A non-government entity
Central Health San Mateo Medicare Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Central Health San Mateo Medicare Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Central Health San Mateo Medicare Plan (HMO) in 2025, please refer to our full plan details page.
Central Health San Mateo Medicare Plan (HMO) is a HMO plan offered by Molina Healthcare, Inc. available for enrollment in 2025 to people living in San Mateo County. This plan received an overall rating of 2.5 out of 5 stars in 2025.
It's important to know that Central Health San Mateo Medicare Plan (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Central Health San Mateo Medicare Plan (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Central Health San Mateo Medicare Plan (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Central Health San Mateo Medicare Plan (HMO) has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay different amounts for your prescriptions depending on the drug tier and the pharmacy you use. For example, you will have no copay for preferred generic drugs at standard or mail-order pharmacies. For standard generic drugs, you will pay a $35 copay at either standard or mail-order pharmacies. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Central Health San Mateo Medicare Plan (HMO) offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have a mix of copays and no copays depending on the service. Emergency services have copays, including worldwide emergency coverage. The plan also covers primary care, preventive, hearing, vision, and dental services, often with no copay. Additional benefits include ambulance services, home health, medical equipment, diagnostic services, and other services like acupuncture and over-the-counter items, with varying cost-sharing such as copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric services, both requiring prior authorization and a doctor's referral. For both, there is a $310 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services and Observation Services have a copay between $0 and $250, while Ambulatory Surgical Center Services and Outpatient Blood Services have no copay. Individual and Group Sessions for Outpatient Substance Abuse have a copay between $5 and $5.
Partial Hospitalization See details
Partial Hospitalization is covered by the Central Health San Mateo Medicare Plan (HMO), with a $40 copay. Prior authorization and a doctor's referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Central Health San Mateo Medicare Plan (HMO). Ground ambulance services have a copay between $0 and $300, while air ambulance services have a 20% coinsurance. Transportation Services to a plan-approved health-related location have no copay, and the plan covers 12 one-way trips per year. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services, are covered with a copay of $0 to $125, and no coinsurance. Worldwide Emergency Services are also covered, including Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, each with a $125 copay and no coinsurance, up to a maximum of $50,000.
Primary Care See details
Primary Care benefits include no copay for Primary Care Physician Services, and also no copay for Chiropractic Services, with routine care not covered. Occupational Therapy Services have a $25 copay, and Physician Specialist Services have a $25 copay. Mental Health Specialty Services and Psychiatric Services both have a $40 copay for individual and group sessions. Other Health Care Professional services have a copay between $0 and $25, and Physical Therapy and Speech-Language Pathology Services have a $25 copay. Additional Telehealth Benefits have no copay. Opioid Treatment Program Services have a $5 copay.
Preventive Services See details
Preventive Services are covered, including Medicare-covered preventive services with no copay and additional preventive services such as Health Education, Personal Emergency Response System, and Fitness Benefit with no copay. Annual Physical Exams, In-Home Safety Assessments, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, and Telemonitoring Services are not covered.
Hearing Services See details
Hearing services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams, routine hearing exams, and fitting/evaluation for hearing aids have no copay. Prescription Hearing Aids (all types) are covered, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered. OTC Hearing Aids have no copay.
Vision Services See details
Vision Services includes coverage for eye exams and eyewear. Eye exams have no copay, while eyewear has a combined maximum of $150.00 per year.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with no copay, Oral Exams with a copay between $0 and $17, Dental X-Rays with a copay between $0 and $41, Other Diagnostic Dental Services with a copay between $0 and $15, Prophylaxis (Cleaning) with no copay, Fluoride Treatment with a copay between $0 and $13, Other Preventive Dental Services with no copay, Restorative Services with a copay between $0 and $424, Adjunctive General Services with a copay between $0 and $166, Endodontics with no copay, Periodontics with no copay, Prosthodontics, removable with a copay between $0 and $220, Implant Services with a copay between $0 and $2160, Prosthodontics, fixed with a copay between $75 and $295, and Oral and Maxillofacial Surgery with a copay between $0 and $237. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment are covered. Durable Medical Equipment has no copay and a coinsurance between 0% and 20%, while Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay. Prosthetic Devices and Medical Supplies have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with all diagnostic services, lab services, and radiological services requiring prior authorization and a doctor's referral. Diagnostic Procedures/Tests have a copay between $0 and $15, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $250, Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the Central Health San Mateo Medicare Plan (HMO) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor referral, but additional days beyond Medicare-covered and non-Medicare-covered stays are not covered. The plan charges the Medicare-defined cost share for tier 1, and more details about the coinsurance are available.
Other Services See details
Under the Central Health San Mateo Medicare Plan (HMO), acupuncture is covered with no copay, and over-the-counter items are covered with no copay, while a meal benefit is also covered with a copay between $0 and $5. Other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and more are not covered.
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