Benefits and Covered Services

Get Health Care Services

Getting care is simple for Healthy Workers HMO members!

Schedule check-ups and routine care

Do not wait until you are sick to see your doctor. Schedule an appointment for a check-up within 120 days after you enroll in the program. Your doctor will advise you about the best time for routine appointments and shots, depending on your child’s age.

Call and make an appointment

Call the doctor listed on your San Francisco Health Plan member ID Card to schedule an appointment. Simply present your ID Card at the doctor’s office or clinic when you go in for your appointment. Remember to give at least 24 hours notice if you need to cancel or change your appointment.

Contact your doctor when you are sick

Except in the case of an emergency, always call your doctor first if you get sick or hurt. Your doctor will make sure your family gets the health care they need, either by providing treatment or by referral to a specialist.

Specialty Care

Your doctor will arrange most types of specialty care that your family may need. After talking with you, your doctor will refer you to a specialist. If you go to another doctor without a referral from your doctor and are not seeking emergency services or OB/GYN services, these services may not be covered under your member benefits.

Timely Access to Care

You should be able to make an appointment for Covered Services based on your health needs. The California Department of Managed Health Care (DMHC) created standards for appointment wait times. They are:

Type of AppointmentStandard Wait Time
For Urgent Care,
if a prior authorization is not needed
Within 48 hours of the request for appointment
For Urgent Care,
if a prior authorization is needed*
Within 96 hours of the request for appointment
For routine Primary Care visit
(non-urgent)
Within 10 business days of the request for appointment
For routine visit with a specialist physician
(non-urgent)
Within 15 business days of the request for appointment

*Prior authorization may be needed if you are seeing a provider who is not part of your medical group.

If you wish to wait for a later appointment that will better fit your needs, check with your provider. In some cases, your wait may be longer than the standard wait times if your provider decides that a later appointment will not harm your health.

The standard wait times do not apply to preventive care appointments. Preventive care means prevention and early detection of illnesses. This includes physical exams, immunizations, health education and pregnancy care. The standard wait times also do not apply to periodic follow-up care that is scheduled in advance. Examples of periodic follow-up care are standing referrals to specialists and recurring office visits for chronic conditions. Your provider may suggest a specific schedule for these types of care, based on your needs.

Interpreter services are available at no cost to you. If you need help in your language during your appointment, ask your provider to arrange for an interpreter for you. Or you can call SFHP Customer Service at 1(800) 288-5555 toll-free or TDD/TTY 1(888) 883-7347, Monday through Friday, 8:30am to 5:30pm.

The DMHC also created standards for answering phone calls. They are:

  • For calls to SFHP Customer Service – within 10 minutes during normal business hours, Monday-Friday, 8:30am – 5:30pm
  • For triage or screening calls – within 30 minutes, 24 hours a day, 7 days a week

Triage or screening is done by a physician, registered nurse, or other qualified health professional to determine where and how quickly you need to get care. If you need triage or screening, you should call your PCP or clinic first. If you cannot reach your PCP or clinic, you can call Teladoc® to have a phone or video consultation with a physician. This service is free of charge and available to you in your language. Call Teladoc at 1(800) 835-2362 or visit sfhp.org/teladoc.

Authorizations for Specialty Care

San Francisco Health Plan may make utilization management (UM) decisions regarding some of your health care services.

A UM decision, also known as prior authorization, is the process of getting an approval before you access certain health services.  Usually your PCP’s office will get the authorization for you.
Your medical group or SFHP reviews the authorization request by using nationally accepted medical criteria and your Evidence of Coverage to decide if a service is medically necessary and covered under your plan.

Once the decision is made, a letter called a notice of action letter, will inform you if the authorization request has been denied or modified.

SFHP or your medical group will give you a copy of the letter which will contain all of the information used to make the decision.

Some services requiring prior authorization are (Please note this list is not all inclusive. Please see Services Requiring Prior Authorization List):

  • Outpatient Physical Therapy
  • Outpatient Occupational Therapy
  • Outpatient Speech Therapy
  • MRIs, PET Scans
  • Certain laboratory tests
  • Durable Medical Equipment

Generally, you do not need a referral from your PCP or an authorization for the following services:

  • Emergency services
  • OB/GYN care
  • Family planning
  • Abortion (except for the use of general anesthesia for an abortion)
  • Certain sensitive services
  • Preventive care

For a complete list of services requiring prior authorization, please check with your medical group.

Emergency Care

An emergency is when you have a condition that endangers your life, are in extreme or intense pain, have serious difficulty breathing, or may have a broken bone.

When you have a medical emergency:

  1. Call 911 or go to the closest emergency room for help
  2. Show your member ID Card to the hospital staff
  3. Ask the hospital staff to call your PCP

If you are not sure if it is an emergency, call your doctor to find out if you need to go to the emergency room. If you go to the hospital emergency room for care when there is not a “true” emergency, the emergency room may send you to your doctor or clinic for treatment.

Urgent Care After Regular Hours and On Weekends

Some medical problems may require urgent care but are not emergencies. Urgent medical problems are problems that usually can wait 24 to 48 hours for treatment without getting worse. If you think you have an urgent medical problem, call your doctor for advice on what to do.

If you have any other questions about how to get medical care, email San Francisco Health Plan Customer Service, or call us at 1(888) 558-5858, Monday through Friday, 8:30am to 5:30pm.