Health plan San Mateo in summary

Table of Contents

Health Plan San Mateo is a public health plan that was created on the 1st of December, 1987 to offer health insurance benefits to the underserved residents of California’s San Mateo County. It provides a network of health care providers and preventive health services for Medi-cal recipients.

Before the formation of the health plan in San Mateo, residents in need of Medi-cal services were known to travel to other counties because of the lack of local health care providers offering Medi-cal benefits. Today, health care in San Mateo provides Medi-cal benefits to over 130,000 residents of the county.

From the 1st of January this year(2022), it also started managing dental services for its Careadvantage and Medi-cal members in a new program called the Health Plan of San Mateo Dental ( HPSM Dental).

San Mateo medical health plans.

These are the Careadvantage, Medi-cal, Healthworx, and Ace plans. These were all created either to meet specific needs or for a class of San Mateo residents.

San Mateo Care advantage.

This is offered to the health plan of San Mateo Medi-cal members but it’s a combination of both the Medi-cal health plan and Medicare, under one plan.

To participate in this plan you are required to be a resident of San Mateo and have full Medi-cal coverage including Medicare parts A and B. Some of the features are:

1. Case manager: You’ll be given a case manager who will be your first point of call when you need health services. He is responsible for making the arrangements for you to get the care you need. His work descriptions are to:
• Contact the providers you need.
• Make arrangements for your appointments.
• Arrange for free transportation to and from your appointments.
• Arrange for follow-up visits.
• Find or arrange for support services you may need like home care.

2. Large network of providers,

3. Absence of out-of-pocket costs like deductibles, copayments, and monthly premiums.

4. Free transportation,
5. Outpatient behavioral care or services,
6. Coverage for prescription drugs
7. Vision care,
8. Dental car.

The San Mateo access and care for everyone (ACE) plan.

It is a locally funded program for the low-income class who are not eligible for any run both at the state and federal levels.

To be eligible for this plan you’ll need to be above 19 years and ineligible for other health care programs available in the county.

The application fee for the program is $360. Then there is an annual health coverage fee of $360 to be paid at the rate of $30 monthly or at once.

Covered services.

Preventive health care services,
Physician and specialist appointments,
Mental health services
Breast cancer and cervical cancer screenings if not covered by other programs,
Immunizations,
Diagnostic services and X-rays.
Physiotherapy,
Skilled nursing care, etc.

Most of the services offered under the health plan of San Mateo Ace plan have $15 copayments. Oral surgeries have $100 while some other major or long-duration services carry $300 copays. Click To Tweet

San Mateo Medi-Cal health plan.

As the state’s own Medicaid program, it complies with the Affordable Care Act in the provision of 10 categories of healthcare services known as Essential Health Benefits (EHB).¹ These are:

Emergency health services,
Inpatient services or hospitalization,
Mental or behavioral health services and substance use disorder,
Ambulatory services: care given on an outpatient basis,
Pregnancy, maternity, and infant services,
Various laboratory services,
Preventive health and wellness programs,
Prescription drug coverage,
Physical and occupational therapy services and devices,
Pediatric Healthcare, which also covers vision and oral health.

You can access the full details of the above-listed essential health benefits on the state’s Department of Health Care Services website.²

You’ll notice that adult vision and dental health are not included under the 10 essential health benefits, however, Medi-cal makes provision for their coverage.

By calling the Medi-cal dental service line, 1-800-322-6384, you can access adult and children’s dental benefits³ some of which are:

Dental fillings,
Tooth extraction services,
Scaling,
Root canal treatment services,
Root planning,
Periodontal care,
Emergency services,
Complete or partial dentures,
Diagnostic services,
Orthodontics for Kids,
Preventive dental services.

San Mateo Healthworx health plan.

The healthworx health plan is specifically designed to cater to the health needs of specific employees of San Mateo County. To be eligible you’ll need to fall into either one of two classes of workers.

1. A part-time employee of the city,
2. An in-home supportive service (IHSS) employee of the San Mateo public authority.

The health plan covers services like:

Doctor or Hospital visitations,
Long-term care in nursing homes,
Pregnancy and maternity services,
Preventive health care services,
Prescription drug coverage (mostly for in-network pharmacies),
Emergency services,
Dental and vision care for in-home supportive service workers.

The health care costs include a monthly premium that is determined by employers and copayments for certain services such as hospital visits and emergency care:
A doctor or hospital visitation- $5,
Emergency services- $25.

You don’t pay for pregnancy-related health care, maternity, or interpreter services.
You also get a personal case manager who helps to coordinate your health care plan.

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Health plan of San Mateo urgent care.

These are for non-emergency or non-life-threatening health problems like flu, joint pain, blurred vision, etc. You may have to call the health plan San Mateo nurse line, 1-833-846-8773, for guidance on whether your health situation needs urgent care or an emergency.

Cases that usually fall under urgent care are:

Neck, ear, eye, or back pain,
Sprains or strains,
Non-severe asthma attacks,
Animal bites,
Cold or flu,
Fever except for infants which could be an emergency,
Sore throats,
Minor burns, etc.

When you have any of the above-listed conditions or any problem you know doesn’t put your life at risk, you should go to an urgent care center rather than an emergency room. Moreover, the wait times for urgent care have been noted to be often shorter than those for the emergency rooms. (source)

There are many urgent care centers, and you can easily get the care you need by searching for the nearest center.

Health plan San Mateo formulary

This is a list of quality drugs covered by the health plan San Mateo that are taken to be essential, safe, and effective as part of patients’ treatment plans.⁴ Drug formularies differ according to health plans such that each plan has a formulary that’s distinct in a way from the others. Below are links to the formulary of some health plans under HPSM.

Healthworx Formulary,

Careadvantage Formulary,

Aceprogram formulary,

You could find the drug you are looking for in the formulary either according to the condition you are using it for or in the index where they are listed in alphabetical order. Among other things, you’ll also find drugs that require prior authorization before they can be used otherwise they won’t be covered.

Health plan San Mateo prior authorization forms

Apart from urgent and emergency care, certain health services require prior authorization to be covered by your plan. Providers are mandated to obtain approval before providing these services.

Medical authorizations

For acceptance, medical authorization requests must meet the following criteria.

The use of the current authorization form,
Keep the long-term care box unchecked except if you provide long-term care,
Keep the urgent care box unchecked except if it’s urgent,
Use of the typed, fillable form.
The form should appear on the first page when faxing the request and with no cover sheet.

For inpatients, the following apply:

HPSM has to be notified within 24 hours of admission with a face sheet faxed to 650-829-2060. Face sheets are to be placed before all other clinically relevant information.
Emergency and observation services are directly billable and not in need of authorization.
Review clinical information is to be faxed to 650-829-2068.

Dental authorizations.

All dental providers are to fill and submit an American Dental Association claim form Further information may be needed for services like dental images, periodontal charts, and X-rays.

Nonetheless, prior authorization forms could be turned down for the following reasons:

Incomplete forms,
Non-accurate or misleading information,
Handwritten forms,
Request form containing multiple information on a patient,
Use of outdated forms,

Authorization forms.

Below are the links to some health plan San Mateo forms in common use:

Prior or Medical authorization request form.

Dental authorization request form.

Prescription drug authorization request form.

Referral Authorization correction form.

Referral Authorization form.

Ace referral authorization form.

Authorization for life-sustaining treatment form.

Complex case management referral form.

Home health physician referral form.

Home advantage member referral form.

Medical authorization request form.

I hope the information provided here is helpful, you also may be interested in reading about the Geisinger health plan or health plan San Joaquin.

Health plan San Mateo.