General Member Information

Here is information on how to make the most of your membership. And remember that help is always just a phone call or email away...

At Renewal Time

Here are some simple steps you can take to ensure your healthcare coverage doesn't lapse:

Watch for a renewal letter in the mail. This letter will ask you to fill out a renewal form. The letter may come from Healthy Families, Medi-Cal, the Social Services Agency, or Santa Clara Family Health Plan.
Fill out the renewal form and return it to us as soon as possible.
Let us know if you move. Call SCFHP, Healthy Families, or the Medi-Cal office to let us know when your address or telephone number has changed.

By doing these three things your benefits will continue working for you without interruption, giving you the peace of mind of knowing that your healthcare coverage is secure.

Ongoing Health Education

We believe that an informed member is an empowered member, so we provide our members with access to classes and printed info to help them effectively manage their health care. If you would like to see topics covered other than those on the list, please contact Member Services.

Authorization for Services

Your health care provider will need to get Approval for most covered Services, such as Hospitalization and various tests.

Before approving services related to your medical condition or treatment, SCFHP must have all the facts. Facts include exam and test results. Decisions are made by either a licensed Physician or other Appropriately Qualified Health Professional (specially trained to treat your condition). For Services that are not urgent, decisions are made within 5 working days from receipt of the request. If Services are urgent, decisions are made within 72 hours from receipt of the request. Sometimes more time is needed to review a pre-Approval request. This can happen if SCFHP does not have all of the facts or tests needed to Approve or deny the request. If SCFHP cannot meet the above time frames, SCFHP will let you and the health care provider who requested the Service know in writing the date your request will be decided.

SCFHP will tell your PCP whether the Service is Approved or denied within 24 hours after making a decision. If the Services are not Approved, SCFHP will send you and your PCP a letter within 2 working days after the decision is made. The letter will tell you the reason for the denial and your rights to appeal the decision.

For a hardcopy of this information, please contact Member Services at 1-800-260-2055.

Continuity of Care

Continuity of Care for New Members and for Members Whose Provider’s Contract is Terminated:

When you first enroll in SCFHP, if you have been receiving care from a Non-Plan Provider, such as a Hospital, you may be able to continue that care for a period of time. If a provider stops working with SCFHP and that provider, including a Plan Hospital, has been caring for you for a Service that SCFHP covers, SCFHP will help you continue to get or complete your medical care. You may continue such care under the following conditions:

You ask SCFHP to help you by calling Member Services; and
The Non-Plan Provider agrees to SCFHP’s requirements; and
The care is for one of the conditions listed below and is a covered benefit.

SCFHP may also transfer care to an in-plan provider to make sure your care is not interrupted.

For specific conditions where SCFHP will cover your medical care with a Non-Plan Provider, the list below tells you which conditions are eligible and for how long:

An Acute condition: SCFHP will help you continue getting care for a covered Service until you no longer have the Acute condition.
Serious Chronic condition: SCFHP will help you continue getting care for a covered Service for as long as it takes for your treatment of the serious Chronic condition to be complete. After your treatment is completed, SCFHP will transfer your care to an in-plan provider.
SCFHP will help you:
- Get a surgery or other medical procedure from the Non-Plan Provider as long as it is a covered Service, Medically Necessary, and has already been Approved as part of a documented treatment plan.
- Continue getting care that is a covered Service for a newborn child between birth and 36 months, for up to 12 months from the effective date of coverage.
- Continue getting care that is a covered Service for a pregnancy, including postpartum (6 weeks after delivery) care.
- Continue getting care that is a covered Service for the duration of a terminal illness.

Note: If you are a new Member who is already receiving treatment or Services for a complex medical condition, including pregnancy, you may prefer to stay in the MediCal FeeForService Program. If so, you or your health care provider may call the Health Care Options Program at 1-800-430-4263. Ask them for a “medical exemption.” This means that you will be exempt from joining a managed care plan. You must show Health Care Options that you qualify for the program. To qualify, you must prove that you have a “complex medical condition” and need to continue care with the health care provider you are seeing.

If a PCP’s contract is ended, SCFHP will notify you. The notice will tell you to select a new PCP by calling Member Services. The letter will also include other important things you need to know if you want to continue to see your current provider. You must tell SCFHP that you want the provider (Physician, medical group, or Hospital) providing health care Services to continue to provide and complete the Services.

If the provider and SCFHP cannot agree on payment or other terms for providing care, then SCFHP does not have to pay for the Services. In this case, if you still want the Services, then you will be responsible for paying the provider.

For a hardcopy of this information, please contact Member Services at 1-800-260-2055.

Help In Your Language

We Speak Your Language!
Santa Clara Family Health Plan wants to be sure that your health needs are met. You can talk with your doctor or Health Plan staff in the language that you prefer. Many of our staff speak your language. If not, we can arrange to have a telephone interpreter for you.

Free Language Assistance Services
You can ask for an interpreter free of charge

Whenever you have a doctor’s appointment or receive medical care
Whenever you contact the health plan

You do not have to use a family member or friend to interpret for you.
You can also ask for a face-to-face interpreter, including sign language, at no cost to you or your doctor, when you get medical care or services.

If you need an interpreter, let the doctor’s office know ahead of time so an interpreter will be available for your appointment. Or you can call our Member Services Department to ask for an interpreter.

We prefer a 5 day notice to schedule face-to-face appointments. Your provider can use phone interpreter service at any time. Call us at (800)-260-2055 or TTY (800)-735-2929, 8:30 a.m. – 5:30 p.m., Monday through Friday to request an interpreter.

Information in your Language
You have the right to receive information in another language or alternative formats (such as audio, large print or Braille). Please let us know if you would like to have materials in your preferred language or in an alternate format. Call us at (800)-260-2055 or TTY (800)-735-2929, 8:30 a.m. – 5:30 p.m., Monday through Friday.

Transportation Needs

If you have no way of getting to a non-emergency doctors appointment, we can help by arranging for transportation. The appointment in question must be for services covered by your health plan, and the doctor in question must be a recognized SCFHP provider.

Providing of transportation is based on:

your medical and physical condition
the urgency of the appointment
availability of transportation at the time needed

To request transportation help, please call your Member Services Department at 1-800-260-2055 at least 7 days prior to the appointment. Note that we will contact your doctor to verify your need.

For a hardcopy of this information, please contact Member Services at 1-800-260-2055.