Health Plan of San Joaquin.

Health Plan of San Joaquin (HPSJ) is a publicly sponsored, California-based, not-for-profit health management organization (HMO) that has been existing since 1996.

It has a contract with the Department of Health Care Services (DHCS) in the provision of a health insurance plan for Medi-cal members in Joaquin and Stanislaus counties.

Medi-cal is the name given to the popular nationwide Medicaid program, in California. Being qualified for Medi-cal and a resident in Joaquin or Stanislaus County ultimately qualifies you for the health plan in San Joaquin.

This health plan started with a total of about 300 members in Joaquin back in 1996 but presently boasts over 400,000 in membership out of which 248,360 reside in San Joaquin and 152,220 in Stanislaus.

How health plan San Joaquin works and eligibility.

Health plan San Joaquin (HPSJ) partners with various healthcare providers operating within its areas of coverage to provide healthcare services for Medi-cal beneficiaries with the Medi-cal benefits identification card (BIC).

Having Medi-cal coverage makes you eligible for the health plan of San Joaquin.

After enrolling in the health plan San Joaquin you’ll get the insurer’s identification card within two weeks. This card and the Medi-cal identity card are what you’ll present when you access health care services including prescribed drugs.

Once enrolled, you’ll be able to access emergency and urgent medical services throughout the state of California irrespective of your county. However, preventive health services will only be available in the county where you live except for students leaving for school in another county.

Relocating students will have to inform the social services agency in their counties of residence and update them with their address in the new county to access routine or preventive health care services after relocation.

Otherwise, routine preventive care services are only available in the county of residence of the head of a family.

Buying into a new health plan is possible in counties that are not within the health plan of San Joaquin’s areas of service. The number to call for this switch is 1-800-430-4263 (TTY 1-800-430-7077 or 711).

If, as a student, you are moving to a school in another state it may be wise to apply for Medicaid in the new state. This is because routine checkups, preventive medical services, and prescription drugs are only covered within California.

However, emergency care is covered beyond the state and can go as far as Canada and Mexico if the healthcare provider meets Medi-cal operational service requirements or rules.

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Covered services of HPSJ.

1. HPSJ advice nurse line,

This is a 24/7 free medical advice line otherwise called Healthreach. With this, you could talk to a qualified nurse or doctor about your health problems when your doctor isn’t reachable. You could also listen to audio health recordings on topics of interest in English or Spanish.

2. Hospital care,

It’s a hospital inpatient service that is only available on order by your doctor or specialist with approval by the health plan of San Joaquin.

3. Doctor visits,

Under this benefit are services like popular routine immunization, family planning, and visitations when you are sick,

4. Vision benefits,

You get to do cost-free routine examinations of your eyes every 2 years. It could get more frequent for those with diabetes. With prescriptions, you also get your eye frames and appropriate lenses.

Replacement of these items can also be made within 24 months in the event of a change in prescription, including when broken or stolen in which case a written account must be presented that proves you were not at fault for the loss.

HPSJ also grants you access to the vision service plan (VSP) network.

5. Specialty care,

When referred by your doctor, you could access the services of any of the over 3,000 specialists that work with HPSJ in areas such as pediatrics, orthopedics, ophthalmology, obstetrics & gynecology, etc. You won’t always need a referral to see a specialist like in cases that have to do with emergencies and prenatal.

6. Dental care,

HPSJ dental benefits under the state’s Denti-cal program¹ California Dept. of Health Care Services (governmental authority) visit source  are available in the areas of emergency, diagnostic, and prevention. Various tooth surgeries like extractions and root canal treatments are not left out.

7. Pharmacy services,

Medi-cal members are not expected to pay for prescribed drugs. Drugs are to be obtained within the Medi-cal pharmacy network listed in the pharmacy directory² California Dept. of Health Care Services (governmental authority) visit source using your HPSJ membership ID card and Medi-cal benefits card.

You may also get any of these pharmacies by calling the Medi-cal treatment line: 800-977-2273 (TTY 800-977-2273 and press 5 or 711).

Additionally, there is a covered drug list or formulary³ California Dept. of Health Care Services (governmental authority) visit source from which your drugs are to be chosen, going out of this list will require a prior review appeal sent to Medi-cal.

8. Transportation services,

Medical and non-medical transportation is available for covered services and appointments for those in need of it. However, it’s not available when you go out of network or areas of service without authorization from HPSJ. In cases of emergency, authorization will not be needed.

9. Immunization,

The recommended immunization vaccines by the advisory committee are covered but usually only available within California.

10. Wellness appointments,

These are preventive health screening services like Mammograms,⁴ Healthcrust article. (trustworthy) see the article and routine check-ups, often given at no cost to you.

11. Behavioral health,

HPSJ is in partnership with a mental health company called Beacon Health Strategies to meet your mental health needs.

12. Language assistance services.

Where language constitutes a barrier or communication impairment exists, HPSJ has your back 24/7. Interpreters and experts in sign language are provided at no cost to you.

Services that are only obtainable with approval.

Generally, pre-approval is needed when you seek out-of-network health care unless it has to do with urgent care or an emergency. Nonetheless, several in-network health services require pre-authorization such as:

• Physical Therapy,
• Chiropractic treatment,
• Enteral or parenteral nutrition.
• Audiology,
• Acupuncture,
• Home health services,
• Major organ transplants,
• Inpatient Medical care,
• Occupational therapy,
• Inpatient surgical care,
• Behavioral health services,
• Laboratory services,
• Radiological services,
• Prostheses and Orthotics,
• Podiatry,
• Speech therapy,
• Transgender-related services,
• Vision services,
• Palliative health care, plus a few others.

How much does HPSJ cost?

For the most part, HPSJ members don’t pay for services that are covered except when they go out of network for non-emergency care without pre-approval. In such cases, the bill will be on you.

If you are on long-term care⁵ Healthcrust article (trustworthy) see the article  and share the cost, you pay your bills each month till you’ve reached your share of the cost for that month before HPSJ starts to pay its part. Your share of the cost is determined by your income and other resources available to you.

Getting HPSJ to pay your bills.

You are not supposed to pay out-of-pocket for covered services received within the HPSJ network. If you’ve already paid for such services HPSJ will reimburse you in part or in full and you’ll be informed about that decision in a letter called “notice of action”.

The following conditions must be met for any reimbursements:

• The service was received after you became an HPSJ member.
• The service is covered by Medi-cal or HPSJ therefore HPSJ is responsible for the payment.
• There was proof of out-of-pocket payment for the service.
• The date of your reimbursement request is not later than a year after the service was received.
• The service was received within the network.
• For covered services received outside the network, it must be among those that are exempted from pre-authorization like emergencies, prenatal, and family planning.
• For reimbursement requests for out-of-network services requiring pre-approval, you’ll need to provide proof from the healthcare provider showing a need for that service.

A Medi-cal enrolled provider should pay you back if the above conditions are met but where the provider doesn’t want to pay, HPSJ will pay.

There are situations you will not be entitled to reimbursements and they are as follows:

• If you are in long-term care and haven’t met your share of the cost.
• If the services you received are not covered by Medi-cal.
• If the provider is not on Medi-cal and you signed up to be seen on the premises you’ll foot the bill.

Continuity of care for HPSJ.

The HPSJ continuity of care is an arrangement that grants you the privilege to go to out-of-network healthcare providers for up to 12 months or more. This is enabled in the following circumstances.

• The Provider agrees to HPSJ requirements and is willing to work in line.
• You have established a relationship with the provider before enrolling with HPSJ.
• HPSJ doesn’t have any known quality of care concerns with the provider.
• You went to the provider for a non-emergency service within 12 months before enrolling with HPSJ.
• You went to the provider 6 months before transitioning from a regional service center to HPSJ.

You’ll be required to switch to HPSJ network providers if your non-plan provider doesn’t meet these requirements.

Continuity of care also encompasses continuing with providers who were attending to you while they were still in the HPSJ network but later exited. More information on the continuity of care is available from the HPSJ customer service desk at 1-888-936-PLAN
(7526), TTY/TDD 711.

I hope this was informative. You may be interested in other articles like deductibles for health insurance⁶ Healthcrust article (trustworthy) see the article  and how to get health insurance⁷ Healthcrust article (trustworthy) see the article