We want to make sure you get the most out of your Medi-Cal or Healthy Kids health plan, and that you know how to access all of the services and benefits your health plan has to offer. Please read this page carefully to learn more about your membership and the services we provide. You can also watch these helpful videos about getting started using the plan.
If you have any questions or need additional information, please contact Customer Service at 1-800-260-2055 or TTY/TDD 1-800-735-2929.
Cal MediConnect members please visit the Cal MediConnect - Helpful Information page.
An advance health care directive is a form you fill out in advance to tell your health care provider, family and friends about the health care you want if you can no longer make decisions for yourself. The directive explains the types of treatment you want or do not want. It also allows you to name a person to be your health care agent. This person can be a spouse, family member, friend or other person you choose. This person can make decisions for you if you can no longer make them for yourself. Your rights as a member of SCFHP apply to this designated health care agent.
At your request, we will send you information about state law regarding advance health care directives, including any changes to the law, within 90 days after the change is effective.
You may contact Customer Service at 1-800-260-2055 for instructions for setting up and using an advance health care directive. You can also download an advance health care directive form here.
You can give legal permission to have someone represent you. You can choose a relative, friend, or other trusted person to act on your behalf to contact SCFHP with questions, or to make a complaint or make an appeal about a coverage decision.
To appoint a Personal Representative who is authorized to discuss or disclose protected health information and other benefit information with SCFHP at your request, complete an Authorized Representative Form.
Please send the completed Authorized Representative Form to:
Attn: Customer Service
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
If you have any questions, please call Customer Service 1-800-260-2055.
Your doctor or health care provider will need approval for most covered services, such as hospitalization and tests.
Before approving services related to your medical condition or treatment, we 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 you need a decision urgently, please talk to your doctor and a decision can be made within 72 hours from receipt of the request.
Sometimes we need more time to review a pre-approval request. This can happen if we do not have all of the facts or tests needed. If we cannot meet the above time frames, we will let you and the health care provider who requested the service know in writing the date on which your request will be decided.
We will tell your health care provider whether the service is approved or denied within 24 hours after making a decision. If the services are not approved, we will send you and your health care provider a letter within 2 working days after the decision is made. The letter will tell you the reason for the denial and what your rights are to appeal the decision.
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, we 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 Customer Service; 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 we will cover your medical care with a non-plan provider, this list 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, we will transfer your care to an in-plan provider.
- We 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 Medi-Cal Fee-For-Service Program. If so, you or your health care provider may call Health Care Options 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 provider’s contract is ended, SCFHP will notify you. The notice will tell you to select a new primary care provider by calling Customer Service. 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 us 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.
SCFHP offices are accessible to people with disabilities. So are many of the offices of plan providers. If you need help finding a plan provider’s office that you can access, please call Customer Service.
Access for the deaf, hard of hearing or speech impaired:
SCFHP uses the text telephone device (TTY, also known as TDD) number through the California Relay Services to help callers. To use the TTY/TDD services to talk to us, call 1-800-735-2929 toll-free.
Access for those who are blind or have low vision:
You can get important plan materials in large print, Braille, and computer disk formats. For any of these formats, or for help with reading any of our materials, please call Customer Service.
If you are more comfortable speaking a language other than English, Santa Clara Family Health Plan can help you. Whether you are contacting SCFHP or visiting a doctor, we have interpreters available.
Know your rights
- You can get an in-person or telephone interpreter at no cost to you. This includes Sign Language.
- When you go to the doctor, interpreters are available 24-hours a day.
- You can ask for SCFHP plan materials in English, Spanish, Simplified Chinese, Tagalog, and Vietnamese.
How can you get an interpreter?
Tell your doctor’s office you’d like one. You can do this when you call to set up your next visit. You can also ask us for an interpreter or for translated materials.
Call Customer Service at 1-800-260-2055, TTY users should call 1-800-735-2929 or 711.
If you are a new SCFHP Medi-Cal or Healthy Kids member, you will receive a Health Information Form (HIF) in the mail. Filling out the HIF form is voluntary. It will help us better support your health needs. You will not be denied care based on your confidential answers.
If you have questions about completing the HIF form, please call Customer Service at 1-800-260-2055, Monday through Friday, 8:30 a.m. to 5:00 p.m. TTY/TDD users should dial 1-800-735-2929 or 711.
Please return completed form/s in the postage-paid envelope to:
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
You can view or download the form by clicking here.
As an SCFHP Member, you have the right to:
- Be treated with respect and courtesy regardless of your gender, culture, language, appearance, sexual orientation, race, disability, or source of payment.
- Be told in a clear way about all health care services available and how to get them.
- Receive written member materials in English, Spanish, or Vietnamese (depending on the plan you are enrolled in), or alternative formats, including Braille, large print and audio format upon request.
- Select a health care provider or clinic as your primary care provider (PCP). Your PCP will provide or arrange for all the health care you need.
- Receive needed and appropriate medical care, including preventive health services and health education.
- Access family planning services, Federally Qualified Health Centers, Indian Health Services facilities, sexually transmitted disease services, and emergency services outside of the SCFHP network according to federal law.
- Access minor consent services.
- Know and understand your medical condition as diagnosed by your health care provider; know what the health care provider plans to do to treat the condition; know what results you can expect; and know what effects the treatment may have on your daily life.
- Actively take part in decisions about your medical care. If permitted by law, you have the right to refuse or stop treatment.
- Formulate advanced directives.
- Have the meaning and limits of confidentiality explained to you.
- Have your health records kept confidential, except when disclosure is required by law or permitted in writing by you. With adequate notice, you have the right to see your Protected Health Information (PHI), as allowed by law.
- Know that if you must be moved or transferred from one hospital to another, you may receive information about why you need to be moved and about any other choices you may have.
- Receive a second opinion from another plan physician about your diagnosis, the proposed plan of treatment, and other available options.
- Know how to get help and solve problems; know how to file a grievance or appeal with SCFHP; know how to ask for a State Fair Hearing. Understand how to use the grievance or State Fair Hearing process without fear of interruption or loss of health care, or risk of retaliation.
- Take part in establishing SCFHP’s public policy, by attending and/or joining the SCFHP Consumer Advisory Committee and attending any SCFHP Governing Board meeting.
- Have an interpreter who speaks your language (including Sign Language) available 24 hours a day, 7 days a week, at no cost to you.
- File a grievance if your cultural and linguistic needs are not met.
- Disenroll from SCFHP.
- Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
- Freedom to exercise these rights without adversely affecting how you are treated by SCFHP, plan providers, or the State.
American Indians and Alaska Natives (AIANs) have the right to choose to receive primary care services at Indian Health Service Facilities or Federally Qualified Health Centers (FQHCs) or from any other plan provider within SCFHP’s geographic service area (Santa Clara County). AIANs also have the right to stay in regular Medi‑Cal and not enroll in a managed care plan.
As an SCFHP Member, you have the responsibility to:
- Carefully read all SCFHP materials as soon as you enroll so you understand how to use our services.
- Ask questions when you do not understand something about your coverage or medical care.
- Follow the rules of SCFHP membership as explained in your plan’s Evidence of Coverage document.
- Be responsible for your own health and the health of your children.
- Talk to your health care provider so you can develop a strong relationship based on trust and cooperation.
- Call your health care provider when you need routine or urgent health care.
- Report unexpected changes in your health to your PCP.
- Ask questions about your medical condition. Make sure you understand the answers, and what you are supposed to do.
- Follow the treatment plan your health care provider gives you, and know what might happen if you do not follow the treatment plan.
- Make and be on time for medical appointments. Let your health care provider know at least 24 hours before your scheduled appointment if you need to cancel.
- Tell SCFHP about any changes in: address; phone number; family status, such as marriage, divorce, etc.; and changes in any other health care coverage you might have. Tell us about these changes as soon as you know them or within 10 days of these changes.
- Call or write SCFHP as soon as possible if you feel you were improperly billed or if the bill is wrong.
- Treat all SCFHP personnel and health care providers with respect and courtesy.
- Submit requests for claims reimbursement for covered services within the required time period.
- Be honest in your dealings with SCFHP and its plan providers. Do not commit fraud or theft or do anything that threatens the property of SCFHP or the property or safety of any of its representatives, plan providers, plan providers’ employees, or agents.
It can be hard to know what kind of services you need. This is why we have licensed health care professionals who can help you by phone 24 hours a day, 7 days a week. Here are some of the ways they can help you:
- They can answer questions about a health concern, and instruct you on self-care at home if appropriate.
- They can advise you about whether you should get medical care, and how and where to get care. For example, if you are not sure if your condition is an Emergency Medical Condition, they can help you decide if you need Emergency Services or Urgent Care. They can also tell you how and where to get that care.
- They can tell you what to do if you need care and a health care provider’s office is closed.
You can reach one of these licensed health care professionals by calling 1-877-509-0294. When you call, a trained support person may ask you questions to help determine how to direct your call.
Urgent Care—Nights and Weekends
Some medical problems may require urgent care but are not emergencies. Urgent medical problems are problems that usually need attention within 24 to 48 hours. If you think you have an urgent medical problem or feel sick, call your primary care provider’s office even when your primary care provider’s office is closed. Your doctor, or the on-call physician, is always available 24-hours-a-day, 7 days a week, to help if there is an urgent medical problem and will tell you what to do.
We try to make it as easy as possible for you to keep your coverage. Follow these three easy steps to make sure your health care coverage is not interrupted:
- Watch for a renewal letter in the mail. This letter will ask you to fill out a renewal form. The letter may come from Medi-Cal or Santa Clara Family Health Plan.
- Fill out the renewal form and return it as soon as possible.
- Let us know if you move. Call SCFHP (Healthy Kids members) or the County of Santa Clara Department of Benefits and Services (Medi-Cal members) to let us know when your address or telephone number has changed. The County of Santa Clara Department of Benefits and Services’ telephone number is: 1-877-962-3633.
We recognize the importance of maintaining the confidentiality of all members’ medical record information and personal identification. All such information will be held confidential by SCFHP and its contracting providers.
We will not use any member’s confidential information for any purpose other than:
- Carrying out the express terms of our contract with the Department of Health Care Services.
- As otherwise permitted or required by our contract with the Department of Health Care Services.
- As permitted by any applicable state or federal law.
- As permitted with the member’s written consent, when consent is required by applicable law.
A statement describing our policies and procedures for preserving the confidentiality of medical records and personal identifying information is available in our Notice of Privacy Practices.
As an important step in receiving health care from your doctor, SCFHP asks our new and current members to complete the Staying Healthy Assessment (SHA). The SHA is a set of questions that allows your doctor to understand your health and better help you decide what types of services you may need.
Based on your age, the form asks questions on topics such as the types of food you eat, how much you exercise, and if you smoke. Some of the questions may be personal. You may choose not to answer any questions if you don’t want to. If you choose to answer a question, be honest and as complete as possible.
It should only take a few minutes to fill out the form. You may fill out a SHA at your doctor’s office or fill out the form at home and take it with you to your appointment. You (or your child) do not have to be sick to schedule this doctor visit.
You can print out a Staying Healthy Assessment form from the Member Forms & Documents page. For forms in languages other than English, Spanish, or Vietnamese, go to the Californa Department of Health Care Services website and view their Staying Healthy Assessment page.
Your responses are confidential. The completed SHA will be kept in your medical record.
Within the first 4 months of becoming a member, schedule an appointment with your doctor to complete the SHA. You (or your child) do not have to be sick to schedule this doctor visit.
If you are a current Member and have not completed an SHA form, or have not completed one recently, please schedule a preventive care visit and complete the SHA as part of that visit.
Newborns, Toddlers, Kids, and Teen Members
Parents with children under 18 years of age should complete a form for your child on the first scheduled doctor visit and again when your child reaches a new SHA age group. The SHA Periodicity Table below shows the SHA age groups.
Adult and Senior Members
Adult and Senior Members, 18 years of age and older, should complete a new SHA form every 3 to 5 years.
SHA Periodicity Table
As a member, you have the right to refuse, decline or skip any or all parts of the SHA. Your doctor will ask you to sign the refusal document and this document will be kept in your medical record.
If you have any questions about SHA, call your doctor or SCFHP Member Services at 1-800-260-2055.
Example Staying Healthy Assessment Form
This is an example of a Staying Healthy Assessment:
If you have no way of getting to a non-emergency doctor’s appointment, we can help by arranging for transportation. The appointment must be for services covered by your health plan, and the doctor must be an SCFHP provider.
Providing 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 Customer Service at 1-800-260-2055 at least 7 business days before the appointment. We will contact your doctor to verify your need.
SCFHP covers eye screenings and eye exams for all Medi-Cal members through Vision Service Plan.
For more information or to find an optometrist see the VSP Provider Directory, or call VSP Member Services at 1-800-877-7195.
Hearing impaired customers may call 1-800-428-4833 for assistance.