. You lost your HPSM card. The primary care physician (PCP) name on your card has to be changed. If your home address or phone number has changed. If you have questions about HPSM s services. You want to know if a medical procedure or prescription will be covered. Your doctor ordered medical equipment for you and you want to know if it will be covered. 3
About Your Doctor If you cannot get a doctor s appointment. The wait is too long or your doctor is unavailable. If you need a new doctor. Find a doctor in your area. You prefer a female or male doctor. You want a doctor who speaks your language. About Your Prescription If you have problems getting a prescription filled. The pharmacy told you that your prescription is not approved for coverage. About Your Medical Care If you have questions about a bill. You don t understand why a clinic or doctor s office has sent you a bill. You had to get urgent medical care from a non-network doctor when you were outside of HPSM s service area. If you have a complaint. You do not like the way the staff at your doctor s office responded to you on the phone, or in person. You are not satisfied with your doctor s decisions about your medical care. You are not satisfied with a decision HPSM has made related to coverage for a service. 4
Visiting Your Doctor What to Bring Your Medi-Cal Benefit ID Card (from the State) Your Medi-Cal Benefit ID Card (BIC) is your proof of Medi-Cal enrollment. You are required to present this card to all providers (doctors, pharmacies, hospitals, etc.). Redesigned BIC cards are being sent to new Medi-Cal recipients and those requesting replacement cards. Either card is valid. AND Your HPSM Medi-Cal ID Card Your HPSM Medi-Cal ID Card displays the name of your primary care physician (PCP) and is your proof of HPSM membership. You are required to present this card, along with your Medi-Cal Benefit ID Card, at the time you receive health services. Show your two ID cards to have services billed to HPSM Medi-Cal. You must present your HPSM Medi-Cal ID card and your Medi-Cal Benefit Identification Card (BIC) when you see a doctor, fill a prescription at a pharmacy, and receive emergency and hospital services. Without these cards, your health care may not be covered and you may be responsible for the full cost of services. 5
Drug Coverage Prescription Drugs Medi-Cal covers brand and generic drugs prescribed by your doctor. Some over-the-counter medicines that are medically necessary may also be covered, but require a prescription from your doctor. Your doctor and pharmacy must use the HPSM Formulary (list of covered drugs) for your prescriptions. Go to pharmacies in the HPSM provider network to fill prescriptions. These are listed in your Medi-Cal Provider Directory. Brand-name drugs in the HPSM formulary and drugs that are not in the formulary need prior authorization from HPSM to be covered. Your doctor has to send medical justification to HPSM s Pharmacy Unit. If your prescription isn t covered by HPSM, call HPSM Member Services. If the pharmacy tells you that your prescription does not have prior authorization, call your doctor. Other Services Mental Health Services Dental Specialty mental health services are covered through San Mateo County Behavioral Health and Recovery Services (BHRS). Specialty mental health services include inpatient and outpatient services. Call BHRS Access Call Center at 1-800-686-0101 for information about receiving mental health services TDD: 1-800-943-2833 Denti-Cal, the state dental program, covers dental services for children and adults. Call Denti-Cal at 1-800-322-6384 with questions about covered services and dentists. Information is available online at www.denti-cal.ca.gov TTY: 1-800-735-2922 or 7-1-1 Please note that you must show your Medi-Cal Beneficiary Identification Card (BIC) to obtain Denti-Cal Services. 6
Your HPSM Medi-Cal Benefits The chart below describes some of your HPSM Medi-Cal benefits that cover essential health care services. It also provides instructions on what you need to do, or who to call, to receive a service covered by Medi-Cal. A complete description of all your benefits and covered services is in the Medi-Cal Member Handbook / Evidence of Coverage, Section 6, Covered Services and Benefits. Benefit and Covered Services Hospital Services All services related to inpatient care, surgery, and emergency care. Includes nursing care, room and meals, medications, and lab work. Emergency care services are covered at any hospital, in and outside of San Mateo County. Includes pregnancy-related emergencies. Physician Services Medically necessary office or clinic visits for preventive care, diagnosis and treatment of a medical condition, and services at a hospital. Covers adult, pediatric, and women s health services. To Receive Covered Services For non-emergency hospital services, your primary care physician (PCP) has to request prior authorization from HPSM. Your primary care physician (PCP) is linked to an HPSM network hospital. Emergency services do not need prior authorization. Call 9-1-1 or go to the nearest hospital emergency room. Go to the primary care physician (PCP) on your HPSM Medi- Cal ID card. Your PCP s phone number is on your ID card. You can receive many services, including physical exams and immunizations from your primary care physician (PCP). Your primary care physician (PCP) will refer you to a specialist when it is necessary. You must choose physicians in the HPSM provider network. Long-term Care Services and Supports (LTSS) Different types of long-term care services are covered though this benefit (LTSS). These services include: In-Home Supportive Services, Community-Based Adult Services (adult day health care), Multiple Senior Services Program (coordinates social and health care services for members 65 and older), and Nursing Home care for members who need to receive care in a skilled nursing facility. For information on how to receive these services, call 1-800-675-8437 (TIES line). This is the 24-hour advice line for San Mateo County Aging and Adult Services. 7
Benefit and Covered Services Podiatry Covers office visits with podiatrists that are in the HPSM provider network. To see a podiatrist, members do not need a referral from their primary care physician (PCP). They can choose a podiatrist from the Medi-Cal provider directory, and contact the podiatrist directly without a PCP referral. Family Planning Covers office visits, counseling, pregnancy tests, different FDA-approved birth control methods, pregnancy termination, testing and treatment of STDs, and procedures for sterilization. HPSM Prenatal Care Program Assistance with finding an OB doctor (obstetrician), incentive gifts and childbirth classes. To Receive Covered Services Members can self-refer to see podiatrists in the HPSM network. PCP referral is not required. Your podiatrist will need to get prior authorization for coverage of additional services that are medically necessary. You can go directly to any family planning doctor or clinic in San Mateo County that accepts Medi-Cal. Services from out-of-network providers are covered. For help with finding a Medi-Cal family provider, call HPSM Member Services at 650-616-2133. PCP referral and prior authorization is not required. To enroll in the Prenatal Care Program call HPSM Health Promotions at 650-616-2165. Prenatal/Maternity Care Prenatal and postpartum care, hospital services for labor, delivery and pregnancy related complications. Newborn hospital care after delivery. Outpatient Mental Health Services Outpatient mental health services apply to services for mild to moderate mental health conditions and are covered by the Health Plan of San Mateo. Services include individual and group mental health testing and treatment (psychotherapy); psychological testing to evaluate a mental health condition; outpatient services that include lab work, drugs and supplies; outpatient services to monitor drug therapy; and psychiatric consultation. Mental health services for relationship and family problems are not covered. Choose an OB/GYN doctor from the HPSM Prenatal Provider List. Call HPSM Health Promotions at 650-616-2165. These services are provided by San Mateo County Behavioral Health and Recovery Services (BHRS). If you need outpatient mental health services, call the BHRS ACCESS Call Center at 1-800-686-0101. You can also talk to your PCP about your outpatient mental health needs; your PCP will speak with BHRS to get the help you need. 8
Continuing Your Medi-Cal Coverage HPSM Administers your Medi-Cal benefits. To help continue your Medi-Cal coverage, you will still need to contact either the Social Security Administration (SSA) or the San Mateo County Human Services Agency (HSA), depending on who processed your application. It is your responsibility to provide updated information about yourself to: Either the Social Security Administration (SSA) or the County of San Mateo Human Services Agency (HSA) HPSM I Have Medi-Cal Through SSA and... Call HSA 1-800-223-8383 Call SSA 1-800-772-1213 In addition, you must contact HPSM Member Services if you: Want to switch to a new primary care physician (PCP) Change your address Change your phone number Need a new HPSM ID card 9
I Have Medi-Cal Through the County Human Services Agency (HSA) and... Call HSA 1-800-223-8383 HPSM Member Services Local: 650-616-2133 Toll-Free: 1-800-750-4776 TTY: 1-800-735-2929 or 7-1-1 10
Important Phone Numbers San Mateo County Human Services Agency (HSA): 1-800-223-8383 Call to speak to a person who can answer your questions about health insurance and help you apply for health insurance. Denti-Cal: 1-800-322-6384 TTY: 1-800-735-2922 or 7-1-1 Call if you have questions about your dental benefits or dentists. HPSM Health Promotions: 650-616-2165 Call if you have general health education questions or want information on community resources. HPSM Member Services: 1-800-750-4776 or 650-616-2133 TTY: 1-800-735-2929 or 7-1-1 Call if you have questions about your medical benefits or appointments. San Mateo County BHRS Access Call Center: 1-800-686-0101 TDD: 1-800-943-2833 Call if you are looking for mental health or substance use recovery services. Social Security Administration (SSA): 1-800-772-1213 Call for questions regarding your social security benefits. Nurse Advice Line (24/7) Toll Free: 1-866-535-6977 TTY: 1-800-735-2929 or 7-1-1 Call to speak to a nurse if you have urgent questions about your or your child s symptoms when your clinic is closed. Call 24 hours a day, 7 days a week. This is a free service for HPSM members only. 11
We Speak Your Language HPSM Member Services Can Help You in Your Primary Language HPSM has bilingual Member Services Representatives who can help you in English, Spanish, Chinese (Mandarin and Cantonese), and Tagalog. For other languages, we use professional phone interpreters. This is a free service. Our staff is also prepared to work with hearing, speech, and visually impaired members. Contact Us by Phone Local: 650-616-2133 Toll-free: 1-800-750-4776 Monday through Thursday: 8:00 a.m. to 6:00 p.m. Friday: 9:30 a.m. to 6:00 p.m. For hearing and speech impaired TTY: 1-800-735-2929 or dial 7-1-1 Visit the HPSM Office 801 Gateway Blvd., Suite 100 South San Francisco, CA 94080 Walk-in office hours No appointment necessary Monday through Thursday: 8:00 a.m. to 5:00 p.m. Friday: 9:30 a.m. to 5:00 p.m. Our bilingual staff can help you in English, Spanish, Chinese (Mandarin and Cantonese), and Tagalog. Other languages are available through our telephone interpreter service. 12
HPSM Nurse Advice Line 24/7 Nurse Advice Line (24 hours every day) Call 1-866-535-6977; TTY: 1-800-735-2929 or 7-1-1 The Nurse Advice Line is a free phone service that you can use when you are not sure if a health condition needs urgent or emergency medical attention. A nurse can tell you if you need to see a doctor right away. Depending on your situation, the nurse may give you home self-care instructions. Use HPSM s Nurse Advice Line if your clinic is closed Call for health problems that are not life-threatening emergencies. For your baby, child, or teen You are worried about a high fever, a severe cough, or vomiting; You don t know what to do about a painful earache or an unfamiliar rash; or Your baby has diarrhea or is constipated. For adults You have a severe cough, chest pain, or difficulty breathing; You have abdominal pain or vaginal bleeding (for women); You have vertigo (dizziness) or a headache that doesn t stop; You have an urgent question about your medicine; or You cannot decide if you need to go to the emergency room. A Registered Nurse will give you advice Depending on your symptoms, you may receive instructions for self-care at home if it s medically appropriate. If you need urgent care and your doctor s clinic is closed, you will receive instructions on where to get care. For a medical emergency, call 9-1-1 or go to the nearest emergency room. Heart attack or stroke symptoms You cannot breathe Severe, uncontrolled bleeding 13
Notes: Fill in this section to help keep track of your health care. My HPSM ID Number: My Primary Care Physician (PCP): My PCP Address: My PCP Phone: My Next Appointment: (Date) / / (Time) a.m./p.m. My Next Appointment: (Date) / / (Time) a.m./p.m. My Next Appointment: (Date) / / (Time) a.m./p.m. My Next Appointment: (Date) / / (Time) a.m./p.m. Current Medications: Health Conditions: Emergency Contact: Emergency Contact Phone: Relationship: 14
Health Plan of San Mateo Nondiscrimination Notice The Health Plan of San Mateo (HPSM) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. HPSM does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. HPSM Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) HPSM Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Member Services. If you believe that HPSM has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: HPSM Member Services Toll-free: 1-800-750-4776 Local: 650-616-2133 TTY: 1-800-735-2929 or 7-1-1 Fax: 650-616-8581 You can file a grievance in person or by mail, fax, or phone. If you need help filing a grievance, Member Services staff are available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal. hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 15
16
17
Founded in 1987, the Health Plan of San Mateo (HPSM) is a local non-profit health care plan that offers health coverage and a provider network to San Mateo County residents. HPSM improves the health of our members through high quality and preventive care. We have a vision that healthy is for everyone, and we fight to make that possible for you. 2016 Health Plan of San Mateo (HPSM). All Rights Reserved.