Member Handbook and Evidence of Coverage

Transcription

1 Medi-Cal Member Handbook and Evidence of Coverage Last Updated 11/10/ 2015

2 Last Updated 11/10/ 2015

3 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. THIS NOTICE ALSO DESCRIBES HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have questions about this Notice, please contact a Health Plan of San Mateo (HPSM) Member Services representative at or Why Am I Receiving this Notice? We understand that health information about you is personal. We are committed to protecting your health information. In general, health information is any information about your physical or mental health or about your payment for health services that can be identified with you as an individual. This information can be about your past, present, or future health. Examples of health information are your name, date of birth, diagnoses, medical treatments, and past medical claims, though this is far from a complete list. This notice contains a summary of HPSM s privacy practices and your rights relating to health information. This notice only covers HPSM s privacy practices. Your doctor may have different policies or notices regarding his or her use and disclosure of your health information created in the doctor s office. We Are Required by Law to: y Make sure that health information that identifies you is kept private; y Give you this notice of our legal duties and privacy practices about your health information; and y Follow the terms of the notice that is currently in effect. How May HPSM Use or Share My Health Information? The following are ways in which we may use your health information. The types of uses and disclosures of information listed below are allowed by state and federal law. Use refers to how we use information within HPSM. Disclosure means sharing information with someone outside HPSM. Following is a description of each type of use or disclosure and some examples. The list below does not include every possible allowable use and disclosure, and it is not intended to limit uses and disclosures that are permitted by law. However, all of the ways we are allowed to use and disclose your health information will fall within one or another of the following purposes: y For Payment. We use your health information to pay bills for the health services you receive as an HPSM Member. For Example: We may need to get information from your doctor about a treatment that the doctor is considering for you. We will review the information to make a decision about whether to approve payment for the treatment. Decisions are based on medical need. We may need to let the doctor know if the treatment is a covered benefit for you. y For Health Care Operations. We may use and disclose health information about you to carry out HPSM s operations. This is done in a confidential manner. These uses and disclosures are necessary to run the health plan and perform many of the services that you receive. For Example: We may use health information about you in our review of the doctors who provide your care. We check their performance to make sure you are receiving quality care. We may also use health information about you to compare the quality of our services to that of other health plans. This will help us check if there are ways we can improve the quality of care you receive. y For Treatment. We may use your health information in managing your care. We may share your health information with a provider for use in treating you. For Example: We may review your i 2016 Medi-Cal EOC Privacy Policy

4 health information, including medications that you are taking, to make sure that none of the treatments you receive will conflict. y Health-related Benefits and Services. We may use and share health information to tell you about HPSM s health benefits or services that may be of interest to you through HPSM s Health Education Programs. y To Contractors. We may disclose your health information to our contractors who assist us in our operations. Our contractors agree in writing to keep the health information provided to them confidential and secure, and not to use it except to assist us. For example, we contract with a company known as a Pharmacy Benefit Manager. This company processes claims for pharmacy services. We provide information that we have that is needed to pay the pharmacy claims for our Members. The Pharmacy Benefit Manager agrees to keep this information confidential. y To Health Insurance Program Sponsors. Employers and other organizations sponsor health insurance programs. These employers or sponsors contract with HPSM to provide services to you and pay claims. We may notify the plan sponsor if you are enrolled in, or disenrolled from the plan. We may also disclose your health information so the plan sponsor can audit HPSM s performance. The sponsor agrees to keep your health information confidential and secure. y To Family Members or Individuals Involved in Your Care or Payment for Your Care. We may release health information about you to a person who is responsible for paying for your health care, as necessary to enable that person to make payment. We may also disclose health information to family members and others who are involved in your health care. However, we may only disclose this information if you are present and agree to the disclosure. If you are not present, we may only disclose your health information to people involved in your care if you are unable to respond because of your medical condition and we believe that disclosing your information would be in your best interest. We may also disclose your health information to individuals involved in your care or payment for your care after your death, unless you tell us not to share your information with them. y To Schools Regarding Immunizations. We may provide a record of immunizations to a school about a student either enrolled or to be enrolled in the school if the school is required by the State or other law to have such proof of immunization. We will obtain your verbal authorization before disclosing this information. Special Situations y As Required by Law. We will disclose health information about you when required to do so by federal, state or local law. y To Avoid a Serious Threat to Health or Safety. We may use and disclose health information about you to prevent a serious threat to your health and safety or the health and safety of others. We would only give the information to someone who can help prevent the threat. y Military and Veterans. If you are a member of the armed forces or a veteran, we may release health information about you as required by military authorities or to assist in determining your eligibility for veterans benefits. y Correction Institutions. If you are in custody, release of health information may also be made to correction institutions in the course of coordinating your care. y Workers Compensation. We may release health information about you for Workers Compensation or similar programs. These programs provide benefits for work-related injuries or illness. ii 2016 Medi-Cal EOC Privacy Policy

5 y Public Health Risks. We may disclose health information about you for public health activities. These activities generally include the following: To prevent or control disease, injury or disability; To report child abuse or neglect; To report births or deaths; To report reactions to medications or problems with products; To notify people of recalls of products they may be using; To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease. To notify the appropriate government authority if we believe a Member has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when authorized by law. y Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. For example, we may disclose your health information to the public agency responsible for overseeing HPSM s operations. These activities are necessary for the government to monitor the health care system and government health benefit programs. y Lawsuits and Disputes. We may disclose health information about you if ordered to do so by a court or tribunal. We may also disclose health information about you in response to a subpoena, or other lawful process, but only if efforts have been made to notify you of the request or to obtain an order protecting the information requested. y Law Enforcement. We may release health information if required to do so by a law enforcement official or, in limited circumstances, if the official requests the information, or in order to report criminal conduct. Generally, this would have to be in connection with a criminal investigation and/or in response to a court order, warrant, or similar process. We also may release your health information to authorized federal officials for national security activities authorized by law. y Military Functions. We may release your information if it is requested to assist in a military mission or other governmental activity related to intelligence, national security, or protecting the President. y Coroners, Medical Examiners, and Funeral Directors. We may release the health information of Members who are deceased to coroners, medical examiners and funeral directors to enable them to perform their duties. y Organ Transplant Organizations. We may release your health information to organizations working on organ or tissue transplantation for the purposes of facilitating an organ transplant. y 50 Years after Death. We may release the health information of Members who are deceased to any agency if the Member has been deceased for at least 50 years. y Disaster Relief. We may release your health information in a disaster relief situation. However, if you prefer for us not to release your information for this type of situation, you have the right to make that choice. Limitations Other laws may limit or prevent the disclosures listed above. For example, there are special limits on the disclosure of health information relating to HIV/AIDS status, mental health treatment, developmental disabilities, and drug and alcohol abuse treatment. We comply with these restrictions in our use of your health information. We cannot sell your information. iii 2016 Medi-Cal EOC Privacy Policy

6 Authorization We will not allow uses and disclosures of your health information other than those described on the previous pages without your written permission or authorization. We must obtain your authorization before we use or disclose your information for any other reason. For Example: We may use and share health information about you for research purposes if we have your authorization. Your decision to grant us an authorization does not affect your medical treatment, health plan benefits, payment for treatment, or enrollment eligibility. You have the right to change your mind even after you have signed an authorization for use or release of your health information. If you decide to do this, we will not further use or disclose the information. Of course, we cannot take back any disclosures we had already made during the time we had your permission to do so. Your Rights Regarding Health Information about You You have the following rights regarding your health information that we store: y Right to Obtain a Copy of this Privacy Notice: You have the right to have a paper copy of this notice at any time. This notice is also available for your program on our website: y Right to Assign Someone to Represent You: You have the right to give someone medical power of attorney, which allows that person to act on your behalf and make choices about your health information. This right also applies if you have a legal guardian. We will make sure that anyone who represents you has this authority before we take any action. y Right to Request Restrictions. You have the right to request a restriction or limits on the use or disclosure of your health information. In your request, you must tell us: 1. What information you want to limit; 2. Whether you want to limit our use of information, disclosure of information, or both; and 3. To whom you want the limits to apply. To request restrictions, you must make your request in writing. See page v for instructions. Note: We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. y Right to Request Confidential Communications. You have the right to request that we contact you about medical matters privately and with special handling. For example, you can ask that we only contact you at work or by mail. We will not ask you for the reason for your request. We will make every effort to accommodate reasonable requests. Your request must specify how or where you wish to be contacted. To request special handling in the way you are contacted, you must make your request in writing. See page v for instructions. y Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures. This is a list of disclosures that we made of your health information. This list includes disclosures that we make for your treatment or our health plan operations, including payment for your care. It also includes most other disclosures that we are required or permitted to make without your authorization. For example, these include disclosures to governmental agencies that review our programs. To request this list, or accounting of disclosures, you must submit your request in writing. See page v for instructions. Your request must be for a period not longer than three (3) years prior to the date of your request and may not include dates before April 14, iv 2016 Medi-Cal EOC Privacy Policy

7 y Right to Access Your Health Information. You have the right to obtain a copy of certain health information that HPSM maintains in its records. In general, this includes health and billing records. You will have to contact your doctor for a copy of your medical record. To get a copy of health information that we maintain, you must submit your request in writing. See page v for instructions. We may deny your request to obtain a copy in certain cases. If you are denied access to health information, we will tell you the reason why in writing. If denied access, you may request that the denial be reviewed. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. y Right to Receive Notice of a Breach. A breach occurs when protected health information is obtained, used or revealed in a way that violates relevant privacy laws. The health information must be unsecured, meaning that others could access the information. HPSM is required to inform you of any such incident within 60 days of discovering that the privacy of your information has been violated. The Secretary, U.S. Department of Health & Human Services, and in certain circumstances the media, may also have to be notified. The notice of the breach that you receive will include the following information: a description of what happened, the types of information that were involved in the breach, and the steps that you should take to protect yourself from potential harm. The notice will also tell you what HPSM is doing to investigate the situation and minimize harm to you, and to prevent breaches from occurring again. See Instructions on Page v about Your Right to Make a Complaint or File a Grievance y Right to Amend. You have the right to add a written comment that will be kept with your health information at HPSM. If you feel that health information we have about you is wrong or incomplete, you may ask us to amend the information. This is usually done if you disagree with the health information that we have on file for you. You have the right to request an amendment for as long as we maintain the information. To request an amendment, your request must be made in writing. See page v for instructions. We are not required to amend health information that: was not created by HPSM, unless the person that created the information is no longer available to make the amendment; is not part of the information we maintain; is not part of the information which you would be allowed to obtain a copy of; or is correct and complete. If HPSM denies your request to amend your health information, we will notify you in writing. You will also receive a written explanation of why your request was denied. Changes to this Notice This notice is effective as of November We reserve the right to change this notice. We reserve the right to make the revised notice effective for all health information we already have about you as well as any information we receive in the future. You can find the effective date of the Notice on the bottom of each page. In addition, each time there are changes to the notice, we will notify you through the mail within 60 days. We will also post a copy of the current notice on our website at v 2016 Medi-Cal EOC Privacy Policy

8 Instructions: (1) How to file a Grievance regarding your privacy rights: If you believe your privacy rights have been violated, you may file a grievance with the Health Plan of San Mateo. You may also contact the U.S. Department of Health and Human Services to file a complaint. Grievance Coordinator Health Plan of San Mateo 701 Gateway Blvd., Suite 400 South San Francisco, CA or Secretary of the U.S. Department of Health and Human Services Office of Civil Rights Attn: Regional Manager 50 United Nations Plaza, Room 322 San Francisco, CA For additional information, call U.S. Office for Civil Rights at or TTY (OCR-PRIV) You will not be penalized for filing a Grievance. (2) For requests pertaining to your rights as listed in this notice, please send written requests to: Attention: Privacy Officer Health Plan of San Mateo 701 Gateway Blvd., Suite 400 South San Francisco, CA [email protected] If you request a copy of your health information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We will notify you of the cost involved and you may choose to withdraw or change your request at that time before it is processed. If you have questions about this Notice, please contact Health Plan of San Mateo (HPSM) Member Services at or Members with hearing or speech impairments can call TTY: or dial California Relay Service (CRS). vi 2016 Medi-Cal EOC Privacy Policy

9 Notice of Privacy Practices... i Why Am I Receiving this Notice?... i We Are Required by Law to:... i How May HPSM Use or Share My Health Information?... i Special Situations... ii Limitations... iii Authorization...iv Your Rights Regarding Health Information about You...iv Changes to this Notice...v Instructions:...vi The Health Plan of San Mateo Medi-Cal Program 2015 Member Handbook and Evidence of Coverage...1 Welcome... 1 About the Health Plan of San Mateo... 1 Member Services... 1 Physical Access... 2 Access for the Hearing Impaired... 2 Access for the Vision Impaired... 2 The Americans With Disabilities Act of Disability Access Grievances... 2 How To Use This Member Handbook And Evidence Of Coverage... 2 Health Plan of San Mateo Service Area... 3 Disenrollment from HPSM... 3 How to contact the Nurse Advice Call Line... 3 Contact the Nurse Advice Call Line about:... 3 If You Have Questions... 3 Section 1 Definitions...5 Section 2 Member Rights and Responsibilities...9 As a Member of the Health Plan of San Mateo (HPSM) You Have the Right to:... 9 As a Member of the Health Plan of San Mateo (HPSM) You Have the Responsibility to:... 9 Section 3 Choice of Doctors and Facilities...11 Why Do I need a Primary Care Provider (PCP)? How to Pick Your Primary Care Provider (PCP) Changing Your PCP Special Members Continuity of Care for New Members Continuity of Care for Termination of Provider Federally Qualified Health Centers Native American Indian Health Care Services vii 2016 Medi-Cal EOC Contents

10 Section 4 How to Receive Health Care Services...15 Member Identification Card Timely Access to Non-Emergency Health Care Services Making Appointments Canceling Appointments Women s Services OB/GYN Services Referrals to Specialty Physicians Standing Referrals Treatment Authorization Request (TAR) Services Excluded from Prior Authorization Urgent Care and Night and Weekend Care Emergency Care Follow-up Care Post Stabilization and Follow-up Care After an Emergency Non-Qualifying Emergency Services Out-of-Area Care Obtaining a Second Opinion Medications Prescriptions Refills Over-the-Counter/Non-Prescription Drugs The Health Plan of San Mateo Drug Formulary Generic Equivalent Drugs Non-Formulary Drugs Availability of Drugs for Off-label Use Changes in Formulary Medications Submitting Prior Authorization Requests Evening, Weekend or Holiday Prior Authorization Requests (PAs) Deferred, Modified or Denied Medication Request Forms (MRFs) Prescription Drug Coverage for Members with Both Medicare and Medi-Cal Section 5 Member Payments, Co-payments, and Other Health Insurance Information...27 Member Payment Responsibilities (Billing) Claims Reimbursement Medi-Cal Co-payments Share-of-Cost Medi-Cal Transitional Medi-Cal (Medi-Cal for Working People) Medi-Cal with Medicare Medi-Cal and Other Health Insurance (not Medicare) Health Insurance Premium Payment (HIPP) Section 6 Covered Services and Benefits...31 Medi-Cal Program Detailed Description of Benefits, Conditions, and Exclusions Introduction Recommended Schedule for Well Child Visits Preventive Screening and Immunization Recommendations for Healthy Individuals* viii 2016 Medi-Cal EOC Contents

11 Health Plan of San Mateo Clinical Practice Guidelines Linkages to Other Programs Child Health and Disability Prevention (CHDP) Program Early Periodic Screening and Diagnostic Treatment (EPSDT) Program California Children s Services (CCS) Genetic Testing and Counseling Genetic Disease Treatment Genetically Handicapped Persons Program (GHPP) Other Available Benefits and Programs Not Covered by HPSM Section 7 Exclusions and Limitations on Benefits...57 General Exclusions and Limitations Specific Exclusions and Limitations Section 8 Member Complaint and Appeals...59 Grievance and Appeals Filing a Complaint or Appeal State Hearing Expedited State Hearing Independent Medical Reviews An IMR is available in the following situations: Independent Medical Review for Denials of Experimental / Investigational Therapies Review by the Department of Managed Health Care Mediation DHCS Medi-Cal Managed Care Ombudsman Section 9 Coordination of Benefits...63 Coordination Of Benefits (COB) Applicability Benefit Coordination with Other Coverage Recovery from Third-party Liability Medi-Cal Estate Recovery Program Section 10 General Provisions...65 Entire Contract Payment to Providers Durable Power of Attorney for Health Care or Advanced Directive Relationship Between Parties Privacy Practices Authorization for Release of Information Workers Compensation Not Affected Non-Discrimination Consumer Advisory Committee ix 2016 Medi-Cal EOC Contents

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13 The Health Plan of San Mateo Medi-Cal Program 2016 Member Handbook and Evidence of Coverage Welcome We are very pleased to welcome you to the Health Plan of San Mateo (HPSM). HPSM is your Medi-Cal managed care insurance plan. You automatically became an HPSM member when you were approved for Medi-Cal by the San Mateo County Human Services Agency or through the SSI (Supplemental Security Income) program. Your basic Medi-Cal benefits are the same as those of other Medi-Cal recipients in California, but you also have access to additional services. It is important that you understand how the Health Plan of San Mateo (HPSM) works so you can get the health care you need. This booklet, called a Member Handbook and Evidence of Coverage, explains your benefits and how to get care. It will also answer many of your questions. You will learn: y How to choose a doctor or change your doctor; y How to receive care; y What your benefits are; and, y What to do if you have a question or a problem. If you do not understand something in this Handbook, call and speak with an HPSM Member Service Representative. About the Health Plan of San Mateo The Health Plan of San Mateo is the health insurance plan for Medi-Cal recipients in San Mateo County. Since you now have Medi-Cal, you are a member of HPSM. This means that you will see doctors and other health care providers who are part of HPSM. HPSM will pay for your medical care, including your prescription drugs. Member Services The HPSM Member Services Department is here to help you. The Health Plan of San Mateo is located at 701 Gateway Blvd., Suite 400, South San Francisco, CA If you need help or want more information, call Member Services at or If you are hearing impaired you can use the California Relay Service at (TTY) or dial For California Relay services in Spanish call Member Services Representatives are available to speak with you Mondays through Thursdays from 8:00 a.m. to 6:00 p.m. and Fridays from 9:30 a.m. to 6:00 p.m. Our office hours are Monday through Friday, 8:00 a.m. to 5:00 p.m. If you do not speak or read English well, you may get help in the following ways: y HPSM staff speaks several languages, including Spanish and Tagalog, and can answer questions, solve problems or help you choose a doctor Medi-Cal EOC Introduction

14 y Interpreter services are available by phone free of charge 24 hours per day at service sites. You do not have to use family members, friends, or children as interpreters. y You can see doctors who speak your language. HPSM s Provider List has information about languages spoken in each doctor s office, office locations and hours available for appointments, including evening and weekend hours. A Member Services Representative can help you choose a doctor if you need help or have questions. y HPSM documents are available in Spanish. Please call the Member Services Department if you would like information in Spanish. y Sign language interpreters are also available. You do not have to use family members, friends, or children as interpreters. Physical Access HPSM has tried to make our offices and the offices and facilities of HPSM providers accessible to the disabled. If you want help in finding an accessible provider, please call Member Services. Access for the Hearing Impaired If you are hearing impaired, you can use the California Relay Service at (TTY) or dial For California Relay Service in Spanish call HPSM also offers free sign language interpretation. We can arrange for a sign language interpreter to go with you to your appointments if you let us know at least two (2) days in advance. You do not need to use friends, family members, or children to interpret for you. Access for the Vision Impaired This booklet and other important HPSM materials are available in large print for the vision impaired. For other formats, or for help in reading this booklet and other materials, please call Member Services. The Americans With Disabilities Act of 1990 HPSM complies with the Americans with Disabilities Act of 1990 (ADA). This Act prohibits discrimination based on disability. The Act protects Members with disabilities from discrimination concerning program services. In addition, section 504 of the Rehabilitation Act of 1973 states that no qualified disabled person shall be excluded, based on disability, from participation in any program or activity which receives or benefits from federal financial assistance, nor be denied the benefits of, or otherwise be subjected to discrimination under such a program or activity. Disability Access Grievances If you believe HPSM or its providers have failed to respond to your disability access needs, you may file a Grievance with HPSM. See page [55] for more information. How To Use This Member Handbook And Evidence Of Coverage Please read this entire booklet. Many of the sections go together; so, if you read just one or two sections, you may not have complete information about the Health Plan of San Mateo. Many words used in this booklet have special meanings. These words are explained in Section 1, Definitions, and appear in this booklet with capital first letters. Refer to the Definitions to help you understand your benefits, rights and responsibilities under the Health Plan of San Mateo Medi-Cal EOC Introduction

15 Health Plan of San Mateo Service Area HPSM s service area includes all of San Mateo County. Disenrollment from HPSM You will be disenrolled from HPSM if: y You lose your Medi-Cal eligibility or y Your Medi-Cal changes to a category not covered by HPSM, or y You move out of San Mateo County. How to contact the Nurse Advice Call Line HPSM provides 24 hour 7 day per week access to Nurse Advice Line (NAL) services through its vendor. NAL services provide access to triage medical questions and facilitate appropriate follow up with member s provider. CALL This call is free. 24 hours a day, 7 days a week We have free interpreter services for people who do not speak English. TTY or dial This call is free. 24 hours a day, 7 days a week Contact the Nurse Advice Call Line about: Questions about your health care If You Have Questions The information in this booklet and New Member Packet should answer most of your questions about your health care benefits. If you have other questions about the Health Plan of San Mateo, your benefits, or your rights with HPSM, please call Member Services at or Situations When You Should Contact Member Services Choosing and changing your doctor You receive a bill to pay for a service y Find a doctor in your area y You prefer a female or male doctor y You want a doctor who speaks your language y You don t understand why a clinic or doctor s office has sent you a bill y You had to get urgent medical care from a non-network doctor when you were outside of HPSM s service area You need a new HPSM ID card y You lost your HPSM card y The PCP name on your card has to be changed Your home address or phone number has changed y You have moved or have changed your phone number Medi-Cal EOC Introduction

16 You have a complaint related to your doctor s office, your medical care, or HPSM y You do not like the way the staff at your doctor s office respond to you on the phone, or in person y You are not satisfied with your doctor s decisions about your medical care y You are not satisfied with a decision HPSM has made related to coverage for a service You have questions about HPSM s services y You want to know if a medical procedure or prescription will be covered y Your doctor ordered medical equipment for you and you want to know if it will be covered You cannot get a doctor s appointment y You have to wait too long to see your doctor because appointments are not available to be seen sooner Problems getting a prescription filled y The pharmacy told you that your prescription is not approved for coverage If you have questions about your Medi-Cal eligibility, call the San Mateo County Human Services Agency at Office hours are Monday through Friday 8:00 a.m. to 5:00 p.m. If you received your Medi-Cal eligibility through Social Security (Supplemental Security Income), please call Medi-Cal EOC Introduction

17 Section 1 Definitions Active Labor means labor when there is not enough time to safely transfer the member to another hospital before delivery or when transferring the member may be a threat to the health and safety of the member or the unborn child. Acute Condition means a condition that begins suddenly because of an illness, injury, or other medical problem and needs prompt medical attention. An acute condition continues for a limited time. Amendments mean changes to the services covered by the Medi-Cal Contract. You will receive a written description of an amendment when it causes a change in the Evidence of Coverage. You should read the amendment and then attach it to your Evidence of Coverage. Appropriately Qualified Health Care Professional A Primary Care Provider or Specialist who is acting within his or her scope of practice and who possesses a clinical background, including training and expertise, related to a particular illness, disease, condition, or conditions. Authorization means approval by your Primary Care Provider (PCP) or HPSM for a service. Auto Assignment means when a PCP is assigned to you because you do not make a choice or HPSM does not receive your PCP choice on time. Benefits or Coverage or Covered Service(s) means the health care services HPSM provides to Members. Benefits are described in this booklet. California Children s Services (CCS) is a program for children who have disabling medical conditions. This program provides insurance and case management for certain conditions. Case Management means a process to coordinate a Member s health care. It is a joint effort that includes the Member, his/her physician(s), provider staff, and the case manager. Clinics are places where doctors, nurses and other providers treat patients. Clinic care is sometimes called outpatient care, while hospital care is called inpatient care. Coverage Decision means the approval or denial of a service by HPSM or its providers. The coverage decision is based on whether or not the service is a medically necessary covered benefit. DMHC means the California State Department of Managed Health Care. Disputed Health Care Service means a covered health care service that is denied, modified, or delayed to a Member. The decision to deny, modify, or delay a service is based on a finding that the service is not medically necessary. A Member may dispute or disagree with a decision and file a Grievance. Emergency Care means care received right away for an illness or injury that puts your health in serious danger or for a medical condition that causes severe pain. An emergency is defined as an illness, injury, or medical condition that a careful or prudent person who has no medical training believes could: Medi-Cal EOC Section 1

18 put your health or, in the case of a pregnant woman, the health of the woman or her unborn child, in serious danger. This includes active labor when there is not enough time to transfer to another hospital before delivery or when moving to another hospital would pose a threat to your health or your unborn child s health. result in serious harm to the way your body works, or result in serious damage of any body organ or part. Emergency care includes medical or psychiatric screening, examination, evaluation, and treatment by a physician or other personnel. Care and treatment for a medical or psychiatric emergency is covered to the extent permitted by the law. Such care may also be limited by the privileges and licensing of the facility. Established Patients Only (EPO) means doctors that will only see Members who received services from them in the past. Exclusion means any medical, surgical, hospital or other treatment for which Medi-Cal offers no coverage. Formulary means the list of medications covered by HPSM. The medications on the Formulary have been approved by HPSM and may be prescribed without Prior Authorization. Grievance means a written or oral expression of dissatisfaction regarding the Plan and/or Provider, including quality of care concerns, which includes a complaint, dispute, request for reconsideration or appeal made by a Member or the Member s representative. Where the plan is unable to distinguish between a Grievance and an inquiry, it shall be considered a Grievance. Health Plan or HPSM means the Health Plan of San Mateo. Identification (ID) Card means the card given by HPSM to each Member. This card should be presented whenever you need care. It is also called an ID Card. Investigational Services means drugs, equipment, and procedures that are now being tested in humans. Investigational services may be covered if the following conditions are met: You have a life-threatening or seriously debilitating condition, and Standard therapies have not been effective, or are not appropriate, or there is no standard therapy covered by HPSM that is more beneficial than the proposed therapy. Life Threatening means a disease or condition that is highly likely to cause death unless the disease or condition is promptly treated. Medical Emergency [See Emergency Care]. Medical Group means a group of doctors, clinics, hospitals, and other health care providers. A medical group in HPSM has a contract with HPSM to arrange for and provide health care services to Members. Medically Necessary Services means health care services that are needed to meet a person s basic health needs. The decision whether or not a service is medically necessary is based on many factors, including, but not limited to, the standards of the medical community. The fact that a doctor has Medi-Cal EOC Section 1

19 performed, prescribed or recommended a procedure or treatment does not mean that it is medically necessary. Medically Necessary Services must be: consistent with the diagnosis and prescribed course of treatment for the condition, or be generally accepted by the medical community as a preventive health service; required for reasons other than the convenience of the patient or his or her doctor; performed in the most cost efficient setting appropriate for the condition; and provided at a frequency which is accepted by the medical community as medically appropriate. Medically necessary services must not be required only for custodial, comfort, or maintenance reasons. If medically necessary services are not provided, the Member s condition or the quality of the medical care given will be adversely affected. Member means a person eligible for Medi-Cal and enrolled in HPSM. Out-of-Area Care means Emergency Care or Urgent Care provided outside of HPSM s Service Area that could not be delayed until the Member returned to the Service Area. Participating Hospital means a hospital that has a contract with HPSM to provide services. Participating Provider means a doctor, clinic, hospital, hospice, or other provider, which has a contract with HPSM to arrange for and provide health care services to Members. Pharmaceutical Benefits Manager (PBM) means a third party administrator of a health plan s prescription drug program that is mainly responsible for authorizing and paying prescription drug claims. PBMs assist the health plan with development and maintenance of drug formularies, contracts with pharmacies, and negotiate discounts and rebates with drug manufacturers. Primary Care Provider or PCP is the provider who provides your basic care. Your PCP is your regular doctor, nurse practitioner, or physician s assistant and knows your overall health situation. Your PCP is always the first provider you see and must set up referrals for Specialist care if you need it. You select or are assigned a PCP at the time you join HPSM. Prior Authorization means approval for a service. Before you receive a service, your PCP or HPSM must usually approve it. Provider List is a list of doctors, clinics, hospitals and other specialty providers who have a contract with HPSM to provide services to Members. Referral means that when you need special kinds of care, your PCP will refer or send you to a Specialist who is a Participating Provider. Serious Chronic Condition is due to a disease, illness, or other medical problem or disorder that is serious and will last, get worse over time, or require ongoing treatment to maintain remission or prevent deterioration Medi-Cal EOC Section 1

20 Service Area means the geographic area served by HPSM. The County of San Mateo is HPSM s Service Area. Special Member means you do not have a PCP assigned to you. You may see any HPSM doctor for health services. HPSM is listed as your PCP on your ID card. Specialist or Referral Provider means a doctor or other provider who only treats certain kinds of problems like broken bones or heart trouble. Your regular doctor will tell you if you need special care and will refer you to a Specialist. State means the State of California. Terminal Illness is a condition that is either incurable or irreversible and is expected to cause death within one year or less. Treatment Authorization Request (TAR) is a request from your doctor for a service/treatment that needs approval from HPSM. The TAR is reviewed by HPSM medical staff for approval. Urgent Care means services that need a quick diagnosis and/or treatment of a medical or mental condition. Urgent care is provided when a condition could become an emergency if not treated in a timely manner Medi-Cal EOC Section 1

21 Section 2 Member Rights and Responsibilities As a Member of the Health Plan of San Mateo (HPSM) You Have the Right to: y Get dignified, courteous, and considerate treatment regardless of race, religion, age, gender, national origin, disability, sexual identity or orientation, family composition or size, medical condition, or stage of illness. y Get up-to-date information about HPSM, HPSM s services and how to use them. y Get care from the Primary Care Provider (PCP) you choose from HPSM s network or change your PCP to another HPSM Network doctor. y Get appointments within a reasonable amount of time. y Access family planning services, Federally Qualified Health Centers, certified nurse practitioner services, Indian Health Service Facilities, sexually transmitted disease services and Emergency services outside HPSM s network according to federal law. You have a right to information from HPSM about how to access these services. If you are a minor, you have the right to access minor consent services. y Know and understand your medical problem. Receive information on available treatment. Obtain a second opinion from a different doctor. y Participate in decisions about your medical care. You also have the right to refuse or discontinue treatment and prepare advance directives. y Have your confidential health information protected. You also have the right to access your health information for reasons allowed by law and receive copies of, or add a statement to, your record. y Receive information and health care services in a manner that is easily understood in accordance with State and Federal laws and regulations. y Get information and services in a way that respects your language and culture. Receive information in your language or alternative formats and large size print upon request. y Not use family, friends, or children as interpreters, including as sign-language interpreters. y Use HPSM s free interpreter service, including during discussion of complex medical conditions and treatment options and after hours services, and file a Grievance if your language needs are not met. y File a Grievance about HPSM or the care you receive, either orally or in writing and to request a Medi-Cal State Hearing. y Be free from any form of restraint or seclusions used as a means of control, discipline, convenience, or retaliation. y Freely exercise these rights without adversely affecting how you are treated by HPSM, providers, or the State. As a Member of the Health Plan of San Mateo (HPSM) You Have the Responsibility to: y Carefully read all HPSM Member materials so you understand how to use your benefits and what procedures to follow when you need care. y Do your best to keep appointments; if you need to cancel or reschedule an Appointment, call your provider or clinic 24 hours in advance or as soon as possible Medi-Cal EOC Section 2

22 y Show your HPSM ID card or remember to tell your Provider (for example your doctor, hospital or pharmacy) you are an HPSM Member before receiving care. y Follow the treatment plan you and your provider have agreed upon. y Provide accurate and complete information about your health care needs when you see your provider. Let your provider know if you have a medical condition. y Ask your doctor questions if you do not understand something or aren t sure about the advice you are given. y See the Specialists to whom your Primary Care Provider (PCP) refers you. y Actively participate in health care programs that keep you well. y Work with your provider to build and maintain a good working relationship. y Use the emergency room only in cases of an emergency or as directed by your provider. y Follow-up with your Primary Care Provider (PCP) after getting care at an emergency facility. y Report lost or stolen ID cards to the Health Plan of San Mateo s Member Services Department and do not let anyone else use your card. y Contact the Health Plan of San Mateo s Member Services Department if you do not understand how to use your benefits or have any problems with the services provided. y Tell HPSM if you move or change your phone number. Call HPSM Member Services and your San Mateo County Medi-Cal Worker. If you receive SSI, call Social Security Administration. We all need to have your correct address and phone number. y Promptly follow the HPSM Grievance procedure if you believe you need to submit a Grievance. y Treat all HPSM personnel and health care providers respectfully and courteously Medi-Cal EOC Section 2

23 Section 3 Choice of Doctors and Facilities PLEASE READ THE FOLLOWING INFORMATION. THIS INFORMATION WILL EXPLAIN WHICH DOCTORS YOU CAN SEE FOR MEDICAL CARE. HPSM works to meet your health care needs through a network of qualified doctors, medical groups, clinics, hospitals, pharmacies, and other providers located in San Mateo County. Our network also includes some providers in San Francisco and Santa Clara counties. All your health care should be provided by network providers unless authorized by us or if the service does not require prior authorization. For a list of services and a description of those services that do not require prior authorization by law, please see pages [19]. The Health Plan of San Mateo Provider List, which you have received along with this booklet, lists the Primary Care Providers, clinics, hospitals, and other health care providers and facilities available to you. The List also has the doctors and other providers addresses, telephone numbers, languages spoken and the hospitals they work with. HPSM updates the list every three (3) months and shows which doctors are not accepting new patients. You can write or call the Member Services Department at or to request a Provider List or ask for specific information about a doctor, including board education, board certification, or specialty training. Why Do I need a Primary Care Provider (PCP)? Your PCP will provide most of your health care. Your PCP will give you regular check-ups and see you when you get sick. Your PCP will know your medical history and what medicines you take. A PCP may be a Pediatrician, a General Practitioner, a Family Practitioner, an Internist, or in some cases an OB/ GYN doctor. If you want to choose a specific nurse practitioner or physician assistant to be your PCP, select the primary care facility where he or she works. Your PCP will also refer you to other doctors such as Specialists you may need and will make arrangements if you need to be hospitalized. If you need to go to a hospital, you will usually be admitted to the hospital where your PCP is on staff or has made arrangements to admit you. The hospitals where HPSM doctors work or have arrangements with are listed in your Provider List. Each HPSM member in your family may choose a PCP. The name and telephone number of the PCP will be listed on each person s HPSM Member Identification (ID) Card. By the time you receive this booklet, we hope you will already have selected a PCP for yourself and any eligible family member. If you are returning as an HPSM Member and do not select a PCP, you will be automatically assigned to your previous doctor if you were assigned to that doctor in the previous four (4) months. If you have not yet selected your PCP or want to change your PCP, here are some ideas to help you choose a PCP. How to Pick Your Primary Care Provider (PCP) y You may choose the provider you already use if you see his or her name in the HPSM Provider List. y You may choose a new provider from the Provider List. The Provider List has helpful information about each provider and the offices and clinics where they work Medi-Cal EOC Section 3

24 Here are some things to think about when picking a doctor: Does the PCP take care of children? Does the PCP work at a clinic I like to use? Is the office close to my home, work or children s school? Is it easy to get to by public transportation? Do the doctors and nurses speak my language? Does the PCP work with a hospital that I like? Does the PCP provide the services I may need? What are the PCP s office hours? Some doctors and hospitals do not provide one or more of the following services that you or your family member may need: y Family Planning y Contraceptive services, including emergency contraception y Sterilization, including tubal ligation at the time of labor and delivery y Abortion You and your PCP are a team, working to keep you and your family healthy. It is best to stay with the same PCP, so she or he can get to know your health care needs. If you change your PCP often, your health care may not be as good as it could be. The PCP whom you choose will provide, authorize and coordinate your health care, except for emergency and out of area urgent care services and sensitive services if you choose to self-refer to another qualified provider in or out-of-network. Working with your PCP is the key to your health care. Your PCP will take care of most of your health care needs, including preventive care. Your PCP can refer you to Specialists when needed. Your PCP may want to see you at his/her office before authorizing your visit to a Specialist. If you do not choose a PCP for yourself and each family member within the first 30 calendar days of enrollment, we will assign each of you to a PCP based on your address, age and other available information to help us make a good choice for you. To receive more information before you select a PCP, you can call the provider s office. Member Services can also give you information to help you make a PCP choice. If you and your PCP are not able to establish a good relationship, either of you have the right to ask for a change. For example, if you miss too many appointments, do not follow your PCP s medical advice, or are disruptive or abusive, your PCP may request that you select a new PCP. If you are not satisfied with the treatment or service from your PCP, you may select a new doctor. A Member Services Representative may ask the reason for your PCP change. This information helps HPSM be sure our providers meet the needs of our Members. Changing Your PCP If you decide to change your PCP, we will do our best to meet your request. A PCP selection or choice may not be approved, in the following situations: (1) the PCP only accepts established patients (EPO) and you have not seen the PCP before; (2) the provider s practice is full; (3) you have been removed from the PCP s practice in the past; or (4) you have chosen a PCP who does not see Members in your age group. After you ask for a change, you should continue to see your current PCP until the end of the month. The PCP change will be effective the first day of the following month Medi-Cal EOC Section 3

25 Please note: A new Member ID Card, will be mailed to you with the name of your new PCP. Your new ID Card will show the date your PCP change is effective. If you do not receive a new ID Card within ten (10) days or have questions about the effective date of change, please call HPSM at or to speak with a Member Services Representative. Special Members Some HPSM Members are called Special Members. As a Special Member, you don t have an assigned PCP, and HPSM is listed on your HPSM ID Card as your PCP. New HPSM Members are Special Members for the first month only. This allows time for a new Member to choose a PCP. If you do not choose a PCP within the first 30 calendar days of enrollment, HPSM will automatically assign you to a PCP. Other Members are Special Members because of their Medi-Cal eligibility group. Some of these groups include adopted children or children in foster care, and members who have been in a skilled nursing home for more than 30 days. Members with complicated medical conditions that require frequent visits to Specialists may also be Special Members. If you have questions or would like more information about Special Members, please call HPSM at or to speak with a Member Services Representative. Continuity of Care for New Members If you are a new member, you may be able to continue care with your current doctor who is not an HPSM participating provider if you have one of the following conditions: y An Acute Condition, for the length of time of the acute condition. y A Serious Chronic Condition, for a period of time (up to twelve (12) months) necessary to complete a course of treatment and to arrange for a safe transfer to another provider. y A pregnancy, for the length of time of the pregnancy and the immediate postpartum period. y A Terminal Illness, for the length of time of the terminal illness. y The care of a newborn child whose age is between birth and age thirty-six (36) months, for a period of up to twelve (12) months. y Performance of a surgery or other procedure that has been authorized by your previous plan as part of a documented course of treatment and that has been recommended and documented by the non-participating provider to occur within 180 days of the time you enroll with HPSM. Please contact us at or to request continuing care or to obtain a copy of our Continuity of Care policy. Normally, eligibility to receive continuity of care is based on your medical condition. Eligibility is not based strictly upon the name of your condition. If your request is approved, you will not be financially responsible for any services for which continuity of care is authorized. We will request that your non-participating provider agree in writing to the same terms and conditions of an HPSM network provider who provides similar services. This includes acceptance of HPSM s payment. If a non-contracted provider will not agree to this, HPSM does not have to pay for services you receive from the non-contracted provider. Continuity of care does not provide coverage for benefits not otherwise covered under this agreement Medi-Cal EOC Section 3

26 A Member Services Representative will notify you of HPSM s decision. If we determine that you do not meet the criteria for continuity of care and you disagree with our decision, see HPSM s Grievance and Appeals Process on page [55]. If you have more questions about continuity of care, you can also contact the Department of Managed Health Care, which protects HMO consumers, at, HMO-2219; or at the TDD number for the hearing impaired, ; or online at Continuity of Care for Termination of Provider If your PCP or Specialist is no longer an HPSM provider, HPSM will notify you in writing. You will be asked to choose a new doctor. Member Services Representatives will be available to help you. If you are being treated for certain conditions you may be able to continue care with your current doctor for up to twelve (12) months while you find another doctor. This includes care for the following type of conditions: y An Acute Condition, for the length of time of the acute condition; y A Serious Chronic Condition, for a period of time (up to 12 months) necessary to complete a course of treatment and to arrange for a safe transfer to another provider. y A pregnancy for the length of time of the pregnancy and the immediate postpartum period. y A Terminal Illness, for the length of time of the terminal illness. y Care of a newborn child whose age is between birth and 36 months, for a period of up to 12 months. y Performance of a surgery or other procedure that has been authorized by the HPSM as part of a documented course of treatment that is to occur within 180 days. For definitions of Acute Condition, Serious Chronic Condition, and Terminal Illness, see Section 1, pages [5 through 7]. If you feel any of these examples applies to you, please call HPSM at or and speak with a Member Services Representative. You may also request a copy of our Continuity of Care Policy. If your doctor will not agree in writing to provide care on the same terms and conditions in effect prior to termination as an HPSM provider, including payment, then HPSM does not have to continue to pay your provider for services. If your PCP is part of a medical group that terminates its contract with HPSM, we will notify you in writing at least sixty (60) days prior to the termination. If your PCP leaves a medical group that is still part of HPSM s network, then the medical group will send you this notice. Federally Qualified Health Centers HPSM members have the right to get services at Federally Qualified Health Centers (FQHCs) that are part of the HPSM provider network. For more information on contracted FQHCs in San Mateo County, please call Member Services. Native American Indian Health Care Services Native American Indians and Alaskan Natives who are HPSM members have the right to receive medical services from an Indian Health Clinic without approval from HPSM. If you are a Native American Indian or Alaskan Native and would like more information, call Member Services Medi-Cal EOC Section 3

27 Section 4 How to Receive Health Care Services Member Identification Card When you become eligible for Medi-Cal, you will be mailed a plastic Medi-Cal Benefits Identification Card (BIC) from the California Department of Health Care Services. When you become an HPSM member, you will be mailed an HPSM Identification Card (ID). If you do not receive your HPSM ID Card within ten (10) business days of the date you become eligible, please call Member Services at or Each family member who is covered under HPSM will receive his or her own HPSM Member ID card. Remember to carry and show your current HPSM ID card when you get any medical service such as when you go to the pharmacy or see a doctor. Always remember to tell your provider that you are an HPSM member. This is what your HPSM ID Card looks like: Member DOB Medi-Cal In case of emergency, call or seek appropriate emergency care. HPSM Medi-Cal ID Group Plan (80840) PCP HPSM Member Services: Assigned to PCP as of HPSM Member as of Medicare: Emergency services do not require pre-authorization. For information about Mental Health Services call For Provider Use Only For Provider Use Only For Provider Use Only Providers with a PIN can check member eligibility verification 24 hours a day at , or online at Submit pharmacy manual claims to: Argus Health Systems Department 586 P.O. Box Kansas City, MO Submit medical claims to: HPSM Claims Department 801 Gateway Blvd., Suite 100 South San Francisco, CA Claims Department: Provider Services: Front side of card Back side of card This side describes how you use the card ID #: This is the member identification number assigned to you by HPSM. Eff Date: This date shows when the information on this card becomes effective. Name: This is the name of the person eligible to receive benefits through HPSM. DOB: This is the date of birth of the HPSM member. PCP: This is the Primary Care Provider of the HPSM member. Address & Telephone: This is the PCP s address and phone number. If any information on your card is wrong, please call HPSM and speak to a Member Services Representative at or Medi-Cal EOC Section 4

28 Carry both your HPSM ID card and your Medi-Cal Benefits Identification Card (BIC) with you. Always show both of your ID cards when you go to the pharmacy or see your doctor. Always remember to tell your providers that you are an HPSM Member. They need to know that you are an HPSM Member so you will not be billed for the services you receive. Timely Access to Non-Emergency Health Care Services Sometimes it s difficult to know what kind of care you need. Your doctor or a nurse will be available to assist you by phone 24 hours a day, seven days a week. This is known as triage. Here are some of the ways that triage can help you. y They can answer your questions about a health concern, and instruct you on self-care at home if appropriate. y They can advise you about whether you should get medical care, and how and where to get care (for example, if you are not sure whether your condition is an Emergency Medical Condition, they can help you decide whether you need Emergency Health Care Services or Urgent Care, and how and where to get that care.) y They can tell you what to do if you need care and your provider s office is closed. HPSM providers will make sure that you speak with a doctor or nurse over the phone within a time period that is appropriate for your medical condition. The waiting time to receive a return call from a doctor or nurse will not be longer than 30 minutes. HPSM will make sure that all contracted health providers also have an answering service, or answering machine, available during non-business hours that can provide information regarding how to seek urgent or emergency service. Please contact your PCP at the number on your HPSM Member ID Card to use telephone triage or screening services, 24 hours a day, 7 days a week. If you have any questions, please call HPSM Member Services at , Monday through Thursday, 8:00 a.m. to 6:00 p.m., and Friday 9:30 a.m. to 6:00 p.m. TTY users may call (California Relay Service) or dial Making Appointments When you receive your ID card you need to call your PCP and make an appointment. The best time to get to know your PCP is not when you are sick, but when you are well. As a new Member you should have an initial well exam within four (4) months of becoming an HPSM Member. During your initial well exam, your doctor will record your complete health history and give you a physical exam. This initial well exam assesses your health status and health risk. To make an appointment with your PCP, call the PCP s phone number on your HPSM ID Card. You can ask the office staff how to schedule appointments, rules about appointments, and directions to the office. We suggest that you arrive at your doctor s office about 15 minutes before your appointment. Please remember it is important to keep your appointments. This is a key way for you and your PCP to get to know each other and your health care needs. Remember to show your HPSM ID Card and Medi-Cal Benefits Identification Card (BIC). For urgent or routine care, always call your PCP Medi-Cal EOC Section 4

29 When you or your children are sick, call your doctor s office for an appointment. The doctor s office staff will talk to you about seeing the doctor. They will tell you what to do and where to go. By contacting your doctor early, you may be able to prevent a trip to the hospital emergency room. HPSM has to make sure that your doctors give you and your children an appointment that is acceptable for your medical need. Depending on the type of appointment you need, this table shows how long you should wait to get an appointment to see your doctor: Type of Visit Waiting time to get an appointment from the day you call for an appointment. Within 2 days (48 hours) Type of Provider/ Approval Examples Urgent Care If HPSM doesn t need to approve the service Urgent Care Within 4 days (96 Hours) Within 2 weeks (10 business days) Within 3 weeks (15 business days) Within 2 weeks (10 business days) Within 3 weeks (15 business days) If HPSM needs to approve the service Primary Care Provider Non-Urgent Care Primary Care Provider Non-Urgent Care Specialist Physician Eye, Ear-Nose-Throat, Orthopedists Psychologist, Marriage Family Therapist X-rays, physical therapy Non-Urgent Care Non-Physician Mental Health Care Provider Ancillary Services for the diagnosis or treatment of injury, illness, or other health conditions Non-Urgent Care Canceling Appointments Sometimes something happens, and you can t keep your doctor s appointment or you decide that you don t need it. Things like work, school, not having a way to get to the doctor or not having child care. If you can t keep an appointment, call the office and let them know. It s important to call the office as soon as possible if you cannot come. Try to call at least 24 hours (1 day) in advance. If you miss appointments on short notice or without canceling, your doctor can decide not to see you as a patient anymore. Talk to your doctor if you need appointments only at certain times. For example, if you start work at 3:00 p.m. and can only see the doctor in the morning, let the office know. They might be able to work around your schedule. Women s Services OB/GYN Services Female Members have direct access to OB/GYN services. Members may choose to have these services provided by their PCP, or Members may self-refer to any contracted OB/GYN or PCP within the HPSM network for OB/GYN services. Please refer to your Provider Directory for a list of all HPSM OB providers Medi-Cal EOC Section 4

30 Referrals to Specialty Physicians Your Primary Care Provider (PCP) may decide to refer you to a doctor who is a Specialist so that you can receive care for a specific medical condition. Most covered services not directly provided by your PCP, such as specialty services, non-emergency hospital services, laboratory and x-ray services, must be authorized in advance by your PCP. In consultation with you, your PCP will choose an HPSM specialist physician, hospital, or other HPSM provider from whom you may receive services. For a list of specialists, call Member Services at or or refer to your Provider List. If there is no HPSM provider available to perform the medical service you need, your PCP will refer you to a non-hpsm provider for the services after obtaining authorization from HPSM. Standing Referrals If you have a condition or disease that requires specialized medical care over a long period of time, you may need a standing referral to a specialist in order receive this special care. If you receive a standing referral to a specialist, you will not need to get authorization every time you see that specialist. Additionally, if your condition or disease is life threatening, degenerative, or disabling, you may need to receive a standing referral to a specialist or specialty care center that has expertise in treating the condition or disease so the specialist can coordinate your health care. To get a standing referral, call your PCP. If you have any difficulty getting a standing referral, call HPSM at or If, after calling HPSM, you feel your needs have not been met, please refer to HPSM s Grievance and Appeals Process on page [55]. If you see a specialist or receive specialty services before you receive the required referral, you may be responsible to pay for the cost of the treatment. If HPSM denies a request for specialty services, HPSM will send you a letter explaining the reason for the denial and how you can appeal the decision if you do not agree with the denial. This is a summary of HPSM s specialist referral policy. To obtain a copy of our policy, please contact us at or to speak with a Member Services Representative. At some time in the future, HPSM may change its policy on whether or not HPSM approval is needed for PCP referrals to see specialists. If we do, we will give you advance notice of the effective date of any change to the referral process. After the effective date of the change, you may be required to have HPSM approve a written referral from your PCP before you can see a specialist. If you do not have an approved written referral before you obtain services, you may have to pay for these services yourself. Treatment Authorization Request (TAR) Some medical services and some medications need prior authorization from HPSM. Prior authorization means HPSM and your doctor agree that the services that are needed are medically necessary for your treatment before you receive the service or medication. To receive these services, your doctor will send a form called a Treatment Authorization Request (TAR) to HPSM. This is a request for a service/treatment that needs prior authorization from HPSM. When HPSM receives the TAR, it is reviewed by our medical staff (doctor, nurse, and/or pharmacy staff) for approval. When we review the TARs, we use current clinical guidelines that meet state and national standards to help make the decision about whether or not the service or medication requested for you is medically necessary. Most TARs are approved, but in some cases they may be denied or deferred. When a TAR is denied for a medical reason, that means it has not been approved for the services/treatments that your doctor Medi-Cal EOC Section 4

31 requested. You and your doctor will then get a letter explaining why the TAR was denied, and why HPSM s medical staff have determined that the service is not medically necessary. You will be sent a Notice of Action letter. This is a formal letter telling you that a medical service has been denied, deferred or modified. If your TAR is denied for an administrative (non-medical) reason, we will explain the reason for the denial. Reasons for administrative TAR denials can include such things as: you do not have HPSM eligibility for the time under review or the service is covered by the state and not by HPSM. The letter will also explain your right to appeal the decision and how to appeal the decision. An authorization is deferred if HPSM staff needs more information from your doctor in order to decide if the services/treatment your doctor is requesting can be approved. If that happens, you will receive a notice of action letter to let you know that we have requested more information from your provider in order to approve the authorization. If you receive a Notice of Action Letter, you have three options for filing a grievance or appeal. y You have ninety (90) days from the date on the Notice of Action to file an appeal with HPSM. y You may also request a state hearing from the Department of Social Services (DSS) within ninety (90) days. y You may request an Independent Medical Review (IMR) from the Department of Managed Health Care. Please refer to the Section on Grievances and Appeals later in this document for additional information. We respond to non-urgent TARs sent to HPSM within five (5) working days. If a TAR is urgent, we will respond to it within 24 hours. Requested services are reviewed for medical necessity. Criteria and guidelines used to review TARs are developed with input from practicing health care providers and are consistent with sound clinical principles and processes. Criteria and guidelines are evaluated at least annually and updated as necessary. HPSM can provide you with guidelines or criteria used for a specific TAR decision. Please remember that these relate to the treatment or service requested, the benefits covered under Medi-Cal, and individual need. HPSM s overall policies and procedures for making TAR decisions are also available upon request. Services Excluded from Prior Authorization Some services do not need prior authorization or a referral from your PCP. You may go directly to a medical provider for the services listed below. Some of these services are limited. Please see the benefits section for details. Some of the services that do not need prior authorization are: 1. Emergency and out of area urgent services to any provider. 2. Primary and Preventive Care Services to your PCP, who must be an HPSM provider. 3. Family Planning/Sexually Transmitted Disease and Confidential HIV/AIDS Testing These are services that relate to pregnancy planning, birth control, prevention of sexually transmitted disease (STDs), confidential testing and counseling for STDs and HIV/AIDS. These services are available from your PCP, a participating family planning agency, OB/GYN, or any qualified Medi- Cal doctor who provides these services. See page [39 41] for more information. Family Planning services are provided to Members of child bearing age to help you decide when you want to have Medi-Cal EOC Section 4

32 children. These services include all methods of birth control approved by the Federal Food and Drug Administration. HPSM s Member Services staff can provide referrals to family planning clinics if you want some help, or you can contact the California Office of Family Planning s Information & Referral Service toll-free number at Women s Services - OB/GYN - see page [17] 5. Acupuncture, Chiropractic services, Prayer, Spiritual Healers, Occupational and Speech therapy, Podiatry services, Audiology and Physical therapy are provided as a self-referral benefit up to a maximum of 2 services per calendar month (for any combination of services listed). Please note these services must be provided by an HPSM provider. 6. Native American Indian Health Health Care Services - see page [14] Urgent Care and Night and Weekend Care There is a difference between urgent and emergency care. Urgent care is when you have a condition, illness or injury that is not life-threatening, but needs medical care right away. If you or a member of your family feels sick or has a fever or some other urgent medical problem, call your PCP s office. Your PCP s office is available for you at night and on weekends. When you go to your initial appointment, please ask your PCP what arrangements the office has made for night and weekend care. Your PCP or a doctor-on-call will always be available to tell you how to handle the problem at home or if you should go to an urgent care center or a hospital emergency room. Be sure to tell the PCP s answering service that you have an urgent problem and need to speak to the doctor. If you need urgent care on a night or weekend and you are outside of San Mateo County, try to contact your PCP. If you cannot reach your PCP, go to the nearest urgent care center or a hospital emergency room. You can also call our Nurse Advice Line at , 24 hours a day, 7 days a week. Always show your HPSM ID card when seeking medical care. You have the right to interpreter services to assist in receiving after-hours services. Interpreter services are available by phone free of charge 24 hours per day at service sites. You do not have to use family members, friends, or children as interpreters. Emergency Care You are covered for emergency care, both within and outside San Mateo County (HPSM s service area). A medical emergency is a medical condition that causes severe pain or a serious illness or injury which a prudent lay person (a careful or cautious non-medical person) believes could reasonably expect without medical care could: y Put your health in serious danger, or y If you are pregnant, put your health or the health of your unborn child in serious danger. This includes active labor when there is not enough time to transfer to another hospital before delivery or when moving to another hospital would pose a threat to your health or your unborn child s health. y Cause serious harm to the way your body works, or y Cause serious damage to any body organ or part Emergency services and care include medical or psychiatric screening, examination, evaluation, and treatment by a doctor or other personnel to the extent permitted by applicable law and within the scope of their licensure and privileges. Coverage is provided for care and treatment necessary to relieve or eliminate the medical or psychiatric emergency medical condition within the capability of Medi-Cal EOC Section 4

33 a facility. If you have a medical emergency call or go to the nearest hospital emergency room for help. You do not have to go to the hospital where your PCP works if you have a medical emergency. At the emergency room, be sure to show your HPSM ID and BIC (plastic) cards or tell the staff you are an HPSM Member. Remind the hospital, the doctor, or the nurse to call your PCP or HPSM. The telephone numbers are on your blue and white HPSM ID Card. Follow-up Care After you receive care at the emergency room, be sure to follow-up with your PCP. Your PCP is responsible for continuing your care, such as removing stitches, rechecking a wound, monitoring your medication, or just seeing how you are doing. Post Stabilization and Follow-up Care After an Emergency Once your emergency medical condition has been treated at a hospital and an emergency no longer exists because your condition is stabilized, the doctor who is treating you may want you to stay in the hospital for a while longer before you can safely leave the hospital. The services you receive after an emergency condition is stabilized are called post-stabilization services. If the hospital where you received emergency services is not part of HPSM s contracted network ( noncontracted hospital ), the non-contracted hospital will contact HPSM to get approval for your poststabilization care in the non-contracted hospital. It is important that you carry your HPSM ID card at all times so the non-contracted hospital can contact HPSM. If the non-contracted hospital does not know you are an HPSM member, you may receive a written notice regarding payment. If you can safely be moved to one of HPSM s contracted hospitals, HPSM will consult with your physician to arrange and pay for you to be moved from the non-contracted hospital to an HPSM contracted hospital or nursing facility. If HPSM decides that an HPSM contracted hospital or nursing facility can provide the care and you do not agree to being transferred, the non-contracted hospital may give you a written notice stating that you will have to pay for all of the post-stabilization services provided to you at the non-contracted hospital after your emergency condition was stabilized. HPSM may not pay for unauthorized poststabilization care or related transport provided by non-contracted hospitals and providers. If you have been hospitalized at a non-contracted hospital and feel that you were improperly billed for post-stabilization services you received from a non-contracted hospital, please call the hpsm member services department at (toll free) or The call center is open Monday through Thursday, 8:00 a.m. to 6:00 p.m. and Friday, 9:30 a.m. to 6:00 p.m. The TTY line is or dial Non-Qualifying Emergency Services When you go to a hospital emergency room for a non-emergency medical condition, the Emergency Room staff will try to contact your PCP for instruction. HPSM will pay for services provided to you if HPSM determines that an emergency condition existed and that you reasonably believed emergency services were required when you went to the emergency room Medi-Cal EOC Section 4

34 Out-of-Area Care If you are outside of San Mateo County and get sick, try to call your PCP unless it is an emergency. If it is an emergency, or if you think it is an emergency, please go to the nearest hospital emergency room or call If you do not need emergency care, please call your PCP to get authorization to be treated by a doctor or clinic outside of San Mateo County. If you are outside of California, you are covered for emergency care, but not all hospitals and doctors accept Medicaid. (Medicaid is what Medi-Cal is called in other states). If you need emergency care out of the state of California, tell the hospital or emergency room doctor that you have Medi-Cal and are an HPSM member as soon as possible. Ask the hospital to make copies of your ID cards. Tell them to bill HPSM. If you get a bill for services you received out of the state of California, call Member Services immediately. We will work with the hospital and/or doctor to arrange for HPSM to pay for your care. If you need Urgent or non-emergency care, try to contact your PCP for advice or ask to get approval from your PCP or HPSM before you get services. Services are not covered outside of the United States. You will only be covered if you need emergency service and have to be admitted to a hospital in either Canada or Mexico. If you pay for emergency services because you were admitted to a hospital in Canada or Mexico, HPSM will only pay you the Medi-Cal allowable amount, which may be less than what you actually paid. If you are out of the area and get sick but it is not a Medical Emergency, call your PCP to find out what to do. Always keep your HPSM ID card and BIC Medi-Cal card with you. Your PCP s phone number is listed on your HPSM ID Card to help you. Obtaining a Second Opinion Sometimes you may have questions about your illness or your provider s recommended plan of care. You may want to get a second opinion. You may request a second opinion for any reason, including the following: y You question the reason or need for a recommended surgical procedure. y You have questions about a diagnosis or a plan of care. y Your provider s advice is not clear, or it is complex and confusing. y Your provider is not able to diagnose your condition, or the diagnosis is in doubt due to conflicting test results. y The plan of care has not improved your medical condition within an appropriate amount of time. y You have tried to follow the plan of care and talked with your provider about your concerns about your diagnosis or the plan of care. You should speak to your PCP if you want a second opinion. After you or your PCP has requested permission to obtain a second opinion, HPSM will make a decision about whether or not to approve your request in a quick manner. If your medical condition poses an imminent and serious threat to your health, including but not limited to, the potential loss of life, limb, or other major bodily function, or if a delay would be detrimental to your ability to regain maximum function, your request for a second opinion will be processed within 72 hours after HPSM receives your request. If your request to obtain a second opinion about care provided by your PCP is authorized, you will receive a second opinion from an Appropriately Qualified Health Care Professional of your choice from any doctor in HPSM s network who is appropriate / trained to address your condition. If there Medi-Cal EOC Section 4

35 is no Appropriately Qualified Health Care Professional within HPSM s network, HPSM will authorize a second opinion from a non-participating appropriately qualified health care professional. If your request to obtain a second opinion is denied, and you would like to appeal our decision, please refer to HPSM s Grievance and Appeals Process on page [55]. Medications Note: If you are a member who has both Medicare and Medi-Cal, your drug coverage will be different from what is described below. For more information on your coverage, see the section on page [24] titled Prescription Drug Coverage for Members with both Medicare and Medi-Cal. Prescriptions One of your benefits as an HPSM member is getting prescription medications you need as a part of your medical care. You may go to any of the pharmacies in the HPSM Provider List to get your prescription medicine. When you get a prescription filled, show your HPSM ID Card and BIC card to the pharmacist. Your prescription may be written by your PCP, your Specialist, or other doctor, podiatrist or dentist. Please note that members assigned to Kaiser Foundation Health Plan will get all their prescriptions filled at the Kaiser pharmacy. HPSM works with our pharmaceutical benefits manager (PBM), Argus Health Systems, to provide prescription drugs to our members. Information about Argus Health Systems is included on the back of your HPSM ID Card. Some drugs need prior authorization from HPSM. Prior authorization means HPSM and your doctor agree that the drugs that are needed are medically necessary for your treatment. Refills If you take medications on a regular basis, never wait until your medication is gone before getting a refill. Some medications may need a new prescription from your doctor before they can be refilled. Do not go to a hospital emergency room to refill your medication. Over-the-Counter/Non-Prescription Drugs Some over-the-counter medications may be covered by HPSM if you have a doctor s prescription and they are medically necessary. Remember to talk with your doctor about any over-the-counter drugs you may be using. The Health Plan of San Mateo Drug Formulary HPSM has a list of medications that are covered (paid for) by HPSM. This list is called a Drug Formulary. HPSM uses the State of California Medi-Cal Formulary as a guide. Medications are added to the Formulary by HPSM s Pharmacy and Therapeutics Committee. This committee has pharmacists and doctors who decide what medications are included on the Formulary. If you would like to know which medications are on the formulary, visit our website at or call a Member Services Representative at or for a copy. The HPSM Medi-Cal formulary is reviewed and updated on a regular basis when HPSM staff performs review of new Food and Drug Administration (FDA) approved drugs. HPSM staff works together with the Pharmacy and Therapeutics Committee in the maintenance of the HPSM Medi-Cal formulary. The HPSM Formulary lists all covered medications by either the generic name or brand name (if one exists). Please note that the presence of a medication on HPSM s Formulary does not guarantee that you will be prescribed the medication by your PCP or a Specialist Medi-Cal EOC Section 4

36 Generic Equivalent Drugs HPSM covers generic medications. Generics are equal to brand name medications, but made by different companies. Generic medications are approved by the U.S. Food and Drug Administration (FDA) in the same way as are brand name medication. The HPSM Formulary lists available generic medications that are covered by HPSM. HPSM will not cover brand name drugs, except in the following cases: y If there is no generic medication available, and HPSM agrees that other drugs that could treat your condition would not work as well for you. y If there is a shortage of the generic drug. y If a medication has a narrow therapeutic index. This means that a very small change in the dosage level of the drug could cause toxic dangerous results. A Member Services Representative can give you a list of narrow therapeutic index drugs. y If your doctor believes a brand name medication must be provided. In this case, your doctor can write Dispense as Written (DAW) or Do Not Substitute on your prescription. Your doctor or pharmacist must then use a Medication Request Form (MRF) and explain why only the brand name and not a generic drug can be used. HPSM must then approve the request before HPSM will cover the brand name drug. y If you request a brand name medication. In this case, your doctor must also show that there is medical necessity (not just patient preference) for the brand name drug and write that on the Medication Request Form (MRF). HPSM must approve this MRF request before you can get the medication. Your doctor and/or your pharmacist will help collect information regarding medical necessity and will then ask for a MRF for you. Non-Formulary Drugs HPSM s participating doctors and pharmacies are responsible for using the HPSM Formulary. If a drug is prescribed that is not on the HPSM Formulary, the pharmacist will call the doctor to request a change to a Formulary medication. If the substitution of a Formulary medication is not approved by the requesting doctor, the physician must submit a MRF to HPSM for the Non-Formulary medication and explain why a formulary medication would not be appropriate for your condition. The pharmacist may also submit the request. Availability of Drugs for Off-label Use All medications covered by HPSM must be approved by the U.S. Food and Drug Administration (FDA). The FDA decides how the medication can be used. A drug company must prove to the FDA that the medication is safe and effective in treating specific conditions, and the conditions must be clearly listed on the medication label before the FDA will approve it. Sometimes, however, there may be a need for you to use a medication for a condition that is not on the medication label. This is called off-label usage. HPSM allows doctors to prescribe medication for off-label use if you have a life threatening condition, or if you have a condition that is chronic and likely to cause serious long-term problems. The medication can only be used when there is enough information from your doctor and in medical journal articles to support using the medication for the off-label condition. In addition, medication prescribed for off-label use requires HPSM prior authorization for coverage. If you have any questions about being treated with a drug for an off-label use, please talk to your doctor Medi-Cal EOC Section 4

37 Changes in Formulary Medications If you are taking a medication and HPSM drops the medication from its Formulary, and your doctor continues to prescribe the medication, HPSM will provide coverage for the medication for up to 90 days. Prior authorization will be required for continued use of this non-formulary drug beyond 90 days. Submitting Prior Authorization Requests As described above, there are several cases when a Medication Request Form (MRF) is required to get the drug you want. Some examples are: y Getting a brand name drug y Getting a drug that is not on the HPSM Formulary y Getting a drug for off-label use HPSM staff processes all MRFs. Your doctor or your pharmacist can send a MRF to HPSM via fax to Pharmacy Services at during HPSM s office hours, 8:00 a.m. to 5:00 p.m. A decision about a MRF usually takes one (1) working day, but no more than five (5) working days. More time may be needed if the MRF is incomplete or more information is needed. If you have any questions about a MRF, please talk to your doctor. Evening, Weekend or Holiday Prior Authorization Requests (PAs) HPSM is available to review MRFs Mondays through Fridays during regular business hours from 8:00 a.m. to 5:00 p.m. In urgent situations that arise on weekends or holidays, while waiting for a review decision, members may be given up to a three-day supply of medication to allow time for the pharmacy to receive HPSM s decision on the next business day. The pharmacist can call the pharmacy call center at HPSM s pharmacy benefits manager (PBM), Argus Health Systems at , for an emergency override. A one-time fill may be authorized. Deferred, Modified or Denied Medication Request Forms (MRFs) If your request for a medication is deferred, modified, or denied, a Notice of Action letter will be sent to you. The Notice of Action letter will explain the reason it was deferred, modified, or denied and provide information on how you may file an appeal with HPSM about the decision. Prescription Drug Coverage for Members with Both Medicare and Medi-Cal If you are a member who has both Medicare and Medi-Cal, the way you get your prescription drugs has changed. Now, most of your prescription drugs should be covered by your Part D Medicare Prescription Drug Plan (PDP) or if you have Medicare through a health plan by your Medicare Advantage Prescription Drug (MA-PD) Plan. If you are not enrolled in a PDP or MA-PD plan, or if you do not know which plan you have, call MEDICARE. This is the number to customer services representatives who can help you sign up with a PDP or MA-PD Plan. You do still have prescription drug coverage under HPSM Medi-Cal for some drugs that Medicare will not cover. These drugs are: y Nonprescription drugs, unless they are part of an approved step therapy under your PDP or MA-PD y Drugs when medically necessary for anorexia (severe loss of appetite), weight loss, or weight gain y Drugs when used for the symptomatic relief of cough or colds y Prescription vitamins and minerals Medi-Cal EOC Section 4

38 For these types of drugs, HPSM will cover drugs that are also on HPSM s Medi-Cal formulary. If you need one of these drugs and it is not on the HPSM Medi-Cal formulary, your physician or pharmacist will need to submit a PA. Contact HPSM s Member Services Department if you have any questions about your Medi-Cal drug coverage Medi-Cal EOC Section 4

39 Section 5 Member Payments, Co-payments, and Other Health Insurance Information Member Payment Responsibilities (Billing) To make sure your doctor knows how to bill for your care, please tell the doctor s office staff that you are an HPSM Member and tell them about any other health insurance you may have. If you had private health insurance before but don t have it now, please tell the office staff. Show them your HPSM ID and Medi-Cal BIC Cards. As a Medi-Cal recipient, you should not be billed for services except in certain situations. However, you CAN be billed if: y You ask for and get services that aren t covered by Medi-Cal, such as cosmetic surgery. y You don t tell the doctor that you have Medi-Cal. y You go to a doctor who doesn t take Medi-Cal, but you tell the doctor you want to be seen there anyway and that you will pay for the services yourself. y You have other insurance AND Medi-Cal, and you don t follow the rules on how to get services under your other insurance. y You have an unmet Medi-Cal Share of Cost. You will never have to pay a provider for money owed by HPSM. Request for Reimbursement If you are asked to pay for services, except for the situations listed above, please ask the doctor s office to call HPSM. We will explain to them how to bill us. However, if you are billed for a service, you may submit the bill to HPSM. You must submit a copy of the bill with your name, ID number (on your Member ID card), your phone number, and date and reason for the bill. If you paid the bill, you will need to submit proof of payment (such as a statement indicating payment and description of services received). Send the bill to: Member Services Department Health Plan of San Mateo 701 Gateway Blvd., Suite 400 South San Francisco, CA Your written request for reimbursement should be mailed to the Plan within 90 days (3 months) of the date you received the services, or as soon as reasonably possible, but no more than 12 months from the date of service (date your received care). HPSM may not reimburse you directly. If we do not, we will work with the Provider to have the Provider reimburse you. If HPSM pays you directly, HPSM will only pay you the Medi-Cal allowable amount, which may be less than what you actually paid. Medi-Cal Co-payments Under the Medi-Cal Program, providers are allowed to charge some Members $1.00 each time they receive outpatient services or a prescription medication. (This amount is different if you have Medicare and get your medication through Medicare.) Hospitals are also allowed to charge $5.00 if you go to a hospital emergency room for a non-emergency service. This amount is known as a copayment Medi-Cal EOC Section 5

40 A doctor may not refuse to treat you if you do not have the money for a copayment. You do not need to make a copayment if you are: y A child under age 18 y In the hospital or in a facility providing long term care y A pregnant woman or if you just delivered your baby. In this case you don t have to pay a copayment until 60 days after delivery. y A child in foster care. y A member with both Medicare and Medi-Cal. y A hospice patient. y Receiving family planning services and supplies. y Any service for which HPSM s payment is $10 or less. Your doctor will tell you if you need to make a copayment. HPSM cannot make these copayments for you. If you have other health insurance that requires a copayment and you are a Member of HPSM, you are not required to pay the copayment for the other insurance, but you may still be responsible for the Medi-Cal copayment. Share-of-Cost Medi-Cal If you have Medi-Cal with a Share of Cost, you will have to spend some of your own money on health care each month before you are covered by Medi-Cal. This is called a Share of Cost payment. Each month you will pay your own medical bills until the amount that you pay is equal to your Share of Cost. After that, your care will be covered by HPSM for the rest of that month. You will not be covered by HPSM until you have paid your entire Share of Cost for the month. After you meet your Share of Cost for the month, you can go to any HPSM doctor. You do not need to pick a PCP. If you have a question about your Medi-Cal Share of Cost, please call the San Mateo County Human Services Agency at HPSM cannot make changes to your Share of Cost or remove it. Transitional Medi-Cal (Medi-Cal for Working People) Transitional Medi-Cal or TMC is for California families who lose cash aid and Medi-Cal (or who would have been eligible for cash under old rules) but are no longer eligible because of higher earnings from work. If you are the principal earner or caretaker and get a job or your job pays you more money, you may get no-cost Medi-Cal for 12 months or more. For more information, call the San Mateo County Human Services Agency at Medi-Cal with Medicare You may be eligible for Medicare along with your Medi-Cal coverage if you: y Are at least 65 years of age and have had a job in the past or y Have been disabled for over two years or y Have end stage renal disease. Medicare usually pays for most of your medical care and prescription drugs, but not all. For example, Medicare only covers a limited number of days during a hospital stay. HPSM will pay for hospital days that are not covered by Medicare Medi-Cal EOC Section 5

41 There are three parts to Medicare: y Medicare Part A pays for stays in the hospital. y Medicare Part B pays for doctor visits, lab work and e-rays. y Medicare Part D pays for prescription medicines. y If you have Medicare Parts A, B & D and Medi-Cal, your Medicare is always primary and your Medi- Cal is always secondary. When you get health care services, make sure to show your providers both your Medicare card and your HPSM card. Medi-Cal and Other Health Insurance (not Medicare) If you currently have other health insurance like Blue Cross or Kaiser or any other health insurance, it is your primary insurance. That means that your primary insurance pays first. You should follow their rules and go to the doctors they require, or you may be billed for services. HPSM is your back-up insurance. HPSM will only pay for Medi-Cal covered services and copayments that your primary health insurance does not cover. Make sure that your provider knows about all of the health insurance coverage that you have. Tell a Benefit Analyst at the Human Services Agency and/or the Social Security Administration about any other insurance you may have. If you lose your other health insurance, tell the San Mateo County Human Services Agency or Social Security. If your other health insurance information is not current, you may have trouble getting services. Health Insurance Premium Payment (HIPP) If you have health insurance besides through HPSM and have a serious, chronic disease, HPSM may pay insurance premiums to your other insurance company or health plan. Call our Member Services Department and ask to speak to the Billing and Benefits Specialist. HPSM will review your medical condition, insurance benefits, and health care costs. Decisions about HIPP applications are made on a case-by-case basis and are re-reviewed every six months Medi-Cal EOC Section 5

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43 Section 6 Covered Services and Benefits Medi-Cal Program Detailed Description of Benefits, Conditions, and Exclusions Introduction As an HPSM Member, you should read all descriptions of the covered services and benefits in this handbook and any attachments to get the full details of your covered benefits. The services described in this section are Covered Services if they are medically necessary. Emergency medical services do not need prior authorization. However, a decision about the need for emergency services may occur after services have been provided. If you disagree with a decision on medical necessity or on whether a particular situation was a Medical Emergency, you can request a review through our Grievance procedure described in Section 8. Outpatient Preventive Health Services Description: y Periodic health examinations including all routine diagnostic testing and laboratory services appropriate for such examinations consistent with the most current recommendations for preventive adult and pediatric health care, as adopted by the United States Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics, respectively. y Preventive services, including services for the detection of asymptomatic disease, including the following: 1. a variety of voluntary family planning services 2. prenatal care 3. vision and hearing testing 4. allergy testing and treatment 5. Sexually transmitted diseases (STDs) tests, including confidential HIV/AIDS counseling and testing 6. cervical cancer screening test 7. generally medically accepted cancer screening tests 8. screening and diagnosis of breast cancer consistent with generally accepted medical practice and scientific evidence, upon referral from a doctor 9. coverage for the screening and diagnosis of prostate cancer 10. health education services, including information regarding personal health behavior and health care, and recommendations regarding the optimal use of health care services provided by the Plan 11. dental screening and referral for children and youth up to 21 years of age, pregnant women for treatment of conditions that might complicate the pregnancy, and for members receiving long-term care in a nursing facility. 12. Please note that an adult dental benefit through Denti-Cal is available as of May y Immunizations consistent with the most current version of the Recommended Childhood Immunization Schedule/United States, adopted by the Advisory Committee on Immunization Practices (ACIP), other age appropriate immunizations as recommended by the ACIP, and guidelines for immunizing adults provided by the USPSTF Medi-Cal EOC Section 6

44 Recommended Schedule for Well Child Visits The following chart is a summary of recommendations for Preventive Pediatric Care. The chart divides children into three groups - Infants, Children between 15 months and 10 years, and Adolescents. Please check with your doctor for more details. There may be more visits needed than those recommended. Complete Physical Examinations and Tests Infants (Newborn to 12 months) Yes newborn, 2 4 days, 1, 2, 4, 6, 9, 12 months Exams to include: Hereditary/Metabolic Screening by 1 month, Lead screening and Hematocrit or Hemoglobin between 9-12 months, immunizations, Vision and Hearing Screening Medical History Yes newborn, 2 4 days, 1, 2, 4, 6, 9, 12 months Developmental and Behavioral Assessment Measurements Exams, Tests, for Patients at Risk Health Education: Nutrition Counseling, Injury/Violence/ other High Risk Behaviors Prevention Yes newborn, 2 4 days, 1, 2, 4, 6, 9, 12 months Height, Weight, Head Circumference Tuberculin Test at 12 months Discussion and Counseling at each visit. Sleep positioning counseling from newborn to 9 months Early and Middle Childhood (15 months to 10 years) Yes 15, 18, 24, 30 months, from 3 years through 10 years once a year Exams to include: Lead screening at 24 months and urinalysis at 5 years. services performed. Immunizations, Vision and Hearing Screening Yes 15, 18, 24, 30 months, from 3 years through 10 years once a year Yes 15, 18, 24, 30 months, from 3 years through 10 years once a year Height, Weight, Head Circumference (up to 30 months), Blood Pressure (from 3 years), Body Mass Index (BMI) Tuberculin Test, Cholesterol Screening beginning at 24 months Discussion and Counseling at each visit Adolescence (11 to 21 years) Yes Once a year Exams to include: Hematocrit or Hemoglobin between years and urinalysis between years. Immunizations, Vision and Hearing Screening Yes once a year Yes once a year Height, Weight, Blood Pressure, Body Mass Index (BMI) Tuberculin Test, Cholesterol Screening, Pelvic Exam Discussion and Counseling at each visit Please check with your doctor for more details and about how often you should have these Medi-Cal EOC Section 6

45 Preventive Screening and Immunization Recommendations for Healthy Individuals* Health Plan of San Mateo Clinical Practice Guidelines The following chart lists the recommended preventive services for adults. The chart lists how often you should consider getting specific services based on your age. You and your doctor should decide how often you should get each service. If you are this age, years years years years 2015 Recommended Immunizations for Adults: By Age talk to your health care professional about these vaccines Flu Influenza Flu vaccine every year Td/Tdap Tetanus, diphtheria, pertussis 1 dose of Tdap* Td booster every 10 years Shingles Zoster Pneumococcal Meningococcal MMR HPV Chickenpox Varicella PCV13 PPSV23 1 dose 1 or 2 doses 1 or more doses 1 or 2 doses for women 3 doses for men 3 dose s 3 dose s Hepatitis A Hepatitis B HIB Haemophilus influenzae type b 2 doses 2 doses 3 doses 1 or 3 doses years 1 dose 65+ years 1 dose 1 dose More Information: There are several flu vaccines available. Talk to your health care profession al about which flu vaccines are right for you. * If you are pregnant, you should get a Tdap vaccine during the 3 rd trimester of every pregnancy to help protect your baby from pertussis (whooping cough). You should get zoster vaccine even if you ve had shingles before. There are two different types of pneumococcal vaccine: PCV13 (conjugate) and PPSV23 (polysaccharide). Talk with your health care professional to find out if one or both pneumococcal vaccines are recommended for you. Your health care professional will let you know how many doses you need. Recommended for you if you did not get it when you were a child. Your health care If you were born in 1957 or after, and don t have a record of being professional vaccinated or having had measles, mumps, and rubella (MMR), talk to will let you your health care professional about how many doses you may need. know how many doses There are two HPV vaccines, but only one HPV vaccine (Gardasil) you need. should be given to men. If you are a male age 22 through 26 and have sex with men, you should complete the HPV vaccine series if you have not already done so. Recommended for You: This vaccine is recommended for you unless your health care professional tells you that you cannot safely receive it or that you do not need it. May Be Recommended for You: This vaccine is recommended for you if you have certain risk factors due to your health, job or lifestyle that are not listed here. Talk to your health care professional to see if you need this vaccine. If you are travelling outside the United States, you may need additional vaccines. Ask your health care professional about which vaccines you may need at least 6 weeks prior to your travel. Source: Last accessed: 2/23/ Medi-Cal EOC Section 6

46 When Do Children and Teens Need Vaccinations? Age HepB Hepatitis B DTaP/Tdap Diphtheria, tetanus, pertussis (whooping cough) Hib Haemophilus influenzae type b IPV Polio PCV13 Pneumococcal conjugate RV Rotavirus MMR Measles, mumps, rubella Varicella Chickenpox HepA Hepatitis A HPV Human papillomavirus MCV4 Meningococcal conjugate Influenza Flu Birth 2 months (1 2 mos) 4 months 6 months 12 months 15 months 18 months months 4 6 years (6 18 mos) (15 18 mos) (12 15 mos) (6 18 mos) (12 15 mos) (12 15 mos) (12 15 mos) Catch-up Catch-up Catch-up Catch-up Catch-up Catch-up (2 doses given 6 mos apart at age mos) (One dose each fall or winter to all people ages 6 mos and older) 7 10 years Catch-up Catch-up years Tdap Catch-up Catch-up Catch-up Catch-up years years Catch-up (Tdap) Catch-up Catch-up Please note: Cases of pertussis (whooping cough) have increased in children, teens, and adults in the last few years. Tragically, some infants too young to be fully protected by vaccination have died. Ask your doctor or nurse if your children have received all the pertussis shots needed for his or her age. Also, if you haven t had your pertussis shot, you need to get one. What is Catch-up? If your child s vaccinations are overdue or missing, get your child vaccinated as soon as possible. If your child has not completed a series of vaccinations on time, he or she will need only the remainder of the vaccinations in the series. There s no need to start over. Technical content reviewed by the Centers for Disease Control and Prevention Item #P4050 (4/13) Immunization Action Coalition 1573 Selby Avenue, Suite 234 Saint Paul, MN (651) Medi-Cal EOC Section 6

47 Age HepB Hepatitis B Birth 2 Months (1 2 months) DTaP/Tdap Diphtheria, tetanus, pertussis (whooping cough) Hib Haemophilus influenzae type b Immunization Schedule for Children and Adolescents When Do Children and Teens Need Vaccinations? IPV Polio PVC13 Pneumococcal conjugate RV Rotavirus 4 Months 1 6 Months 1 12 Months 15 Months 18 Months Months (6 18 months) 2 (15 18 months) (12 15 months) (6 18 months) (12 15 months) MMR Measles, mumps, rubella Varicella Chickenpox HepA Hepatitis A HPV Human papillomavirus MCV4 Meningococcal conjugate Influenza Flu 1 (One dose each fall or winter to all (12 15 months) 3 Catchup Catch-up Years (12 15 months) Catch-up 3 Catch-up 3 Catch-up 3 Catch-up 3 (2 doses given 6 months apart at age months) 7 10 Years Catch-up 3 Catch-up Years Catchup 3 Catch-up3 Catch-up 3 Catch-up 3 Tdap Years Catch-up Years (Tdap) Catch-up 3 Catch-up 3 Technical content reviewed by the Centers for Disease Control and Prevention Item #P4050 (8/14) Source: (used with permission/last accessed: 2/23/2015). people ages 6 months and older) 1 Your infant may not need this dose depending on the type of vaccine that your health care provider uses. 2 This dose of DTaP may be given as early as age 12 months if it has been 6 months since the previous dose. 3 If your child s vaccinations are overdue or missing, get your child caught up as soon as possible. If your child has not completed a series of vaccinations on time, he or she will need only the remainder of the vaccinations in the series. There s no need to start over Medi-Cal EOC Section 6

48 Chickenpox (also called Varicella) is a common childhood disease. It is usually mild, but it can be serious, especially in young infants and adults. Getting a chickenpox vaccine is much safer than getting the chickenpox disease.the chickenpox virus can be spread from person to person through the air, or by contact with fluid from chickenpox blisters. It causes a rash, itching, fever, and tiredness. It can lead to severe skin infections, scars, pneumonia, brain damage, or death. A person who has had chickenpox can get a painful rash called shingles (also called herpes zoster) years later. Diptheria is a disease caused by bacteria. The disease causes a thick covering in the back of the throat. It can lead to breathing problems, paralysis, heart failure, and even death. The bacteria can spread from person to person through close contact. Haemophilus influenzae type b (HIB) disease is a serious disease caused by bacteria. The disease is a leading cause of serious illness in children under 5 years old. It can lead to meningitis (infection around the brain and spinal cord), pneumonia, and a severe throat infection that can cause choking. It can spread from person to person through close contact. Hepatitis A is a virus that causes jaundice, tiredness, stomach pain, loss of appetite, vomiting, diarrhea and fever. Hepatitis A is spread from person to person by putting something in the mouth that has been contaminated with the stool of a person infected with Hepatitis A. Hepatitis B is a serious disease caused by a virus that attacks the liver. The virus which is called hepatitis B virus (HBV), can cause lifelong infection, scarring of the liver, liver cancer, liver failure and death. The disease can cause jaundice (yellow skin or eyes), vomiting, loss of appetite, joint pain, tiredness and stomach pain. The virus can be spread through blood or body fluids from someone who has the disease. Everyone under 18 years of age should get the vaccine to prevent the disease. Influenza (Flu) is caused by a virus that spreads from infected persons to the nose or throat of others. Influenza can cause fever, sore throat, chills, cough, headache, and muscle aches. Many get much sicker and may need to be hospitalized. The Influenza (flu) vaccine is recommended once a year for children 6 months or older with high risk conditions such as heart conditions, asthma, diabetes, and others. It is also encouraged for healthy children between 6-23 months of age and their caregivers to get a flu shot once a year and may be indicated for older children. Please talk to your doctor about the need for your child to get a flu shot. Measles virus causes fever, rash, cough, runny nose and watery eyes. It can also cause ear infections and pneumonia. Measles can also lead to more serious problems, such as brain damage, seizures and even death. The virus can be spread from person to person through the air. Meningitis is a serious infection of the fluid around the brain that can lead to serious disabilities or death. The meningitis vaccine helps prevent this infection in 90% of the people who get the shot. Because this disease is especially common in teenagers and young adults, it is now recommended that children ages 11 to 12 receive the vaccine at their usual check-up, and any teens who have never received it should also get the vaccine at their next check-up. Mumps virus causes fever, headache, and swollen glands. It can lead to deafness, meningitis, painful swelling of the testicles or ovaries, and rarely, death. The virus can spread from person to person through the air Medi-Cal EOC Section 6

49 Pertussis (Whooping Cough) causes coughing spells so bad that it is hard for infants to eat, drink or breathe. These severe coughs can last for weeks. It can lead to pneumonia, seizures (jerking and staring spells), brain damage and death. The bacteria can spread from person to person. Teenagers and adults can also get severe lung problems from Pertussis. In 2010 California had a major outbreak of pertussis and ten previously healthy babies died. That is another reason why older children and adults need to get the pertussis vaccine booster; it is to be sure they don t get the disease and pass it to babies too young to be vaccinated. Pneumococcal infection causes severe disease in children under five years old including meningitis, blood infections, and ear infections. It can lead to other health problems including pneumonia, deafness, and brain damage. Children under two years old are at highest risk for serious disease. The bacteria are spread from person to person through close contact. Infection with the bacteria that causes this disease can lead to serious illness and death. It is the leading cause of bacterial meningitis in children. Meningitis is an infection of the brain and spinal cord covering. Pneumonia is an infection of the lungs, causing problems breathing. The germ that most commonly causes pneumonia in children also causes ear infections, blood infections and other illnesses. Children under age two are especially at risk. The pneumonia vaccine helps prevent these serious problems. That is why children should get this vaccine. It is recommended at the baby s two month, four month and six month check-ups, and then at the month visit. If older children have never had the vaccine, they can also get this to help prevent this disease. Polio is a disease caused by a virus. It enters the body through the mouth. It can cause paralysis (can t move arm or leg). It can kill people who get it by paralyzing the muscles that help them breathe. Rubella (German Measles) virus causes rash, mild fever, and swelling of the glands in the neck. Rubella can also cause brain swelling or a problem with bleeding. If a pregnant woman gets rubella, she could have a miscarriage or her baby could be born with serious birth defects. The virus is spread from person to person through the air. Tetanus (Lockjaw) is a serious disease caused by bacteria that enters the body through an opening in the skin like a cut or wound. Children can also get the disease after a severe burn, ear infections, tooth infections, or animal bites. Tetanus causes serious, painful spasms of all muscles and can lead to locking of the jaw so the patient cannot open his or her mouth or swallow. Tdap vaccine: In the past, children would get the last vaccine that included protection against pertussis (whooping cough a serious lung infection) before they entered kindergarten or first grade. After that time, if a child or teen needed a tetanus booster they got one that did not contain the vaccine against pertussis, because it was thought that the disease was not that common in older children, teens or adults. However, we now know that people older than age 5 can get very sick from pertussis. That is why the tetanus booster now includes an ingredient to help fight pertussis. Instead of the Td booster, older children, teens and adults should get a Tdap booster to help fight this serious infection. This is recommended every 10 years for life. (See above also about pertussis.) Medi-Cal EOC Section 6

50 Physician Services Description: Services that are medically necessary and are provided by an HPSM doctor. Inpatient Hospital Services Description: General hospital services with customary furnishings and equipment, meals (including special diets as medically necessary), and general nursing care. Includes all medically necessary ancillary services such as: Use of operating room and related facilities Intensive care unit and services Drugs, medications, and biologicals Anesthesia and oxygen Diagnostic laboratory and x-ray services Special duty nursing as medically necessary Physical, occupational, and speech therapy (subject to limitations under the physical occupational and speech therapy benefit) Respiratory therapy Administration of blood and blood products Other diagnostic, therapeutic and rehabilitative services as appropriate Coordinated discharge planning, including the planning of such continuing care as may be necessary This also includes inpatient hospital services, general anesthesia and associated facility charges, in connection with dental procedures when hospitalization is necessary because of a medical condition or clinical status or because of the severity of the dental procedure. Services of a dentist or oral surgeon are excluded for dental procedures. This also includes inpatient hospital services, general anesthesia and associated facility charges in connection with life threatening complications, including but not limited to, those resulting from cosmetic surgery. Exclusions: Personal or comfort items or a private room in a hospital unless medically necessary. The services of a dentist or oral surgeon (except medically necessary surgical procedures for conditions affecting the upper and lower jawbone or associated bone joints). Outpatient Rehabilitation Services Description: y Physical, speech, occupational and respiratory therapy as medically necessary Hospital services which can reasonably be provided on an ambulatory basis Related services and supplies in connection with these services, including operating room, treatment room, ancillary services, and medications which are supplied by the hospital or facility for use during your stay at the facility Medi-Cal EOC Section 6

51 Exclusions: Services of dentist or oral surgeon for dental procedures (except medically necessary surgical procedures for conditions affecting the upper and lower jawbone or associated bone joints) Emergency Health Care Services Description: y Twenty-four (24) hour Emergency Care for a medical condition that causes severe pain, or a serious illness or injury. It could be a medical emergency if illness or injury: Puts your health or, in the case of a pregnant woman, the health of the woman or her unborn child, in serious danger. This includes active labor when there is not enough time to transfer to another hospital before delivery or when moving to another hospital would pose a threat to your health or your unborn child s health. Causes serious harm to the way your body works, or causes serious damage of any body organ or part. y Emergency coverage is a benefit in or out of HPSM s provider network in the United States. No prior authorization is needed for emergency services. Diabetes Self Management Description: Medically necessary equipment and supplies for the management and treatment of insulin-using diabetes, non-insulin using diabetes, and gestational (in pregnancy) diabetes as medically necessary. Blood glucose monitors and blood glucose testing strips Blood glucose monitors designed to assist the visually impaired Insulin pumps, and all related necessary supplies Ketone urine testing strips Lancets and lancet puncture devices Pen delivery systems for the administration of insulin Podiatric foot support to prevent or treat diabetes-related complications Visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin Prescription Drug Program Description: Injectable medication, needles and syringes necessary for the administration of the covered injectable medication Insulin, glucagon, syringes and needles and pen delivery systems for the administration of insulin Prenatal vitamins, and fluoride supplements included with vitamins or independent of vitamins which require a prescription Medically necessary drugs administered while you are a patient or resident in a rest home, nursing home, convalescent hospital or similar facility when prescribed by a plan physician in connection with a covered service and received through an HPSM pharmacy Medi-Cal EOC Section 6

52 A 14 week treatment of stop smoking medication is covered Birth Control Methods. All FDA-approved oral and injectable birth control are covered, including internally implanted birth control drugs such as Norplant Medically necessary medications for life-threatening complications including, but not limited to, those resulting from cosmetic surgery, are covered. HPSM covers generic medications. You may receive brand name medications under certain situations. See page [23] for details. Exclusions (Not Covered circumstances By HPSM): Experimental or investigational medications, except in certain circumstances. (See page [56] for more information regarding Independent Review of a denied experimental or investigational service.) Medications for cosmetic purposes Over-the-counter medicines, including nonprescription contraceptive jellies, ointments, foams, condoms, etc. Medicines that usually don t need a prescription (that are not on HPSM s formulary) Appetite suppressants, or any other diet medications (except when medically necessary to treat morbid obesity) Dietary supplements (except for formulas or special food products to treat phenylketonuria or PKU) Non-formulary medications Specialty Mental Health Services Description: Specialty mental health services apply to services for clients with serious mental illnesses. These services are provided by San Mateo County Behavioral Health and Recovery Services and include outpatient services and inpatient services. Outpatient services include medication management, therapy, case management, and lab tests. If you need specialty mental health services, please call the BHRS ACCESS Call Center at They authorize services based on the needs of each person. You can call the ACCESS Call Center to find out more about receiving specialty mental health services. Specialty mental health benefits are available to clients of any age and will be provided for on the same basis as any other illness. Call the phone numbers below to get information about how BHRS can address your mental health care needs. BHRS ACCESS Call Center Monday through Friday, 8:00 a.m. to 5:00 p.m. TDD: Psychiatric Emergency Services In a Psychiatric Emergency, Please call Or go directly to the closest emergency room for help. Mental Health Services Patient Rights Advocate or Medi-Cal EOC Section 6

53 Outpatient Mental Health Services Description of covered services: Outpatient mental health services are now covered by the Health Plan of San Mateo. You can call the San Mateo County Behavioral Health and Recovery Services (BHRS) ACCESS Call Center at , or ask your Primary Care Provider (PCP) for the name of a BHRS mental health provider. These services are for the treatment of mild to moderate mental health conditions, which include*: y Individual and group mental health testing and treatment (psychotherapy); y Psychological testing to evaluate a mental health condition; y Outpatient services that include lab work, drugs, and supplies y Outpatient services to monitor drug therapy; and y Psychiatric consultation You can also get specialty mental health services from San Mateo County Behavioral Health and Recovery Services. Not Covered: y Mental health services for relational problems are not covered. This includes counseling for couples or families for conditions listed as relational problems.* * As defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV) Behavioral Health Treatment for Autism Spectrum Disorder Description: Health Plan of San Mateo (HPSM) now covers behavioral health treatment (BHT) for autism spectrum disorder (ASD). This treatment includes applied behavior analysis and other evidence-based services. This means the services have been reviewed and have been shown to work. The services should develop or restore, as much as possible, the daily functioning of a Member with ASD. BHT services must be: y Medically necessary; and y Prescribed by a licensed doctor or a licensed psychologist; and y Approved by the Plan; and y Given in a way that follows the Member s Plan-approved treatment plan. You may qualify for BHT services if: y You are under 21 years of age; and y Have a diagnosis of ASD; and y Have behaviors that interfere with home or community life. Some examples include anger, violence, self-injury, running away, or difficulty with living skills, play and/or communication skills. You do not qualify for BHT services if you: y Are not medically stable; or Medi-Cal EOC Section 6

54 y Need 24-hour medical or nursing services; or y Have an intellectual disability (ICF/ID) and need procedures done in a hospital or an intermediate care facility. If you are currently receiving BHT services through a Regional Center, the Regional Center will continue to provide these services until a plan for transition is developed. Further information will be available at that time. You can call HPSM at if you have any questions or ask your Primary Care Provider for screening, diagnosis and treatment of ASD. You can also get additional Information about Behavioral Health Treatment services by calling the San Mateo County Behavioral Health and Recovery Services ACCESS Call Center at Cost to Member: y There is no cost to the Member for these services. Substance Abuse Disorder Preventive Services Description of covered services: Alcohol misuse screening services are now a benefit covered by Health Plan of San Mateo for members ages 18 and older. The services for alcohol misuse are**: y One expanded screening for risky alcohol use per year y Three 15 minute brief intervention sessions to address risky alcohol use per year Not Covered: Treatment for major alcohol problems. You may be referred to San Mateo County Behavioral Health and Recovery Services by your Primary Care Physician (PCP). ** Screening, brief intervention, and referral to treatment (SBIRT) Family Planning Services Description: Family planning services that you choose are covered, including the following: Office visits for family planning Pregnancy tests Counseling and surgical procedures for sterilization, as permitted by state and federal law Contraceptive drugs (birth control methods) including insertion or removal of IUD and Norplant, diaphragms, or other FDA approved birth control methods Lab and x-rays Treatment for problems resulting from family planning care Elective pregnancy terminations (Abortions) Emergency contraception when provided by an HPSM pharmacist or a non-hpsm pharmacist Screening, testing and counseling for HIV Testing and treatment of sexually transmitted diseases (STDs) Medi-Cal EOC Section 6

55 Unlike other benefits you may receive, Family Planning Services may be obtained from any qualified network or out-of network Medi-Cal provider. Your doctor does not have to refer you or authorize services. Family Planning Services are available from your PCP, a participating family planning agency, OB/GYN, or any Medi-Cal provider who provides these services. HPSM s Member Services Representatives can provide you with a list of family planning providers, or you can contact the California Department of Health Care Services, Office of Family Planning, Information & Referral Service toll-free number at We can help you find a doctor that provides pregnancy options, including abortion services. This includes providing appropriate counseling, education, information, and referral. HPSM s Member Services Representative, can provide you with a list of HPSM providers, or you can contact the California Department of Health Care Services, Office of Family Planning, Information & Referral Service toll-free number at Minor Consent Services Description: According to California State law, minors (children under age 18) may, without their parents consent, receive the following service(s): services related to sexual assault, including rape pregnancy and pregnancy related services family planning services sexually transmitted disease (STD) testing and treatment drug and alcohol abuse counseling outpatient mental health services If you are a Member under age 18 you do not need consent (permission) from your parents to access pregnancy related services, including Family Planning Services. If you are a Member 12 years of age or older, you do not need consent from your parents to receive testing or treatment of STDs. State law also provides minors the right to obtain abortion services without parental consent. Contact HPSM s Member Services Department, and ask to speak to a Member Services Representative if you need to find a provider who offers minor consent services. Maternity / Pregnancy Care Description: Medically necessary professional and hospital services relating to maternity care including: Pre-natal and Postpartum care and complications of pregnancy Newborn examinations and nursery care while the mother is hospitalized after the delivery Diagnostic and genetic testing Counseling for nutrition, health education and social support needs Labor and delivery care, including midwifery service Participation in the statewide prenatal testing program the Expanded Alpha Feto Protein Program High risk pregnancy referrals to appropriate specialists Medi-Cal EOC Section 6

56 Members do not have to leave the hospital before 48 hours after a vaginal delivery or 96 hours after a C-section unless the Member and doctor decide this together. If a Member leaves the hospital before 48 or 96 hours, the doctor may prescribe a follow-up visit within 48 hours of discharge. The followup visit shall include parent education, assistance and training in breast or bottle feeding, and any necessary physical assessment of the mother or baby. The mother and doctor together shall decide whether the follow-up visit shall be at home, the hospital or the doctor s office depending on the best solution for the family. y Pregnancy Care The Health Plan of San Mateo strongly encourages pregnant women to get early prenatal care (within the first three months of pregnancy). Seeing your doctor or Certified Nurse Midwife (CNM) regularly and following his/her directions will help keep you and your baby healthy. If you need to find an Obstetrician (OB) or Certified Nurse Midwife (CNM) for care during pregnancy, you may receive a list of HPSM Providers by calling the Health Promotion Specialist at Members have the right to receive CNM services from an out-of-plan Medi-Cal Provider if they are not available through HPSM. HPSM will work with members and providers to assist pregnant members in obtaining their first prenatal visit within two weeks of a request. As part of your prenatal care, ask your doctor about the Comprehensive Perinatal Services Program (CPSP), where you can get additional prenatal education, counseling and information on nutrition. You can also get free food and nutritional education from the Women, Infants and Children (WIC) program. Ask your doctor about WIC or call Member Services for more information. y Prenatal Care Program Another service available to you is the HPSM Prenatal Care Program. Call Health Education at for more information. To enroll, call the Health Promotion Coordinator at Enrollment takes about 10 to 15 minutes. The Health Promotion Coordinator can assist you with choosing a doctor, give you referrals to community agencies, and help you select a childbirth class. After your first prenatal visit within 12 weeks of pregnancy, you get a $15 Target gift card. After three months of confirmed prenatal visits, you get the book What to Do When You Are Having a Baby. After six months of confirmed prenatal visits, you get a $50 Target gift card. After a post-partum visit within three to eight weeks after delivery, you get a $40 Safeway gift card. Important educational materials about pregnancy are sent with the gifts. This program is free to all pregnant HPSM Members, but you must enroll before your baby is born. Diagnostic X-Ray and Laboratory Services Description: Diagnostic laboratory services, diagnostic and therapeutic radiological services necessary to appropriately evaluate, diagnose, treat, and follow up on the care of Members. This includes, but is not limited to: Mammograms for screening or diagnostic purposes. All Food and Drug Administration approved technologies, including bone mass measurement technologies as deemed medically appropriate to diagnose, treat or manage osteoporosis. Durable Medical Equipment Description: Durable Medical Equipment is medical equipment that is ordered by a doctor for use in the home. Durable Medical Equipment (DME) when prescribed by a licensed practitioner is covered when Medi-Cal EOC Section 6

57 medically necessary to preserve bodily function essential to activities of daily living or to prevent significant physical disability. Includes, but not limited to: Oxygen and oxygen equipment Blood glucose monitors Apnea monitors Asthma related equipment - Nebulizer machines, tubing and related supplies, and spacer devices for metered dose inhalers Ostomy bags, and urinary catheters and supplies Insulin pumps and all related supplies Other diabetic self-management supplies, as medically necessary Exclusions: Comfort and convenience items Experimental or research equipment Devices not medical in nature, including modifications to the home or automobile, or items used primarily for visits in the community rather than activities of daily living More than one piece of equipment that serves the same function, unless medically necessary Orthotics and Prosthetics Description: Orthotics are medical supplies that support bones and joints. Prosthetics are medical devices that replace a body part. Orthotics and prosthetics are covered when such appliances are necessary for the restoration of function or replacement of body parts. Covered items must be prescribed by a physician or podiatrist, authorized by HPSM and dispensed by an HPSM Provider. The Health Plan of San Mateo may decide whether to replace or repair an item. Medical Transportation Services Description: y Emergency ambulance services ( service) to the first hospital that accepts the Member for emergency care is covered in connection with an emergency medical condition. Emergency transportation is covered for a medical condition that causes severe pain, a serious illness or injury, or a psychiatric emergency, which a prudent lay person (a careful or cautious non-medical member) believes is an emergency condition that requires ambulance transport, even if it is later determined that an emergency did not exist. y Non-emergency medical transportation is covered when a Member s medical and physical condition is such that a Member cannot be transported by any other means and the use of public or private transportation is not medically advisable. Such transportation includes: ambulance, litter van, and wheelchair van medical transportation services when such transportation is needed to obtain medically necessary services No prior authorization from HPSM is required. Members should work with their providers to arrange transportation services with contracted non-emergency transport providers listed in the Member Provider Directory. Note that HPSM, in accordance with federal and State law and Medi-Cal Medi-Cal EOC Section 6

58 rules, covers (pays for) the least costly service that meets a Member s needs. This means that, for example, if wheelchair van transportation is able to transport you, HPSM will not pay for ambulance transportation. Home Health Care Services Description: Home health services are medically necessary services that are prescribed by a doctor and provided in the home by health care personnel such as nurses and home health aides and include physical therapy, occupational therapy, speech therapy, respiratory therapy, and social services. If a basic health service can be provided in more than one medically appropriate setting, it is within the discretion of the attending physician or other appropriate authority designated by the Health Plan of San Mateo to choose the setting for providing the care. The Plan exercises prudent medical case management to ensure that appropriate care is provided in the appropriate setting. Exclusions: Custodial care and services which are not medically necessary. Custodial care means non-skilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops. Community Based Adult Services (CBAS) CBAS is a service you may qualify for if you have health problems that make it hard for you to take care of yourself and you need extra help. If you qualify to get CBAS, the Health Plan of San Mateo (HPSM) will send you to the center that best meets your needs. If there is no center in San Mateo County, HPSM will make sure you get the services you need from other providers. At the CBAS center you can get different services. They include: Skilled nursing care Social services Meals Physical therapy Speech therapy Occupational therapy CBAS centers also offer training and support to your family and/or caregiver. You may qualify for CBAS if: You used to get these services from an Adult Day Health Care (ADHC) center and you were approved to get CBAS Your primary care doctor refers you for CBAS and you are approved to get CBAS by HPSM You are referred for CBAS by a hospital, skilled nursing facility or community agency and you are approved to get CBAS by HPSM Medi-Cal EOC Section 6

59 Skilled Nursing Facility or SNF Care (Subacute/Intermediate Facility Care) HPSM covers Skilled Nursing Facility (SNF) Services. SNF Services may be available to you if you have a physical or mental condition that requires short term rehabilitation. SNF Services must be prescribed by a Plan Physician or certified nurse practitioner and provided in a licensed Skilled Nursing Facility (SNF). Covered Services include: Skilled nursing care on a 24 hour per day basis. Bed and board (daily meals). Case management X-ray and laboratory procedures. Physical, Speech, and Occupational Therapy. See also Physical and Occupational Therapy (page 44), and Speech Therapy (page 45). Prescribed drugs and medications. Medical supplies, appliances, and equipment ordinarily furnished by the SNF. IMPORTANT: If you think you need any of the above services or would like more detailed information about your eligibility for these services, please contact your PCP or the HPSM Member Services Department. Vision Description: Vision services are covered for children and youths up to the 21st birthday. These services are covered for those adults who receive long-term care in a nursing facility or in an intermediate care facility and for pregnant women if a condition might complicate the pregnancy. Members eligible for this service may receive an examination and may go directly to an optometrist for a visit once every two years. Please note that you must choose a provider who is an HPSM provider. Members are eligible for new eyeglass frames and lenses every two years. Lost, stolen, or broken glasses may be replaced. For other more serious eye conditions, members should see their PCP for a referral to a Specialist. Vision services provided by an Ophthalmologist (Doctor of Medicine in Ophthalmology) are covered for all Medi-Cal Members. Ocularist services (a specialist in the fabrication and fitting of ocular prostheses for people who have lost an eye due to trauma or illness) are also covered. Exclusion: Vision services for adults are not covered except as noted above. This means that glasses are not covered. Acupuncture, chiropractic services, prayer or spiritual healer services, occupational therapy, speech therapy, podiatry, and audiology are limited to two (2) services per Member per calendar month for any combination of these services). Note that you must choose a provider who is an HPSM provider. Acupuncture Description: HPSM covers acupuncture services for children and youths up to the 21st birthday. These services are covered for adults who receive long-term care in a nursing or intermediate care facility, and for adults who receive these services at a hospital outpatient clinic or adult day health care center, and Medi-Cal EOC Section 6

60 for pregnant women if a condition might complicate the pregnancy. Services are provided as a selfreferral benefit and do not require referral from a PCP, other doctor, or health professional. They must be provided by an HPSM provider. Exclusion: Acupuncture services for adults are not covered except as noted above. Chiropractic Services Description: HPSM covers chiropractic services for children and youths up to the 21st birthday. These services are covered for adults who receive long-term care in a nursing or intermediate care facility, for adults who receive these services at a hospital outpatient clinic or adult day health care center, and for pregnant women if the condition might complicate the pregnancy. Services are provided as a self-referral benefit and do not require referral from a PCP, other doctor, or health professional. They must be provided by an HPSM provider. Exclusion: Chiropractic services for adults are not covered except as noted above. Prayer or Spiritual Healer Description: Services of a Christian Science Practitioner Occupational and Physical Therapy Description: Therapy may be provided in a medical office or other appropriate outpatient setting, hospital, skilled nursing facility or home. The provider must be an HPSM provider. Speech Therapy Description Speech services are covered for children and youths up to the 21st birthday. Therapy may be provided in a medical office or other appropriate outpatient setting, hospital, skilled nursing facility or home. These services are covered for adults who receive long-term care in a nursing or intermediate care facility, for adults who receive these services at a hospital outpatient clinic or adult day health care center, and for pregnant women if the condition might complicate the pregnancy. The provider must be an HPSM provider. Exclusion: Speech services for adults are not covered except as noted above. Podiatry Services Description: Outpatient podiatric office visits are provided as a self referral benefit and do not require referral from a PCP, other doctor, or health professional. Additional services may be approved as medically necessary with prior authorization. The provider must be an HPSM provider Medi-Cal EOC Section 6

61 Audiology (Hearing) Description: HPSM covers screening and examinations for children and youths up to the 21st birthday. These services are covered for adults who receive long-term care in a nursing or intermediate care facility, for adults who receive these services at a hospital outpatient clinic or adult day health care center, and for pregnant women if the condition might complicate the pregnancy. The provider must be an HPSM provider. Hearing aids are covered for all Medi-Cal Members when medically necessary and provided by an HPSM hearing aid provider. This benefit is subject to change depending on State Medi-Cal guidelines. Members will be notified if this benefit is modified. Exclusions: Screening and examinations for adults are not covered except as noted above. Charges for a hearing aid which is more than the prescribed correction for the hearing loss are not covered. Respiratory Therapy Description: Therapy may be provided in a medical office or other appropriate outpatient setting, hospital, skilled nursing facility or home Blood and Blood Products Description: y Processing, storage and administration of blood and blood products in inpatient and outpatient settings y Includes the collection and storage of autologous (your own) blood when medically indicated Health Education Description: y HPSM s Health Educators are available to give you information about staying healthy, preventing illness, and ways to handle a health problem. Please call the Health Education staff for the following services: Health Programs in the Community Diabetes Childbirth Stop Smoking Blood Pressure and Cholesterol Asthma y HPSM Newsletter Articles about your health and how to care for yourself and your family Chances for you to tell us about your favorite topics for future articles Medi-Cal EOC Section 6

62 y Information on Health Topics and Resources Questions about health problems, nutrition, etc. Community resources and agencies available Free or low-cost exercise facilities and programs Please call HPSM s Health Educators at for more information. Hospice Description: Hospice care is care provided by a health care team to meet the needs of Members who are diagnosed with a Terminal Illness with a life expectancy of six months or less and who choose hospice care instead of the usual medical services covered by HPSM. The hospice choice may be cancelled at any time. Hospice care is used to relieve pain and suffering and treat symptoms rather than to cure illness. Hospice care and services are provided in a home by a licensed or certified provider. The hospice benefit includes: Nursing services Home health aide services Bereavement Services Social services/counseling services Dietary counseling Physician services Short-term inpatient care (respite care) Physical therapy, occupational therapy, and speech therapy for symptom control or to maintain activities of daily living Pharmaceuticals, medical equipment and supplies to the extent reasonable and necessary for the palliation and management of terminal illness Organ and Bone Marrow Transplants Description: y HPSM follows the state s Medi-Cal patient selective criteria on organ and bone marrow transplants. All transplants are only approved at Medi-Cal Centers of Excellence. If possible, HPSM will authorize care at a Medi-Cal Center of Excellence that is an HPSM provider. If a Center of Excellence for your specific condition is not an HPSM provider, your doctor needs to contact HPSM s medical staff so that HPSM can make arrangements for your care at that non-contracted Medi-Cal Center of Excellence. y Transplant services may be covered by the California Children s Services (CCS) program (if under age 21), if the Member is found to be eligible. The Health Plan of San Mateo will coordinate these services with CCS or Genetically Handicapped Persons Program GHPP for adult Members with certain conditions (see page [49 and 50]) Medi-Cal EOC Section 6

63 y HPSM also covers: Reasonable medical and hospital expenses of a donor or an individual identified as a prospective donor if these expenses are directly related to the transplant for a Member Charges associated with the search and testing of unrelated bone marrow donors through a recognized Donor Registry and charges associated with the procurement of donor organs through a recognized Organ Procurement Agency, if the expenses are directly related to the anticipated transplant of a Member Mastectomies and Lymph Node Dissection Surgeries Description: y The length of a hospital stay associated with mastectomies and lymph node dissections are determined by the attending physician and surgeon in consultation with the Member y Coverage includes all complications from a mastectomy Reconstructive Surgery Description: y Reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: Improve function Create a normal appearance to the extent possible y Reconstructive surgery to restore and achieve symmetry incident to mastectomy is covered for women of any age. Exclusions: Cosmetic surgery that is performed to alter or reshape normal structures of the body in order to improve appearance Clinical Cancer Trials Description: HPSM covers your participation in a cancer clinical trial, Phase I through IV, when your doctor has recommended participation in the trial, and you meet the following requirements: You must be diagnosed with cancer You must be accepted into a Phase I, Phase II, Phase III, or Phase IV clinical trial for cancer Your treating doctor, who is providing covered services, must recommend participation in the clinical trial after determining that participation will have a meaningful potential to you, and The trial must meet the following requirements: Trials must have a therapeutic intent with documentation provided by the treating doctor Trials must be approved by one of the following: 1) the National Institute of Health, the Federal Food and Drug Administration, the U.S. Department of Defense, or the U.S. Veterans Administration, or 2) involve a medication that is exempt under the federal regulations from a new drug application Medi-Cal EOC Section 6

64 If under age 21 these services may be covered by the California Children s Services (CCS) program, if you are found to be eligible. The Health Plan of San Mateo will coordinate these services with CCS for you (see page [49]) Charges for routine patient care costs of a Member are covered. These are costs associated with the provision of health care services, including, medications, items, devices and services that would otherwise be covered if they were not provided in connection with an approved clinical trial program. Routine patient costs for cancer clinical trials include: Health care services required for the provision of the investigational medication, item, device or service Health care services required for the clinically appropriate monitoring of the investigational medication, item, device, or service Health care services provided for the prevention of complications arising from the provision of the investigational medication, item, device, or service Health care services needed for the reasonable and necessary care arising from the provision of the investigational medication, item, device, or service, including diagnosis or treatment of complications You may request an Independent Medical Review (IMR) of HPSM s coverage decisions. Information on how to request an IMR is on page [56] Exclusions: y Provision of non-fda-approved medications or devices that are the subject of the trial y Services other than health care services, such as travel, housing, and other non-clinical expenses that you may incur due to participation in the trial y Any item or service that is provided only to satisfy data collection and analysis needs and that is not used in the clinical management of the patient y Health care services that are otherwise not a benefit y Health care services that are customarily provided by the research sponsors free of charge for any enrollee in the trial y Coverage for clinical trials is restricted to participating hospitals and doctors in California, unless the protocol for the trial is not provided in California Phenylketonuria (PKU) Description: Testing and treatment of PKU is covered. Additionally, formula, as defined below and certain special food products, as defined below, which may be prescribed for the treatment of PKU are covered. Formula and special food products are covered to the extent that the Member s costs for such items exceed the cost of a normal diet. The formula and/or special food product must also be prescribed by a doctor or nurse practitioner, or ordered by a Registered Dietician upon referral by a participating provider who is unauthorized to prescribe dietary supplements, as medically necessary, for the treatment of PKU. Formula means enteral product(s)for use at home. Special food product : means a food product that is both of the following: Medi-Cal EOC Section 6

65 Prescribed by a doctor or nurse practitioner for the treatment of PKU and is consistent with the recommendations and best practices of a qualified health professional with expertise related to, and experience in, the treatment and care of, PKU. It does not include food that is naturally low in protein, but may include food that is specially formulated to have less than one gram of protein per serving, and Used in place of normal food products. Normal foods are those found in retail establishments, and used by the general population. Linkages to Other Programs Child Health and Disability Prevention (CHDP) Program Your child s PCP may also be a CHDP doctor. He or she will provide checkups and immunizations for your child. Remember that you can keep your child healthy and free of childhood diseases by regularly taking your child to his/her PCP for immunizations and checkups. This includes well care for your children through age 21. Early Periodic Screening and Diagnostic Treatment (EPSDT) Program Early and Periodic Screening, Diagnosis, and Treatment Services are extra Medi-Cal services. You can get them in addition to other Medi-Cal services. You must be under age 21 and have full scope Medi- Cal to get these services. EPSDT services correct or improve medical problems that your doctor or other health care provider finds, even if the health problem will not go away completely. Ask your doctor or clinic about EPSDT services. You may get these services if you and your doctor, or other health provider, clinic or county mental health department agree that you need them because they are medically necessary for you, and they submit a request for these services to HPSM for review. California Children s Services (CCS) In April 2013, HPSM, with the support of the California Department of Health Care Services, started a new pilot program in San Mateo County. Children under age 21 with certain significant health problems, genetic diseases, and chronic or catastrophic illnesses that will last at least twelve (12) months may qualify for this special health care program called California Children s Services (CCS) Demonstration Pilot. This pilot will test new ways to coordinate health care services for children with special health care needs. The goal of the pilot is to improve coordination of care, improve health outcomes, and increase patient and provider satisfaction. The pilot offers coordination for all health care needs including community referrals and resources for parenting, education, and emotional support. Your child will stay enrolled in HPSM and will continue to receive all other services provided through HPSM. Your child may benefit from the CCS Demonstration pilot services if your child resides in San Mateo County, is enrolled in HPSM, is Medi-Cal eligible, and: 1. Has a CCS condition as of April 1, Your child will be automatically enrolled into the CCS Demonstration Pilot without disruption of services. 2. Has not previously been identified as being eligible for the CCS program, but either you, HPSM, or the child s PCP believes your child may qualify for the CCS program. To apply for CCS services, contact the San Mateo Health Department. The intent of the pilot is to improve the care coordination you receive. Enrollment in the pilot does not reduce your child s services or coverage if he or she is already in the CCS program Medi-Cal EOC Section 6

66 To find more about the San Mateo County CCS Program you can contact the San Mateo Health Department at or visit their website at: Genetic Testing and Counseling Genetic testing and counseling are Medi-Cal benefits. Specific services are provided by doctors certified to give genetic counseling. These services are for children and adults who need them on a limited basis. Genetic Disease Treatment Genetically Handicapped Persons Program (GHPP) Adults who have specifically designated genetic conditions may be eligible for special counseling and treatment at one of the State of California California Department of Health Services regional programs. Examples of these conditions include hemophilia, cystic fibrosis, and sickle cell anemia; neurological diseases such as Huntington s disease, Joseph s disease, and Frederick s Ataxia; and metabolic diseases such as PKU, galactosemia and Wilson s disease. For more information, please contact the Genetically Handicapped Persons Program at Other Available Benefits and Programs Not Covered by HPSM HPSM does not cover all your Medi-Cal benefits. The following services are not covered by HPSM, but they are available to Medi-Cal Members in San Mateo County: Woman, Infants, and Children (WIC) Golden Gate Regional Center (for the developmentally disabled) Dental Services (Denti-Cal) Substance Abuse Special Services for Adults Most senior and disabled adults can continue to live at home even when they have chronic medical conditions. There are many agencies and programs that can help you in increasing your independence and quality of life at home, for example: y Adult Day Health y Multi-purpose Senior Service Program y In-Home Supportive Services (IHSS) When you participate in these programs and live at home, your PCP will continue to be in charge of your medical care. For more information, contact the San Mateo County Office of Aging and Adult Services at or Long Term Services and Supports (LTSS) Description: Some LTSS benefits are covered by HPSM for all members who qualify to receive these services in Call HPSM Members Services to determine your eligibility and effective date. Covered Services: Multi-Purpose Senior Services Program (MSSP) You may qualify for MSSP services if you are Medi-Cal EOC Section 6

67 65 years or older with disabilities and are eligible for nursing facility placement but wish to remain at home. MSSP services allow you to remain safely at home as an alternative to nursing facility placement. Services provided by MSSP may include: Adult day care / support center Housing assistance Chore and personal care assistance Protective supervision Care management Respite Transportation Meal services Social services Communication services. y In-Home Supportive Services (IHSS) If you are disabled, or blind, or are over 65 years of age and are unable to live at home without help, you may qualify for IHSS benefits. IHSS allows you to remain safely in your own home. You do not qualify if you live in a nursing or community care facility. IHSS benefits may include the following services: Meal preparation and clean up Laundry Personal care services (such as bowel and bladder care, bathing, grooming and paramedical services) Grocery shopping and errands Transportation to medical appointments Household and yard cleaning Accompaniment to medical appointments Protective supervision For more information, contact the San Mateo County Office of Aging and Adult Services at or Medi-Cal EOC Section 6

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69 Section 7 Exclusions and Limitations on Benefits General Exclusions and Limitations Services not received from, referred by, or authorized by HPSM or your PCP, except for those Covered Services which specifically do not need a referral, are not covered. You should read all descriptions of the Benefits in this booklet and any inserts to this document to get the full details of their coverage and non-coverage under HPSM Membership. No service is covered unless it is medically necessary. Specific Exclusions and Limitations The following services and supplies are not covered by HPSM; additional exclusions that apply only to a particular service are listed in the description of that service in the Benefits section. However, some of the services may be benefits through the State Medi-Cal fee-for-service program. Each service covered through the State Medi-Cal fee-for-service program has an asterisk, or star (*) next to the service. 1. Services, supplies, items, procedures or equipment, which are not medically necessary, are excluded from coverage under state and federal law. 2. Those medical, surgical (including implants), or other health care procedures, services, products, medications, or devices which are either experimental or investigational, unless the following conditions are met: you have a life threatening or seriously debilitating condition or which, standard therapies have not been effective, or are not appropriate, or there is not standard therapy covered by Medi-Cal that is more beneficial than the therapy being proposed. You may seek an Independent Medical Review (IMR) if experimental or investigational therapy is delayed, denied, or modified. Please see page [61] for information on how to request an IMR. 3. Emergency facility services for non-emergency conditions, unless you believe an emergency existed, even if it is later determined that an emergency did not exist. 4. Diagnosis and treatment of infertility unless provided in conjunction with covered gynecological services. Treatment of medical conditions of the reproductive system are not excluded. 5. Services which are eligible for reimbursement by insurance, Workers Compensation benefit plan or covered under any other insurance or health care service plan. HPSM shall provide the services at the time of need, and the Member shall cooperate to ensure that the HPSM is reimbursed for such benefits. 6. Personal or comfort items such as telephones, TVs, guest trays, personal hygiene items, disposable supplies (except ostomy bags or urinary catheters) and other supplies not covered under Medi-Cal Program guidelines. 7. Dental oral surgeon services performed by a dentist or oral surgeon. Dental oral surgeon services performed by a non-physician dental oral surgeon i.e. dentist, are not covered by Medi-Cal Medi-Cal EOC Section 7

70 Medi-Cal benefits cover any surgical procedure performed by a physician oral surgeon. Also covered as benefits are general anesthesia and associated facility charges for dental procedures rendered in a hospital or surgery center for Members for whom general anesthesia is medically necessary. The clinical status or underlying medical condition of the Member must require general anesthesia for dental procedures that would not ordinarily be performed under general anesthesia. Consult Denti- Cal at for all other coverage. It should be noted that, except for limited emergency procedures, dental care is no longer a Medi-Cal (Denti-Cal) benefit for Medi-Cal beneficiaries 21 years old and older except for pregnant women who may need treatment for a dental condition that might complicate the pregnancy and members receiving long-term care in a nursing facility. 8. Medications for cosmetic use. 9. Cosmetic surgery that is performed only to alter or reshape normal structures of the body in order to improve appearance or any surgery aimed at improving appearance and not aimed at improving function or otherwise medically necessary. 10. Exercise and hygiene equipment; experimental or research equipment; devices not medical in nature such as sauna baths and elevators, or modifications to the home or automobile; deluxe equipment; or more than one piece of equipment that serve the same function, unless medically necessary. 11. Corrective shoes and arch supports, (except for therapeutic footwear for diabetics); nonrigid devices such as elastic knee supports, corsets, elastic stockings, and garter belts, dental appliances, electronic voice producing machines; except as medically necessary. 12. Coverage for transportation by passenger car, taxi or other form of public transportation. 13. Home Health custodial care and physical therapy and rehabilitation which are not medically necessary. 14. Hospice services include the provision of palliative medical treatment of pain and other symptoms associated with a terminal disease, but do not provide for efforts to cure the disease. Members who choose hospice care are not entitled to any other benefits for the treatment of the terminal illness. However, the Member may choose to revoke the selection of hospice at any time. A Member under the age of 21 may concurrently receive hospice services in addition to curative services for a hospice-related diagnosis Medi-Cal EOC Section 7

71 Section 8 Member Complaint and Appeals Grievance and Appeals HPSM has a complaint (grievance) process to help you resolve problems with medical care and/or service. You can make a complaint or grievance about the quality of care you ve received or about the customer services you received in a provider s office. If we make a decision you are not satisfied with about your benefits and coverage, you can appeal the decision we made. If you need help solving a problem, please call Member Services at the address and phone numbers listed to file a complaint or an appeal at You may also call a Grievance and Appeals Coordinator directly at You have the right to file a complaint or an appeal if you disagree with a decision made by HPSM or by one of its providers, or if you are not happy with the service you received. You must file your complaint or appeal within one hundred eighty (180) calendar days following any incident or action with which you were dissatisfied. If you decide to file a complaint or an appeal, you may do so by telephone, in writing or in person at our office at the address and phone numbers listed below. If your PCP is with the Kaiser Foundation Health Plan, you must file your grievance or appeal with Kaiser. To find out about Kaiser s grievance resolution process, please contact a Member Services Representative at the Kaiser Foundation Health Plan, or call Kaiser s Member Service Call Center at or (TTY). Filing a Complaint or Appeal The following sections describe how to file a grievance with HPSM. The information applies except in the situation where you receive either prenatal care or pediatric care through the Kaiser Permanente Redwood City Medical Center. You may file a Complaint or Appeal at any time with HPSM. They can be filed with either a Member Services Representative by calling or or by speaking with a Grievance and Appeals Coordinator at or You can obtain a copy of HPSM s Grievance or Appeals Policy and Procedures by calling our Member Service number in the above paragraph. To begin the complaint process or file an appeal, you can call, write, or fax the plan at: Grievance and Appeals Coordinator Health Plan of San Mateo 701 Gateway Boulevard, Suite 400 South San Francisco, CA Phone or Fax HPSM will acknowledge receipt of your complaint or appeal within five (5) days and will resolve your grievance or appeal within thirty (30) days. You will be sent a letter letting you know the decision we ve made. Any services that were authorized will continue to be provided until your complaint or appeal is being resolved. If your complaint involves an imminent and serious threat to your health, including but not limited to severe pain, potential loss of life, limb or major bodily function; you or your provider may request that HPSM expedite its review. HPSM will evaluate your request for an Medi-Cal EOC Section 8

72 expedited review and, if your appeal qualifies as an urgent appeal, we will resolve your appeal within three (3) days from receipt of your request. You are not required to file a complaint with HPSM before asking the Department of Managed Health Care to review your case on an expedited review basis. If you decide to file a complaint with HPSM in which you ask for an expedited review, HPSM will immediately notify you in writing that: 1. You have the right to notify the Department of Managed Health Care about your grievance involving an imminent and serious threat to health, and 2. We will respond to you and the Department of Managed Health Care with a written statement on the pending status or disposition of the grievance no later than 72 hours from receipt of your request to expedite review of your grievance. State Hearing A State Hearing is an appeal if you disagree with a decision HPSM has made regarding your health care services, including termination or reductions in service. It is not a court hearing. This is a hearing with you, an Administrative Law Judge from the California Department of Social Services and an HPSM representative. You can also have an authorized representative represent you at the hearing. You can notify the State Hearings Division if you need language assistance. If you request an interpreter, a state approved interpreter will be there to assist you. You can request a State Hearing at any time in the Grievance process. You have 90 days from the date of the HPSM decision that you disagree with to ask for a State Hearing. For terminations or reductions in service, if you submit your request within 10 days of receiving HPSM s notice of termination or reduction, or before the service is terminated (whichever is first), HPSM may continue to pay for the disputed health care service until a decision on the hearing is made. HPSM s Grievance and Appeals Coordinator can help you with a State Hearing. To request a State Hearing, call the following toll free number: Public Inquiry and Response or write to: Toll free (Teletypewriter (TTY) only State Department of Social Services State Hearings Division Post Office Box Mail Station Sacramento, Ca Fax Expedited State Hearing An Expedited State Hearing means a faster review of your appeal. You can request an Expedited State Hearing if you disagree with a decision HPSM has made regarding a health care service and if proceeding with a Grievance or State Hearing would endanger your life or health. You can represent yourself at the Expedited State Hearing, or you can appoint a representative. If you request an Expedited State Hearing, HPSM will have two (2) business days to provide information to the State. If your request for an Expedited State Hearing is accepted, the State must resolve your case within three (3) business days. For terminations or reductions in service, if you submit your request within 10 days of receiving HPSM s notice of termination or reduction, or before the service is terminated (whichever is first), HPSM may continue to pay for the disputed health care service until a decision on the hearing is made. For general information or questions about an Expedited State Hearing, you can call the California Department of Health Care Services Ombudsman at or HPSM s Grievance and Appeals Coordinator at or All requests for an Expedited State Hearing should be sent to: Medi-Cal EOC Section 8

73 Expedited Hearing Unit State Hearings Division 744 P Street, MS Sacramento, CA FAX: Independent Medical Reviews If medical care that is requested for you is denied, delayed or modified by HPSM or a plan provider, you may be eligible for an Independent Medical Review (IMR). If your case is eligible and you submit a request for an IMR to the Department of Managed Health Care (DMHC), information about your case will be submitted to a medical specialist who will review the information provided and make an independent determination on your case. You will receive a copy of the determination. If the IMR specialist so determines, HPSM will provide coverage for the health care services. An IMR is available in the following situations: 1. (a) Your provider has recommended a health care service as medically necessary, or (b) You have received urgent care or emergency services that a provider determined was medically necessary, or (c) You have been seen by an in-plan provider for the diagnosis or treatment of the medical condition for which you seek independent review; and 2. The disputed health care service has been denied, modified, or delayed by HPSM or one of its plan providers, based in whole or in part on a decision that the health care service is not medically necessary; and 3. You have filed a grievance with HPSM and the disputed decision was upheld or the grievance remains unresolved after 30 calendar days. If your grievance qualifies for expedited review, you are not required to file a grievance with HPSM prior to requesting an IMR. Also, the DMHC may waive the requirement that you follow HPSM s grievance process in extraordinary and compelling cases. For cases that are not urgent, the IMR organization designated by DMHC will provide its determination within thirty (30) days of receipt of your application and supporting documents. For urgent cases involving an imminent and serious threat to your health, including but not limited to severe pain, potential loss of life, limb or major bodily function; the IMR organization will provide its determination within three (3) business days. At the request of the experts, the deadline can be extended by up to three (3) days if there is a delay in obtaining all necessary documents. The IMR process is in addition to any other procedures or remedies that may be available to you. A decision not to participate in the IMR process may cause you to forfeit any statutory right to pursue legal action against the plan regarding the care that was requested. You pay no application or processing fees for an IMR. You have the right to provide information in support of your request for IMR. For more information regarding the IMR process or to request an application form, please call HPSM s Member Services at or or a Grievance and Appeal Coordinator at or Members with hearing or speech impairments can use the California Relay Service (CRS) at TTY or dial Medi-Cal EOC Section 8

74 Independent Medical Review for Denials of Experimental / Investigational Therapies You may also be entitled to an Independent Medical Review, through the Department of Managed Health Care, when we deny coverage for treatment we have determined to be experimental or investigational. y We will notify you in writing of the opportunity to request an Independent Medical Review of a decision denying an experimental/ investigational therapy within five (5) business days of the decision to deny coverage. y You are not required to participate in HPSM s grievance process prior to seeking an Independent Medical Review of our decision to deny coverage of an experimental/investigational therapy. y If a physician indicates that the proposed therapy would be significantly less effective if not promptly initiated, the Independent Medical Review decision shall be rendered within seven (7) days of the completed request for an expedited review. Review by the Department of Managed Health Care The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against HPSM, you should first telephone HPSM at or and use HPSM s grievance process before contacting the department. Members with hearing or speech impairments can use the California Relay Service (CRS) at or dial Using this grievance procedure does not prohibit any legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by HPSM, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial view of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency and urgent medical services. The Department of Managed Health Care has a toll free telephone number, HMO-2219, to receive complaints regarding health plans. The hearing and speech impaired may use the department s TDD line ( ) number, to contact the department. The Department s Internet website ( has complaint forms, IMR application forms and instructions online. HPSM s grievance process and DMHC s complaint review process are in addition to any other dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law. Mediation You or your authorized representative can request voluntary mediation with HPSM. You need not participate in mediation for more than thirty (30) days before being able to submit a Grievance to the Department of Managed Health Care. You can still submit a Grievance with the Department after completing mediation. You and HPSM will share the cost of mediation. DHCS Medi-Cal Managed Care Ombudsman If you have questions about Medi-Cal Managed Care or want help to resolve problems with HPSM, you can call the California Department of Health Care Services Office of Ombudsman at Medi-Cal EOC Section 8

75 Section 9 Coordination of Benefits Coordination Of Benefits (COB) Applicability If you have other health insurance and Medi-Cal, your other insurance will be your primary insurance and Medi-Cal will be your secondary insurance. Your primary insurance will always be billed first, before Medi-Cal. If you have to go to certain doctors, clinics, or hospitals under your primary insurance, you are responsible for following those rules. If you are not sure about how to access health care benefits under your primary insurance, please call them and ask. If you don t access health care benefits the right way under your primary health insurance, you may be responsible for paying the bill. If you have a copayment under your primary insurance (for example, $10 every time you go to the doctor s office as your copayment), you will not have to pay it if you have Medi-Cal as your secondary insurance. If your doctor asks you for a copayment, explain to him or her that you have Medi-Cal as your other insurance and don t have to pay the copayment for your primary insurance. If your doctor has questions about this, he or she can call us for more information. If your doctor of pharmacy charges you a copayment, please call Member Services. If your other health insurance doesn t pay for your prescription medication, please only go to pharmacies that are contracted with us. They are listed in the Provider List. We cannot reimburse Members for prescriptions, so if you have paid for medication that should have been covered, you will need to ask the pharmacy to bill us and give you a refund for the money you have paid them. If you have a question or a problem, please call a Member Services Representative. If you had other health care coverage but do not have it any more, please tell your Medi-Cal Benefits Analyst at or Social Security Administration at as soon as possible. Benefit Coordination with Other Coverage If you are covered by more than one health insurance plan, your benefits will be coordinated according to California regulations. If you would like more information about coordinating benefits, please contact our Member Services Department. Recovery from Third-party Liability If you are in an accident of any kind and need medical care, tell the doctor and/or hospital how you were hurt and where. If you are injured in an accident, HPSM will provide covered benefits. Medi-Cal Estate Recovery Program The State of California must seek repayment of Medi-Cal benefits from the estate of a deceased Medi-Cal beneficiary for services received on or after the beneficiary s 55th birthday. For Medi-Cal beneficiaries enrolled (either voluntarily or mandatorily) in a managed care organization, the State must seek recovery of the total premium/capitation payments for the period of time they were enrolled in the managed care organization. Additionally, any other payments made for services provided by non-managed care providers will also be recovered from the estate. For further information regarding the Estate Recovery program only, call , or seek legal advice Medi-Cal EOC Section 9

76 Please Do Not Call Your Medi-Cal Eligibility Worker or HPSM. He or she does not have this information, so they cannot help you. This means that the State can ask for money back after a Medi-Cal beneficiary dies. The State will ask for the money back from the person s family or estate. The State can ask for the amount that it paid for services received after the beneficiary turned 55. If a beneficiary is in a managed care plan like HPSM, the amount the State can ask for is the amount the State paid HPSM. This is not the same as the amount HPSM may have paid the providers. If you have questions about this, please call the State s Estate Recovery Program at Medi-Cal EOC Section 9

77 Section 10 General Provisions Entire Contract The contract between Health Plan of San Mateo and the California Department of Health Services, this Evidence of Coverage, and any amendments shall constitute the entire contract for coverage. Payment to Providers HPSM pays most doctors and health care providers on a fee-for-service basis. This means that the doctors provide health care services to Members and then send a bill to HPSM for services they give you. HPSM pays contracted PCPs a capitation payment. This means that doctors receive a fixed amount of money each month for each of their HPSM Members to manage their care. Hospitals and Hospices are paid a daily rate. Doctors may get financial incentives to provide quality health care to our Members. You may request information about these incentives by calling a Member Services Representative. Durable Power of Attorney for Health Care or Advanced Directive When you have surgery or are very sick or hurt, you may not be able to tell the doctor what treatment you want. California laws exist to help you and your family make those decisions ahead of time. You can now sign a special paper which tells your doctor and other health care providers what you want to do about your treatment when you are too sick or hurt to decide for yourself. When you sign this paper, called The Durable Power of Attorney, you can name someone else - a family member or friend - as your agent to make health care decisions for you. You can also specify which health care treatments can be used when you are incapacitated. Incapacitated means you have temporarily or permanently lost the power to make decisions for yourself. If you have a Durable Power of Attorney, please share it with your family and doctor. Ask your doctor for more information about this and other options available to you. We will let you know if there is a change in State law regarding advance directives no later than 90 calendar days of the date such a change will take place. Relationship Between Parties The relationships between the San Mateo Health Commission and Participating Providers are contractual relationships between independent contractors. Participating Providers are not agents or employees of the Health Plan of San Mateo nor is the Health Plan of San Mateo or any employee of the Health Plan an agent or employee of any Participating Provider. Privacy Practices HPSM will protect the privacy of Members health information. Contracted providers are also required to protect your health information. Protected health information includes your name, social security number, and other information that reveals who you are. You have the right, with certain exceptions, to see and receive copies of your health information that HPSM maintains, correct or update your health information, and ask us for an accounting of certain disclosures of your health information. HPSM may use or disclose your health information for treatment, payment and health care operations in connection with the administration of the Medi-Cal program, including measuring the quality of care and services that you receive. In addition, we will not use or disclose your health information for any other purpose without your (or your representative s) written authorization, except as described in our Notice of Privacy Practices Medi-Cal EOC Section 10

78 A copy of HPSM s Notice of Privacy Practices is included at the beginning of this Evidence of Coverage on pages [i vi]. You can also contact HPSM s Member Services Department at or , or visit HPSM s website at for another copy of HPSM s Notice of Privacy Practices. Authorization for Release of Information The Health Plan of San Mateo will not release individually identifiable medical or personal information without obtaining authorization from the patient or the patient s designee, except as allowable in statute. HPSM may release information that is not individually identifiable. Workers Compensation Not Affected If a Member requires services for which benefits are in whole or in part either payable or required to be provided in accordance with any Workers Compensation or Occupational Disease law, HPSM will provide covered services to which the Member is entitled. Non-Discrimination Primary Care Provider shall not discriminate on the basis of sex, race, color, ancestry, religious creed, national origin, marital status, sexual orientation, physical disability including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), mental disability, age, medical condition or mental status. In addition all Primary Care Providers shall ensure that the evaluation and treatment of their employees and applicants for employment are free from discrimination and harassment. Consumer Advisory Committee HPSM has a Consumer Advisory Committee (CAC) that represents HPSM members to improve health care services. The CAC is made up of HPSM members, community advocates and staff from agencies who work with HPSM members. The CAC makes recommendations to HPSM s governing body, the San Mateo Health Commission. CAC meetings are held quarterly. If you would like to join the CAC, please call Member Services Medi-Cal EOC Section 10

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80 Healthy is for everyone. Health Plan of San Mateo 701 Gateway Boulevard, Suite 400 South San Francisco, CA Tel Toll Free TTY